Dental Implants in an Aged Population: Evaluation of Periodontal Health, Bone Loss, Implant Survival, and Quality of Life William Becker, DDS, MSD;* Philippe Hujoel, DDS, MS, PhD;† Burton E. Becker, DDS;‡ Peter Wohrle, DDS, MMSc§ ABSTRACT Purpose: To evaluate aged partially and fully edentulous patients who received dental implants and were maintained over time. Further, to determine how the partially and edentulous ageing populations (65 and above) with dental implants maintain bone levels, proper oral hygiene, and perceive benefits of dental implants. Materials and Methods: Since 1995, patients receiving dental implants have been prospectively entered into an Access-based computerized program (Triton Tacking System). Patient demographics (age, sex), bone quality, quantity, implant location, and type of surgery have been continuously entered into the database. The database was queried for patients receiving implants (first stage) between 66 and 93 years of age. Thirty-one patients were within this age group. Twenty-five patients returned to the clinic for periodontal and dental implant evaluation. The Periodontal Index was used to evaluate selected teeth in terms of probing depth, bleeding on probing, plaque accumulation, and mobility. Using NIH Image J, radiographs taken at second stage and last examination were measured for changes in interproximal bone levels. Once identified, each patient anomalously filled out an abbreviated quality of health life form. Due to small sample size, descriptive statistics were used to compare clinical findings. Results: Fifteen males ranging from 78 to 84 (mean age 84 years) years and 16 females from 66 to 93 (mean age 83 years) (age range 66–93) were contacted by phone or mail and asked to return to our office for a re-examination. For this group, the first dental implants were placed in 1996 (n = initial two implants) and continuously recorded through 2013 (n = last seven implants). Thirty-one patients received a total of 84 implants. Two patients were edentulous, and the remaining were partially edentulous. Four implants were lost. Between implant placement and 6- to 7-year interval, 13 patients with 40 implants had a cumulative survival rate of 94.6%. Of the original group (n = 33), three were deceased, two were in nursing homes, and three could not be located. Conclusions: Aged patients receiving dental implants had excellent implant survival rates, low periodontal disease index scores with minimal changes in interproximal bone levels. Results from this study indicate that patients with advanced age, in reasonably good health, have excellent implant survival rates, excellent quality of life scores, and can be maintained in good oral health. KEY WORDS: bone changes, elderly patients, implant survival, medications, periodontal health, quality of life
*Private Practice Limited to Periodontics and Dental Implants, Tucson, AZ, USA, clinical professor, University of Southern California, Los Angeles, CA, USA, Graduate Periodontics, University of Washington, Seattle, WA, USA, Affiliate Clinical Professor, Department of Graduate Periodontics, University of Washington, Seattle, Washington, USA; †Professor, Department of Oral Health Sciences, School of Dentistry, University of Washington, Seattle, WA, USA; ‡ Private Practice Limited to Periodontics and Dental Implants, Tucson, AZ, USA; §Private Practice Limited to Periodontics and Dental Implants, Newport Beach, CA, USA
INTRODUCTION The elderly population in the USA (>65 years) was 43.1 million in 2012. About one in every seven persons is considered an older American. Persons reaching 65 years of age have a life expectancy of an additional 19.2 years.1 In 2012, 44% of noninstitutionalized older persons assessed their health as excellent or very good. Most aged
Corresponding Author: Dr. William Becker, University of Southern California, 801 N. Wilmot, B2, Tucson, AZ 85711, USA; e-mail: [email protected]
© 2015 Wiley Periodicals, Inc.
Conflict of interest: Authors declare no conflicts of interest and corporate or other sponsorships.
DOI 10.1111/cid.12340
473 1
Clinical Implant Dentistry Related Research, Volume 18, Number 3, 2016 2474 Clinical Implant Dentistry andand Related Research, Volume *, Number *, 2015
persons have at least one chronic condition and many have multiple conditions. Between 2009 and 2011, the most frequently occurring conditions among older persons were diagnosed arthritis (51%), all types of heart disease (31%), any cancer (24%), diagnosed diabetes (20% in 2007–2010), and hypertension (high blood pressure or taking antihypertensive medication) (72% in 2007–2010). The elderly population will be candidates for quality dental care including replacement of single teeth, multiple teeth, or fully edentulous situations, and will be requesting dental implant supported restorations. A study compared oral health-related and general quality of life for seniors (aged 65–75 years) who received either mandibular implant over dentures or conventional dentures.2 Mandibular over dentures retained by two implants provided elderly patients with better oral health quality of life outcomes (OHQOL questionnaire) when compared with conventional dentures. Bryant and Zarb compared osseointegration in young and aged populations.3 A comparison was made between closely matched groups of 39 older adults who had 190 implants supporting 45 oral prostheses and 43 younger adults who had 184 implants supporting 45 oral prostheses. Patients were monitored for a period of 4 to 16 years after