Review
Critical appraisal of evidence supporting the placement of dental implants in patients with neurodegenerative diseases Clovis Mariano Faggion Jr1,2 1
Department of Periodontology, Faculty of Dentistry, University of M€ unster, M€ unster, Germany; 2Department of Oral Sciences, Faculty of Dentistry, University of Otago, Dunedin, New Zealand
Gerodontology 2013; doi: 10.1111/ger.12100 Critical appraisal of evidence supporting the placement of dental implants in patients with neurodegenerative diseases Objective: To assess the available scientific evidence regarding the effectiveness and complications associated with using dental implants in patients with neurodegenerative diseases. Materials and Methods: PubMed, EMBASE, Biosis Citation Index, CINAHL, Web of Science and LILACS electronic databases were searched, with the last search performed on 20 May 2013. Reference lists of the included systematic reviews were manually reviewed. No restriction regarding the study design or publication language was applied for study inclusion. Only studies involving human subjects were included. In case randomised or other controlled trials were identified, methodological assessment of included studies was planned. Results: Fifty-eight potential papers were initially retrieved from the electronic databases. Eleven papers were finally included. No randomised controlled trial or other controlled trial was found. Eight papers were case reports and three were case series. The sample included three types of neurodegenerative diseases: dementia, Parkinson’s disease and Huntington’s disease. Generally, the reports showed improvements in chewing function and quality of life after the placement of implants and prostheses. Nevertheless, the follow-up time was typically short (≤12 months), and the overall sample size was small (N = 22 patients). Inclusion of studies without controls prevented a more robust methodological assessment from being performed. Conclusions: The results of the included reports suggest positive outcomes for dental implant use in patients with neurodegenerative diseases. Nevertheless, more robust studies, with better design and longer follow-ups, are needed to set strategies to prevent and treat potential complications in patients with neurodegenerative disorders treated with dental implants. Keywords: dental implants, neurodegenerative diseases, critical appraisal, geriatric dentistry. Accepted 30 October 2013
Introduction Neurodegenerative diseases (NDDs) are chronic and progressive conditions that debilitate people both psychologically and physically. There are more than 600 neurological disorders, with a high prevalence in the population. For example, more than 50 million North Americans are affected each year by NDDs1. Dementia, one of the most prevalent neurodegenerative disorders, affects 5.9–9.4% Europeans above 65 years of age2. In Europe, the prevalence of Parkinson’s disease (PD), another important neurodegenerative disorder, is 1280–1500 per 100 000 people older than
60 years3. Moreover, the incidence of diseases such as dementia continues to increase with age4. The more developed the disease progression, the more impaired the patient will be in terms of his or her cognitive and physical abilities. Thus, it might be expected that patients with NDDS will face problems in performing normal daily tasks. The placement of dental implants has become a recognised and well-established therapy for patients who have lost their teeth. High levels of survival and success are expected when implantsupported prostheses are used5,6. Like teeth, dental implants need frequent care and supervision to prevent plaque formation, inflammation and
© 2013 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd
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deterioration of tissues supporting the implants. Deposits in the form of plaque and calculus may put peri-implant tissue at risk of further deterioration. For example, in its later stages, peri-implantitis might require surgical implant removal. Patients with NDDs may have problems with performing daily procedures to avoid and eliminate plaque, such as toothbrushing and dental flossing. The objective of this study was to perform a critical appraisal of the literature on clinical outcomes, in terms of effectiveness and adverse events, regarding the placement of dental implants in patients with NDDs.
Materials and methods Outcome measures used in this appraisal The present critical appraisal was designed to generate a systematic overview of the literature regarding outcomes of the use of dental implants in patients with NDDs. Any outcome of effectiveness (e.g. implant survival or success) or adverse event (e.g. peri-implantitis) was reported. Inclusion and exclusion criteria Clinical studies on the treatment for oral conditions with dental implants in patients with NDDs were included. Randomised controlled trials (RCTs) and other controlled trials were intended
to be included. In the case that no evidence from high-hierarchic studies7 was found, studies of lower hierarchy would be included, such as retrospective/prospective cohort, case series and clinical reports. For the sake of simplicity, to be considered a case series, the report should involve more than one patient. Review studies or studies not involving humans were excluded from the present study. Definition of neurodegenerative diseases Neurodegenerative diseases were defined as ‘hereditary and sporadic conditions characterized by progressive nervous system dysfunction. These disorders are often associated with atrophy of the affected central or peripheral nervous system structures’ (MeSH database). Table 1 depicts the specific definitions of some NDDs covered in this appraisal. Literature search The PubMed, EMBASE, Biosis Citation Index, CINAHL, Web of Science and LILACS electronic databases were searched, with the last search performed on 20 May 2013. Reference lists of the included systematic reviews were manually reviewed. There was no language restriction. The detailed literature search, with the keywords and Boolean operators used, is depicted in Table 2.
Table 1 Definitionsa of neurodegenerative diseases reported in this review. Neurodegenerative disease Definition Dementia
Parkinson’s
Huntington′s
An acquired organic mental disorder with loss of intellectual abilities of sufficient severity to interfere with social or occupational functioning. The dysfunction is multifaceted and involves memory, behavior, personality, judgment, attention, spatial relations, language, abstract thought, and other executive functions. The intellectual decline is usually progressive, and initially spares the level of consciousness A progressive, degenerative neurologic disease characterized by a tremor that is maximal at rest, retropulsion (i.e. a tendency to fall backwards), rigidity, stooped posture, slowness of voluntary movements, and a masklike facial expression. Pathologic features include loss of melanin containing neurons in the substantia nigra and other pigmented nuclei of the brainstem. Lewy bodies are present in the substantia nigra and locus coeruleus but may also be found in a related condition (Lewy body disease, diffuse) characterized by dementia in combination with varying degrees of parkinsonism A familial disorder inherited as an autosomal dominant trait and characterized by the onset of progressive chorea and dementia in the fourth or fifth decade of life. Common initial manifestations include paranoia; poor impulse control; depression; hallucinations; and Delusions. Eventually intellectual impairment; loss of fine motor control; athetosis; and diffuse chorea involving axial and limb musculature develops, leading to a vegetative state within 10–15 years of disease onset. The juvenile variant has a more fulminant course including seizures; ataxia; dementia; and chorea
a
MeSH terms’ definition from PubMed. © 2013 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd
Dental implants and neurodegenerative diseases
Table 2 Search strategy in PubMed.
3
Studies included
14) (#12 AND #13) 13) (#3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11) 12) (#1 OR #2) 11) Lewy Body Disease 10) Spinocerebellar ataxia 9) Spinal Muscular Atrophy 8) Multiple System Atrophy 7) Motor Neuron Disease 6) Dementia OR sclerosis 5) Alzheimer OR Parkinson OR Huntington 4) degenerative nerve AND (disorders OR diseases) 3) neurodegenerative AND (disorders OR diseases) 2) peri-implantitis OR perimplantitis 1) (dental implants OR dental implant)
Of the 11 included papers, eight were case reports9–16 and three were case series (including two case series with three patients each)17–19. Seven reports9,10,12,13,16–18 were related to patients with PD, two reports11,15 were related to Huntington’s disease (HD), and two reports were related to dementia14,19. Initially, one case series20 on the placement of dental implants in patients with various systematic diseases and congenital defects (including one case of amyotrophic lateral sclerosis, a neurodegenerative disease) was included. However, this paper was excluded because the patient’s two implants failed during the healing phase, and the patient was excluded from the assessment. Table 3 depicts the detailed characteristics of the included reports.
