Rehabilitation of Edentulism and Mortality:

A Systematic Review
Avni Gupta, BDS MPH CPH ,1 David A. Felton, DDS MS, FACP,2 Torsten Jemt, DDS, Odont Dr/PhD,3,4 &
Sreenivas Koka, DDS, MS, PhD, MBA, FAP, FACD5,6,7
1
Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Harvard T.N. Chan School of Public Health, Boston,
MA
2
School of Dentistry at the University of Mississippi Medical Center, Jackson, MS
3
Department of Prosthetic Dentistry/Dental Material Science, Institute of Odontology, Sahlgrenska Academy at Göteborg University, Göteborg,
Sweden
4
Brånemark Clinic, Public Dental Health Service, Region of Västra Götaland, Sweden
5
Department of Prosthodontics, Loma Linda University, Loma Linda, CA
6
Department of Restorative Dentistry, UCLA, Los Angeles, CA
7
Private practice limited to removable and implant prosthodontics, Koka Dental Clinic, San Diego, CA

Keywords
Complete denture and mortality; denture;
edentulism; edentulism and mortality;
prosthesis and mortality; tooth loss.
Correspondence
Avni Gupta, Center for Surgery and Public
Health, Brigham and Women’s Hospital, One
Brigham Circle, 1620 Tremont St. 4–020,
Boston, MA 02120. E-mail:
avnigup07jan@gmail.com
Avni Gupta
http://orcid.org/0000-0003-4653-1272
The authors deny any conflicts of interest.
Accepted January 22, 2018
doi: 10.1111/jopr.12792
Abstract
Purpose: It has been shown that tooth loss is associated with an increased risk
of early mortality, and that prosthetic rehabilitation of edentulism improves quality
of life and reduces morbidity. This review examines association between prosthetic
rehabilitation of the edentulous state with a complete denture and mortality.
Methods: A systematic search using combinations of related keywords for “com-
plete denture” and “mortality” was performed on PubMed, Web of Science, and
Google Scholar. A reference search of included articles and author contacts was also
performed.
Results: None of the studies reported results for association between mortality
and wearing complete dentures among edentulous individuals; however, based on the
published methods and results, a total of 15 studies were found to be eligible for author
contacts to obtain relevant data. Overall, 5 eligible studies were included and critically
evaluated to summarize their findings. The follow-up period in these studies ranged
from 3 to 24 years, and the age group of included samples ranging from 52 to 105 years.
The proportion of individuals not wearing dentures ranged from 3.0% to 13.3%. Four
of the included studies showed fewer individuals without complete dentures surviving
over the follow-up years as compared to the group wearing complete dentures. One of
two studies that could adjust for certain confounders found no significant difference
in mortality after adjusting, but another study found a 42% reduced risk of dying
among those wearing complete dentures, as compared to those not wearing complete
dentures after adjusting for age, sex, educational level, smoking, alcohol drinking,
body mass index, time spent walking daily, medical history, psychological distress
score, energy intake, and protein intake. Due to the small sample size of nondenture
wearers, it was not possible to analyze with statistical rigor the comparative risk of
dying associated with wearing or not wearing complete dentures.
Conclusion: Most of the included studies indicated a higher proportion of deceased
edentulous patients not using dentures as compared to denture wearers. Nevertheless,
small sample size prevents a definite conclusion being drawn regarding a relationship
between prosthetic rehabilitation and mortality among edentulous individuals.

Edentulism refers to complete absence of teeth and is consid- variations. In a review by Polzer et al2 that included populations
ered a disability by the World Health Organization (WHO). The from 42 countries, the prevalence was reported to range from
most frequent cause of edentulism is loss of all the permanent 1.3% to 78% for people aged 65 years and above. While in the
teeth after eruption.1 It is widely prevalent and shows regional developed countries prevalence ranges from 16.3% in France

