Original article

Interventions for edentate elders – what is the evidence?

€ ller1,2
Frauke Mu
1
Division of Gerodontology and Removable Prosthodontics, University of Geneva, Geneva, Switzerland; 2Department of Internal Medicine,
Rehabilitation and Geriatrics, University Hospitals Geneva, Geneva, Switzerland

doi: 10.1111/ger.12083
Interventions for edentate elders – what is the evidence?
Demographic developments indicate an increasing proportion of elderly persons in the population as
well as longer life expectancies. Furthermore, the prevalence of edentulism is decreasing, and natural
teeth are being retained until later in life. Geriatric patients are more frequently fragile with multiple
co-morbidities, including frequent medication-related side effects such as xerostomia. Cognitive impair-
ment also increases with age and presents a considerable challenge to oral hygiene and dental treat-
ment. Edentulous patients present a particular challenge, as muscle skill and the ability to adapt to a
new denture diminish with age. Duplication techniques reduce the adaptation of replacement dentures,
and implants are increasingly used to stabilise lower complete dentures, significantly improving chewing
efficiency and preventing peri-implant bone loss. Implant overdentures may reverse some of the func-
tional, psychological and psychosocial effects of tooth loss and thus increase the oral health-related
quality of life until late in life. Evidence from RCTs exists on the 10-year survival of implants and
implant overdentures, but few studies have investigated the problems and survival rates when the
patient loses autonomy. The standard of care in geriatric patients has to be adapted to the patient’s
motivation, functional and cognitive impairment, and medical condition as well as his/her socio-eco-
nomic context.

Keywords: complete dentures, implant - over dentures, edentate elders.

Accepted 19 June 2013

These recent developments are also reflected

Edentulism – a declining entity?
Sound epidemiological data support predictions
that the prevalence of edentulism is falling in the
industrialised world1,2 and is becoming extinct in
the working population3. This may be due to the
progress in prevention of oral disease or to the
advances of restorative dentistry, both from a
material as well as from a technical point of
view. Certainly, adhesive techniques allow devel-
oping minimally invasive treatment approaches
that significantly reduce the sacrifice of dental tis-
sue for purely retentive purposes. At the same
time, life expectancy is increasing, and if this
trend continues, most babies born after 2000 will
be live to celebrate their 100th birthday4. Both
falling rates of edentulism and increasing life
expectancy lead to natural teeth being lost later
in life5, when maintaining oral hygiene can
become difficult and thus further accelerating
tooth loss.
in the restorative status of the elderly popula-
tion. Whereas fixed prostheses are increasingly
seen in the 65- to 74-year-old population, the
prevalence of removable prostheses is declining
in the same age strata, with the latter signifi-
cantly more common in patients with low socio-
economic status6. However, more recent studies
have extended this widely used age range for
‘elderly’ participants, such that age cohorts of
85+ years are more frequently included in popu-
lation-based surveys. In Switzerland, 85.9% of
persons aged 85 years or above report wearing a
removable prosthesis, and amongst them, 37.2%
are complete upper and lower dentures6. In the
United States, the growing elderly population
has overshadowed the fall in prevalence, so den-
tists will continue to be confronted with provid-
ing and maintaining increasing numbers of
complete dentures7. The prevalence of edentu-
lism and tooth replacement varies highly

44 © 2014 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd,
Gerodontology 2014; 31 (Suppl. 1): 44–51