Methodological assessment planned
Outcomes with dental implants
Included studies were organised by study design. Whenever possible, their methodological quality was evaluated by validated tools. In the case that RCTs were selected, the Risk of Bias Tool (RoB tool) would be used to assess the risk of bias. The RoB tool evaluates six domains: selection bias (random sequence generation and allocation concealment), performance bias (blinding of participants and personnel), detection bias (blinding of outcome assessment), attrition bias (incomplete outcome data), reporting bias (selective reporting) and other bias (other sources of bias)8. In the case that controlled clinical trials or cohorts (with a control group of patients without neurodegenerative disease) were included, whenever possible, some domains of the RoB tool would be applied to assess the methodological quality.
Parkinson’s disease. Three clinical case reports9,10,12 demonstrated the technique of using mandiblesupported overdentures to rehabilitate a 72-, 72or 83-year-old patient. The first and second clinical reports9,10 demonstrated only the technique for placing the implants and confectioning the overdenture, without clearly reporting outcomes. The first report9 described only one patient from seven treated patients with PD. The third clinical case12 reported good satisfaction of the patient after 12 months of follow-up. In the fourth case report,13 a 72-year-old patient with stage II PD according to the Hoehn and Yahr scale21 was treated with an implant and a fixed maxillary prosthesis. The authors only reported that the treatment was successful; there was no follow-up for the report. The fifth clinical case16 reported an adverse event (aspiration of a dental implant screwdriver) during implant placement surgery in an 88-yearold patient. One case series17 of three patients with PD severity of at least grade III assessed the clinical outcomes of treatment with mandibular implant overdentures. After a follow-up of 28–42 months, the patients demonstrated remarkable improvements in chewing ability. The gingival index score improved in the three patients after the follow-up period. In a second case series18, nine patients with PD were treated with dental implants and removable and fixed prostheses. Implant survival in patients with PD was lower than in patients without PD (overall survival rate 82%). Qualityof-life scores measured by the Oral Health Quality of Life Inventory and the Self-Reported Assess-
Keywords
Data reporting Evidence was planned to be hierarchically presented by study design and type of neurodegenerative disorder and reported in a table with outcomes of effectiveness and potential adverse events.
Results Selection process A total of 58 potential papers were initially selected. After the assessment of titles, abstracts and full text, 11 papers were finally included. The complete literature search results, with reasons for exclusion of papers, are depicted in Fig. 1.
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Records identified through database searching (N = 57)
Additional records identified through other sources (N = 1)
Records after duplicates removed (N = 57)
Records screened (N = 57)
Records excluded (N = 46) Reasons: Not related to the topic (N = 42) Review article (N = 2) No study report (N = 2)
Full-text articles assessed for eligibility (N = 11)
Studies included in qualitative synthesis (N = 11)
Studies included in quantitative synthesis (meta-analysis) (N = 0)
Figure 1 PRISMA Flow diagram30 of the literature search.
ment of Oral Health and Functional Status were improved after 12 months. However, some difficulties in managing the prostheses were identified, including difficulties in removing the prostheses and maintaining oral hygiene, as well as gingival hyperplasia below the overdentures. Huntington’s disease. A case report11 described a 56-year-old male patient with HD who received a mandible overdenture supported by two implants. After 1 year of follow-up, the patient presented improved chewing function but limited oral hygiene, as evidenced by the findings of soft deposits on the bar. Another case report15 demonstrated improvement in the patient’s masticatory function after 12 months of function of a mandibular overdenture with two implants. Dementia. One case report14 of an 89-year-old woman highlighted the strategy used to maintain an overdenture supported by three implants placed in the mandible 22 years before. No longterm results were presented. Another case series19 concerned oral implants in three dependent elderly persons, including two patients with dementia. For the first patient, an 86-year-old
woman, the ball attachments of the mandibular overdenture were covered by plaque and calculus, and the tissues were inflamed, a potential cause of pain for the patient. The second patient (85year-old woman) had complained about pain in mouth. She had transmandibular implants covered in plaque and calculus. The soft tissues were severely inflamed, and radiographs showed substantial bone loss around the implants. The implants were surgically removed, and conventional dentures were fabricated. Authors of this report suggested that the patient’s oral function has been satisfactory. Table 4 depicts the outcomes of the included reports. Methodological quality of studies included Because no RCT or other controlled trial was found, the assessment of risk of bias of studies was not possible with the RoB tool.
Discussion The objective of this critical appraisal was to assess the level of evidence supporting dental implant placement in patients with NDDs. Unfortunately,
© 2013 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd
Dental implants and neurodegenerative diseases
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Table 3 Characteristics of reports including patients with neurodegenerative diseases receiving dental implants.
Study W€achter et al.9
Number of patients Gender 1
Applebaum 1 et al.10 Heckmann et al.17
3
Jackowski et al.11
1
Kubo and Kimura13
1
Chu et al.12 1
Deniz et al.15
1
Packer et al.18 Laidlaw14
9 1
Visser 2 et al.19 Deliberador 1 et al.16
Age (years)
Dental statusa
Oral Hygiene (OH) (self- or careroperated)
Not reported Maxillary complete edentulism (complete denture) and overdenture with four implants in lower jaw Not reported Female 72 Maxillary complete edentulism (complete denture) and mandibular partial edentulism Authors 2 males, 75.7 (mean Maxillary complete edentulism suggest self1 female age) (complete denture) and operated OH overdenture with 2,3 and 4 implants in lower jaw Not reported Male 56 Maxillary partial edentulism and overdenture with two implants in lower jaw Not reported Male 72 Maxillary/mandibulary partial edentulism with bridges supported by teeth and implants Not reported Female 83 Maxillary complete edentulism (complete denture) and overdenture with four implants in lower jaw Authors only Female 67 Maxillary partial edentulism reported they and overdenture with two instructed implants in lower jaw patient and caregivers about OH Male 54–77 Partial and total edentulism Not reported (range) Carer-operated Female 67 Maxillary complete edentulism (complete denture) and overdenture with three implants in lower jaw Female 85, 86 Maxillary complete edentulism Carer-operated (complete denture)b Male 88 Partial edentulism with bridges Not reported supported by implants Female
72
Disease Parkinson’s
Parkinson’s
Parkinson’s
Huntington′s
Parkinson’s
Parkinson’s
Huntington′s
Parkinson’s Dementia
Dementia Parkinson’s
a
Dental status after the treatment with implants. One patient had mobile transmandibular implants that were removed, and the patient was treated with two complete dentures. Another patient had their two implants ‘put to sleep’ and a conventional complete denture in lower jaw was fabricated. b
the present findings reveal very low evidence of positive outcomes and potential adverse events for the use of dental implants in these patients. No RCT or any study with a control group was found; therefore, a precise assessment of the effect of implant therapy on patients with NDDs was hindered.
