TOOTH LOSS Tooth loss, especially total tooth loss or edentulism, is the dental equivalent of death.

Tooth loss diminishes the quality of life, often substantially, and tooth loss is also related to poorer general health. If retaining teeth were just a matter of preventing disease conditions then the issue would be reasonably straightforward, but it is more complicated than that. Although loss of teeth is an end product of oral disease, it is also a reflection of patient and dentist attitudes, the dentist-patient relationship, the availability and accessibility of care, and the prevailing philosophies of care. The historical picture For centuries, tooth loss was considered an inevitable part of the human condition and was thus generally accepted with resignation. Long before dentistry emerged as a true profession the tooth-puller was a necessary part of most cultures, sometimes based in a village and sometimes plying a traveling trade. As the profession of dentistry evolved during the nineteenth century, much of the work of dentists was still devoted to tooth extraction. Caries was rampant at this time, restorative techniques crude and painful, prevention unknown. As a result, people expected to lose teeth and dentists expected to extract them. Awful oral health status marked by extensive loss of teeth extended well into the twentieth century in high-income countries. The oral condition of the millions drafted into the armies of many countries during World War I (1914-18) was generally terrible. The response of authorities was to extract more teeth, so that troops preparing to run through each other would not be bothered by toothache. By the beginning of the twenty-first century tooth retention was much improved in all the high-income nations. Change came about with improvements in restorative dentistry (especially the development of the air-turbine dental engine in the late 1950s), increasing affluence and its accompanying positive attitudes toward tooth retention, and significant research advances in preventing oral diseases. In that latter context, the arrival of water fluoridation was probably the most profound influence, because it demonstrated to individuals and their families that dental caries and subsequent tooth loss were not inevitable.

Edentulism Edentulism continues to decline steadily in the United Statest and in other economically developed nations. The Table shows the proportion of persons ages 65 and over who are edentulous in 10 countries, along with the national income category for each country. Data indicate that edentulisrn has declined consistently in each age-group with each succeeding survey. The relative decline in edentulism has been sharpest in the younger age-groups, which suggests that edentulisrn will become even rarer as today's younger cohorts grow older.

'As defined by the World Bank in World Bank Group, Data and statistics, Country groups, website: http://www.worldbank. org/data/countryclass/classgroups.htm. Accessed December 19, 2003.

Country Canada Finland Slovenia United Kingdom United States Malaysia Albania Egypt Thailand Indonesia

Percent Edentulous 58 41 16 46 24 57 69 7 16 24

National Income Category' High High High High High Upper middle Lower middle Lower middle Lower middle Low

The importance of non-disease factors in edentulism emerge. the total tooth loss was one of the eight indicators of oral health. Historically, there has been a higher degree of edentulism among women than among men, and women have tended to become edentulous at a younger age. These historical gender differences are not easy to explain; many think they reflected dentist-patient relationships more than disease occurrence. Data from the 1980s and later, however, suggest that these gender differences are fading, In the United States, there has historically been a greater degree of edentulism among whites than among African-Americans, perhaps because whites have traditionally had better access to dental care and thus were at greater risk of having teeth extracted. Like gender differences, however, differences between the races have become less distinct since the 1980s, perhaps because edentulism overall is becoming so uncommon among younger cohorts. Edentulism is tightly related to socioeconomic status (SES). These SES-related differences are found consistently in many societies and probably reflect expectations and health attitudes at least as much as occurrence of oral diseases. Data show that the strongest risk indicator for edentulism in employed adults (other than age) was SES: 10.2% of those with fewer than 8 years of education were edentulous compared to 1.6% of those with 13 or more years. Edentulous people have also been found to have more risk factors for cardiovascular disease than dentate people, and it should not be surprising that older people in good health enjoy greater tooth retention than do people of the same age in poor health. Partial tooth loss Like edentulism, the extent of partial tooth loss has been diminishing as caries comes under control, more and better treatment becomes available, and attitudes toward tooth retention improve with increasing affluence. In contrast to edentulism, in which attitudes are a major factor in a person's decision to have all the teeth removed, partial tooth loss appears to be more closely related to oral disease. For the same reasons as found for edentulism, the sharpest improvement in reducing tooth loss is evident in younger age-groups.