Journal of Prosthodontics 00 (2018) 1–10 

C 2018 by the American College of Prosthodontists 1
Rehabilitation of Edentulism and Mortality
to 58% in Canada,2 developing countries showed a range from
as low as 1.3% in Nigeria to 78% in Bosnia-Herzegovina.2
Jahangiri et al1 stated the overall prevalence of edentulism in
the general adult population in the US, Canada, Australia, and
the UK to be 6% to 8%, rising to 20% to 26% in those above
65 years of age. Prevalence in India, Mexico, Russia, China,
Ghana, and South Africa was reported to be 11.7%.1 In lower
and middle-income countries, rural India, Brazil, and Turkey,
the prevalence of edentulism was found to as high as 48% to
60% in the elderly.1
Loss of teeth has several negative consequences. It is as-
sociated with deterioration of orofacial tissues such as bony
ridges, nerves, receptors, and musculature.2,3 There is loss
of chewing efficiency,2,3 which leads to reduced intake of
food and, in particular, a reduced consumption of fruits and
vegetables. There is a concurrent increased intake of sugar-
and fat-rich foods3 leading to a higher risk of malnutrition.4
Tooth loss and edentulism have also been found to be asso-
ciated with poor oral-health related quality of life (OHRQoL)
through their physiological (speech and mastication), social
(related to esthetics/appearance), nutritional, and psychologi-
cal impacts.5-9 Polzer et al found tooth loss to be perceived as
a traumatic event.2 Several reviews have reported tooth loss
and complete edentulism to be associated with multiple sys-
tematic comorbid conditions such as obesity, COPD-related
events, pneumonia, head and neck cancer, and cognitive de-
cline as well as with an increased risk of mortality.10,11 Gupta
and Koka conducted a systematic review to examine the as-
sociation between tooth count and all types of mortality and
found an overall trend towards a relationship between the num-
ber of teeth and mortality, with a lower tooth count being as-
sociated with higher all-cause and cause-specific mortality.12
Furthermore, Osterberg et al showed tooth loss to be an in-
dependent risk factor for increased mortality in 70-year-old
patients, irrespective of socioeconomic or lifestyle factors.13
Jemt et al have also shown that patients treated with im-
plants in the partially edentulous jaw present a lower mortality
than patients missing all teeth.14 They also showed that the
younger the patient was when treated in the edentulous jaw, the
higher the risk for increased mortality compared to the normal
population.14
Since edentulism has a negative impact for esthetic and func-
tional restoration, edentulism is managed through prosthetic
rehabilitation, either implant- or tissue-supported, with a fixed
or removable prosthesis.2,3 Various studies have assessed the
effectiveness of different treatment options for the rehabilita-
tion of edentulism. A Delphi panel to identify the first choice
standard of care for an edentulous mandible used the following
criteria for assessment: retention, stability, speech, masticatory
efficiency, comfort while eating food, confidence in intimate
situations, satisfaction, and self-esteem.15 Oral rehabilitation
following total or partial tooth loss has also been shown to lead
to significant improvement in OHRQoL.16 Specifically, several
studies report highly favorable outcomes of implant therapy in
terms of QoL.9,17-20
McGrath and Bedi21 assessed the impact of self-reported
tooth loss and denture use as well as the use of a removable
prostheses in individuals with considerable tooth loss (<20
remaining teeth) on OHRQoL. They found that people with
2 Journal of Prosthodontics 00 (2018) 1–10 
Gupta et al
considerable tooth loss who do not seek recourse with an RDP
have reduced QoL. Jahangiri et al1 are working on a sys-
tematic review to compare effects of no treatment, treatment
with conventional removable complete denture, and treatment
with implant-retained removable prosthesis for rehabilitation
of edentulous mandibles. They are assessing outcomes related
to QoL, chewing ability, nutrition, complications, cost effec-
tiveness, and maintenance.
Few studies have tried to assess whether prosthetic rehabil-
itation of the edentulous state may have an impact on patient
mortality. Polzer et al,11 in their review to study if tooth loss
is associated with all-cause and cardiovascular mortality, also
examined the association between tooth replacement and mor-
tality. They summarized five publications that “explored the
putative relation between denture use and all-cause mortal-
ity.” However, their selection criteria for the studies included
both partial and complete prostheses (i.e., they included both
partially edentulous and completely edentulous individuals).
They pointed out serious methodological limitations that im-
paired drawing of any valid conclusions, with the most impor-
tant limitation being nonadjustment for the number of remain-
ing teeth/unreplaced teeth.11 This methodological limitation, as
noted by Polzer et al,11 has motivated this systematic review.
The aim of this review is to systematically assess the existing
evidence for any associations between prosthetic rehabilita-
tion of complete edentulism and patient mortality performed in
studies comparing difference in mortality between those who
wear complete dentures and those who do not wear complete
dentures.
Methods
Protocol
Preferred reporting items for systematic reviews and meta-
analysis (PRISMA) guidelines were used for conducting and
reporting this systematic review.22
Eligibility criteria
PICO criteria were used to define the eligibility for the research
studies to be included.
r Population: Completely edentulous
r Intervention: Wearing prosthesis (fixed tooth-supported
or implant-supported or post and core supported; remov-
able tooth-supported or implant-supported or post and
core supported; complete or partial) in both jaws
r Comparison: Wearing prosthesis versus not wearing
prosthesis
r Outcome: Mortality
The last search for the studies was conducted on 11/15/2016,
and all studies published until that date were eligible for in-
clusion. Excluded studies: Where the intervention was tooth-
borne; non-English studies; non-full text studies, e.g., abstracts.
C 2018 by the American College of Prosthodontists
Gupta et al
Search strategy
Search terms
Search terms identified using MeSH search terms relevant to
the focus area were combined and applied using Boolean Oper-
ators, ‘OR’ or ‘AND’ as appropriate in the searched databases.
The exact search term used was: (“tooth replacement” OR
“teeth replacement” OR “dental implant” OR “dental implants”
OR “dental prosthesis” OR “denture” OR “dentures”) AND
(mortality OR “death” OR “all-cause mortality”).
Although the review focused on the completely edentulous
state, no such specification was added to search strategy, as
there was a great deal of heterogeneity in how the completely
edentulous state was described in different studies. An addi-
tional goal was to include all primary studies where it was