prosthetic loading. At the most recent follow-up, the cumulative implant success was 92.0% for the older group compared with 86.5% for the younger group. No statistical significance was attributed to the difference in implant survival between the groups throughout the study period. A review article evaluated success of dental implants in elderly patients.4 Two studies suggested that implants could be considered safe and predictable for older individuals. Three studies found no increased implant failure-rate in patients with a compromised medical status. Four studies revealed high success rates of dental implants among groups of elderly people. This literature review concluded that old age does not seem to represent a factor of major prognostic significance in treatment with dental implants. Another study evaluated changes in subjective oral health among patients receiving single dental implants.5 Ninety self-referred patients were enrolled in a study evaluating oral health impact of dental implants. The age of the patients ranged from 24 to 75 years. Patients received a total of 131 implants. Patients filled out the Oral Health Impact Profile before and after implant restoration. Implants were primarily placed in bicuspid and anterior sextants. Results indicate that implant
placement, especially in women, may significantly improve subjective oral health. Engfors and colleagues compared 133 edentulous patients who were 80 or more years of age and who were consecutively treated with fixed implant-supported prostheses between January 1986 and August 1998.6 A total of 761 Branemark System implants (Nobel Biocare AB, Göteborg, Sweden) were placed into 139 edentulous jaws. The control groups comprised 115 edentulous patients younger than 80 years and were treated consecutively from March 1996 to November 1997 with similar prostheses. In this group, 670 implants were placed in 118 edentulous jaws. The 5-year cumulative survival rate (CSR) for implants in the maxilla was 93.0% in the study group and 92.6% in the control group. The most common complications for patients in the study group were soft tissue inflammation (mucositis), cheek, and lip biting (p < .05). Resin veneer fractures were the most common complications for the control group. Overall 5-year marginal bone loss for the study group was 0.7 mm (standard deviation [SD] 0.45) in the upper jaw and 0.6 mm (SD 0.50) in the lower jaw. Differences in bone levels and bone loss between the two groups did not reach significant levels (p > .05). Implant treatment in elderly patients showed treatment results comparable with those observed in younger age groups. MATERIALS AND METHODS All patients included in this study signed treatment consent forms, and all care was within the guidelines of the Helsinki Accords.7 To identify elderly patients in a private practice, a database was queried (Triton) for patients receiving implants between 66 and 93 years of age. Thirty-one patients were identified. Bone grafting or sinus lifting were not performed in any patients included in this report. At the time of implant surgery, patient’s age, sex, bone quality and quantity,8 as well type of implant surgery, were entered into the Triton database. Fifteen males ranging in age between 78 and 89 years with an average age 84 years were identified. There were 16 females ranging in age from 66 to 93 years, with an average of 83 years. All implants were manufactured by Nobel Biocare, Yorba Linda, CA, USA and were either titanium turned implants (25), MKIII (11), Nobel Direct (1), TiUnite surfaced (41), or TiUinte Wide Platform (6). Thirty implants were placed using a flapless approach, 35 placed with a flapped two-stage approach, and 19 were placed with a flapless immediate
Dental Implants in Aged Population Dental Implants in Aged Population 4753
implant protocol. Fifty-four implants were placed in maxillae with a loss of two, and 30 implants were in mandibles with loss of two. Of the 31 patients, three have deceased, two are in living nursing homes, and two patients could not be located. Twenty-five patients were evaluated for periodontal health and radiographic marginal bone level changes. The radiographic measurements were taken at the second stage appointment (prior to implant restoration) and longest follow-up evaluation. Rationale for using second stage as radiographic baseline was 19 patients had immediate implant placement. Implants placed immediately after tooth extraction usually have observable bone deficiencies adjacent to the implants. Comparing bone measurements taken for implants placed in healed sites with those placed in extraction sites present confounding variables when evaluating bone level changes, since these deficiencies usually fill in with bone over time. Radiographic Evaluation Prior to implant restoration (second stage), a nonstandardized parallel long cone periapical radiograph was taken on all patients included in this study. Clinical radiographs were also at follow-up evaluations. Radiographs taken at second stage and at last examination were scanned (Epson Perfection V700 Photo, Epson America, 3840 Kilroy Airport Way, Long Beach, CA 90806) (300 dpi) and saved in a computer. Mesial and distal bone levels were measured using Image J.9 Measurements are based on implant length and were made from the bottom of the prosthetic table to the first bone to implant contact. Mesial–distal measurements were stored in a computer-based system. For each time interval, patient’s mesial–distal measurements were averaged.
