A 64-year-old requesting clearance of all remaining teeth: risk assessment and strategic abutment decisions
A 64-year-old retired teacher is referred to the prosthodontic clinic by his general dentist, asking to have 'everything out and new dentures made'. He has type 2 diabetes (HbA1c 8.9% last month), hypertension managed with amlodipine, and chronic low back pain for which he takes ibuprofen 400 mg three times daily. He smoked 30 pack-years and stopped five years ago. He has a marked gag reflex and a shallow maxillary labial vestibule. Thirteen teeth remain. Maxillary canines 13 and 23 carry 15-year-old metal-ceramic crowns with recurrent caries and roughly 2 mm of ferrule; 12, 11, 21 and 22 have 4 mm of attrition with exposed dentine. There is a 5 mm localised probing depth on the distal of 13. In the mandible, 31 to 42 remain with 30% horizontal bone loss; 45, 46 and 47 are missing, 44 is mobile grade I, and 37 has a vertical root fracture with a draining sinus. Bitewing radiographs show three additional teeth with recurrent caries and no other periapical pathology.
1. Which findings change the prognosis of the plan the patient has requested, and what would you do about each before any definitive treatment?
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The teeth are not the main problem
1. Glycaemic control. An HbA1c of 8.9% is above the threshold at which most units defer elective surgery (commonly quoted as about 7.5-8%). It raises post-extraction infection risk and, if implants enter the plan, osseointegration failure. Refer to his physician, defer elective surgery, and meanwhile complete non-surgical periodontal therapy, caries control and oral hygiene instruction.
2. Medication and saliva. Chronic ibuprofen plus hypertension means checking renal function before prescribing anything further. Amlodipine is a recognised cause of gingival overgrowth and of reduced salivary flow; ask specifically about dryness and examine the mucosa. Low saliva changes caries risk, denture retention and candidiasis risk, and would make a conventional maxillary denture even less comfortable.
3. Gag reflex plus a shallow labial vestibule. These are the strongest single argument against the plan he has requested. Together they compromise border seal, extension and tolerance of a conventional maxillary complete denture. They justify discussing an implant-assisted or tooth-supported overdenture rather than accepting a complete denture by default.
4. Active periodontal disease on 13. The 5 mm distal pocket must be treated and re-assessed before any impression; a prosthesis made over untreated periodontitis will simply lose its abutments.
Only after these are addressed can the tooth-by-tooth decisions be made with the patient.
2. Which of the remaining teeth would you retain and which would you extract? Explain the reasoning behind the ferrule and probing depth findings on 13, and the role of 44.
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Extract
- 37: vertical root fracture with a draining sinus has no predictable restorative option; the tract and bone loss would sit beneath a distal extension base.
Retain, subject to re-assessment
- 44: it is the only terminal abutment for a Kennedy Class II base. Grade I mobility with a 5 mm mesial pocket is not an automatic extraction, but it must be re-assessed after scaling and root planing. If the pocket resolves to 3 mm or less with no furcation involvement, retain it and prepare a rest seat and guide plane. If it stays at 5 mm or more with bleeding, plan the prosthesis knowing the base may convert to a free-end saddle and warn the patient.
- 13 and 23: remove the crowns and excavate caries before deciding. Two millimetres of ferrule is at the accepted minimum (about 1.5-2 mm circumferential). The 5 mm distal pocket on 13 indicates localised bone loss that will worsen once the crown is removed. Their strategic value is high: canines as overdenture abutments preserve proprioception and alveolar bone and provide retention where a shallow vestibule cannot. Retain if they remain restorable after caries removal; extract if the ferrule is lost.
- 11, 12, 21, 22: 4 mm of wear with exposed dentine. Check vitality and whether wear is still active. If restorable they can serve as overdenture or crown abutments; do not extract sound teeth simply because a denture was requested.
3. How would you structure the consent conversation and the transitional phase so that the patient can make a genuine choice?
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Separate the request from the diagnosis
Explain in plain language what the examination showed: generalised bone loss, several unrestorable teeth, active caries, poor glycaemic control, and anatomical features that make an upper denture difficult to retain.
Present at least three real options
- Conventional maxillary complete denture plus mandibular partial denture after extractions. Cheapest and quickest, but with his gag reflex and shallow vestibule the prognosis for upper retention and comfort is guarded, and it will not restore chewing like teeth.
- Maxillary overdenture retained by 13 and 23, or by two to four implants if bone permits, with a mandibular partial denture.
- Fixed implant-supported maxillary prosthesis if the CT shows adequate bone - mention it, but note the cost and the HbA1c issue.
Be explicit that no prosthesis restores normal sensation, that further surgery may be needed around 13, and that diabetes control is a condition of treatment.
Transitional phase
Extractions with an immediate denture where indicated, tissue conditioning, a three to six month healing period, then reline or definitive prostheses. Stage payments against stages of treatment.
Documentation
Record the options given, the patient's choice, and any option he declined, with his signature. Agree review intervals and the criteria for success (comfort, function, appearance) before treatment starts.