Update in clinical procedures
Implant rehabilitation in older patients
Identifying the best treatment option
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.
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.
Batty GD et al. Oral disease in relation to future risk of dementia and cognitive decline: prospective cohort study based on the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified-Release Controlled Evaluation (ADVANCE) trial. Eur Psychiatry 2013;28(1):49-52.
de Grandmont et al. Within-subject comparisons of implant-supported mandibular prostheses: psychometric evaluation. J Dent Res 1994;73(5):1096-104.
Ellis et al. Refusal of implant supported mandibular overdentures by elderly patients. Gerodontology 2011;28(1):62-8.
Feine et al. Within-subject comparisons of implant-supported mandibular prostheses: choice of prosthesis. J Dent Res 1994;73(5):1105-11.
Kimoto et al. Rotational movements of mandibular two-implant overdentures. Clin Oral Implant Res 2009;20(8):838-43.
Thomason et al. Patient satisfaction with mandibular implant overdentures and conventional dentures 6 months after delivery. J Prosthodont 2003;16(5):467-73.
Peri-implantitis in elderly patients with dementia
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.
 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?
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
Bertl K, Ebner M, Knibbe M, Pandis N, Kuchler U, Ulm C, Stavropoulos A. How old is old for implant therapy in terms of early implant losses? J Clin Periodontol, 2019;46(12):1282-93.
Ebersole JL, Graves CL, Gonzalez OA, Dawson III D, Morford LA, Huja PE, Wallet, SM. Aging, inflammation, immunity and periodontal disease. Periodontology 2000 2016;72(1):54-75.
Niessen LC, Jones JA, Zocchi M, Gurian B. Dental care for the patient with Alzheimer’s Disease. J. Am Dent Ass 1985;100:207- 9.
Srinivasan M, Meyer S, Mombelli A, Müller F. Dental implants in the elderly population: a systematic review and meta-.analysis. Clin Oral Implant Res, 2017;28(8):920-30.
Syrjälä AMH, Ylöstalo P, Ruoppi P, Komulainen K, Hartikainen S, Sulkava R, Knuuttila M. Dementia and oral health among subjects aged 75 years or older. Gerodontology 2012;29(1):36.42.