possible to extract associations between our exposure and out-
come for edentulous individuals, even if it was only a part of
the complete analysis and/or a subanalysis among a group of a
studied population. The search was restricted to human subjects
only.
Sources
Systematic searches were performed at the academic databases
PubMed and Web of Science; and Google Scholar. The bibli-
ography and the related citations of the included studies were
also reviewed and searched.
To maximize the thoroughness of the review, studies were
included where the published data did not address the primary
question of this review, but from the described methods and
results of those papers, it seemed possible that the authors
might have collected data to address the research question. For
such studies, the listed corresponding author was contacted to
request data and results specific to this review. After a first
email request, 10 days later, a follow-up email was sent to
nonresponders.
Study selection
Two co-investigators independently performed systematic
searches of the aforementioned databases and sources. Search
results were screened based on manuscript titles to select stud-
ies for abstract review, and then, based on the abstract reading,
studies were identified for full-text analysis. Any disagreement
among the co-investigators in the selection of studies for screen-
ing and/or for final inclusion was resolved by mutual discussion.
Studies meeting the eligibility criteria were included for data
extraction.
Data extraction
A standardized data extraction form was developed in Microsoft
Excel to tabulate data relevant to the research focus. Only data
specific to completely edentulous patients was extracted. Data
items extracted included title of paper, authors, year of pub-
lication, journal, country of sampled population, aim of the
study, study design, follow-up/observation period, sample size
of edentulous individuals, sampling methodology and other de-
tails (attrition, inclusion and exclusion criteria), age group, gen-
der specificity if any, type of rehabilitation, other information
about rehabilitation (data self report or not, functioning capac-
Journal of Prosthodontics 00 (2018) 1–10 
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Rehabilitation of Edentulism and Mortality
ity, how many years, satisfaction with prosthesis), comparison
groups, possible confounders, outcome (method of collection,
cause-specific), data analysis, and primary findings.
Quality assessment of included studies
The Newcastle Ottawa Scale was used to assess the quality of
cohort and case-control studies,23 as has been used in many
other previous reviews.19
Summary measures
The primary comparison groups were edentulous individuals
who have been administrated a prosthesis to restore their eden-
tulous state and edentulous individuals who have not been ad-
ministrated a prosthesis for the restoration of their edentulous
state. The primary outcome was mortality over the study follow-
up period.
Results
Study selection
Twenty-one articles were included for full-text reading; how-
ever, based on the inclusion and exclusion criteria, none of the
21 articles was found to report mortality in complete denture
wearers compared to mortality in edentulous patients who were
not wearing complete dentures. Of these 21 articles, 15 studies
were eligible for potential inclusion, as on reading their meth-
ods and results section, it appeared that data specific to the
aim of this review was collected, even if not reported. These
papers constitute “grey search” data as described by Layton,
who proposes that such data strengthens systematic reviews.24
The corresponding authors of these 15 papers were contacted
to request the data and relevant subset analysis. A copy of the
email sent is included in Appendix A. After communication
with the respective authors of these 15 papers, data relevant
to this review could only be obtained from five studies, which
have been used in the present review (Fig 1).
Bias assessment
Each of the five studies was critically assessed and scored for
quality using the Newcastle-Ottawa Scale (NOS). Results of
the assessment of studies are included in Appendix B. Scores
ranged from 5 to 7 out of a maximum score of 8 for the five
cohort studies. The NOS scale item on the ‘adequacy of the
follow-up’ was excluded from assessment, as there is no ac-
cepted duration, and the adequacy of follow-up time likely
depends on the age group studied. For the assessment of stud-
ies for their quality of comparability as per the item in the
NOS scale, the most important factors predefined for which
to control were age, baseline morbidity, and socioeconomic
status/insurance variables.
Study characteristics
Table 1 summarizes the key characteristics of the five included
studies. Two studies were conducted in Finland, two in Japan,
and one in the United States. Age of included subjects ranged
from 52 to 105 years, where four studies covered elderly pa-
tients with a mean age of 80 years or older. All studies except
3
Rehabilitation of Edentulism and Mortality
Figure 1 Selection of the studies for inclusion in this review.
Ajwani et al25 and Saarela et al26 recruited a community sam-
ple. Ajwani et al25 recruited patients from a dental clinic, and
Saarela et al26 recruited from residents of service housing. Re-
sults from the longest follow-up, which was 24 years, were
reported by Paganini-Hill et al27 while Saarela et al26 had the
shortest follow-up (3 years). Sample size ranged from 4772 sub-
jects reported by Hayasaka et al28 to 172 subjects reported by
Ajwani et al.25 Two studies were based on questionnaires,27,28
and three on basic clinical examinations.25,26,29 All five used
population registries to assess the outcome of mortality. Ac-
cordingly, the exposure variable “wearing or not wearing com-
plete denture” was self-reported in two studies and based on
examination for the other three studies. Most of the partici-
pants in all five studies were wearing complete dentures at the
baseline.
4 Journal of Prosthodontics 00 (2018) 1–10 
Gupta et al
Findings
“Grey search data“ showed that the proportion of deceased
patients among those edentulous patients not wearing dentures
at baseline was higher than for those wearing dentures in four
of the included studies.25-28 In Ansai et al’s study,29 however,
all patients (n = 7; 3.0%) who were not using dentures were
still alive after termination of the study, while 25.3% of denture
wearers were deceased after 10 years. Thus, data in most studies
indicated a lower risk for mortality for those patients wearing
complete dentures; however, since most of the studies reported
very few individuals who were not wearing dentures (3.0% to
13.3%), none had a sample size large enough to be reliable for
a statistical regression model. Except for Hayasaka et al28 and
Saarela et al,26 only the unadjusted actual number of deaths
was available for analysis.
C 2018 by the American College of Prosthodontists
Gupta et al Rehabilitation of Edentulism and Mortality