for redness or tissue or mucosal lesions, or suppuration expressed on tissue palpation. Probing of tissues adjacent to implants without suspected pathology was not performed.13,14 In addition, a blinded seven-question quality of life questionnaire was sent to all patients evaluated. Twentyfive patients returned the quality of life questionnaire. Statistical Methods Due to small sample size, descriptive statistics were used to compare changes in clinical measurements (Table 3). Bone level changes, implant length and diameter, and average bone height were estimated using generalized linear models with an identity link and a Gaussian error taken into account the clustering of dental implants within patients (proc genmod). Kaplan–Meier survival probabilities were used to determine the implant survival table and are based on 31 patients with 84 implants.15 RESULTS Table 1 describes bone quality and quantity. Fifty-three implants were placed in bone shape A, with bone quality 2.16 Success and CSRs can be seen in Table 2. The 6- to 7-year interval was arbitrarily chosen as the cutoff for evaluation of implants survival and success rates. At 6 to 7 years, 13 patients with 40 implants were evaluated. The CSR was 94.6%. Patients lost to follow-up were assumed to have no failures. There were four implant failures. Three lost implants had a TiUnite surface (Nobel Biocare); one had a smooth, turned surface. One implant was lost 4 months after placement (early failure), one after 1 year, 1 after 3 years, and one after 5 years (smooth, turned surface). Twenty-five patients
Clinical Evaluation Periodontal evaluation was based on Periodontal Disease Index10 measurements. For natural teeth present, probing depth, plaque, bleeding on probing, and mobility were evaluated.10–12 Mobility was evaluated for teeth measured in the Periodontal Disease Index. At second stage or prerestorative visit, using two-mouth mirror handles, mobility of implants that were uncovered or with healing abutments was assessed for mobility. At this visit, none of the implants were mobile. If one of the index teeth was missing, the contralateral tooth was measured. In addition to radiographic evaluation, implants were evaluated for mobility, visual evaluation
TABLE 1 Bone Ridge Shape and Bone Quality for Aged Patient Population* Quality
A
B
C
D
Total
1 2 3 4 Total
0 49 3 0 52
2 24 0 0 26
0 1 5 0 6
0 0 0 0 0
2 74 8 0 84
*Classification of ridge shape: Quality A, most of alveolar ridge is present; Quality B, moderate ridge resorption; Quality C, advanced residual ridge resorption; Quality D, some resorption of basal bone; Quality E, extreme resorption of basal bone.16
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TABLE 2 Survival and Success Rates for Implants Placed in 31 Aged Patients Time Period
0 years 0–1 years 1–2 years 2–3 years 3–4 years 4–5 years 5–6 years 6–7 years
Patients
Implants
Lost
Success Rate
Cumulative Survival Rate
31 31 27 22 21 18 16 13
84 81 75 64 61 56 49 40
1 1 1 0 0 1 0 0
98.8 96.8 98.7 100 100 98.2 100 100
98.8 97.6 96.3 96.3 96.3 94.6 94.6 94.6
From implant insertion through 6 to 7 years. Based on all treated patients treated and all placed implants.
were examined and interviewed. Descriptive data obtained using the Periodontal Disease Index exam can be seen in Table 3.10 The mean age was 89.41 years; mean probing depth for 25 examined were statistically insignificant. The number of medications taken for patients ranged between 5 and 19 (average 5.3). Comparison of measured bone levels between a previously reported control group17 was made with the aged group for implant length and width, crestal bone levels at implant insertion, and longest follow-up and change in bone height. Changes between control and aged groups were significant only for implant diameter, with the aged group having significantly wider implants placed when compared with the younger group.17 All other changes were statistically insignificant (Table 4). A seven-question short form quality of oral health questionnaire was mailed to 25 patients.18–20 Question 7 was added to the form and related to dental implants. Twenty-five patients anonymously returned the sevenquestion survey (Table 5). Most patients classified themselves as having a good quality of life with minimal distress from eating, relaxing, and socially engaging with
others. Relating to improved oral health with dental implants, 15 patients did not perceive a change in quality of life, while eight had improvement oral health. DISCUSSION Despite continued interest in dental implants and high implant survival rates, dental implants appear to be minimally used in elderly patients. There are demographic trends toward increasing populations of elderly in need of dental care.21 It is interesting to note that there are only two fully edentulous patients included in this study, while the remaining patients were partially edentulous. Elderly patients in reasonably good health not only want to eat and function in comfort, but are also interested in esthetics. It has been previously demonstrated that advanced age is not necessarily a contraindication for dental implant placement and osseointegration, and success is not entirely dependent upon oral hygiene.22,23 Patients in this study were generally were in good health with excellent bone quality and quantity and did not require bone augmentation. There is sufficient evidence that placement of dental implants
TABLE 3 Descriptive Data Derived from Periodontal Disease Index Variable
N
Mean
Standard Deviation
Minimum
Maximum
Number of teeth Probing pocket depth Plaque index Bleeding index Mobility Age Number of medications
25 25 25 25 25 24 25
5.3 2.6 1.1 0.6 0.2 89.4 5.3
1.1 0.3 1.0 0.7 0.4 4.5 5.1
3 2.0 0 0 0 82 0
7 3.3 3.0 3.1 1.5 98 19
Dental Implants in Aged Population Dental Implants in Aged Population 4775
TABLE 4 Comparisons between Age Groups for Implant Diameter Implant Length, Average Bone Height at Second Stage, and Last Follow-Up Visit in mm and Average Change in Bone Height (mm) between Examination Intervals
Implant diameter (mm) Implant length (mm) Average bone height baseline (mm) Average bone height second visit (mm) Change in bone height (mm)
Young Patients
Aged Patients
p Value
3.8 11.9 11.8 11.3 −0.4
4.1 11.5 11.6 11.6 −0.1
.007 .4684 .6957 .5732 .0843
for anchorage of varying types of prosthetic restorations enhances the lives of geriatric patients, and success is not entirely dependent on oral hygiene. Elderly patients adapt poorly to complete dentures and can improve nutrition and digestion when restored with dental implants. One study recruited patients from a geriatric hospital, private clinic, and a long-term care facility.24 The average age of the patients was 81 years. Patients answered questions related to attitudes toward dental implants. The strongest apprehensions against implants were cost, lack of perceived necessity, and old age. One of the conclusions of the study was aged patients should be educated about the benefits of dental implants. Results of this study indicate that implants placed in an aged population (>66 years of age) have excellent clinical outcomes in terms of implant survival and maintenance of periodontal health with minimal longterm loss of interproximal bone levels. Radiographic evaluations together with absence of implant mobility are important indicators of implant success.13 Others reported successful clinical outcomes for edentulous, elderly patients with dental implants.23 Their conclusions indicate that age alone does not preclude implant placement and restoration and that successful osseointegration can be maintained. We used a short form oral health quality of life questionnaire. All patients (n = 25) who returned for periodontal and implant evaluation anonymously filled out the form. The forms were based on a conceptual model of oral health and quality of life and were related to physical function, social function, distress, and worry.25 We added one question relating to dental implants (question 7). Overall, 25 patients have positive personal and social lifestyles, while eight of 25 had positive improvement of oral health as a result of having dental implants.