The greatest number of reports (N = 7) concerned patients with PD. Generally, dental treatment in patients with PD by mandibular implant overdentures improved their chewing function and quality of life. Six of the seven included reports had follow-up of ≤12 months. Only one study17 included three patients with a follow-up
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Table 4 Outcomes in patients with neurodegenerative diseases receiving dental implants
Study
Design
Follow-up (months)
Type of outcome Outcome measure: measure objective or perceiveda
Outcome of the study
Case No follow-up Not clearly report reported (difficult to interpret) No follow-up Not clearly Applebaum Case report reported et al.10 (difficult to interpret) Heckmann Case 28, 35, 42 HI, GI-S, et al.17 series SFFR, PTV, chewing ability Jackowski Case 12 Prosthesis et al.11 report stability and chewing ability Kubo and Case No follow-up Unknown Kimura13 report
Perceived
Authors only reported that the treatment was ‘successful’.
Not reported
Outcomes were not reported. Authors only demonstrated the techniques for implant placement and prosthesis construction. Improvements in GI-S and chewing ability were found. Authors did not report baseline measurements of other outcome measures. Improvements in prosthesis stability and chewing ability were found.
Chu et al.12 Case 12 report Deniz Case 12 et al.15 report
Perceived
W€achter et al.9
Packer et al.18
Laidlaw14
Visser et al.19
Case series
Chewing ability Prosthesis stability and chewing ability
12
OH-QoL, SROH, adverse events, implant survival Case No follow-up Not clearly report reported (difficult to interpret) Case No follow-up Not clearly series reported (difficult to interpret)
Deliberador Case No follow-up Not clearly et al.16 report reported (difficult to interpret)
Objective
Perceived
Unknown
Outcomes were not reported. Authors only reported the safety of performing implant surgery by combining regional anaesthesia with intravenous midazolam. Improvement in chewing ability was found. Improvements in prosthesis stability and chewing ability were found.
Objective (plaque index) and perceived (prosthesis stability and improvement of chewing) Objective (validated Improvements in OH-QoL and SROH checklists) scores were found. Patients with PD showed lower implant survival compared to non-PD patients, as well as difficulties in prosthesis removal.
Perceived (caregiver Authors suggested that chewing function perception) was improved.
Objective (peri-implant conditions) and perceived (patient free of pain) Objective
Patients were free of pain and showed improved peri-implant tissue inflammation.
An aspirated implant screwdriver was successfully removed from the patient’s lung.
HI, hygiene index; GI-S, Gingival Index Simplified; SFFR, sulcus fluid flow rate PTV, Periotest Values; OH-QoL, Oral Health Quality of Life Inventory; SROH, Self-Reported Assessment of Oral health and Functional Status; PD, Parkinson’s disease. a Outcome measure: objective when any tool was used to compare baseline and final outcomes (for example, a questionnaire); perceived when patients or relatives subjectively reported treatment changes.
© 2013 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd
Dental implants and neurodegenerative diseases
of >12 months (28, 35 and 42 months, respectively). Interestingly, these three patients presented better outcomes in terms of the gingival index score after treatment, although two patients showed deteriorations of PD level (from stage III to IV by the Hoehn and Yahr scale)21. In the patient with the longest follow-up (42 months), who showed PD deterioration from stage III to IV, plaque was found in only one of four implants. Another case series18 reported difficulties in maintaining oral hygiene around implants for four of nine patients with PD. Gingival hyperplasia below the overdenture bars was presented in all six patients who received this type of treatment. Implant survival (authors reported implant success as survival) was lower than survival in previously reported non-PD patients. The authors indicated that the lower survival might be associated with not fully controlled PD-associated movements (although intravenous sedation was used), which may have affected the surgical precision. Despite these negative outcomes, the patients reported improvements regarding chewing function and quality of life. HD is a complex neurodegenerative disorder involving involuntary movements of the muscles, including the tongue and peri-oral musculature. It is expected that patients with HD will face problems in using conventional dentures, due to their lack of stabilisation. In two clinical reports11,15, mandibular overdentures supported by two dental implants were planned and performed to improve prosthesis stability. Although chewing function was improved in both cases, a follow-up of only 12 months was reported. The small number of patients assessed (N = 2) also hindered a more robust conclusion from being drawn. Dementia is a broad term used to designate deterioration of brain function. Alzheimer’s disease has been suggested to account for around 60% of all dementia cases22. The two reports selected14,19 described adverse events of therapy with dental implants in patients affected by dementia. The reports emphasised inflammation of the peri-implant soft tissues due to a lack of proper plaque control. Despite the lack of reasonable sample of patients with dementia (N = 3) and the lack of long-term follow-up data, the findings might indicate that, as in patients without degenerative disease, strict plaque control plays an important role for the success of treatment in patients with dementia. The strength of the present report is that it informs the lack of solid evidence on this pivotal
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topic and suggests some guidance for further research. Dental implants have become the firstline therapy for the replacement of lost teeth23. The incidence of complications, such as peri-implantitis24, is anticipated to increase in coming decades. Because NDDs are normally progressive (i.e. they worsen with age, limiting the patient’s functions), dental-implant-related problems will also very likely increase. For example, a potential scenario in which a very old patient with neurodegenerative disease is suffering from severe peri-implantitis (in which implant extraction is probably needed) is a big challenge to the whole clinical staff. Cleaning problems and associated peri-implant soft tissue inflammation may be expected when old patients (≥80 years) are treated25. This scenario is particularly important in nursing homes where the population is normally formed by elderly patients, many of whom requiring specialised health and dental care. Some studies suggest a lack of programmes for systematic dental care in these institutions26–28, and many nursing home managers and staff workers may be unfamiliar with oral healthcare maintenance requirements. For example, in the present sample, one case report19 found that caregivers recognised the overdenture supported by two implants as a complete denture in a dependent patient. Therefore, adequate education of caregivers about oral health care, including dental implants and their maintenance, seems to be a priority. It is very important that measures be taken to reduce the chance of adverse events of dental implant treatment in patients with neurodegenerative disorders, especially those who are very old or in later disease stages.
Recommendations Some recommendations for further research and clinical practice on the placement of dental implants in patients with neurodegenerative diseases are described: 1. Research should focus on robust study designs, namely RCTs, to test approaches for the prevention of complications and maintenance of periimplant tissue health. This research should include validated approaches for objectively measuring the effectiveness of therapies with dental implants. 2. A minimum number of dental implants should be used to restore the oral function of patients with neurodegenerative diseases. Increasing the number of dental implants might also increase the probability of further complications, such as
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peri-implantitis. Older patients seem to prefer removable prostheses29, due to the easier access for cleaning. For example, a strategy of using an overdenture supported by two implants placed in the intraforaminal area seems to be acceptable for restoring function in the edentulous mandible. 3. Systematic dental care is necessary in nursing homes, to prevent mucositis and further periimplantitis in patients with NDDs. Caregivers in nursing homes require professional training, especially regarding the maintenance of dental implants. A recommendation might be that dental professionals having good experience with dental implants periodically visit nursing homes to assess the needs of patients and train caregivers.
