el impacto de edentulismo

8/12/2019 El Impacto de Edentulismo

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Hindawi Publishing CorporationInternational Journal o DentistryVolume , Article ID ,pageshttp://dx.doi.org/.//

Review ArticleThe Impact of Edentulism on Oral and General Health

Elham Emami,1 Raphael Freitas de Souza,2 Marla Kabawat,1 and Jocelyne S. Feine3,4

Departement de Dentisterie et de Restauration, Faculte de Medecine Dentaire, Universite de Montreal, CP ,Succursale Centre-Ville, Montreal, QC, Canada HC J

Department of Dental Materials and Prosthodontics, Ribeirao Preto Dental School, University of Sao Paulo,- Ribeirao Preto, SP, Brazil

Oral Health and Society Research Unit, Faculty of Dentistry, McGill University, Montreal, QC, Canada HA C Department of Epidemiology and Biostatistics and Department of Oncology, Faculty of Medicine, McGill University,Montreal, QC, Canada HA A

Correspondence should be addressed to Elham Emami; [email protected]

Received January ; Revised April ; Accepted April

Academic Editor: Yasuhiro Morimoto

Copyright Elham Emami et al. Tis is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

An adequate dentition is o importance or well-being and lie quality. Despite advances in preventive dentistry, edentulism is stil la majorpublic healthproblemworldwide. In this narrative review, we providea perspective on thepathways that linkoralto generalhealth. A better understanding o disease indicators is necessary or establishing a solid strategy through an organized oral health

care system to prevent and treat this morbid chronic condition.

1. Epidemiology of Tooth Loss

Edentulism is a debilitating and irreversible condition andis described as the nal marker o disease burden ororal health[]. Although the prevalence o complete toothloss has declined over the last decade, edentulism remainsa major disease worldwide, especially among older adults[] (able ). However, there are intra- and intercountry

variations in the prevalence o complete edentulism [],and direct comparison between national samples is difficult

because o the impact o various actors like education,economic circumstances, liestyle, oral health knowledge andbelies, and attitudes to dental care[]. In the United States,the number o edentate individuals is likely to stay stable at million and, according to the most recent inormation, theprevalence o edentulism amongst adults over years oage was % []. In , the overall rate o edentulism inCanada was .%, and among adults between and yearso age, it was .%[]. Te rate o edentulism tends to varyamong different regions within a country. In Canada, thereis a wide variation between provinces, rom % (Quebec)to % (Northwest erritories) due to associated actors suchas access to uoridated water and smoking []. In Brazil,

the wealthier, more industrialized states tend to have lowerrates than other parts o the country[].

Studies show that edentulism is closely associated withsocioeconomic actors and is more prevalent in poor popu-lations and in women [,]. In , the ratio o edentulismwas times higher in low-income than in higher incomeCanadian amilies []. Other actors contributing to theprevalence o complete tooth loss are age, education, accesstodental care, dentist/population ratios, and insurance coverage[,]. Most edentate people are elders who wear complete

dentures in one or both jaws. Studies have demonstrated thatdenture wearing continues to increase due to the increase inthe aging population; a large number o people still dependon removable dentures or oral unction [].

Edentulism can lead directly to impairment, unctionallimitation, physical, psychological, and social disability, andhandicap []. Tus, the impact o edentulism on generalhealth should be examined by analyzing the major dimen-sions o health: physical symptoms and unctional capacity,social unctioning and perception o well-being. Tis meansthat well-quantied endpoints o demographic signicancecan be used to understand the global burden o this disease.Te literature has been reviewed accordingly.
http://dx.doi.org/10.1155/2013/498305http://dx.doi.org/10.1155/2013/498305


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International Journal o Dentistry

: Prevalence o edentulism in the elderly rom different countries.