One of the primary problems encountered when evaluating an elderly population with dental implants is accounting for all patients initially included within the study. Others have also reported this problem.6,26 Kowar and colleagues reported 33% of the patients were lost to follow-up. Reasons for patient drop out were death, disease, or noncompliance. In the present study, 24% (eight out of 33 of the patients) were lost to follow-up. At 6- to 7-year follow-up the cumulative implant survival rate was 94.6%. This survival rate is comparable with that reported by others (93.9%) for maxillary implants and 99.3% for mandibular implants.26 It is important to note that the database used to track patients and dental implants is a locked system. This assumes patients lost to follow-up have not lost implants. This assumption may result in an overestimation of implant survival. The database system does not allow for arbitrary removal of patients or implants without verification of patient death. In the present study, probing depth adjacent to natural teeth, plaque scores, and implant bone level measurements were consistent with maintenance of health around their remaining natural teeth and implants. Others investigated using implants to replace missing teeth for elderly patients living in supportive care facilities.27 Twenty-six patients older than 65 years of age were evaluated for number of retained teeth and implants, plaque scores, bleeding, and general oral hygiene habits. One hundred forty-four implants and 148 periodontal conditions surrounding natural teeth were evaluated. No correlations were evident between oral hygiene habits, plaque scores, or bleeding. Tissues around implants were healthier than around evaluated teeth. One shortcoming of the present study was the limited number of patients available for evaluation. Since only two patients within this study were fully edentulous, reported findings are primarily related to partially edentulous patients. Further, use of
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TABLE 5 Oral Health Questionnaire and Answers Based on 25 Patient Responses 1. Have you had to avoid eating some foods? a. Never 17 b. Hardly ever 5 c. Occasionally 3 d. Fairly often 0 e. Very often 0 2. Have you found it difficult to relax? a. Never 17 b. Hardly ever 5 c. Occasionally 3 d. Fairly often 0 e. Very often 0 3. Have you avoided going out? a. Never 22 b. Hardly ever 2 c. Occasionally 1 d. Fairly often 0 e. Very 0 4. Have you felt nervous or self-conscious? a. Never 19 b. Sometimes 5 c. Always 1 5. How much pain or distress has your teeth or gums caused you? a. None at all 15 b. A little bit 8 c. Some 1 d. A great deal 1 6. Have you had uncomfortable bridges, partials or dentures? a. Never 15 b. Hardly ever 3 c. Occasionally 5 d. Fairly often 2 7. Since having dental implants has your oral health? a. Stayed the same 15 b. Improved a little 2 c. Improved considerably 8 d. No improvement 0
the Ramfjord Index10 provided limited information on the entire periodontal conditions of the studied patients. A recent report indicated that periodontitis prevalence could be estimated with limited bias when a half-mouth four sites protocol is used when Center for Disease Control and Prevention/American Academy of Periodontology case definitions are used.28
CONCLUSIONS With careful diagnosis and treatment planning, aged patients are excellent candidates for dental implants.29 Caution must be exercised, as many of these patients are taking multiple medications. Where appropriate, consultations with patients’ physicians are suggested. Changes in bone levels are comparable with younger populations, and oral hygiene scores were indicative of excellent oral hygiene.
REFERENCES 1. A profile of Older Americans: 2014 – Administration on Ageing. Administration for Community Living. U.S. Department of Health & Human Services. http://www.aoa.acl.gov/ Aging_Statistics/Profile/2014/docs/2014-Profile.pdf 2. Kuoppala R, Napankangas R, Raustia A. Quality of life of patients treated with implant-supported mandibular overdentures evaluated with the Oral Health Impact Profile (OHIP-14): a survey of 58 patients. J Oral Maxillofac Res 2013; 4:e4. 3. Bryant SR, Zarb GA. Osseointegration of oral implants in older and younger adults. Int J Oral Maxillofac Implants 1998; 13:492–499. 4. de Baat C. Success of dental implants in elderly people – a literature review. Gerodontology 2000; 17:45–48. 5. Ponsi J, Lahti S, Rissanen H, Oikarinen K. Change in subjective oral health after single dental implant treatment. Int J Oral Maxillofac Implants 2011; 26:571–577. 6. 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; 6:190–198. 7. Schuklenk U. Helsinki declaration revisions. Issues Med Ethics 2001; 9:194–197. 8. Lekholm U, Zarb GA. Patient selection and preparation. In: Branemark P I, Zarb GA, Albrektsson T, eds. Tissue integrated prosthesis: osseointegration in clinical dentistry. Chicago: Quintessence Publishing Company, 1985:199– 209. 9. Schneider CA, Rasband WS, Eliceiri KW. NIH Image to ImageJ: 25 years of image analysis. Nat Methods 2012; 9:671– 675. 10. Ramfjord SP. The periodontal disease index (PDI). J Periodontol 1967; 38(6 Suppl):602–610. 11. Loe H. The Gingival Index, the Plaque Index and the Retention Index Systems. J Periodontol 1967; 38(6 Suppl):610– 616. 12. O’Leary T. Indices for measurement of tooth mobility in clinical studies. J Dent Res 1974; 9(Suppl):94–99. 13. Mombelli A, Lang NP. Clinical parameters for the evaluation of dental implants. Periodontol 2000 1994; 4:81–86.