References 1. Brown RC, Lockwood AH, Sonawane BR. Neurodegenerative diseases: an overview of environmental risk factors. Environ Health Perspect 2005; 113: 1250–6. 2. Berr C, Wancata J, Ritchie K. Prevalence of dementia in the elderly in Europe. Eur Neuropsychopharmacol 2005; 15: 463–71. 3. von Campenhausen S, Bornschein B, Wick R, B€ otzel K, Sampaio C, Poewe W et al. Prevalence and incidence of Parkinson’s disease in Europe. Eur Neuropsychopharmacol 2005; 15: 473–90. 4. Corrada MM, Brookmeyer R, Paganini-Hill A, Berlau D, Kawas CH. Dementia incidence continues to increase with age in the oldest old: the 90+ study. Ann Neurol 2010; 67: 114–21. 5. Pjetursson BE, Br€ agger U, Lang NP, Zwahlen M. Comparison of survival and complication rates of tooth-supported fixed dental prostheses (FDPs) and implant-supported FDPs and single crowns (SCs). Clin Oral Implants Res 2007; 18 (Suppl 3): 97–113. 6. Jung RE, Pjetursson BE, Glauser R, Zembic A, Zwahlen M, Lang NP. A systematic review of the 5year survival and complication rates of implant-supported single crowns. Clin Oral Implants Res 2008; 19: 119– 30. 7. Ho PM, Peterson PN, Masoudi FA. Evaluating the evidence: is there a rigid hierarchy? Circulation 2008; 118: 1675–84. 8. Higgins JP, Altman DG, Gøtzsche PC, J€ uni P, Moher D, Oxman AD
Conclusion The lack of RCTs and other controlled trials suggests that the placement of dental implants in patients with NDDs is a forgotten issue in dentistry. Although most of the included reports showed positive effects for the use of dental implants in patients with NDDs, they provided only lowlevel evidence. Therefore, more robust research is needed to assess the effectiveness and adverse events of the use of dental implants in these populations.
Conflict of interest The author declares he has no conflict of interests.
et al.; Cochrane Bias Methods Group; Cochrane Statistical Methods Group. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ 2011; 343: d5928. 9. W€ achter R, Kartun D, Fabinger A, Krekeler G, Schilli W. Dentale Implantate als wesentlicher Bestandteil der Rehabilitation neurologischer und geriatrischer Problempatienten. Zeitschrift f€ ur Zahn€arztliche Implantologie 1996; 12: 212–7. 10. Applebaum GM, Langsam BW, Huba G. The implant retained UCLA-type clip bar overdenture. A solution to the mandibular edentulous patient affected by Parkinson’s disease. Oral Health 1997; 87: 65–7. 11. Jackowski J, Andrich J, K€ appeler H, Z€ ollner A, J€ ohren P, M€ uller T. Implant-supported denture in a patient with Huntington’s disease: interdisciplinary aspects. Spec Care Dentist 2001; 21: 15–20. 12. Chu FC, Deng FL, Siu AS, Chow TW. Implant-tissue supported, magnet-retained mandibular overdenture for an edentulous patient with Parkinson’s disease: a clinical report. J Prosthet Dent 2004; 91: 219–22. 13. Kubo K, Kimura K. Implant surgery for a patient with Parkinson’s disease controlled by intravenous midazolam: a case report. Int J Oral Maxillofac Implants 2004; 19: 288–90. 14. Laidlaw LA. The impact of dementia on the care of dental implants: a case report. J Disabil Oral Health 2010; 11:192–4. 15. Deniz E, Kokat AM, Noyan A. Implant-supported overdenture in an
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elderly patient with Huntington’s disease. Gerodontology 2011; 28: 157– 60. Deliberador TM, Marengo G, Scaratti R, Giovanini AF, Zielak JC, Baratto Filho F. Accidental aspiration in a patient with Parkinson’s disease during implant-supported prosthesis construction: a case report. Spec Care Dentist 2011; 31: 156–61. Heckmann SM, Heckmann JG, Weber HP. Clinical outcomes of three Parkinson’s disease patients treated with mandibular implant overdentures. Clin Oral Implants Res 2000; 11: 566–71. Packer M, Nikitin V, Coward T, Davis DM, Fiske J. The potential benefits of dental implants on the oral health quality of life of people with Parkinson’s disease. Gerodontology 2009; 26: 11–8. Visser A, de Baat C, Hoeksema AR, Vissink A. Oral implants in dependent elderly persons: blessing or burden? Gerodontology 2011; 28: 76–80. Oczakir C, Balmer S, MericskeStern R. Implant-prosthodontic treatment for special care patients: a case series study. Int J Prosthodont 2005; 18: 383–9. Hoehn MM, Yahr MD. Parkinsonism: onset, progression and mortality. Neurology 1967; 17: 427–42. NICE guidelines. Dementia: A NICESCIE Guideline on Supporting People With Dementia and Their Carers in Health and Social Care, 2007. Editors National Collaborating Centre for Mental Health (UK). Source Leicester (UK): British Psychological Soci-
© 2013 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd
Dental implants and neurodegenerative diseases ety; 2007. National Institute for Health and Clinical Excellence. 23. Bouchard P, Renouard F, Bourgeois D, Fromentin O, Jeanneret MH, Beresniak A. Cost-effectiveness modeling of dental implant vs. bridge. Clin Oral Implants Res 2009; 20: 583–7. 24. Faggion CM Jr, Chambrone L, Listl S, Tu YK. Network metaanalysis for evaluating interventions in implant dentistry: the case of peri-implantitis treatment. Clin Implant Dent Relat Res 2013; 15: 576– 88. 25. Engfors I, Ortorp A, Jemt T. Fixed implant-supported prostheses in elderly patients: a 5-year retrospective study of 133 edentulous patients older than 79 years. Clin Implant Dent Relat Res 2004; 6: 190–8.
26. Schembri A, Fiske J. Oral health and dental care facilities in Maltese residential homes. Gerodontology 2005; 22: 143–50. 27. Smith BJ, Ghezzi EM, Manz MC, Markova CP. Perceptions of oral health adequacy and access in Michigan nursing facilities. Gerodontology 2008; 25: 89–98. 28. Rabbo MA, Mitov G, Gebhart F, Pospiech P. Dental care and treatment needs of elderly in nursing homes in Saarland: perceptions of the homes managers. Gerodontology 2012; 29: e57–62. 29. Feine JS, de Grandmont P, Boudrias P, Brien N, LaMarche C, Tach eR et al. Within-subject comparisons of implant-supported mandibular prostheses: choice of prosthesis. J Dent Res 1994; 73: 1105–11.
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30. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009; 6: e1000097.