Region or country Year o survey Sample size Age group (years) Percentage edentulous

United States, data rom the National Health andNutrition Examination Survey []

- about , %

%

Canada [] , %

%Brazil[] - , to .%

Mexico [] - ,, .%

.%

Valencia, Spain [] , .%

Montpellier, France[] + .%

urkey [] - , .%

Sweden [] , %

Hungary [] , .%

.%

2. Impact of Edentulism on Oral Health

.. ooth Loss: Modier of Normal Physiology. Bone loss isan ongoing process ollowing tooth loss [], affecting themandible our times more than the maxilla []. Edentulismwas ound to have a signicant effect on residual ridgeresorption [], which leads to a reduction in the height oalveolar bone and the size o the denture bearing area. Tisreduction affects ace height and acial appearance, which arealtered ollowing total tooth loss []. Te loss o alveolarbone height and width also leads to substantial changes inthe sof-tissue prole, such as protrusion o the mandibularlip and chin []. Tere exists an interpatient variation in

these anatomic degenerative changes, and the etiology othese is still unclear. It is believed that a combination olocal and systemic actors may be contributors; these includeage, gender, duration o edentulism, paraunctional habits,general health, and several diseases[].

.. ooth Loss: Risk Factor for Impaired Mastication. Tenumber o teeth has been chosen as a key determinant ooral unction and oral health status [,]. Several studiesusing different methodologies have demonstrated that animportant indicator or masticatory efficiency is the numbero unctional tooth units [,]. According to a systematicreview evaluating the relationship between oral unction and

dentition, tooth numbers below a minimum o teeth,with nine to pairs o contacting units, are associated withimpaired masticatory efficiency, perormance, and mastica-tory ability (an individuals perception o his/her ability tochew) [].

Although some evidence suggests that reduced oralunction in elders is related to muscle atrophy, aging alonehas little impact on masticatory perormance []. Moststudies agree that denture wearers have only about one-fh to one-ourth the bite strength and masticatory orceo dentate individuals []. Furthermore, complete denturewearers require times more chewing strokes than thosewith natural dentitions to be able to cut ood into hal o

its original size []. Moreover, the thickness o the massetermuscle was ound to be decreased in edentulous patients,thus decreasing bite orce []. Tis may partly explainwhy individuals wearing complete dentures have difficultychewing hard oods.

Tis disability could substantially inuence the desireto bite, to chew, and to swallow and could lead to amodication o ood choices [,]. As a result, researchhas consistently demonstrated that tooth loss and dentalstatus have a negative impact on diet and ood selection[,].

.. ooth Loss: Determinant of Oral Health. Edentulism canbe accompanied by unctional and sensory deciencies othe oral mucosa, oral musculature, and the salivary glands.Decreased tissue regeneration and decreased tissue resistanceare expected in the edentulous population, which can impairthe protective unction o the oral mucosa. Associations havebeen reported between aging, denture use, and oral mucosaldisorders, including denture stomatitis, an inammatorycondition o the palatal mucosa seen in complete denturewearers, angular cheilitis, oral candidosis, and traumaticulcers []. According to MacEntee et al., the odds onding hyperplasia, stomatitis, and angular cheilitis increaseapproximately three-old in denture wearers[]. Such dis-orders could expose the individual to internal and external

pathogens, and their prevalence is an important parameterin evaluating the oral health o an elderly population [, ].Although a direct correlation between edentulism and aspira-tion pneumonia has not been reported, the potential relationbetween denture plaque and aspiration pneumonia has beendiscussed in susceptible individuals [, ]. Although themajority o oral mucosal conditions in the elderly are benign,some may become malignant, especially i the protectiveunctions o oral mucosa are decreased[].

Edentulism may induce an oral dyskinesia, dened asabnormal, involuntary, patterned or stereotyped, and pur-poseless oroacial movements. Several actors, such as ill-tting and unstable prostheses, oral discomort, and lack o


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sensory contacts, have been proposed to explain oral dyski-nesia in edentulous individuals, but the exact mechanism isstill unclear. Denture wearers may have additional prostheticproblems as a result o sof and hard tissue damage causedby oral dyskinesia []. Edentulism is also associated withtardive dyskinesia, a type o dyskinesia occurring among

patients chronically treated with antipsychotic drugs [].

3. Impact of Edentulism on General Health

According to several studies, tooth loss can affect generalhealth in several ways as indicated as ollows:

(a) lower intake o ruits and vegetables, ber, andcarotene and increased cholesterol and saturatedats, in addition to a higher prevalence o obesity,can increase the risk o cardiovascular diseases andgastrointestinal disorders [,];

(b) increased rates o chronic inammatory changes othe gastric mucosa, upper gastrointestinal and pan-creatic cancer, and higher rates o peptic or duodenalulcers[];

(c) increased risk o noninsulin-dependent diabetes mel-litus [,];

(d) increased risk o electrocardiographic abnormalities,hypertension, heart ailure, ischemic heart disease,stroke, and aortic valve sclerosis [,]. A studyalso demonstrated a possible association betweencomplete edentulism and an increased risk o coro-nary heart disease []. Furthermore, a more recentlarge prospective study concluded that the number oteeth was a dose-dependent predictor to cardiovascu-

lar mortality [];(e) decreased daily unction, physical activity, and physi-

cal domains o health-related quality o lie [,];

() increased risk o chronic kidney disease[];

(g) association between edentulism and sleep-disorderedbreathing, including obstructive sleep apnea [].