Ajwani et al25 also assessed mean survival and observed that

Public health centers

indexes and death
commercial death
assessment mode
Outcome variable

Residential registry
those not wearing a complete denture had a mean survival of

of each district

Central registers
Governmental &
3.17 years, while those wearing a complete denture had a mean

Finnish Death
certificates
survival of 3.72 years. Based on grey search data, Hayasaka

Register
et al28 showed that individuals using dentures had a 42% lower
hazard of mortality when compared to those not using dentures
after adjusting for age, sex, educational level, smoking, alco-
hol drinking, BMI, time spent walking daily, medical history
Exposure variable

Oral examination

Oral examination
mailed survey

questionnaire
Examination by
assessment

(stroke, HT, MI, and DM), psychological distress score, energy

Self-report via

Self report via

by dentists

by dentists
intake, and protein intake (HR: 0.58, CI: 0.38-0.56). While

nurses
Saarela et al26 showed in their analysis that mortality was sig-
nificantly higher among edentulous residents without dentures,
when adjusting for age, gender, comorbidity, and MNA, den-
ture status lost its predictive value for mortality. Thus, Saarela
et al26 could not report any increased risk for mortality in pa-
complete
dentures
Wearing

4393
613
555

164

229

tients not using dentures in the multivariate analysis (HR: 0.99,

CI: 0.72-1.35) (Table 2).