Correspondence to: Clovis Mariano Faggion Jr, Department of Periodontology, Faculty of Dentistry, University of Mu¨nster, Waldeyerstrabe 30, 48149 M€ unster, Germany. Tel.: +49 251 83 47061 Fax: +49 251 83 47134 E-mail: clovisfaggion@yahoo. com
© 2013 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd
Critical appraisal of evidence supporting the placement of dental implants in patients with neurodegenerative diseases Clovis Mariano Faggion Jr1,2 1
Department of Periodontology, Faculty of Dentistry, University of M€ unster, M€ unster, Germany; 2Department of Oral Sciences, Faculty of Dentistry, University of Otago, Dunedin, New Zealand
Gerodontology 2013; doi: 10.1111/ger.12100 Critical appraisal of evidence supporting the placement of dental implants in patients with neurodegenerative diseases Objective: To assess the available scientific evidence regarding the effectiveness and complications associated with using dental implants in patients with neurodegenerative diseases. Materials and Methods: PubMed, EMBASE, Biosis Citation Index, CINAHL, Web of Science and LILACS electronic databases were searched, with the last search performed on 20 May 2013. Reference lists of the included systematic reviews were manually reviewed. No restriction regarding the study design or publication language was applied for study inclusion. Only studies involving human subjects were included. In case randomised or other controlled trials were identified, methodological assessment of included studies was planned. Results: Fifty-eight potential papers were initially retrieved from the electronic databases. Eleven papers were finally included. No randomised controlled trial or other controlled trial was found. Eight papers were case reports and three were case series. The sample included three types of neurodegenerative diseases: dementia, Parkinson’s disease and Huntington’s disease. Generally, the reports showed improvements in chewing function and quality of life after the placement of implants and prostheses. Nevertheless, the follow-up time was typically short (≤12 months), and the overall sample size was small (N = 22 patients). Inclusion of studies without controls prevented a more robust methodological assessment from being performed. Conclusions: The results of the included reports suggest positive outcomes for dental implant use in patients with neurodegenerative diseases. Nevertheless, more robust studies, with better design and longer follow-ups, are needed to set strategies to prevent and treat potential complications in patients with neurodegenerative disorders treated with dental implants. Keywords: dental implants, neurodegenerative diseases, critical appraisal, geriatric dentistry. Accepted 30 October 2013
Introduction Neurodegenerative diseases (NDDs) are chronic and progressive conditions that debilitate people both psychologically and physically. There are more than 600 neurological disorders, with a high prevalence in the population. For example, more than 50 million North Americans are affected each year by NDDs1. Dementia, one of the most prevalent neurodegenerative disorders, affects 5.9–9.4% Europeans above 65 years of age2. In Europe, the prevalence of Parkinson’s disease (PD), another important neurodegenerative disorder, is 1280–1500 per 100 000 people older than
60 years3. Moreover, the incidence of diseases such as dementia continues to increase with age4. The more developed the disease progression, the more impaired the patient will be in terms of his or her cognitive and physical abilities. Thus, it might be expected that patients with NDDS will face problems in performing normal daily tasks. The placement of dental implants has become a recognised and well-established therapy for patients who have lost their teeth. High levels of survival and success are expected when implantsupported prostheses are used5,6. Like teeth, dental implants need frequent care and supervision to prevent plaque formation, inflammation and
© 2013 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd
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C. M. Faggion Jr.
deterioration of tissues supporting the implants. Deposits in the form of plaque and calculus may put peri-implant tissue at risk of further deterioration. For example, in its later stages, peri-implantitis might require surgical implant removal. Patients with NDDs may have problems with performing daily procedures to avoid and eliminate plaque, such as toothbrushing and dental flossing. The objective of this study was to perform a critical appraisal of the literature on clinical outcomes, in terms of effectiveness and adverse events, regarding the placement of dental implants in patients with NDDs.
Materials and methods Outcome measures used in this appraisal The present critical appraisal was designed to generate a systematic overview of the literature regarding outcomes of the use of dental implants in patients with NDDs. Any outcome of effectiveness (e.g. implant survival or success) or adverse event (e.g. peri-implantitis) was reported. Inclusion and exclusion criteria Clinical studies on the treatment for oral conditions with dental implants in patients with NDDs were included. Randomised controlled trials (RCTs) and other controlled trials were intended
to be included. In the case that no evidence from high-hierarchic studies7 was found, studies of lower hierarchy would be included, such as retrospective/prospective cohort, case series and clinical reports. For the sake of simplicity, to be considered a case series, the report should involve more than one patient. Review studies or studies not involving humans were excluded from the present study. Definition of neurodegenerative diseases Neurodegenerative diseases were defined as ‘hereditary and sporadic conditions characterized by progressive nervous system dysfunction. These disorders are often associated with atrophy of the affected central or peripheral nervous system structures’ (MeSH database). Table 1 depicts the specific definitions of some NDDs covered in this appraisal. Literature search The PubMed, EMBASE, Biosis Citation Index, CINAHL, Web of Science and LILACS electronic databases were searched, with the last search performed on 20 May 2013. Reference lists of the included systematic reviews were manually reviewed. There was no language restriction. The detailed literature search, with the keywords and Boolean operators used, is depicted in Table 2.
Table 1 Definitionsa of neurodegenerative diseases reported in this review. Neurodegenerative disease Definition Dementia
Parkinson’s
Huntington′s
An acquired organic mental disorder with loss of intellectual abilities of sufficient severity to interfere with social or occupational functioning. The dysfunction is multifaceted and involves memory, behavior, personality, judgment, attention, spatial relations, language, abstract thought, and other executive functions. The intellectual decline is usually progressive, and initially spares the level of consciousness A progressive, degenerative neurologic disease characterized by a tremor that is maximal at rest, retropulsion (i.e. a tendency to fall backwards), rigidity, stooped posture, slowness of voluntary movements, and a masklike facial expression. Pathologic features include loss of melanin containing neurons in the substantia nigra and other pigmented nuclei of the brainstem. Lewy bodies are present in the substantia nigra and locus coeruleus but may also be found in a related condition (Lewy body disease, diffuse) characterized by dementia in combination with varying degrees of parkinsonism A familial disorder inherited as an autosomal dominant trait and characterized by the onset of progressive chorea and dementia in the fourth or fifth decade of life. Common initial manifestations include paranoia; poor impulse control; depression; hallucinations; and Delusions. Eventually intellectual impairment; loss of fine motor control; athetosis; and diffuse chorea involving axial and limb musculature develops, leading to a vegetative state within 10–15 years of disease onset. The juvenile variant has a more fulminant course including seizures; ataxia; dementia; and chorea
a
MeSH terms’ definition from PubMed. © 2013 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd
Dental implants and neurodegenerative diseases
Table 2 Search strategy in PubMed.
3
Studies included
14) (#12 AND #13) 13) (#3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11) 12) (#1 OR #2) 11) Lewy Body Disease 10) Spinocerebellar ataxia 9) Spinal Muscular Atrophy 8) Multiple System Atrophy 7) Motor Neuron Disease 6) Dementia OR sclerosis 5) Alzheimer OR Parkinson OR Huntington 4) degenerative nerve AND (disorders OR diseases) 3) neurodegenerative AND (disorders OR diseases) 2) peri-implantitis OR perimplantitis 1) (dental implants OR dental implant)
Of the 11 included papers, eight were case reports9–16 and three were case series (including two case series with three patients each)17–19. Seven reports9,10,12,13,16–18 were related to patients with PD, two reports11,15 were related to Huntington’s disease (HD), and two reports were related to dementia14,19. Initially, one case series20 on the placement of dental implants in patients with various systematic diseases and congenital defects (including one case of amyotrophic lateral sclerosis, a neurodegenerative disease) was included. However, this paper was excluded because the patient’s two implants failed during the healing phase, and the patient was excluded from the assessment. Table 3 depicts the detailed characteristics of the included reports.