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14. Eskow RN, Smith VS. Implant complications related to maintenance therapy. In: Froum S, ed. Dental implant complications. 1st ed. Singapore: Wiley-Blackwell, 2010:415– 438. 15. Campos-Filho N, Franco EL. Microcomputer-assisted univariate survival data analysis using Kaplan-Meier life table estimators. Comput Methods Programs Biomed 1988; 27:223–228. 16. Branemark PI, Zarb GA, Albrektsson T, eds. Tissueintegrated prostheses. 1st ed. Chicago: Quintessence, 1985. 17. Becker W, Hujoel P, Becker BE, Wohrle P. Survival rates and bone level changes around porous oxide-coated implants (TiUnite). Clin Implant Dent Relat Res 2013; 15:654–660. 18. Slade GD, Spencer AJ. Development and evaluation of the Oral Health Impact Profile. Community Dent Health 1994; 11:3–11. 19. Atchison KA, Dolan TA. Development of the geriatric oral health assessment index. J Dent Educ 1990; 54:680–687. 20. Kressin NR. Symposium on self-reported assessments of oral health outcomes. Introduction. J Dent Educ 1996; 60:485– 487. 21. Kondell PA, Nordenram A, Landt H. Titanium implants in the treatment of edentulousness: influence of patient’s age on prognosis. Gerodontics 1988; 4:280–284.
22. Zarb GA, Schmitt A. Implant therapy alternatives for geriatric edentulous patients. Gerodontology 1993; 10:28–32. 23. Zarb GA, Schmitt A. Osseointegration for elderly patients: the Toronto study. J Prosthet Dent 1994; 72:559–568. 24. Muller F, Salem K, Barbezat C, Herrmann FR, Schimmel M. Knowledge and attitude of elderly persons towards dental implants. Gerodontology 2012; 29:e914–e923. 25. Kressin NR, Atchison KA, Miller DR. Comparing the impact of oral disease in two populations of older adults: application of the geriatric oral health assessment index. J Public Health Dent 1997; 57:224–232. Fall. 26. Kowar J, Stenport V, Jemt T. Mortality patterns in partially edentulous and edentulous elderly patients treated with dental implants. Int J Prosthodont 2014; 27:250–256. 27. Olerud E, Hagman-Gustafsson ML, Gabre P. Oral status, oral hygiene, and patient satisfaction in the elderly with dental implants dependent on substantial needs of care for daily living. Spec Care Dentist 2012; 32:49–54. 28. Tran DT, Gay I, Du XL, et al. Assessment of partial-mouth periodontal examination protocols for periodontitis surveillance. J Clin Periodontol 2014; 41:846–852. 29. Stanford CM. Dental implants. A role in geriatric dentistry for the general practice? J Am Dent Assoc 2007; 138(Suppl):34S–40S.
*Private Practice Limited to Periodontics and Dental Implants, Tucson, AZ, USA, clinical professor, University of Southern California, Los Angeles, CA, USA, Graduate Periodontics, University of Washington, Seattle, WA, USA, Affiliate Clinical Professor, Department of Graduate Periodontics, University of Washington, Seattle, Washington, USA; †Professor, Department of Oral Health Sciences, School of Dentistry, University of Washington, Seattle, WA, USA; ‡ Private Practice Limited to Periodontics and Dental Implants, Tucson, AZ, USA; §Private Practice Limited to Periodontics and Dental Implants, Newport Beach, CA, USA
INTRODUCTION The elderly population in the USA (>65 years) was 43.1 million in 2012. About one in every seven persons is considered an older American. Persons reaching 65 years of age have a life expectancy of an additional 19.2 years.1 In 2012, 44% of noninstitutionalized older persons assessed their health as excellent or very good. Most aged
Corresponding Author: Dr. William Becker, University of Southern California, 801 N. Wilmot, B2, Tucson, AZ 85711, USA; e-mail: [email protected]
© 2015 Wiley Periodicals, Inc.
Conflict of interest: Authors declare no conflicts of interest and corporate or other sponsorships.