Although evidence is accumulating to support a reciprocalrelationship between oral and general health [, ], themechanisms linking poor general health and tooth loss arenot yet clear. A purported pathway or this associationinvolves deleterious effects o tooth loss on nutrition that,in turn, impacts systemic health []. Nutritional actors,

especially antioxidants, may decrease ollowing tooth loss andmodulate systemic disease by interering with the inam-matory cascade and preventing carcinogenesis[]. A studyon , US women [] showed that diet might partiallyexplain the association between oral health and cardiovas-cular disease. In this cross-sectional analysis, the edentulouswomen had dietary intakes associated with an increased rateo cardiovascular disease. Tese results are supported by alongitudinal analysis on , adults, which conrms anassociation between tooth loss and the prevalence o heartdiseases [].

Furthermore, excessive intakes o highly processed high-at and high-carbohydrate oods contribute to obesity and

obesity-related diseases, such as insulin resistance, cardiovas-cular disease, and hyperlipidemia []. However, it should beunderstood that the nutritional consequences o edentulismare complex due to a plethora o actors that inuence oodintake and nutritional status, including acute and chronicdisease, alterations in the gastrointestinal tract, unctional

disabilities, chewing problems, psychological and social ac-tors, and lowered socioeconomic status[,].Several longitudinal, prospective, and cross-sectional

studies have supported the association between tooth loss,diet, and nutrition. Impaired dentition imposes dietaryrestriction and affects ood taste, ood selection, ood prepa-ration and ood eating patterns [, ]. Results o astudy by Locker[] indicated that % o edentulous elderswere prevented rom eating oods they would like to eat,% reported a decline in their enjoyment o ood, and %avoided eating with others. Suboptimal diets may preventedentulous individuals rom meeting recommended dietaryallowances and lead to compromised nutritional states, espe-cially in edentulous subjects without dentures [, , ].Studies have demonstrated that diet in edentulous subjectsconsists o ood that is low in ber and high in saturatedat, with a signicant lack o intake o high-ber oods suchas breads, ruits, vegetables, and nonstarch polysaccharides(NSP) [,, ,]. Low NSP intakes (> g/d) and lowruit and vegetable intakes (> g/d) have been reportedin edentulous people []. Joshipura et al. [] collecteddietary intake data rom , male health proessionals anddemonstrated that, compared to dentate individuals, edentu-lous respondents consumed ewer vegetables, less ber, andless carotene intake, while consuming more cholesterol andsaturated ats. Tese differences wereindependent o sociode-mographic and health behaviour characteristics. Lowe et al.[] established that total tooth loss was associated withlow citrus ruit consumption, low plasma vitamin C levels,and increased amounts o inammatory reactants, such asplasma C-reactive protein. Tey also demonstrated increasedlevels o plasma interleukin-, brinogen, and actor VIII inwomen. Tese actors are associated with an increased risk ocoronary heart diseases and stroke.

In relation to weightgain, the results o a study carried outbyLeeetal.[] demonstrated thatedentulism was associatedwith a weight gain o>% in one year. Furthermore, an asso-ciation between edentulism and obesity was ound in severalstudies [,]. When edentulism was not rehabilitated withcomplete dentures, it was associated with both underweight

and overweight/obesity in an elderly population[].Despite this evidence, some ndings contradict the

association between dentition and nutrition [, ]. In across-sectional study, Shinkai et al. [] investigated theinuence o dentition status on overall diet quality. Teauthors concluded that, although individuals with betterdentition status had better masticatory perormance andbite orce, no association was ound between dentitionstatus and quality o diet. However, in the same study,they ound an association between masticatory variablesand intakes o specic dietary components, such as vitaminC and ber. Tere also exist some contradicting resultsregarding the inuence o sociodemographic variables on


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the dentition-nutrition relationship. Findings o Nowjack-Raymer and Sheiham [] demonstrated that the associationbetween dentition and nutrition was independent o age, sex,raceethnicity, and socioeconomic actors, whereas Lee et al.[] demonstrated racial-ethnic differences in dietary intakepatterns, showing that the ood intake o Arican American

edentulous elders was similar to those with teeth. How-ever, Caucasian edentate elders displayed different dietaryood patterns than their dentate counterparts. Tis ethnicdifference could be explained by undamental differencesin socioeconomic characteristics o racial groups. AricanAmericans consumed more at, ewer vegetables, and lessber than did the Caucasians, irrespective o dental condition[].

