Over the past few decades, the global population’s average age is rapidly increasing. One of the consequences of this ageing demographic is a continued high prevalence of edentulism.

Being edentulous

Edentulism is associated with a number of health problems: poorer nutrition, higher morbidity and earlier mortality, along with greater risk of cognitive disorders and dementia (Batty et al., 2013). The author stated that these problems are accompanied by higher medical expenses that can be correlated with the number of remaining teeth: the fewer teeth are left, the higher the medical bill. Edentulism also influences patients’ eating habits and their lifestyle.

What do elderly, edentulous patients think of dental prostheses and implant treatment?

The things that elderly patients value the most in their conventional dentures are: the ability to eat and talk; comfort and stability; and aesthetics. As for implant treatment, what worries them most is: cost, pain, and potential complications. Elderly patients tend to have a feeling of ‘fragility’ regarding implant treatment. In fact, there are a number of elderly patients who do not want to have implants, even though they may improve their situation. This topic is covered in the ‘Refuser Study’ (Ellis 2011).

Many of these patients are not happy with their existing conventional dentures. However, over the years, they began to feel more vulnerable or that their gums and bones are too weak, and that implant treatment brings more risks than benefits. In these cases, practitioners should carefully explain the suggested procedures and their benefits to try to assuage their fears.

Mandibular implant-supported prostheses. Think they’re all the same?

A study was carried out to evaluate the quality of life in patients treated with either fixed or removable prostheses on 4–6 implants (de Grandmont et al., 1994). No significant differences were found in terms of overall satisfaction, ability to eat/speak and aesthetics (regardless of whether the prosthesis was fixed or was a bar overdenture). Patients reported that the fixed prostheses were more stable, allowing better eating, but the removable one was more aesthetic and easier to clean (Feine et al., 1994).

However, there are significant differences in the aforementioned indicators between lower overdentures on two implants and conventional complete prostheses (Thomason 2003). Prostheses on two implants usually experience some degree of rotation, which can affect the patient’s function. To this end, two factors must be taken into account: the height of the alveolar flange; and the position of the incisors with respect to the alveolar flange. The more anterior the incisors are positioned (with respect to the flange), the more rotation there is (Kimoto et al., 2009).

There are numerous clinical studies involving narrow-diameter implants (<3 mm) supporting lower overdentures. These studies show that narrow implants can behave the same way as those with conventional diameters. Other studies have shown that the quality of life and satisfaction levels of patients with lower overdentures on one conventional diameter implant is similar to those with overdentures on two implants. The speaker concluded with a general rule for treating older patients: the poorer their overall health, the simpler the treatment should be.

Life expectancy has increased dramatically in the past few decades. In our modern societies, people age with higher levels of physical functionality, active lifestyles and social inclusion. Along with this, their oral health becomes even more important.

Modern ‘active’ ageing has no place for edentulousness

Elderly patients have more persisting teeth, but few are intact. With increasing age, the risk of disease and disability rises. This means it is more difficult for many to maintain good oral hygiene and regularly attend dental appointments. These factors lead to impaired oral health to the point that the more persisting teeth the patient has, the bigger the risk of oral disease. This is called the ‘dental paradox’.

The more persisting teeth, the greater the risk of oral disease

A number of health programmes have been put in place for elderly patients to preserve more of their teeth into old age. The World Health Organisation (WHO) has set the objective of at least 20 teeth per person in the elderly. Of course, the way we replace lost teeth is also changing. The differences in oral health are more pronounced in elderly people, and are more related to their general health status, general limitations, gender and socioeconomic factors. The prevalence of caries in elderly dependents who cannot visit the dentist is much higher[1].

Inflamm-ageing?

Inflamm-ageing describes the increase in the bod’s pro-inflammatory status with advancing age. As age increases, so does inflammation. For elderly people, chronic low-grade inflammation develops (probably due to up-regulation of the inflammatory response), accelerating the biological ageing. Inability to maintain proper oral hygiene, together with progression of chronic periodontitis and greater fragility in the mucosa, in an impaired immune system scenario, all leads to a vicious pathologic feedback cycle between oral inflammation and many age-related diseases, like Alzheimer, atherosclerosis, type-2 diabetes and chronic heart diseases.

Poor dental status and chewing deficiencies associated with cognitive decline

Not all persisting teeth in elderly patients have the same value. Anterior teeth rank highly in the OHRQoL index (oral health related quality of life), whereas posterior teeth are more useful for chewing. According to a recent Swedish study, about 50% of conventional prostheses are in poor condition and have not been adjusted in a long time (Lantto et al., 2018). Chewing function requires a sufficient number of teeth free of disease and in occlusal contact, or a well-fitting prosthesis. Nutrition is usually a challenge for the elderly, and it should be noted that cognitive function has also been shown to correlate with a well-preserved chewing function (Lexomboon et al., 2012, Kossioni et al., 2018).