Methodological assessment planned
Outcomes with dental implants
Included studies were organised by study design. Whenever possible, their methodological quality was evaluated by validated tools. In the case that RCTs were selected, the Risk of Bias Tool (RoB tool) would be used to assess the risk of bias. The RoB tool evaluates six domains: selection bias (random sequence generation and allocation concealment), performance bias (blinding of participants and personnel), detection bias (blinding of outcome assessment), attrition bias (incomplete outcome data), reporting bias (selective reporting) and other bias (other sources of bias)8. In the case that controlled clinical trials or cohorts (with a control group of patients without neurodegenerative disease) were included, whenever possible, some domains of the RoB tool would be applied to assess the methodological quality.
Parkinson’s disease. Three clinical case reports9,10,12 demonstrated the technique of using mandiblesupported overdentures to rehabilitate a 72-, 72or 83-year-old patient. The first and second clinical reports9,10 demonstrated only the technique for placing the implants and confectioning the overdenture, without clearly reporting outcomes. The first report9 described only one patient from seven treated patients with PD. The third clinical case12 reported good satisfaction of the patient after 12 months of follow-up. In the fourth case report,13 a 72-year-old patient with stage II PD according to the Hoehn and Yahr scale21 was treated with an implant and a fixed maxillary prosthesis. The authors only reported that the treatment was successful; there was no follow-up for the report. The fifth clinical case16 reported an adverse event (aspiration of a dental implant screwdriver) during implant placement surgery in an 88-yearold patient. One case series17 of three patients with PD severity of at least grade III assessed the clinical outcomes of treatment with mandibular implant overdentures. After a follow-up of 28–42 months, the patients demonstrated remarkable improvements in chewing ability. The gingival index score improved in the three patients after the follow-up period. In a second case series18, nine patients with PD were treated with dental implants and removable and fixed prostheses. Implant survival in patients with PD was lower than in patients without PD (overall survival rate 82%). Qualityof-life scores measured by the Oral Health Quality of Life Inventory and the Self-Reported Assess-
Keywords
Data reporting Evidence was planned to be hierarchically presented by study design and type of neurodegenerative disorder and reported in a table with outcomes of effectiveness and potential adverse events.
Results Selection process A total of 58 potential papers were initially selected. After the assessment of titles, abstracts and full text, 11 papers were finally included. The complete literature search results, with reasons for exclusion of papers, are depicted in Fig. 1.
© 2013 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd
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C. M. Faggion Jr.
Records identified through database searching (N = 57)
Additional records identified through other sources (N = 1)
Records after duplicates removed (N = 57)
Records screened (N = 57)
Records excluded (N = 46) Reasons: Not related to the topic (N = 42) Review article (N = 2) No study report (N = 2)
Full-text articles assessed for eligibility (N = 11)
Studies included in qualitative synthesis (N = 11)
Studies included in quantitative synthesis (meta-analysis) (N = 0)
Figure 1 PRISMA Flow diagram30 of the literature search.
ment of Oral Health and Functional Status were improved after 12 months. However, some difficulties in managing the prostheses were identified, including difficulties in removing the prostheses and maintaining oral hygiene, as well as gingival hyperplasia below the overdentures. Huntington’s disease. A case report11 described a 56-year-old male patient with HD who received a mandible overdenture supported by two implants. After 1 year of follow-up, the patient presented improved chewing function but limited oral hygiene, as evidenced by the findings of soft deposits on the bar. Another case report15 demonstrated improvement in the patient’s masticatory function after 12 months of function of a mandibular overdenture with two implants. Dementia. One case report14 of an 89-year-old woman highlighted the strategy used to maintain an overdenture supported by three implants placed in the mandible 22 years before. No longterm results were presented. Another case series19 concerned oral implants in three dependent elderly persons, including two patients with dementia. For the first patient, an 86-year-old
woman, the ball attachments of the mandibular overdenture were covered by plaque and calculus, and the tissues were inflamed, a potential cause of pain for the patient. The second patient (85year-old woman) had complained about pain in mouth. She had transmandibular implants covered in plaque and calculus. The soft tissues were severely inflamed, and radiographs showed substantial bone loss around the implants. The implants were surgically removed, and conventional dentures were fabricated. Authors of this report suggested that the patient’s oral function has been satisfactory. Table 4 depicts the outcomes of the included reports. Methodological quality of studies included Because no RCT or other controlled trial was found, the assessment of risk of bias of studies was not possible with the RoB tool.
Discussion The objective of this critical appraisal was to assess the level of evidence supporting dental implant placement in patients with NDDs. Unfortunately,
© 2013 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd
Dental implants and neurodegenerative diseases
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Table 3 Characteristics of reports including patients with neurodegenerative diseases receiving dental implants.
Study W€achter et al.9
Number of patients Gender 1
Applebaum 1 et al.10 Heckmann et al.17
3
Jackowski et al.11
1
Kubo and Kimura13
1
Chu et al.12 1
Deniz et al.15
1
Packer et al.18 Laidlaw14
9 1
Visser 2 et al.19 Deliberador 1 et al.16
Age (years)
Dental statusa
Oral Hygiene (OH) (self- or careroperated)
Not reported Maxillary complete edentulism (complete denture) and overdenture with four implants in lower jaw Not reported Female 72 Maxillary complete edentulism (complete denture) and mandibular partial edentulism Authors 2 males, 75.7 (mean Maxillary complete edentulism suggest self1 female age) (complete denture) and operated OH overdenture with 2,3 and 4 implants in lower jaw Not reported Male 56 Maxillary partial edentulism and overdenture with two implants in lower jaw Not reported Male 72 Maxillary/mandibulary partial edentulism with bridges supported by teeth and implants Not reported Female 83 Maxillary complete edentulism (complete denture) and overdenture with four implants in lower jaw Authors only Female 67 Maxillary partial edentulism reported they and overdenture with two instructed implants in lower jaw patient and caregivers about OH Male 54–77 Partial and total edentulism Not reported (range) Carer-operated Female 67 Maxillary complete edentulism (complete denture) and overdenture with three implants in lower jaw Female 85, 86 Maxillary complete edentulism Carer-operated (complete denture)b Male 88 Partial edentulism with bridges Not reported supported by implants Female
72
Disease Parkinson’s
Parkinson’s
Parkinson’s
Huntington′s
Parkinson’s
Parkinson’s
Huntington′s
Parkinson’s Dementia
Dementia Parkinson’s
a
Dental status after the treatment with implants. One patient had mobile transmandibular implants that were removed, and the patient was treated with two complete dentures. Another patient had their two implants ‘put to sleep’ and a conventional complete denture in lower jaw was fabricated. b
the present findings reveal very low evidence of positive outcomes and potential adverse events for the use of dental implants in these patients. No RCT or any study with a control group was found; therefore, a precise assessment of the effect of implant therapy on patients with NDDs was hindered.