between countries, cultures and socio-economic
status8.
Challenges with ‘new’ edentulous
patients
What will future ‘edentulous cases’ look like?
Physiological ageing is not the only characteristic
of late life; cognitive impairment, frailty and mul-
tiple chronic diseases, as well as the side effects of
the related medications, also become common9,10.
Very old and fragile edentulous patients will often
present a considerable challenge to the clinician,
as the anatomical conditions are likely to be poor
for gaining denture retention and stability, and
muscle control will have likewise deteriorated.
Side effects from the treatment of chronic condi-
tions such as xerostomia or sensitive mucosa can
further affect oral comfort and challenge denture
wearing. Beyond the challenges of wearing a den-
ture, clinical procedures can also be more difficult,
for example, when reduced mobility requires
treating the patient in non-ideal positions or cog-
nitively impaired patients are unable to cooperate
in certain treatment steps such as occlusal regis-
tration11. Thus, before beginning long and inva-
sive treatments, the patient’s physical tolerance
should be investigated to determine the accept-
able treatment burden per session12.
Furthermore, dental care for elderly and depen-
dent patients presents more general challenges
such as transportation logistics for patients with
mobility restrictions. Dental care has to be consid-
ered as just one mosaic in caring for the elderly
person and requires complex coordination with
the physician, nurses, family and other potential
partners in the team of caregivers. Likewise, the
legal context of treatment decisions has to be
respected, which is particularly crucial when
financial agreements have to be signed. And
lastly, communicating with elderly adults should
respect their different life course, experiences and
values.
The conventional complete denture in
geriatric patients
Along with the teeth, several other orofacial
structures are lost when a patient becomes eden-
tulous, such as the periodontal tissues, including
the receptors, parts of the alveolar bone and the
associated gingival tissues as well as the supplying
nerves and blood vessels. With time, more distant
structures also change in complete denture wear-
ers, as the temporo-mandibular ligaments loosen
© 2014 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd,
Gerodontology 2014; 31 (Suppl. 1): 44–51
Interventions for edentate elders 45
and the chewing muscle lose muscle bulk13, these
latter changes being related to the ‘use it or lose
it’ principle rather than the tooth extraction itself.
Conventional dentures replace most of the lost
structures, but cannot fully compensate functional
impairment after tooth loss. Often unnoticed,
patients adapt their food choice and limit their
mandibular movements to the range which pre-
cludes denture displacement or pain14. Mucosa-
born dentures function basically based on three
mechanisms. First, they are retained by physical
suction, as obtained by selective tissue compres-
sion during impression making or the creation of
a posterior palatal seal. This mechanism requires a
thin film of saliva, preferably of mucous consis-
tency. However, over the time a denture is worn,
physical retention decreases, as the denture-bear-
ing bony structures atrophy along with ageing
and occlusal load bearing15. As physical retention
decreases, the importance of ‘muscular’ retention
increases, relying on learned skills to keep the
denture in place during function16. To successfully
perform such a skilful task, the brain processes
afferent information from the oral cavity which is
then translated to motor activity pattern. Thus,
although oral perception is essential for denture
control, it is well established that the sensitivity of
the mechanoreceptors diminishes with age. Early
‘de-afferentiation’ experiments from Nils Brill and
co-workers evince the failure of complete denture
retention and control after edentulous patients
rinsed with diluted 2% xylocaine jelly and 5%
lidocaine ointment17.
A similar challenge in denture wearing derives
from the reduced motor coordination in old age,
which is well known from other body functions
like walking or writing, but is inevitably also pres-
ent in the chewing muscles. Physiological decline
is further accelerated when neurodegenerative
pathologies such as dementia are present, and the
probability of denture use is known to be signifi-
cantly reduced in cognitively impaired institu-
tionalised patients18. Although rare, it is possible
to aspirate complete dentures19. Brill concludes in
his classic paper from 1959 that ‘we may even
venture upon the conclusion that muscle activity
transcends in importance all other factors respon-
sible for denture retention, at least in those cases
where the bony foundation of a lower denture is
greatly resorbed’17.
The third factor that adds to complete denture
function is the occlusion, which repositions the
denture when upper and lower teeth meet in sta-
tic or dynamic contact. This phenomenon
becomes clinically most evident in patients who
46 F. M€
uller
are unable to wear the antagonistic denture, for