Discussion
participants at
Edentulous

baseline

4772
707
575

172

236

This review found the possibility of an association between

wearing complete dentures and decreased mortality as com-
pared to edentulous patients not wearing complete dentures
in primarily elderly patients. These findings, along with the
Maximum
follow-up

24 years

findings from other reviews and studies that have shown im-
3 years
9 years

5 years

4 years
time

proved QoL and/or functional parameters with rehabilitation

of edentulism,16,21 may suggest that those individuals that un-
dergo treatment for their edentulism are more likely to have
improved health and survive longer over follow-up years; how-
No Specification
characteristics

Baseline-2010 No specification
No specification

No specification

No specification
Participants’

ever, due to the small sample size of nondenture wearers, it was

not possible to analyze with statistical rigor the comparative
risk of dying associated with wearing or not wearing complete
dentures. Thus, although it might be tempting to conclude that
these observations support the fabrication of complete dentures
for edentulous individuals, this would oversimplify the nature
Study period

1992-2016

1990-1999

1998-2003

2006-2010

of a complex set of relationships.

In addition, these findings are subject to adaptation of the
individuals to their dentures, which might be directly related
to their existing health conditions, which also in turn is likely
80-year-old (born in 1917)
76-, 81-, and 86-year-olds

people from 3 cities, 4

towns, 1 village, and 1
retirement community

to influence their motivation to receive prosthetic treatment.

housing residents in 2
residents of California

ࣙ 65-year-old residents

The observation by Jemt et al14 that elderly edentulous patients

ࣙ 65-year-old service
from a dental clinic
Setting/Sample

52- to 105- year-old

ward in a region

provided with fixed implant-supported prostheses showed a re-

duced mortality as compared to reference populations, while
younger edentulous patients receiving fixed implant-supported
in a city

prostheses showed a higher or comparable mortality to the ref-

cities

erence population, was suggested to be related to differences in

the health of the patients before implant treatment. Hence, in-
dividuals receiving and adapting to dentures might be the ones
Prospective, Japan
Cohort Prospective,

Cohort Prospective,

Cohort Prospective,
Type of study and

who are healthier physically and/or psychologically, and more

motivated to lead a healthy life, as compared to those who do not
Prospective,
country

get the treatment or fail to adapt to dentures. Therefore, one of

Follow-up

Follow-up
Finland

Finland
Table 1 Included studies

the factors driving longer survival of denture wearers might be

Japan

their better baseline health. All but one of the studies included
US

in this review have not accounted for the differences in the

baseline health status of their sampled individuals; however,
Ajwani et al,25

Ansai et al,29
Author, year

Hayasaka et
al,27 2011

al,26 2014

al,28 2013

the evidence of lower mortality among the complete denture

Paganini et

Saarela et

wearing group from one of these studies, adjusted for the base-
2003

2010

line medical history, indicated that these findings might still be

pertinent and deserve attention.