The greatest number of reports (N = 7) concerned patients with PD. Generally, dental treatment in patients with PD by mandibular implant overdentures improved their chewing function and quality of life. Six of the seven included reports had follow-up of ≤12 months. Only one study17 included three patients with a follow-up
© 2013 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd
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Table 4 Outcomes in patients with neurodegenerative diseases receiving dental implants
Study
Design
Follow-up (months)
Type of outcome Outcome measure: measure objective or perceiveda
Outcome of the study
Case No follow-up Not clearly report reported (difficult to interpret) No follow-up Not clearly Applebaum Case report reported et al.10 (difficult to interpret) Heckmann Case 28, 35, 42 HI, GI-S, et al.17 series SFFR, PTV, chewing ability Jackowski Case 12 Prosthesis et al.11 report stability and chewing ability Kubo and Case No follow-up Unknown Kimura13 report
Perceived
Authors only reported that the treatment was ‘successful’.
Not reported
Outcomes were not reported. Authors only demonstrated the techniques for implant placement and prosthesis construction. Improvements in GI-S and chewing ability were found. Authors did not report baseline measurements of other outcome measures. Improvements in prosthesis stability and chewing ability were found.
Chu et al.12 Case 12 report Deniz Case 12 et al.15 report
Perceived
W€achter et al.9
Packer et al.18
Laidlaw14
Visser et al.19
Case series
Chewing ability Prosthesis stability and chewing ability
12
OH-QoL, SROH, adverse events, implant survival Case No follow-up Not clearly report reported (difficult to interpret) Case No follow-up Not clearly series reported (difficult to interpret)
Deliberador Case No follow-up Not clearly et al.16 report reported (difficult to interpret)
Objective
Perceived
Unknown
Outcomes were not reported. Authors only reported the safety of performing implant surgery by combining regional anaesthesia with intravenous midazolam. Improvement in chewing ability was found. Improvements in prosthesis stability and chewing ability were found.
Objective (plaque index) and perceived (prosthesis stability and improvement of chewing) Objective (validated Improvements in OH-QoL and SROH checklists) scores were found. Patients with PD showed lower implant survival compared to non-PD patients, as well as difficulties in prosthesis removal.
Perceived (caregiver Authors suggested that chewing function perception) was improved.
Objective (peri-implant conditions) and perceived (patient free of pain) Objective
Patients were free of pain and showed improved peri-implant tissue inflammation.
An aspirated implant screwdriver was successfully removed from the patient’s lung.
HI, hygiene index; GI-S, Gingival Index Simplified; SFFR, sulcus fluid flow rate PTV, Periotest Values; OH-QoL, Oral Health Quality of Life Inventory; SROH, Self-Reported Assessment of Oral health and Functional Status; PD, Parkinson’s disease. a Outcome measure: objective when any tool was used to compare baseline and final outcomes (for example, a questionnaire); perceived when patients or relatives subjectively reported treatment changes.
© 2013 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd
Dental implants and neurodegenerative diseases
of >12 months (28, 35 and 42 months, respectively). Interestingly, these three patients presented better outcomes in terms of the gingival index score after treatment, although two patients showed deteriorations of PD level (from stage III to IV by the Hoehn and Yahr scale)21. In the patient with the longest follow-up (42 months), who showed PD deterioration from stage III to IV, plaque was found in only one of four implants. Another case series18 reported difficulties in maintaining oral hygiene around implants for four of nine patients with PD. Gingival hyperplasia below the overdenture bars was presented in all six patients who received this type of treatment. Implant survival (authors reported implant success as survival) was lower than survival in previously reported non-PD patients. The authors indicated that the lower survival might be associated with not fully controlled PD-associated movements (although intravenous sedation was used), which may have affected the surgical precision. Despite these negative outcomes, the patients reported improvements regarding chewing function and quality of life. HD is a complex neurodegenerative disorder involving involuntary movements of the muscles, including the tongue and peri-oral musculature. It is expected that patients with HD will face problems in using conventional dentures, due to their lack of stabilisation. In two clinical reports11,15, mandibular overdentures supported by two dental implants were planned and performed to improve prosthesis stability. Although chewing function was improved in both cases, a follow-up of only 12 months was reported. The small number of patients assessed (N = 2) also hindered a more robust conclusion from being drawn. Dementia is a broad term used to designate deterioration of brain function. Alzheimer’s disease has been suggested to account for around 60% of all dementia cases22. The two reports selected14,19 described adverse events of therapy with dental implants in patients affected by dementia. The reports emphasised inflammation of the peri-implant soft tissues due to a lack of proper plaque control. Despite the lack of reasonable sample of patients with dementia (N = 3) and the lack of long-term follow-up data, the findings might indicate that, as in patients without degenerative disease, strict plaque control plays an important role for the success of treatment in patients with dementia. The strength of the present report is that it informs the lack of solid evidence on this pivotal
7
topic and suggests some guidance for further research. Dental implants have become the firstline therapy for the replacement of lost teeth23. The incidence of complications, such as peri-implantitis24, is anticipated to increase in coming decades. Because NDDs are normally progressive (i.e. they worsen with age, limiting the patient’s functions), dental-implant-related problems will also very likely increase. For example, a potential scenario in which a very old patient with neurodegenerative disease is suffering from severe peri-implantitis (in which implant extraction is probably needed) is a big challenge to the whole clinical staff. Cleaning problems and associated peri-implant soft tissue inflammation may be expected when old patients (≥80 years) are treated25. This scenario is particularly important in nursing homes where the population is normally formed by elderly patients, many of whom requiring specialised health and dental care. Some studies suggest a lack of programmes for systematic dental care in these institutions26–28, and many nursing home managers and staff workers may be unfamiliar with oral healthcare maintenance requirements. For example, in the present sample, one case report19 found that caregivers recognised the overdenture supported by two implants as a complete denture in a dependent patient. Therefore, adequate education of caregivers about oral health care, including dental implants and their maintenance, seems to be a priority. It is very important that measures be taken to reduce the chance of adverse events of dental implant treatment in patients with neurodegenerative disorders, especially those who are very old or in later disease stages.
Recommendations Some recommendations for further research and clinical practice on the placement of dental implants in patients with neurodegenerative diseases are described: 1. Research should focus on robust study designs, namely RCTs, to test approaches for the prevention of complications and maintenance of periimplant tissue health. This research should include validated approaches for objectively measuring the effectiveness of therapies with dental implants. 2. A minimum number of dental implants should be used to restore the oral function of patients with neurodegenerative diseases. Increasing the number of dental implants might also increase the probability of further complications, such as
© 2013 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd
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C. M. Faggion Jr.
peri-implantitis. Older patients seem to prefer removable prostheses29, due to the easier access for cleaning. For example, a strategy of using an overdenture supported by two implants placed in the intraforaminal area seems to be acceptable for restoring function in the edentulous mandible. 3. Systematic dental care is necessary in nursing homes, to prevent mucositis and further periimplantitis in patients with NDDs. Caregivers in nursing homes require professional training, especially regarding the maintenance of dental implants. A recommendation might be that dental professionals having good experience with dental implants periodically visit nursing homes to assess the needs of patients and train caregivers.