example as a result of a surgical intervention or
simply due to discomfort. Given the less precise
motor coordination in geriatric patients along
with the loosening of the TMJ articular ligaments,
it seems favourable to choose a balanced occlu-
sion that ‘guides’ the mandible in maximum in-
tercuspation even when the closing trajectory
results in an eccentric first tooth contact. While
the superiority of one occlusal concept over
another has yet to be definitively proven, recent
research20 indicates that lingualised occlusion can
decrease chewing time and increase maximum
masticatory muscle contraction, masticatory per-
formance and patient satisfaction. Interestingly,
this single-blind study used a denture duplication
approach to mask the change in occlusion in new
dentures from bilaterally balanced to lingualised.
Denture adaptation
A further challenge arises when existing well-
adapted dentures have to be replaced because
they are lost or have become unhygienic, worn or
simply insufficient. Learning new motor skills or
adapting existing motor patterns requires neuro-
plasticity, which may be compromised at a very
high age21. Therefore, the capacity to adapt to a
replacement denture which is different in form
and function may be considerably compromised
and can cause frustration for both the patient and
the dentist22. Denture retention facilitates the
adaptation process as denture kinetics rely less on
motor skills23. Although scientific evidence is still
scarce, it seems intuitive that stabilising a com-
plete denture may facilitate the adaptation pro-
cess. Another strategy to foster denture
adaptation may be fabricating dentures that copy
selected features from the existing well-adapted
prostheses using duplication techniques. The
existing OVD and maximum intercuspation are
often kept as ‘convenience occlusion’, even if the
patient seems over-closed and the jaw relation
too anterior, as a compromise to avoid challeng-
ing muscle growth24 and neuroplasticity. How-
ever, two features should not be copied when
duplicating a complete denture: the denture base
should be adapted to the denture-bearing tissues,
and worn denture teeth should be replaced by
new occlusal surfaces. The latter is particularly
important in patients with advanced chewing
muscle atrophy and low maximum biting force as
well as poor muscle coordination. Well-defined
cusps with an unworn occlusal surface might help
comminuting unblended food stuffs, as demon-
© 2014 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd,
strated with a RCT comparing balanced 0° and
30° occlusal schemes, where patients reported sig-
nificantly greater satisfaction and eating ability
with the 30° teeth25.
Implant overdentures
There is sufficient evidence to state that the man-
dibular implant overdenture (IOD) is a well-estab-
lished treatment modality, certainly in non-
dependent edentulous individuals26,27. The list of
functional benefits they offer is headed by a sub-
stantial increase in chewing efficiency, as indi-
cated by the significantly reduced number of
chewing cycles required to obtain a given commi-
nution of a standardised test food28. This improve-
ment seems largely independent from the chosen
attachment system or the number of implants
used. Accordingly, the maximum bite force is
increased after stabilising a mandibular denture
with dental implants29. However, reports from the
literature usually refer to mean values which
may, or in some cases may not, reflect the situa-
tion of the individual patient. A group of Dutch
scientists evaluated chewing efficiency with a
sieving method in volunteers with different dental
states29. Although they confirmed that their 12
complete denture wearers with significantly re-
sorbed alveolar ridges had the lowest chewing
performance and that the group of investigated
40 mandibular IOD wearers performed much bet-
ter, the 24 edentulous patients with little or no
resorption of the ridges outperformed the IOD
patients in the study (Fig. 1). Little is known
about chewing efficiency in geriatric patients, as
the limiting factors may instead be related to gen-
eral health and functional decline rather than bite
force, occlusal morphology or denture stability.
CT scans have revealed that edentulous persons
present a smaller cross-sectional area of the mas-
seter and lateral pterygoid muscles and a lower
density of the tissues than their age-matched den-
tate peers13. Although with age, muscle waste
occurs in all skeletal muscles, the effect might be
accelerated when wearing complete dentures as
the load bearing during chewing is limited by
pain from the denture-bearing tissues and denture
displacement when the bolus is placed unfavour-
ably. It is therefore safe to assume that a lack of
muscle training is contributing to the lower mas-
seter muscle bulk in edentulous individuals.
Experimental resistance training in elderly adults
proved effective in increasing muscle strength and
bulk30, but data on the training effect of forceful
chewing in elderly adults remain scarce31. In a
Gerodontology 2014; 31 (Suppl. 1): 44–51
 Interventions for edentate elders 47