Although diet has been shown to be poorer in edentulouspopulations, there is still a need or more research aboutthe association between tooth loss and specic changes innutrient intake. Te association between tooth loss and aging[] may become even more important with the growth o theelder population worldwide. Such an increasing populationhas higher prevalence o chronic conditions [] that may beindirectly aggravated by edentulism [].

Regarding lie expectancy o edentulous individuals,tooth loss was ound to be associated with the onset odisability and mortality, even afer adjusting or conoundingactors such as socioeconomic and health behavior actors[], andone studydemonstrated that each tooth that remainsin the oral cavity afer the age o decreased the risko mortality over years by % []. In addition, severalstudies established an association between edentulism beorethe age o and an increased risk o earlier death [].Also, according to Shimazaki et al. [], the mortality rate oedentulous elders without dentures was signicantly higherthan those with or more teeth and, in a large cohort study,an association was ound between tooth loss and mortality, inaddition to death resulting rom gastrointestinal cancer, heartdisease, and stroke[].

4. Impact of Edentulism on the Quality of Life

Te term quality o lie is ofen used as an umbrella termthat covers various concepts, that is, health status, unction,and lie conditions. In general, quality o lie (QoL) is denedas an individuals perception o his or her position in lie, inthecontext o theculture andvalue systems in which they live,

andin relation to their goals, expectations, andconcerns [].Perception o QoL varies among individuals and uctuatesover time or the same person as a result o changes in any oits component parts[]. QoL is partly affected by a personsoral health. Perceptions o how oral conditions affect dailyunction and well-being are reerred to as oral health-relatedquality o lie (OHQoL) []. OHQoL has been widelyused in clinical studies as an outcome to assess the quality,effectiveness, and efficacy o oral health care [,].

Increasingly, it is recognized that patients perceptions otheir oral health are important in evaluating well-being anddetermining health care outcomes []. Te exclusive use oclinical measures has been generally criticized because they

provide little insight into the psychosocial aspects o healthand do not adequately reect the health status, unctioning,and perceived needs o edentulous and elderly individuals[, , ]. Edentulism may lead to changes in most othe domains leading to poorer QoL (e.g., impaired masti-cation, denture trauma, aesthetic concerns, or negative sel-

perception). eeth have an important role in acial appear-ance, speech, and eating ability. Tere is overwhelming evi-dence showing the negative effect o edentulism on OHQoL[, ]. Edentulism negatively inuences not only oralunction, but also social lie and day-to-day activities [].Compromised oral unction has been linked to decreasedsel-esteem and a decline in psychosocial well-being [].Edentulous people may avoid participation in social activitiesbecause they are embarrassed to speak, smile, or eat in ronto others, leading to isolation []. Many people developskills to overcome the limitations o dentures, but some areunable to do so []. Fiske et al. [] demonstrated thatdenture wearers have decreased sel-condence, prematureaging, altered sel-image, and altered behaviour in socializingand orming close relationships. On the other hand, den-tures could improve oral appearance and social interactionso individuals, which might enhance sel-esteem and thuscontribute to psychological well-being [, ]. Variables,including typeo treatment, age, sex,and marital status, couldexplain the variation in ratings o OHQoL andtooth loss [].

5. Conclusion

Edentulism has a series o deleterious consequences or oraland general health. Oral consequences vary rom the well-known residual ridge resorption to an impaired masticatoryunction, an unhealthy diet, social disability, and poor oralhealth quality o lie. Edentulous individuals are also ingreater risk or different systemic diseases and an increase inmortality rate. Tereore, oral health care providers shouldprevent tooth loss with proper dental education, oral healthpromotion, and a high level o dental care in an attempt toassure the existence o a physiologic dentition.

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