Journal of Prosthodontics 00 (2018) 1–10 

C 2018 by the American College of Prosthodontists 5
Rehabilitation of Edentulism and Mortality
Table 2 Results from included studies
Subjects
Final sample experiencing
size for outcome of the final
Author, year analysis sample
Paganini-Hill et al, 201127 575 563
Ajwani et al, 200325 172 92
Ansai et al, 201029 236 58
Saarela et al, 201726 1369 603
Hayasaka et al, 201328 4772 840
Given the amount of prosthodontic care sought by patients
and provided by dentists, the paucity of literature that has as-
sessed the association between rehabilitation of the edentulous
state and mortality is noteworthy. Indeed, using the search cri-
teria described, no studies could be found that had directly
addressed this association. The analysis presented in this re-
view is based on making author contacts for the studies iden-
tified during the literature search that on full-text reading were
found to have possibly collected data relevant for this review.
In essence, this study makes use of so called “grey data.”24
Another interesting finding is that all the included studies re-
ported a relatively small group of edentulous individuals who
did not wear complete dentures at the study baseline. Given the
evidence that prosthetic rehabilitation improves QoL, it is un-
surprising to find that most individuals at the time of enrollment
were wearing complete dentures. Another noteworthy finding
from this review is that all the studies included were conducted
in developed countries where access to dental prosthetic care
might be significantly higher than in less-developed countries.
Hence, the populations included in this review might not be rep-
resentative for the variations that likely exist on a more global
level. This is consistent with research that has been conducted
to assess QoL and functional outcomes of complete denture
rehabilitation, which is also highly inclined towards developed
nations.
Given the small sample size, most of the studies included
in this review reported only descriptive statistics. Further stud-
6 Journal of Prosthodontics 00 (2018) 1–10 
Gupta et al
Quality
assessment
Results score
Died in no CD group: 20/20 (100%) 5
Died in CD group: 543/555 (97.83%)
Died in no CD group: 6/8 (75%) 6
Died in CD group: 86/164 (52.43%)
Chi Square statistic p value: 0.017
Mean Survival at end of FU-
No CD: 3.17 years (± 1.5706)
With CD: 3.72 (± 2.3435)
Died in no CD group: 0/7 (0.00%) 6
Died in CD group: 58/229 (25.32%)
Died in no CD group: 49/94 (52.13%)
Died in CD group: 293/613 (47.79%)
As compared to those not having dentures, those having
dentures, HR: 0.99 (0.72 to 1.35) when adjusted for age,
gender, MNA and comorbidities
Died in no CD group: 124/339 (36.58%) 7
Died in CD group: 716/4,393 (16.29%)
Using dentures versus not using dentures
Age and sex adjusted: 0.46 (0.38-0.56)
Fully adjusted∗ : 0.58 (0.48-0.71)
∗
age, sex, educational level, smoking, alcohol drinking, BMI, time
spent walking daily, medical history (stroke, HT, MI, and DM),
psychological distress score, energy intake, and protein intake.
ies are required to assess if the relationship exists independent
of the key confounding factors. Another significant consid-
eration in the assessment and interpretation of these findings
is the distinction between confounding factors and mediators.
Several causal mechanisms have been proposed to explain the
association between number of teeth and mortality. First, since
periodontal infection and inflammation is a major reason for
eventual tooth loss,30 it is believed that a higher level of tooth
loss is a direct indicator of a higher level of periodontal in-
flammation, and this increasing cumulative inflammation load
caused by the oral bacterial infections has been suggested to
increase the risk of mortality, in particular due to its adverse
impact on the cardiovascular system.11,30,31 Another mecha-
nism suggested is the impact of tooth loss on nutritional status.
With an increased tendency for consuming processed food ver-
sus raw healthy food, there might be a higher likelihood of
inadequate nutrition among people with a reduced number of
teeth.11,30-32 Also, the impact of reduced number of teeth on
QoL and comorbidities, as has been found in various studies
and reviews,5-8,10 might eventually influence the risk of mor-
tality. If these mechanisms can explain the association between
tooth loss and mortality, they can also account for the suggested
protective effect of prosthetic rehabilitation of the edentulous
state. It is also suggested that patients with a general inflamma-
tion susceptibility with early onset of inflammatory driven loss
of teeth or hip or knee joints show higher mortality than normal
populations.33
C 2018 by the American College of Prosthodontists
Gupta et al
Even without an established mechanism, these findings are
significant from a policy and clinical perspective and call for
an awareness at the community level as well as among health-
care professionals. Identification of high risk groups in terms of
gender, age groups, race, inflammation susceptibility, and other
factors is important to target the interventions. It would be of
interest to explore whether the associations are independent of
nutritional impact—if the maintenance of adequate nutrition
can mitigate the effects of tooth loss and how these findings
might be crucial for determining policy or practice level inter-
ventions.
The present review has only considered denture use as a
binary factor (in use or not), and the functioning of dentures
was not accounted for. Thus, in addition to the confounders,
another important variable in rehabilitation is the functional
status of the prosthesis. Poorly retained, unstable, and inade-