6.0

5.0

median parƟcle size (X50) in mm

4.0 implants
full dentures (low)
full dentures (high)
3.0 root overlay
shortend arch
complete arch (old)
complete arch (young)
2.0

1.0

0.0
0 10 20 30 40 50 60 70
number of chewing strokes

Figure 1 Chewing efficiency varies largely between dental states and even in fully edentulous complete denture
wearers29.

cross-sectional study, the thickness of the masse- company and social interaction seem to positively
ter muscle was investigated by means of an ultra- influence the caloric intake in geriatric patients37.
sound technique32. Two groups of patients with Despite these intuitive correlations, improving
implant prostheses, either fixed or removable, chewing efficiency as only the measure does not
were compared with a group of conventional change dietary intake, as other factors such as
complete denture wearers and a fully dentate habits, food preference, general health, mobility,
control group of similar age. The results indicate culture and cooking skills as well as cognitive
that the mean masseter muscle thickness of the impairment and appetite may play a role. A
patients with the implant reconstructions was recent RCT on 217 complete denture wearers
greater than in complete denture wearers, but less who randomly received a replacement denture or
than in persons with a natural dentition. Hence, an implant overdenture confirmed previous
chewing muscle training might be equally as reports that stabilising a lower complete denture
effective as in the leg muscles, although this as the only measure has no significant influence
needs to be confirmed by prospective longitudinal on the nutritional state and weight of edentulous
observations. persons38. While tailored nutritional counselling
has been shown to increase the intake of fruits
and vegetables with edentulous patients who
Nutritional intake were provided replacement dentures39, oral
Tooth loss is accompanied by a decrease in chew- health and chewing efficiency are only one piece
ing efficiency which goes along with a silent
change in nutritional intake, as the food choice is
adapted to what is feasible to chew14. Hence,
edentulous persons tend to consume a diet which
is low in protein, non-starch polysaccharides, cal-
cium and vitamins33. However, Weiss et al.34 con-
firmed that a BMI of 28 or above is associated
with a reduced mortality (Fig. 2). Hence, weight
loss is a critical issue in geriatric care35 and may
even be an early sign of cognitive decline36.
Although chewing efficiency does not seem
directly correlated with a patient’s weight, it may
indirectly contribute towards a better nutritional
intake as it invites a wider food choice and allows
eating unblended meals, which look more appe-
tising. Furthermore, institutionalised patients tend Figure 2 In very old persons, a BMI of 28 or above is
to withdraw from common meals when chewing associated with reduced morbidity and mortality
difficulties preclude ‘decent’ table manners, yet (n = 470)34.

