The Pre-Terminal Dentition: Considering Dentures | PART 1

August 12, 2017 | by Dr Alex Fibishenko
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One dentist had a dilemma about his young patient who had numerous decayed teeth, and who asked him to remove all of her teeth (including some healthy teeth) and get dentures. The dentist refused and posted his dilemma to the wider professional dental community. Below is the dentist’s post on a professional platform:

After engaging many dentists around Australia, I was asked to comment and provide my view on this.

My reply,

Thank you guys for inviting my comments.

I recently did a lecture for the AOS on the Terminal Dentition, including this very topic.

Here’s what I think:

  • Firstly, I am unable to make a proper diagnosis or recommendations off the OPG alone, so my comments are limited by this;
  • Apart from the clinical or radiographic diagnosis of individual teeth, it is even more important to look at the bigger picture and take into account compounding factors such as skeletal discrepancies, the bite, crowding, aesthetic and functional expectations, budget, patient compliance, medication, diet, saliva, as well as psychological factors;
  • We need to listen to our patients, not only the voices in our own heads that prompt us to try and save every individual tooth irrespective of the bigger picture;
  • Every patient has instincts about their own teeth, and quite often those instincts are correct, …they had to deal with the situation their entire life whereas we get introduced to it for the first time at their initial appointment;
  • Our patients well know that as dentists we are capable of dental treatment, what they often want is a solution to their problems, not merely dental procedures;
  • This patient is convinced that she will be better off without her teeth, and refuses treatment to try and save her teeth. Unless the remaining teeth are in immaculate condition, and with no other compounding factors, where you could almost guarantee her a problem-free dental future, there is far lesser of a chance for your patient to be unhappy with you if you did what she wanted rather than what you want to do;
  • Though the dilemma here is not whether its worthwhile saving any individual teeth, but whether this patient understands the consequences of loosing all her teeth, especially at the young age of 25. She needs to be counseled and educated about dentures, and how this is likely to cause a significant deterioration in her quality of life;
  • The solution here might be clearance with immediate implant-supported prostheses, like All-On-4, which will address the patients desire to get rid of all of her teeth, and your and her mutual desires to give her function, aesthetics, quality of life, and overall satisfaction. This needs to be addressed within the context of various risks, as well as risks of alternative options such as perhaps individual implants and how these might look and function over time;

In medicine and dentistry we need to make tough decisions daily, for example, many women who have a 10% risk/predisposition to a certain breast cancer gene would elect to have total bilateral mastectomy to eliminate that risk and stay alive. In the absence of clinical finding of a tumor, is it inappropriate for the surgeon to undertake the mastectomy for these ladies? The same applies to the evaluation and decisions to extract teeth, …it must always be done within the context of the bigger picture.

BTW I reservedly agree with those who allude to appeasing the patient if we obtain informed consent, but “information” is a big part of this “informed” consent and as such, we need to be sure that we educate our patients and give them the relevant information to make their own decisions. For dentists who are not adequately experienced to know or understand the various factors, referral to an appropriately experienced clinician should be considered.

Dr. Alex Fibishenko


Oral Implantology & Reconstructive Dento-facial Surgery
Dental Surgeon in Self-Restricted Practice
Innovator of All-On-4 Plus ® & founder of All-On-4 Clinic

Dr Alex Fibishenko practices exclusively in Oral Implantology, Dento-Facial Surgery and Facial Aesthetics.

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