quately functional prostheses can be counterproductive for the
QoL and may not offer similar beneficial impacts on nutrition
and esthetics. Moreover, they might be associated with addi-
tional direct and indirect costs, through requiring more den-
tal visits for correction/modification/relining, or sometimes a
new denture. Instances when poorly functional and poorly re-
tained dentures cause social embarrassment, especially while
eating, have also been reported.34 In addition, poor performing
dentures are associated with various oral lesions, such as oral
mucositis.34
Inability to maintain adequate oral and denture hygiene can
also predispose an individual to various oral soft tissue in-
fections, such as by C. albicans. As alveolar bone undergoes
resorption over age, relining or reconstruction of the denture
might further add to the time and costs associated with den-
tal visits.35 In fact, insertion of the complete denture is not
the final step in treating the edentulous state, as post-insertion
complaints often continue to bring the patients to dentists even
long after initial insertion.36 The most frequent short-term com-
plete denture complaints have been found to be poor retention,
poor esthetics, inadequate masticatory efficiency, speech is-
sues, oral mucosal pain, ulceration, generalized discomfort on
the denture-bearing area, and denture fracture.36 Poor oral and
prosthesis hygiene is also a common finding in people with
complete dentures.37 Loss of taste sensation and gagging are
other problems associated with wearing dentures.38 Singh et al
studied a rural population with complete dentures and found
that many respondents were unable to eat because of the asso-
ciated discomfort.38 A study conducted among the very elderly
in a community in Japan found a more than 2-fold increase
in the risk of pneumonia among those who were wearing den-
tures at night versus those who were not,39 and that adequate
oral care significantly lowered the risk of pneumonia and death
from pneumonia among hospitalized elderly people and people
living in nursing homes.40-42
These issues bring up the question of quality versus quantity
in oral rehabilitation. It has been suggested that a ‘sociodental’
approach should be adopted in determining the need for den-
tures, rather than a normative treatment need, which is based
on missing teeth. A sociodental approach will involve consid-
ering both the normative needs as well as the perceived benefits
and oral health behaviors.43 While the literature indicates lower
mortality with a higher number of teeth, there is also subtan-
Journal of Prosthodontics 00 (2018) 1–10 
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Rehabilitation of Edentulism and Mortality
tial debate about the importance of the quality of dentition.
Awano et al found a 3.9 times increased risk for pneumonia
mortality in patients 80 years and older among those who had
10 or more teeth with a periodontal pocket probing depth of
>4 mm as compared to those without periodontal pockets.44 If
the remaining teeth are in poor periodontal health, they might
act as a source of infection rather than being of any functional
or survival benefit.45
Clearly, the nature of the oral and systemic and psycho-
logical interactions prevent cause and effect conclusions from
presently available data. At this time, any possible link between
complete denture wearing and increased longevity can only be
considered associative. If edentulous individuals with complete
dentures do have an advantage over noncomplete denture wear-
ers, this might be an important prognostic factor for longevity of
the geriatric population.46 However, a complete understanding
of possible benefits of complete dentures will need to consider
various functional aspects of wearing a denture, including adap-
tation to dentures.36 In contrast, because denture wearing might
be associated with some risks as noted above, there needs to be
a careful balancing of the benefits and risks from the patient’s
perspective, so that the treatment decisions can be optimized
on an individual patient basis.
It has been shown that implant-supported dentures have im-
proved patient satisfaction and performance compared to con-
ventional dentures.47,48 In this review, data on the type of pros-
thesis was unavailable. This is an important consideration for
resource-constrained communities, because even access to con-
ventional dentures might be challenging for most people in
those communities.48
Given the intriguing evidence supporting the beneficial ef-
fects of wearing complete dentures, clinical trials including an
arm without complete dentures might not be ethical. Also, since
delivering a complete denture to edentulous patients is a stan-
dard treatment approach, it may be challenging to gain a suffi-
cient sample size without a huge community-based recruitment
effort. Clearly, socioeconomic considerations are important, as
those without complete dentures may have been forced down
this path by socioeconomic constraints.
If prosthetic rehabilitation with a complete denture is as-
sociated with lower mortality in certain situations, how can a
desirable level of quality of the prosthesis and equal access to
that quality be ensured? With the increasing numbers of Baby
Boomers reaching old age, there is an impending increase in
the number of edentulous individuals in need of nursing staff to
take care of prostheses and maintain hygiene. Their adequate
training and time is crucial to ensure appropriate dental pros-
thesis care. A study in two nursing homes in Istanbul found
that 80% of the residents 55 years or older were denture wear-
ers, and over 60% reported problems with all the questions in