References 1. Brown RC, Lockwood AH, Sonawane BR. Neurodegenerative diseases: an overview of environmental risk factors. Environ Health Perspect 2005; 113: 1250–6. 2. Berr C, Wancata J, Ritchie K. Prevalence of dementia in the elderly in Europe. Eur Neuropsychopharmacol 2005; 15: 463–71. 3. von Campenhausen S, Bornschein B, Wick R, B€ otzel K, Sampaio C, Poewe W et al. Prevalence and incidence of Parkinson’s disease in Europe. Eur Neuropsychopharmacol 2005; 15: 473–90. 4. Corrada MM, Brookmeyer R, Paganini-Hill A, Berlau D, Kawas CH. Dementia incidence continues to increase with age in the oldest old: the 90+ study. Ann Neurol 2010; 67: 114–21. 5. Pjetursson BE, Br€ agger U, Lang NP, Zwahlen M. Comparison of survival and complication rates of tooth-supported fixed dental prostheses (FDPs) and implant-supported FDPs and single crowns (SCs). Clin Oral Implants Res 2007; 18 (Suppl 3): 97–113. 6. Jung RE, Pjetursson BE, Glauser R, Zembic A, Zwahlen M, Lang NP. A systematic review of the 5year survival and complication rates of implant-supported single crowns. Clin Oral Implants Res 2008; 19: 119– 30. 7. Ho PM, Peterson PN, Masoudi FA. Evaluating the evidence: is there a rigid hierarchy? Circulation 2008; 118: 1675–84. 8. Higgins JP, Altman DG, Gøtzsche PC, J€ uni P, Moher D, Oxman AD
Conclusion The lack of RCTs and other controlled trials suggests that the placement of dental implants in patients with NDDs is a forgotten issue in dentistry. Although most of the included reports showed positive effects for the use of dental implants in patients with NDDs, they provided only lowlevel evidence. Therefore, more robust research is needed to assess the effectiveness and adverse events of the use of dental implants in these populations.
Conflict of interest The author declares he has no conflict of interests.
et al.; Cochrane Bias Methods Group; Cochrane Statistical Methods Group. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ 2011; 343: d5928. 9. W€ achter R, Kartun D, Fabinger A, Krekeler G, Schilli W. Dentale Implantate als wesentlicher Bestandteil der Rehabilitation neurologischer und geriatrischer Problempatienten. Zeitschrift f€ ur Zahn€arztliche Implantologie 1996; 12: 212–7. 10. Applebaum GM, Langsam BW, Huba G. The implant retained UCLA-type clip bar overdenture. A solution to the mandibular edentulous patient affected by Parkinson’s disease. Oral Health 1997; 87: 65–7. 11. Jackowski J, Andrich J, K€ appeler H, Z€ ollner A, J€ ohren P, M€ uller T. Implant-supported denture in a patient with Huntington’s disease: interdisciplinary aspects. Spec Care Dentist 2001; 21: 15–20. 12. Chu FC, Deng FL, Siu AS, Chow TW. Implant-tissue supported, magnet-retained mandibular overdenture for an edentulous patient with Parkinson’s disease: a clinical report. J Prosthet Dent 2004; 91: 219–22. 13. Kubo K, Kimura K. Implant surgery for a patient with Parkinson’s disease controlled by intravenous midazolam: a case report. Int J Oral Maxillofac Implants 2004; 19: 288–90. 14. Laidlaw LA. The impact of dementia on the care of dental implants: a case report. J Disabil Oral Health 2010; 11:192–4. 15. Deniz E, Kokat AM, Noyan A. Implant-supported overdenture in an
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elderly patient with Huntington’s disease. Gerodontology 2011; 28: 157– 60. Deliberador TM, Marengo G, Scaratti R, Giovanini AF, Zielak JC, Baratto Filho F. Accidental aspiration in a patient with Parkinson’s disease during implant-supported prosthesis construction: a case report. Spec Care Dentist 2011; 31: 156–61. Heckmann SM, Heckmann JG, Weber HP. Clinical outcomes of three Parkinson’s disease patients treated with mandibular implant overdentures. Clin Oral Implants Res 2000; 11: 566–71. Packer M, Nikitin V, Coward T, Davis DM, Fiske J. The potential benefits of dental implants on the oral health quality of life of people with Parkinson’s disease. Gerodontology 2009; 26: 11–8. Visser A, de Baat C, Hoeksema AR, Vissink A. Oral implants in dependent elderly persons: blessing or burden? Gerodontology 2011; 28: 76–80. Oczakir C, Balmer S, MericskeStern R. Implant-prosthodontic treatment for special care patients: a case series study. Int J Prosthodont 2005; 18: 383–9. Hoehn MM, Yahr MD. Parkinsonism: onset, progression and mortality. Neurology 1967; 17: 427–42. NICE guidelines. Dementia: A NICESCIE Guideline on Supporting People With Dementia and Their Carers in Health and Social Care, 2007. Editors National Collaborating Centre for Mental Health (UK). Source Leicester (UK): British Psychological Soci-
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Dental implants and neurodegenerative diseases ety; 2007. National Institute for Health and Clinical Excellence. 23. Bouchard P, Renouard F, Bourgeois D, Fromentin O, Jeanneret MH, Beresniak A. Cost-effectiveness modeling of dental implant vs. bridge. Clin Oral Implants Res 2009; 20: 583–7. 24. Faggion CM Jr, Chambrone L, Listl S, Tu YK. Network metaanalysis for evaluating interventions in implant dentistry: the case of peri-implantitis treatment. Clin Implant Dent Relat Res 2013; 15: 576– 88. 25. Engfors I, Ortorp A, Jemt T. Fixed implant-supported prostheses in elderly patients: a 5-year retrospective study of 133 edentulous patients older than 79 years. Clin Implant Dent Relat Res 2004; 6: 190–8.
26. Schembri A, Fiske J. Oral health and dental care facilities in Maltese residential homes. Gerodontology 2005; 22: 143–50. 27. Smith BJ, Ghezzi EM, Manz MC, Markova CP. Perceptions of oral health adequacy and access in Michigan nursing facilities. Gerodontology 2008; 25: 89–98. 28. Rabbo MA, Mitov G, Gebhart F, Pospiech P. Dental care and treatment needs of elderly in nursing homes in Saarland: perceptions of the homes managers. Gerodontology 2012; 29: e57–62. 29. Feine JS, de Grandmont P, Boudrias P, Brien N, LaMarche C, Tach eR et al. Within-subject comparisons of implant-supported mandibular prostheses: choice of prosthesis. J Dent Res 1994; 73: 1105–11.
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30. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009; 6: e1000097.
Correspondence to: Clovis Mariano Faggion Jr, Department of Periodontology, Faculty of Dentistry, University of Mu¨nster, Waldeyerstrabe 30, 48149 M€ unster, Germany. Tel.: +49 251 83 47061 Fax: +49 251 83 47134 E-mail: clovisfaggion@yahoo. com
© 2013 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd
