A Panacea for the Edentulous Predicament?

My recurrent July anxiety state is elicited by a flood of IJP submissions-authorial knee-jerk responses to our announcement that we close shop for the month of August. Preliminary reads of these preholiday submissions are not followed by immediate reviewing assignments. They are instead postponed until September to avoid intruding into the concluding phase of our reviewers' "exhausted loyalist" academic year. I concentrate instead on a preholiday stock-taking of my year's scholarly engagements. This may sound like overreach for one who actually retired from academic career timetables. But I continue to regard selected meeting attendances and organizational activities as relevant engagement for my editorial mandate; and the past 12 months were particularly enriching ones. The two 2012 IJP/Karlsruhe Workshops (Baden- Baden, Germany, in June and Beijing, China, in December) were gratifying examples of an international faculty's extraordinary cooperation and commitment, International College of Prosthodontists (ICP) endorsement, and invaluable support from Nobel Biocare and the Chinese Ministry of Education, respectively. These initiatives provide a unique educational clinical vision for Young Prosthodontic Educators and will undoubtedly continue to grow in stature and recognition. There are, inarguably, few comparable global educational initiatives that prioritize prudent patient-mediated needs as an integral part of managing the prosthodontic patient. October 2012 and June 2013 meetings in Toronto and New York City, respectively, offered the privilege of chairing both scientific committees with outstanding colleagues to rely on. We synergized with Nobel Biocare's exceptional international meeting organizational teams and largely adopted traditional lecture formats to focus on patient-mediated concerns in the context of the different therapeutic journeys that are undertaken in implant therapy. The huge audiences in attendance (over 750 in Toronto and 2,000 in New York City) were impressive endorsements of implant prosthodontics' global success trajectory since the original Toronto Conference in 1982, while reflecting somewhat different clinical agendas from the IJP/ Karlsruhe Workshop ones. In fact, a relative newcomer to the field might have come away from the clinical meetings with the conviction that traditional prosthodontic therapy is, indeed, passé. The narratives from both pairs of significantly different formats-equally scientifically robust and clinically relevant-increased my ambivalence about my discipline's stewardship of patient care. It is perhaps best summed up by posing the question: Has the template of traditional prosthodontic interventions been completely eclipsed by the advent of implant therapy? I will try to address this rather compelling question in future editorials via both personal and invited submissions, while initiating the necessary debate with preliminary thoughts about the edentulous predicament. The dental profession's overriding conceit that any form of tooth loss constitutes a disease that demands an intervention, may still be readily challenged in the context of our understanding the causes of teeth loss and its significance rather than in blanket justifications for routine restoration of function and esthetics. Nonetheless, the edentulous state is justifiably regarded as a serious personal predicament that has plagued humanity for hundreds of years and has been ascribed a range of adverse sociologic and health consequences. Since documented experience and research demonstrate impressive progress in materials sciences and clinical techniques, together with an emergent and profound understanding of masticatory function, the profession and surrogate practitioners have already provided a complete denture service that has, until recently, led the body replacement parts effort in the necessary pursuit of restored function and esthetics. And yet, predictably successful management of complete edentulism has never been claimed as a certainty given the harsh fact that time destroys rather than heals complete dentures' vulnerable supporting tissues, and that patients' responses to wearing dentures are often unpredictable. Brånemark's introduction of osseointegration dramatically influenced this concern; it ushered in an exciting scope for raising the management of edentulism to a new level of predictable quality. His work catalyzed new and enriched synergies between surgical and prosthodontic expertise while provoking new concerns regarding stewardship for patientmediated responsibilities and concerns. I readily acknowledge that the proliferation of surgical skills and techniques that are frequently accompanied (sometimes even driven) by professional and commercial ingenuity now offer dramatically improved treatment choices for edentulous patients. Yet, these approaches also resonate as an exercise in ambiguity for those of us instant converts to using one or more implants in the anterior zone of the edentulous mandible to address the majority of patients' denturewearing concerns. The risk here is that the old maxim "when all you have is a hammer, everything around looks like a nail" will prevail; and that the knee-jerk response of a freshly hammered surgical prescription will dominate the field of edentulism. And while this may very well prove to be an optimal management narrative for numerous edentulous patients, it is also grossly insensitive to suggest that complete dentures are no longer the answer for numerous patients who live in prosperous countries, let alone the many more that are not so lucky. There is, of course, a far larger issue here. Current professional pride in new treatment options still needs to be reconciled with the sort of long-term outcome results that engaged so many of us back in 1982 when the osseointegration genie first came out of the bottle. Our prosthodontic stewardship of the edentulous population cannot lose sight of the dramatic increase in life expectancy along with shifts in societal pyramids. Multimorbidity and treatment uncertainties in the elderly cohort are serious emerging concerns that cannot be ignored, irrespective of whether patients wear complete dentures or implant-supported alternatives. Moreover, the context of a continuum of implant treatment outcome management needs also demands cognizance of well-articulated and debated patient-mediated concerns. Ours remains the obligation to ensure that the brilliance of applied osseointegration does not succumb to a formulaic approach. And, above all, that it does not risk becoming an unavoidable and unnecessary burden for an aging edentulous population as well as an insurmountable challenge for our discipline.