DOI 10.1111/cid.12340
473 1
Clinical Implant Dentistry Related Research, Volume 18, Number 3, 2016 2474 Clinical Implant Dentistry andand Related Research, Volume *, Number *, 2015
persons have at least one chronic condition and many have multiple conditions. Between 2009 and 2011, the most frequently occurring conditions among older persons were diagnosed arthritis (51%), all types of heart disease (31%), any cancer (24%), diagnosed diabetes (20% in 2007–2010), and hypertension (high blood pressure or taking antihypertensive medication) (72% in 2007–2010). The elderly population will be candidates for quality dental care including replacement of single teeth, multiple teeth, or fully edentulous situations, and will be requesting dental implant supported restorations. A study compared oral health-related and general quality of life for seniors (aged 65–75 years) who received either mandibular implant over dentures or conventional dentures.2 Mandibular over dentures retained by two implants provided elderly patients with better oral health quality of life outcomes (OHQOL questionnaire) when compared with conventional dentures. Bryant and Zarb compared osseointegration in young and aged populations.3 A comparison was made between closely matched groups of 39 older adults who had 190 implants supporting 45 oral prostheses and 43 younger adults who had 184 implants supporting 45 oral prostheses. Patients were monitored for a period of 4 to 16 years after prosthetic loading. At the most recent follow-up, the cumulative implant success was 92.0% for the older group compared with 86.5% for the younger group. No statistical significance was attributed to the difference in implant survival between the groups throughout the study period. A review article evaluated success of dental implants in elderly patients.4 Two studies suggested that implants could be considered safe and predictable for older individuals. Three studies found no increased implant failure-rate in patients with a compromised medical status. Four studies revealed high success rates of dental implants among groups of elderly people. This literature review concluded that old age does not seem to represent a factor of major prognostic significance in treatment with dental implants. Another study evaluated changes in subjective oral health among patients receiving single dental implants.5 Ninety self-referred patients were enrolled in a study evaluating oral health impact of dental implants. The age of the patients ranged from 24 to 75 years. Patients received a total of 131 implants. Patients filled out the Oral Health Impact Profile before and after implant restoration. Implants were primarily placed in bicuspid and anterior sextants. Results indicate that implant
placement, especially in women, may significantly improve subjective oral health. Engfors and colleagues compared 133 edentulous patients who were 80 or more years of age and who were consecutively treated with fixed implant-supported prostheses between January 1986 and August 1998.6 A total of 761 Branemark System implants (Nobel Biocare AB, Göteborg, Sweden) were placed into 139 edentulous jaws. The control groups comprised 115 edentulous patients younger than 80 years and were treated consecutively from March 1996 to November 1997 with similar prostheses. In this group, 670 implants were placed in 118 edentulous jaws. The 5-year cumulative survival rate (CSR) for implants in the maxilla was 93.0% in the study group and 92.6% in the control group. The most common complications for patients in the study group were soft tissue inflammation (mucositis), cheek, and lip biting (p < .05). Resin veneer fractures were the most common complications for the control group. Overall 5-year marginal bone loss for the study group was 0.7 mm (standard deviation [SD] 0.45) in the upper jaw and 0.6 mm (SD 0.50) in the lower jaw. Differences in bone levels and bone loss between the two groups did not reach significant levels (p > .05). Implant treatment in elderly patients showed treatment results comparable with those observed in younger age groups. MATERIALS AND METHODS All patients included in this study signed treatment consent forms, and all care was within the guidelines of the Helsinki Accords.7 To identify elderly patients in a private practice, a database was queried (Triton) for patients receiving implants between 66 and 93 years of age. Thirty-one patients were identified. Bone grafting or sinus lifting were not performed in any patients included in this report. At the time of implant surgery, patient’s age, sex, bone quality and quantity,8 as well type of implant surgery, were entered into the Triton database. Fifteen males ranging in age between 78 and 89 years with an average age 84 years were identified. There were 16 females ranging in age from 66 to 93 years, with an average of 83 years. All implants were manufactured by Nobel Biocare, Yorba Linda, CA, USA and were either titanium turned implants (25), MKIII (11), Nobel Direct (1), TiUnite surfaced (41), or TiUinte Wide Platform (6). Thirty implants were placed using a flapless approach, 35 placed with a flapped two-stage approach, and 19 were placed with a flapless immediate
Dental Implants in Aged Population Dental Implants in Aged Population 4753
implant protocol. Fifty-four implants were placed in maxillae with a loss of two, and 30 implants were in mandibles with loss of two. Of the 31 patients, three have deceased, two are in living nursing homes, and two patients could not be located. Twenty-five patients were evaluated for periodontal health and radiographic marginal bone level changes. The radiographic measurements were taken at the second stage appointment (prior to implant restoration) and longest follow-up evaluation. Rationale for using second stage as radiographic baseline was 19 patients had immediate implant placement. Implants placed immediately after tooth extraction usually have observable bone deficiencies adjacent to the implants. Comparing bone measurements taken for implants placed in healed sites with those placed in extraction sites present confounding variables when evaluating bone level changes, since these deficiencies usually fill in with bone over time. Radiographic Evaluation Prior to implant restoration (second stage), a nonstandardized parallel long cone periapical radiograph was taken on all patients included in this study. Clinical radiographs were also at follow-up evaluations. Radiographs taken at second stage and at last examination were scanned (Epson Perfection V700 Photo, Epson America, 3840 Kilroy Airport Way, Long Beach, CA 90806) (300 dpi) and saved in a computer. Mesial and distal bone levels were measured using Image J.9 Measurements are based on implant length and were made from the bottom of the prosthetic table to the first bone to implant contact. Mesial–distal measurements were stored in a computer-based system. For each time interval, patient’s mesial–distal measurements were averaged.