The change is naturally not as sharp among adults, because those adults who lost first molars to caries when they were young will continue to influence the data for a while yet. As was seen with edentulism, income (which reflects SES) is an important risk indicator for tooth loss. Also as with edentulism, gender differences in partial tooth loss have diminished Longitudinal studies to identify risk factors that lead to tooth loss, either total or partial, have not been very successful. Smoking, not surprisingly, has been identified as a risk indicator, and early tooth loss was found to be a strong predictor of subsequent edentulism. SES in early life is also a demonstrated predictor of tooth loss in early adulthood. Reasons for tooth loss Conventional wisdom for many years was that caries was the main reason for tooth loss before age 35 and periodontal disease the main reason after age 35. This belief was based on some ancient and rather dubious data. The older of these reports stated that "periclasia" was the main reason for tooth loss "after maturity." Even as late as 1978 there was a report that 8%-10% of teeth are lost to periodontal disease by age 40 and that such loss increases rapidly after that age. Whether or not such historical views were accurate, the picture has changed considerably. From around the mid-1980s, studies in a number of countries and among different types of populations have been consistent in finding that caries is the principal cause of tooth loss at most ages, with the possible exception of the oldest (i.e., persons over 80 years). Data on which these conclusions were based came from surveys of practitioners, reviews of dental records, and examinee questioning or diagnosis during survey examinations. It is interesting to note that data were published as long ago as 1944 showing that most teeth were extracted for caries. Dental care and tooth loss At the risk of stating the obvious, it is worth reminding ourselves that the main reason teeth are lost is because dentists extract them. To expand on that profound thought, "periodontal disease" may have been the chief reason for extraction in the era of "focal infection", because no doubt many teeth with no more than severe gingivitis were extracted in the name of periodontal disease. The reasons given for the extractions were honest, but it seems likely that in many cases the disease was probably not what today would be considered severe. With the better understanding of periodontal diseases now prevailing, most such extractions have now ended. "There are two major reasons for continuing improvement in tooth retention: (1) the modern preventive philosophy governing dental treatment, so that most present-day dentists extract teeth only when there is no practical alternative; and (2) positive attitudes among today's adults, both younger and older. Tooth loss for many of them is like smoking in the sense that both are simply unacceptable. In summary, tooth retention is improving because of better prevention and control of the oral diseases, more positive attitudes toward tooth retention, and more conservative dental treatment philosophies. The result is that the proportion of people who are edentulous will continue to diminish until it bottoms out, probably at around 3%-4% of

the population. Dentate persons will continue to retain more teeth as extractions for all reasons become less common. The greater retention of teeth will continue despite the aging of society, so the older dentate patient will become more and more common in dental practice. Tooth Loss in Jordan Study 1, Adults Authors Hamasha AA. Sasa I. Al-Qudah M. Institution Department of Preventive Dentistry, Faculty of Dentistry, Jordan University of Science and Technology. hadihamasha@hotmail.com Title Risk indicators associated with tooth loss in Jordanian adults. Source Community Dentistry & Oral Epidemiology. 28(1):67-72, 2000 Feb. Abstract OBJECTIVES: The purpose of this study was to evaluate the risk indicators of tooth loss in Jordanian adults. METHODS: A sample of 509 Jordanian adults was randomly selected. The subjects were interviewed regarding demographics, social economic status, smoking habits, and oral hygiene practices and then clinically examined by a single examiner. Multiple regression analysis was performed to estimate the simultaneous impact of risk indicators on tooth loss. RESULTS: The subjects' mean age was 42.6 years with an average of 20.9 teeth remaining per person. The overall educational level of the subjects was low. More than 40% reported not brushing their teeth regularly and 56% had had no professional teeth cleaning during the last year. Monthly family income averaged JOD 231, and about a third of the subjects were smokers. The mean number of remaining teeth decreased significantly with age. Smokers, those who brushed irregularly, and those who had not had professional teeth cleaning in the last year had significantly fewer remaining teeth. Men also had significantly fewer remaining teeth. Education and income were also significantly associated with the number of remaining teeth. Age, income, brushing, prophylaxis, and gender collectively explain 75.1% of the variance in the number of remaining teeth. CONCLUSION: Modification of non-disease independent factors could reduce tooth loss and improve oral health in Jordanians. Study 2, adults Authors Sayegh A. Hilow H. Bedi R. Institution Department of Oral Surgery, Oral Medicine and Periodontology, Faculty of Dentistry/University of Jordan, Amman, Jordan. Title Pattern of tooth loss in recipients of free dental treatment at the University Hospital of Amman, Jordan.