Dry mouth: adverse drug event and major cause of discomfort

Despite recent measures to control drug prescription, there has been a notable increase in the intake of drugs in older people. Hyposalivation has been shown to increase with the number of medications being taken. Another side-effect of numerous medications is oral dryness or xerostomia, a condition that severely impacts patient well-being. The speaker explained that oral dryness paves the way for dental caries, dysgeusia, oral mucosal soreness and oral candidiasis. Dry mouth is primarily caused by drugs used to combat incontinence, followed by antidepressants and psycholeptics (Tan 2018).

Dysphagia, aspiration pneumonia, oral hygiene and risk

Dysphagia is a common problem among elderly patients who are in care or who have been institutionalised. It can lead to aspiration pneumonia. This is because large amounts of plaque and a considerable bacterial load can usually be found in older patients’ mouths due to their inability to adequately maintain their oral hygiene. Nurse assistance to help with this, and no nocturnal use of dentures can reduce mortality from aspiration pneumonia (Müller 2015).

The speaker stated that improving oral care can positively affect general health in the elderly, and vice versa.

Following a diagnosis of dementia, oral health sharply decreases (Ástvaldsdóttir 2018). Proper oral hygiene can not only improve patients’ oral health, but can also have a positive effect on their health in general. Therefore, oral hygiene programmes for elderly patients who are dependent on care should be implemented, and caregivers should be properly educated and motivated.

[1] Data from Sweden. National register SkaPa www.skapareg.se and Oral care AB www.oralcare.se

Dementia is a condition that alters memory and hinders the individual’s ability to maintain social relations. It generally involves at least one of the following symptoms: language disorders, apraxia, cognitive and motor dysfunction. The time between initial diagnosis and patient death can vary between 8 and 12 years on average, depending on age and general health status[2].

[2] American Psychiatric Association 1994

Dementia: a growing challenge for public health

As life expectancy increases, as does the prevalence of dementia. Patients with dementia are more likely to have caries, periodontal disease and impaired oral hygiene (Syrjälä et al., 2010). Additionally, these patients tend to have a diet with higher levels of sugars, have lower levels of salivation, motor function and swallowing problems, habitual sucking motions, impaired chewing function and difficulties in managing their prostheses (especially implant-supported prostheses).

Furthermore, patients with dementia are less likely to co-operate, may refuse to brush their teeth or let them be brushed for them. This makes it difficult to examine or treat them. It is therefore crucial to follow a treatment plan specific to patients with severe cognitive disorders, emphasising prevention rather than treatment (Niessen et al., 1985).

Peri-implantitis is found more and more in elderly patients

The incidence of peri-implantitis in elderly patients is increasing. This is because implants are now being placed at more advanced ages, and patients who have received implants are living longer. Some studies have shown that the rate of implant loss in patients between the ages of 65 and 80 are similar to that of younger age groups (Srinivasan et al., 2017; Bertl et al., 2019), but the inflammatory response is stronger and less reversible. This points to a crucial question: how do we handle implant-reconstructions after the onset of dementia?

Immunosenescence

The immune system weakens with age, leading to greater susceptibility to infection, neoplasia and autoimmunity (Ebersole 2016). This aging of the immune system, or ‘immunosenescence’, results in a pro-inflammatory status. When this ‘inflamm-ageing’ affects the immune cells in the periodontium, it worsens the biological response to the oral bacterial burden.

Peri-implantitis and patients with dementia

We have only anecdotal clinical experience. However, millions of implants have already been placed, and practitioners and researchers have a responsibility to follow them throughout the patient’s life, and to collect enough clinical data to help patients take care of them when they no longer can.

The ‘back-off’ strategy: de-sophistication of treatments

Dementia causes motor coordination to deteriorate. Patients with dementia usually cannot wear their prostheses over time, as they are less able to put them in or use them. The type of prosthesis should therefore be adapted to the patient’s dexterity, which changes continually as the condition progresses. Prothesis retention should be adjusted to the maximum that patients can handle for themselves. Fixed prostheses should be changed to removable prostheses, and bar overdentures changed to locators, which are easier to clean. These can be changed at a later date to ball attachments and magnets as the patient’s abilities deteriorate. Finally, implants can be made ‘dormant’ by placing healing caps and readjusting the denture base.

The speaker outlined an oral health care plan for dementia:

• Prevent technical failures by properly selecting the components and prothesis design
• Optimise prosthesis self-cleaning morphology, and motivate and instruct caregivers in providing assisted oral hygiene
• Provide adequate retention to facilitate chewing efficiency and to ease handling by the patient (according to the ‘back-off’ strategy)
• Anticipate the patient’s future deterioration and potential changes which may be needed when oral hygiene compliance becomes difficult