for redness or tissue or mucosal lesions, or suppuration expressed on tissue palpation. Probing of tissues adjacent to implants without suspected pathology was not performed.13,14 In addition, a blinded seven-question quality of life questionnaire was sent to all patients evaluated. Twentyfive patients returned the quality of life questionnaire. Statistical Methods Due to small sample size, descriptive statistics were used to compare changes in clinical measurements (Table 3). Bone level changes, implant length and diameter, and average bone height were estimated using generalized linear models with an identity link and a Gaussian error taken into account the clustering of dental implants within patients (proc genmod). Kaplan–Meier survival probabilities were used to determine the implant survival table and are based on 31 patients with 84 implants.15 RESULTS Table 1 describes bone quality and quantity. Fifty-three implants were placed in bone shape A, with bone quality 2.16 Success and CSRs can be seen in Table 2. The 6- to 7-year interval was arbitrarily chosen as the cutoff for evaluation of implants survival and success rates. At 6 to 7 years, 13 patients with 40 implants were evaluated. The CSR was 94.6%. Patients lost to follow-up were assumed to have no failures. There were four implant failures. Three lost implants had a TiUnite surface (Nobel Biocare); one had a smooth, turned surface. One implant was lost 4 months after placement (early failure), one after 1 year, 1 after 3 years, and one after 5 years (smooth, turned surface). Twenty-five patients
Clinical Evaluation Periodontal evaluation was based on Periodontal Disease Index10 measurements. For natural teeth present, probing depth, plaque, bleeding on probing, and mobility were evaluated.10–12 Mobility was evaluated for teeth measured in the Periodontal Disease Index. At second stage or prerestorative visit, using two-mouth mirror handles, mobility of implants that were uncovered or with healing abutments was assessed for mobility. At this visit, none of the implants were mobile. If one of the index teeth was missing, the contralateral tooth was measured. In addition to radiographic evaluation, implants were evaluated for mobility, visual evaluation
TABLE 1 Bone Ridge Shape and Bone Quality for Aged Patient Population* Quality
A
B
C
D
Total
1 2 3 4 Total
0 49 3 0 52
2 24 0 0 26
0 1 5 0 6
0 0 0 0 0
2 74 8 0 84
*Classification of ridge shape: Quality A, most of alveolar ridge is present; Quality B, moderate ridge resorption; Quality C, advanced residual ridge resorption; Quality D, some resorption of basal bone; Quality E, extreme resorption of basal bone.16
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TABLE 2 Survival and Success Rates for Implants Placed in 31 Aged Patients Time Period
0 years 0–1 years 1–2 years 2–3 years 3–4 years 4–5 years 5–6 years 6–7 years
Patients
Implants
Lost
Success Rate
Cumulative Survival Rate
31 31 27 22 21 18 16 13
84 81 75 64 61 56 49 40
1 1 1 0 0 1 0 0
98.8 96.8 98.7 100 100 98.2 100 100
98.8 97.6 96.3 96.3 96.3 94.6 94.6 94.6
From implant insertion through 6 to 7 years. Based on all treated patients treated and all placed implants.
were examined and interviewed. Descriptive data obtained using the Periodontal Disease Index exam can be seen in Table 3.10 The mean age was 89.41 years; mean probing depth for 25 examined were statistically insignificant. The number of medications taken for patients ranged between 5 and 19 (average 5.3). Comparison of measured bone levels between a previously reported control group17 was made with the aged group for implant length and width, crestal bone levels at implant insertion, and longest follow-up and change in bone height. Changes between control and aged groups were significant only for implant diameter, with the aged group having significantly wider implants placed when compared with the younger group.17 All other changes were statistically insignificant (Table 4). A seven-question short form quality of oral health questionnaire was mailed to 25 patients.18–20 Question 7 was added to the form and related to dental implants. Twenty-five patients anonymously returned the sevenquestion survey (Table 5). Most patients classified themselves as having a good quality of life with minimal distress from eating, relaxing, and socially engaging with
others. Relating to improved oral health with dental implants, 15 patients did not perceive a change in quality of life, while eight had improvement oral health. DISCUSSION Despite continued interest in dental implants and high implant survival rates, dental implants appear to be minimally used in elderly patients. There are demographic trends toward increasing populations of elderly in need of dental care.21 It is interesting to note that there are only two fully edentulous patients included in this study, while the remaining patients were partially edentulous. Elderly patients in reasonably good health not only want to eat and function in comfort, but are also interested in esthetics. It has been previously demonstrated that advanced age is not necessarily a contraindication for dental implant placement and osseointegration, and success is not entirely dependent upon oral hygiene.22,23 Patients in this study were generally were in good health with excellent bone quality and quantity and did not require bone augmentation. There is sufficient evidence that placement of dental implants
TABLE 3 Descriptive Data Derived from Periodontal Disease Index Variable
N
Mean
Standard Deviation
Minimum
Maximum
Number of teeth Probing pocket depth Plaque index Bleeding index Mobility Age Number of medications
25 25 25 25 25 24 25
5.3 2.6 1.1 0.6 0.2 89.4 5.3
1.1 0.3 1.0 0.7 0.4 4.5 5.1
3 2.0 0 0 0 82 0
7 3.3 3.0 3.1 1.5 98 19
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TABLE 4 Comparisons between Age Groups for Implant Diameter Implant Length, Average Bone Height at Second Stage, and Last Follow-Up Visit in mm and Average Change in Bone Height (mm) between Examination Intervals