a questionnaire to assess oral complaints. Specifically, people
highlighted complaints related to eating and social communi-
cation, and mentioned that these problems adversely influence
their QoL.34
With a high prevalence of challenges that complete denture
wearers are very likely to face, such as short- and long-term
physical, social, and psychological problems,34 it might be an
intriguing question to ask if alternatives are better. For policy
or clinical-level implications, appropriate risk assessment or
7
Rehabilitation of Edentulism and Mortality
weighing of benefits versus costs will be important for each
eligible patient to inform the best treatment decisions. These
decisions will also be influenced by an individual’s esthetic de-
sires that might conflict with maintaining adequate oral health.
These arguments and questions will need to be interpreted in
the light of the appropriateness of mortality as the primary out-
come of interest. QoL might be a more valuable outcome than
mortality for many elderly individuals who often require com-
plete dentures. Also, future research as well as related clinical
decisions must consider the functional quality of the prosthe-
sis as well the ability of denture wearers and caregivers to
adequately maintain their prostheses for them to provide the
expected health benefits. For future policy and clinical prac-
tice purposes, it is crucial to balance patients’ esthetic needs,
QoL, and nutritional requirements, with factors such as ability
to maintain oral hygiene with dentures, functional effectiveness
of dentures, and economical and social challenges of wearing
dentures.
Conclusions
Despite complete dentures being a standard of care for eden-
tulous individuals there is a paucity of information available
regarding the impact of complete dentures on mortality. In this
review, an analysis of limited grey data indicated that, over-
all, fewer edentulous individuals who are wearing a complete
denture die over follow-up years compared to edentulous in-
dividuals who are not wearing complete dentures. While these
findings are consistent with the research that shows tooth loss
being associated with higher mortality, and not wearing den-
tures being associated with poor QoL and higher morbidity,
several key methodological limitations such as small sample
sizes, inability to adjust for confounders, and short follow-up
times prevent definite conclusions regarding a relationship be-
tween prosthetic rehabilitation and mortality among edentulous
individuals.
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Appendix A: Email Draft for requesting
data and results from authors relevant
to the research question of this
systematic review
Dear Dr. xxx
Hope this email finds you well.
I am Dr. Avni Gupta, BDS MPH and I work at Harvard Med-
ical School affiliate hospital, Brigham and Women’s Hospital
in Boston, USA.
I along with my senior author Dr. Sreenivas Koka, DDS MS
PhD MBA FAP FACD are conducting a systematic review to
study association between tooth rehabilitation in completely
edentulous patients and mortality. Dr. Koka is a Clinical Pro-
fessor in Advanced Prosthodontics at Loma Linda University
and Lecturer at University of California Los Angeles, USA.
In our systematic literature search, we identified your paper
titled “xxx”. It was very fascinating to read your great research
paper which is so closely relevant to our interest area.
We are contacting you because we found the paper to be
eligible for inclusion in our review if we can identify, the mor-
tality difference between, completely edentulous (i.e 0 teeth in
both jaws) people who were wearing full dentures, and those
completely edentulous who were not wearing full dentures.
From the descriptive data presented in the paper, it seems that
you collected information on complete edentulous state and full
denture use, however specific associations of these groups with
mortality have not been presented in Results. Since our review
is focused on completely edentulous in both jaws, we would
like to request you, if possible, to provide us with these results
in your sample- i.e mortality in patients with 0 teeth at base-
line who were using full dentures compared to mortality
in patients who had 0 teeth at baseline and were not us-
ing dentures. This analysis would involve a subset analysis on
those who were edentulous (with no teeth), categorizing these
people into, full denture wearers and not full denture wearers;
thereafter comparing mortality in these 2 categories.
We will appreciate your time into addressing our request.
With this data we would be able to include your very important
research findings in our review.
Please feel free to let us know if you have additional questions
or concerns.
Will look forward to hearing from you on this.
9
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Rehabilitation of Edentulism and Mortality

Appendix B: Quality appraisal of included studies using Newcastle-Ottawa Scale

(Each ∗ indicates 1 point on the scale)

COHORT STUDIES

Author, year Selection Comparability Outcome

(2) Selection of
(1) Represen- nonexposed
tativeness cohort
Paganini et al, 2011 ∗ ∗
Ajwani et al, 2003 ∗ ∗
Ansai et al, 2010 ∗ ∗
Saarela et al, 2014 ∗ ∗
Hayasaka et al, 2013 ∗ ∗
(4) Demonstration that
outcome of interest was (1) Comparability of (1) (2) Was follow-up
(3) Ascertainment not present at the start of cohorts on the basis Assessment long enough for (3) Adequacy of follow-up
of exposure study of design or analysis of outcome outcome to appear of cohorts
∗ ∗ ∗
∗ ∗ ∗ ∗
∗ ∗ ∗ ∗
∗ ∗ ∗ ∗ ∗
∗ ∗∗ ∗ ∗

Journal of Prosthodontics 00 (2018) 1–10 

Gupta et al

C 2018 by the American College of Prosthodontists