© 2014 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd,
Gerodontology 2014; 31 (Suppl. 1): 44–51
48 F. M€
uller
in the puzzle that influences the nutritional state
of elderly individuals.
Psychosocial benefits of implant
overdentures
Undoubtedly, when considering the psychosocial
benefits of all dental treatments, the stabilisation of
mandibular complete dentures by means of osseo-
integrated implants is one of the most effective
interventions in dentistry. This is mainly due to the
explicit limitations in social interactions and psy-
chological well-being related to tooth loss and its
consequences. Qualitative research demonstrates
that complete denture wearers modify their behav-
iours, as they feel uneasy smiling or sometimes
learn certain techniques to do so with a hand cov-
ering the mouth40. They may refrain from singing
in a choir, reduce their sports activities and go out
less often to see their family and friends41. Eating
out in a restaurant is often avoided, when the com-
plete denture wearer fears difficulties in eating the
served meal in an appropriate manner or time.
Obviously, complete denture wearing has an
impact on intimate relations, and a study from
Heydecke42 reports that complete denture wearers
feel uneasy kissing. Implant overdentures may
reduce the patient’s biggest fear, which is the loss
of denture retention in a public context, revealing
that they wear complete dentures. Although com-
plete denture wearers experience a significant
increase in satisfaction after the renewal of their
conventional dentures43,44, those with new
implant overdentures seem to be even more satis-
fied with their prostheses. The latter is reported for
randomised controlled research conditions45,46 as
well as for a context where the patient freely
chooses his/her treatment option47.
Survival and success of implant
overdentures
Andreiotelli48 reviewed the survival and success
rates of osseointegrated implants used to retain
overdentures. Whereas survival refers to the
implant being in situ, success is considered as fol-
lows:
 absence of persistent subjective complaints,
such as pain, foreign body sensation and/or
dysaesthesia,
 absence of recurrent peri-implant infection with
suppuration,
 absence of mobility,
 absence of continuous radiolucency around the
implant and the
© 2014 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd,
 possibility for restoration49.
The majority of studies in this review concerned
mandibular implants placed in the interforaminal
region to retain removable overdentures. Observa-
tion periods in four of the analysed studies reached
the critical 10-year mark, indicating implant sur-
vival rates between 93 and 100%. Although the
quality of the available evidence mostly precludes
combining the individual study outcome measures
within a meta-analysis, it seems that neither the
number of implants used nor the attachment
system chosen or splinting the implants has a sig-
nificant impact on the treatment success50,51. Treat-
ment concepts for the maxilla, single-implant
mandibular overdentures and short or small-diam-
eter implants are to date less well documented.
Although immediate, early and conventional load-
ing protocols of mandibular implant dentures are
predictable treatment modalities, early and conven-
tional loading tended to reduce failures of osseoin-
tegration within the first year post-insertion52.
From a patient perspective, early loading seems
particularly attractive, as the time of discomfort due
to temporisation is limited, yet there is sufficient
time for wound healing, hence, the likelihood for
needing a reline shortly after denture insertion is
lower than with immediate loading concepts. It can
be concluded that mandibular implant overden-
tures are a safe and successful treatment modality,
which presents multiple functional, structural and
psychosocial benefits to the patient.
Apprehensions and attitude
Despite the convincing data on mandibular
implant overdentures, a great number of patients
refuse implant placement, even when cost as lim-
iting factor is eliminated within the context of a
clinical trial. Walton and MacEntee53 reported a
35% refusal rate when recruiting for a study
where two implants would be placed to retain a
lower denture, all at no cost to the patient.
Whereas agreeing to participate in the study was
mainly motivated by functional improvement and
comfort, nearly half of the refusals were related to
the surgical intervention or the perception that
implants were not necessary. There may be sev-
eral reasons for this. Firstly, elderly patients tend
to become more satisfied with their dentures,
even if they are according to dental professional
criteria insufficient54. Generally, elderly patients
are also less demanding, and wearing a removable
denture is less stigmatised, especially for those
patients who live in institutions. Elderly patients
may further have other, more important priorities
Gerodontology 2014; 31 (Suppl. 1): 44–51