Implant diameter (mm) Implant length (mm) Average bone height baseline (mm) Average bone height second visit (mm) Change in bone height (mm)
Young Patients
Aged Patients
p Value
3.8 11.9 11.8 11.3 −0.4
4.1 11.5 11.6 11.6 −0.1
.007 .4684 .6957 .5732 .0843
for anchorage of varying types of prosthetic restorations enhances the lives of geriatric patients, and success is not entirely dependent on oral hygiene. Elderly patients adapt poorly to complete dentures and can improve nutrition and digestion when restored with dental implants. One study recruited patients from a geriatric hospital, private clinic, and a long-term care facility.24 The average age of the patients was 81 years. Patients answered questions related to attitudes toward dental implants. The strongest apprehensions against implants were cost, lack of perceived necessity, and old age. One of the conclusions of the study was aged patients should be educated about the benefits of dental implants. Results of this study indicate that implants placed in an aged population (>66 years of age) have excellent clinical outcomes in terms of implant survival and maintenance of periodontal health with minimal longterm loss of interproximal bone levels. Radiographic evaluations together with absence of implant mobility are important indicators of implant success.13 Others reported successful clinical outcomes for edentulous, elderly patients with dental implants.23 Their conclusions indicate that age alone does not preclude implant placement and restoration and that successful osseointegration can be maintained. We used a short form oral health quality of life questionnaire. All patients (n = 25) who returned for periodontal and implant evaluation anonymously filled out the form. The forms were based on a conceptual model of oral health and quality of life and were related to physical function, social function, distress, and worry.25 We added one question relating to dental implants (question 7). Overall, 25 patients have positive personal and social lifestyles, while eight of 25 had positive improvement of oral health as a result of having dental implants.
One of the primary problems encountered when evaluating an elderly population with dental implants is accounting for all patients initially included within the study. Others have also reported this problem.6,26 Kowar and colleagues reported 33% of the patients were lost to follow-up. Reasons for patient drop out were death, disease, or noncompliance. In the present study, 24% (eight out of 33 of the patients) were lost to follow-up. At 6- to 7-year follow-up the cumulative implant survival rate was 94.6%. This survival rate is comparable with that reported by others (93.9%) for maxillary implants and 99.3% for mandibular implants.26 It is important to note that the database used to track patients and dental implants is a locked system. This assumes patients lost to follow-up have not lost implants. This assumption may result in an overestimation of implant survival. The database system does not allow for arbitrary removal of patients or implants without verification of patient death. In the present study, probing depth adjacent to natural teeth, plaque scores, and implant bone level measurements were consistent with maintenance of health around their remaining natural teeth and implants. Others investigated using implants to replace missing teeth for elderly patients living in supportive care facilities.27 Twenty-six patients older than 65 years of age were evaluated for number of retained teeth and implants, plaque scores, bleeding, and general oral hygiene habits. One hundred forty-four implants and 148 periodontal conditions surrounding natural teeth were evaluated. No correlations were evident between oral hygiene habits, plaque scores, or bleeding. Tissues around implants were healthier than around evaluated teeth. One shortcoming of the present study was the limited number of patients available for evaluation. Since only two patients within this study were fully edentulous, reported findings are primarily related to partially edentulous patients. Further, use of
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TABLE 5 Oral Health Questionnaire and Answers Based on 25 Patient Responses 1. Have you had to avoid eating some foods? a. Never 17 b. Hardly ever 5 c. Occasionally 3 d. Fairly often 0 e. Very often 0 2. Have you found it difficult to relax? a. Never 17 b. Hardly ever 5 c. Occasionally 3 d. Fairly often 0 e. Very often 0 3. Have you avoided going out? a. Never 22 b. Hardly ever 2 c. Occasionally 1 d. Fairly often 0 e. Very 0 4. Have you felt nervous or self-conscious? a. Never 19 b. Sometimes 5 c. Always 1 5. How much pain or distress has your teeth or gums caused you? a. None at all 15 b. A little bit 8 c. Some 1 d. A great deal 1 6. Have you had uncomfortable bridges, partials or dentures? a. Never 15 b. Hardly ever 3 c. Occasionally 5 d. Fairly often 2 7. Since having dental implants has your oral health? a. Stayed the same 15 b. Improved a little 2 c. Improved considerably 8 d. No improvement 0
the Ramfjord Index10 provided limited information on the entire periodontal conditions of the studied patients. A recent report indicated that periodontitis prevalence could be estimated with limited bias when a half-mouth four sites protocol is used when Center for Disease Control and Prevention/American Academy of Periodontology case definitions are used.28
CONCLUSIONS With careful diagnosis and treatment planning, aged patients are excellent candidates for dental implants.29 Caution must be exercised, as many of these patients are taking multiple medications. Where appropriate, consultations with patients’ physicians are suggested. Changes in bone levels are comparable with younger populations, and oral hygiene scores were indicative of excellent oral hygiene.
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