Source Journal of Oral Rehabilitation. 31(2):124-30, 2004 Feb. Abstract The aim of this study is to document reasons for tooth loss in disadvantaged Jordanians who seek free dental care at the University Hospital/Dental Clinics. A 4-year (1998-2001) prospective study was undertaken involving 2200 randomly selected patients from this subpopulation. Of their 3069 lost teeth, 46.9% were lost due to caries and its sequel; 18% were lost because of periodontal disease; 8% were lost for a combination of caries and periodontal disease; 19.4% for pre-prosthetic reasons; 4% for orthodontic reasons; 2.8% for eruption problems and 0.7% due to trauma. Logistic regression analysis for reasons of tooth loss in this sector revealed that caries and its sequel was the predominant cause of tooth loss in patients <or=40 years of age whereas periodontal extractions were predominant for the above 40-year-old group. In addition, the most frequently extracted teeth, due to caries, were lower first and second molars while lower incisors were most commonly extracted for periodontal disease. Premolars were extracted for orthodontic reasons, upper incisors for trauma, third molars for eruption problems and canines for pre-prosthetic reasons. In conclusion, dental caries was the main reason for removal of teeth in adults attending the University of Jordan free dental casualty clinic. Therefore, in order to reduce the rate of dental extractions in this sector of the Jordanian population, efforts should focus on prevention and treatment of caries. Efforts should also be made to change the values and beliefs of this sector towards the importance of natural dentition. Study 3, Adults Authors Quteish Taani DS. Institution Division of Periodontics, Department of Preventive Dentistry, Faculty of Dentistry, Jordan University of Science and Technology, Irbid, Jordan. dtaani@hotmail.com Title Periodontal reasons for tooth extraction in an adult population in Jordan. Source Journal of Oral Rehabilitation. 30(1):110-2, 2003 Jan. Abstract This survey studies the reasons for periodontal extraction of permanent teeth in an adult Jordanian population. A random sample of 30 general dental practitioners (GDPs) from a list of 300 GDPs (1:10) was contacted. Of these, the 26 dentists who participated in this study were asked to record teeth extracted and give reasons for extraction. Personal and demographic information and clinical details were obtained from 898 patients aged from 20 to 60 years. A total of 1,098 teeth were extracted during the 3month study period. The results of this study revealed that dental caries (56.4% overall) was the main reason for tooth extraction, especially in 20-39 year olds. Periodontal disease (23.4% overall) was the next most frequent indication for extraction and became the commonest cause of tooth extraction in patients aged 40 years or more. Other reasons for tooth loss accounted for only 20.2% of the series. Advanced

periodontal disease represented by pocketing were the dominant pathology when tooth loss occurred as the result of periodontal disease. As far as the type of tooth was concerned, the most frequently extracted teeth were molars followed by premolars, regardless of whether their loss was the result of the caries or the periodontal disease. This study suggests that caries and its consequences are responsible for more tooth loss in patients less than 40 years of age while extraction because of periodontal problems increases with age, and more commonly related to pocketing. Study 4, Adults Authors Haddad I. Haddadin K. Jebrin S. Ma'ani M. Yassin O. Title Reasons for extraction of permanent teeth in Jordan. Source International Dental Journal. 49(6):343-6, 1999 Dec. Abstract This investigation was carried out to determine the reasons for extraction of permanent teeth in Jordan. A random sample of 200 Jordanian Dentists (1:10) were asked to record reasons for the extraction of permanent teeth during a two week period. Of the 139 dentists responding, only 97 dentists extracted teeth during the study period. A total of 934 teeth were extracted from 582 patients, of these 33.4 per cent were extracted for periodontal disease, and 27.6 per cent because of caries and its sequelae. The study suggests caries and its consequences affected tooth loss throughout life while the rate of tooth loss due to periodontal disease increases with age. Publication Type Journal Article. Study 5, children Authors Albashaireh Z. al-Hadi Hamasha A. Institution Department of Restorative Dentistry, Faculty of Dentistry, Jordan University of Science and Technology, PO Box 3030, Irbid 22110, Jordan. Title Prevalence of dental caries in 12-13-year-old Jordanian students. Source SADJ. 57(3):89-91, 2002 Mar. Abstract The purpose of this study was to determine the caries experience of 12-13-year-old 6th grade students in Jordan. A total of 694 students were selected randomly from a list of schools teaching 6th grade students in Irbid, Jordan. The data were collected by interview and clinical examination performed by two examiners. Dental examinations were done by using dental mirrors and probes under artificial light in classrooms and the diagnosis of dental caries was made by the criteria recommended by the World Health

Organisation (1987). On average students had 24.4 sound teeth, 2.3 decayed teeth (D), 0.05 missing teeth (M) and 0.16 filled teeth (F). The mean DMFT index was 2.51. The D represents 92% of the DMF cases. Of the students examined 188 were caries free (27.1%). Of the 19,432 permanent teeth examined the highest frequency of dental caries (61%) and fillings (77%) was found in first molars, and these were the most commonly missing teeth (67%). Second molars and second premolars had the second and third highest frequencies respectively, whereas incisors and canines were the least affected teeth (< 2%).