in their lives, especially when they suffer from
multiple chronic diseases and/or they present
with severe disabilities. A recent survey of 92 per-
sons who either lived at home, in a long-term care
(LTC) facility or were hospitalised revealed that a
negative attitude seems related to being a women,
the type and quality of the denture, having little
knowledge of implants and being hospitalised55.
Persons wearing temporary and poor dentures
seem to be at particular risk for poor oral function;
thus, it could be assumed that they would be most
interested in improving their oral state. Yet, the
survey demonstrated that these patients had little
interest in dental implants, concluding that they
were not ‘dental minded’. Ellis et al.56 undertook
a qualitative approach to investigate implant refu-
sal in dissatisfied complete denture wearers. They
confirmed the fear of surgery and post-operative
pain, as well as the perception of inadequacy of
the intervention for a person at an advanced age.
The strategy to allow edentulous individuals to
benefit from oral implants late in life should be to
schedule the intervention when they are not (yet)
institutionalised. Their motivation could be fos-
tered by competent professional information and
minimally invasive surgical procedures.
Risks and maintenance in geriatric
patients
Although success and survival rates of dental
implants seem similar in younger and older eden-
tulous patients57–59, there are certain risk factors
that are related to ageing as well as the onset of
dependency for the activities of daily living and
multimorbidity. Maintaining good oral hygiene
becomes more difficult and is usually less meticu-
lously performed. Little is known about the preva-
lence and pathophysiology of peri-implantitis in
geriatric patients, and the dental profession may
face a significant challenge related to this ongoing
maintenance issue in the years to come. Further-
more, handling a (retentive) IOD may exceed the
manual force and/or cognitive ability of the patient
as well as the competence of the caregivers. It must
be borne in mind that denture use as such is less
frequent in geriatric patients in general, but in par-
ticular, in those who are cognitively impaired, bed-
bound, ventilated or undergoing chemotherapy18.
Thus, for geriatric patients, it seems imperative to
add ‘management of implant prosthesis and ability
to maintain oral hygiene’ to the success criteria
mentioned previously. Care should be taken that
implant patients do not ‘disappear’ from the den-
tist’s recall when they become institutionalised.
© 2014 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd,
Gerodontology 2014; 31 (Suppl. 1): 44–51
Interventions for edentate elders 49
They should be closely monitored, and if needed,
the attachments should be removed and the IOD
transformed to a conventional complete denture.
This strategy requires visionary and ‘reversible’
treatment planning when implant prostheses are
planned and fabricated.
Standard of care for edentulous most
elderly
Elderly patients are a very heterogeneous group
requiring an individual approach to treatment
planning. The theoretically ‘ideal’ treatment plan
that prescribes specific treatment to a certain med-
ical condition has to be modified to a more
rational treatment plan that takes into account the
patient’s functional state and autonomy as well as
the cost–benefit ratio. But even a reasonable treat-
ment goal cannot be achieved if the patient is not
motivated, funds are not available or the patient
cannot undergo the necessary treatment proce-
dures, meaning that a practical and feasible treat-
ment plan has to be established. Thus, a standard
of care cannot simply be a certain type of denture,
it has to instead fulfil the following criteria:
 pain- and infection-free oral comfort,
 oral condition that allows masticating
unblended meals,
 restoration of lower face height and physiog-
nomy,
 age-adequate and pleasing dental appearance,
 providing sufficient retention for self-confident
interaction in a social context,
 use of biocompatible and inert materials,
 ‘natural’ speech.
If the patient’s condition no longer allows the
foregoing criteria to be met, the standard of care
can be worded more generally as follows:
 primum nihil nocere,
 restore aesthetics, oral function and comfort,
 assure good oral health-related quality of life
(OHRQoL),
 provide subjective patient satisfaction and well-
being.
Summary and conclusion
Tooth loss will remain a reality in old age, but
will occur later in life which will confront the
dental profession with more complex reduced par-
tial and complete denture cases. The standard of
care in geriatric patients must be adapted to the
patient’s motivation, functional and cognitive
impairment and medical condition as well as his/
her socio-economic context.
50 F. M€
uller
Acknowledgements
Thanks are due to Iain Pretty for language revi-
sion.
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Correspondence to:
Frauke M€ uller, Division of
Gerodontology and Removable
Prosthodontics, University of
Geneva, 19, rue Barthelemy-
Menn, 1205 Geneva,
Switzerland.
Tel.: +41 22 379 4060
Fax: +41 22 379 4052
E-mail: frauke.mueller@unige.ch