Dental Implants: A Treatment for the Geriatric Person

1. Dental Implants: A Treatment for the Geriatric Person Elizabeth S. Pilcher, D.M.D.

2. 2 Learning Objectives Upon completion of this module, the participant will be able to identify: 1. Basic clinical concepts of fixed and removable implant restorations. 2. Differences between dental implants, abutments and prostheses. 3. Risk factors associated with successful implant therapy for the older patient. 4. Advantages and disadvantages of dental implant therapy for the geriatric patient. 5. Factors that are relative contraindications and are absolute for implant therapy.

3. 3 Supplemental Word Documents The Glossary, References, Evaluation Form, Pre-Post Test and Answers for this module are located in a separate MS Word document.

4. 4 Dental Needs of Today’s Aging Population Today’s elderly population is: Experiencing an increase in life expectancy. Experiencing continued tooth loss and need for biologically sound dentition. Greater numbers of elderly seeking quality dental care. Traditional removable prostheses provide less patient satisfaction. Traditional removable prostheses contribute to long-term bone loss. Today, the aging population includes the elderly and the geriatric population. With the increase in life expectancy and overall improved quality of life in the current aging population, there is a greater demand for dental care. While there are fewer missing teeth in this population than in the past, replacement of missing teeth continues to be a concern. While fixed bridgework replaces a few missing teeth, removable, partial or complete dentures have been the treatment of choice for multiple missing teeth. Both removable, partial and complete dentures provide less patient satisfaction than a full complement of natural teeth. Prostheses provide less stability, chewing force and sensory input. Traditional removable partials and compete dentures contribute to long-term ridge resorption and less bony support of the jaws.Today, the aging population includes the elderly and the geriatric population. With the increase in life expectancy and overall improved quality of life in the current aging population, there is a greater demand for dental care. While there are fewer missing teeth in this population than in the past, replacement of missing teeth continues to be a concern. While fixed bridgework replaces a few missing teeth, removable, partial or complete dentures have been the treatment of choice for multiple missing teeth. Both removable, partial and complete dentures provide less patient satisfaction than a full complement of natural teeth. Prostheses provide less stability, chewing force and sensory input. Traditional removable partials and compete dentures contribute to long-term ridge resorption and less bony support of the jaws.

5. 5 Implants Can Transform Your Smile! Opening Activity: Watch what can happen to someone’s smile by utilizing implants in the restorative plan.Opening Activity: Watch what can happen to someone’s smile by utilizing implants in the restorative plan.

6. 6 Impact of Tooth Loss on Overall Health Edentulous patients eat fewer fresh fruits and vegetables. Edentulous patients have greater weight loss. Overall health of patient improves with improved masticatory ability. A full complement of teeth provides the elderly patient with the ability to masticate a variety of foods and will help improve the quality of their diet. With a varied and balanced diet, the overall health of the patient is improved.A full complement of teeth provides the elderly patient with the ability to masticate a variety of foods and will help improve the quality of their diet. With a varied and balanced diet, the overall health of the patient is improved.

7. 7 Replacement of Missing Teeth with Implant-Supported Fixed Crowns and Bridgework In the past, the patient above might have only been offered the option of a removable partial denture to replace the missing teeth. The implants and fixed crowns and bridgework that were fabricated for this patient will offer much greater stability and chewing satisfaction.In the past, the patient above might have only been offered the option of a removable partial denture to replace the missing teeth. The implants and fixed crowns and bridgework that were fabricated for this patient will offer much greater stability and chewing satisfaction.

8. 8 Implants Supporting Fixed Crown and Bridgework Implants can offer the additional benefit of eliminating long-span bridges. It is difficult to define what a long-span bridge is without identifying other parameters such as number of missing teeth, measurement of the span, occlusal forces and the condition of planned abutment teeth. Nevertheless, it is well known that a variety of situations can lead to early failure of fixed bridges. Multiple studies indicate that implant-supported restorations have a longer life expectancy than many compromised fixed bridge situations.1 Therefore, an edentulous area restored with one or multiple dental implants can be a better long term investment for the patient.Implants can offer the additional benefit of eliminating long-span bridges. It is difficult to define what a long-span bridge is without identifying other parameters such as number of missing teeth, measurement of the span, occlusal forces and the condition of planned abutment teeth. Nevertheless, it is well known that a variety of situations can lead to early failure of fixed bridges. Multiple studies indicate that implant-supported restorations have a longer life expectancy than many compromised fixed bridge situations.1 Therefore, an edentulous area restored with one or multiple dental implants can be a better long term investment for the patient.

9. 9 As more and more teeth are lost, the effect on the boney support is devastating. In the past, the client could only be offered the removable prostheses which frequently proved unsatisfactory and was not worn. As more and more teeth are lost, the effect on the boney support is devastating. In the past, the client could only be offered the removable prostheses which frequently proved unsatisfactory and was not worn.

10. 10 Edentulism’s Effect on the Bony Ridge of the Mandible With advancing edentulism, lack of teeth, the degree of bone in the mandible or lower jaw diminishes and traditional dentures become difficult to wear successfully. With advancing edentulism, lack of teeth, the degree of bone in the mandible or lower jaw diminishes and traditional dentures become difficult to wear successfully.

11. 11 Mandibular Overdentures Improve the stability and retention of the denture Can be placed over tooth roots or over implants Tooth roots provide sensory feedback but can decay or lose support due to periodontal disease or fracture Both tooth roots or implants will help retain the bone in the mandibular ridge

12. 12 Overdenture Abutments

13. 13 Removable ProsthesisSupported by Implants: Two Options Two categories of restorations can be described: Implant-Supported Overdenture - A removable prosthesis that is totally supported by implants and the attached superstructure. It derives no support from the mucosal tissue but may contact the tissue. 2) Implant-Assisted Overdenture - A removable prosthesis that has some support provided by the implants and the superstructure, but is also dependent on the mucosal tissue for support. Two categories of restorations can be described: Implant-Supported Overdenture - A removable prosthesis that is totally supported by implants and the attached superstructure. It derives no support from the mucosal tissue but may contact the tissue. 2) Implant-Assisted Overdenture - A removable prosthesis that has some support provided by the implants and the superstructure, but is also dependent on the mucosal tissue for support.

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15. 15 Implant Restoration OptionsFor Complete Overdentures 1. Implant-assisted restorations: The denture relies on some degree of support from the oral tissues or edentulous arches as well as the implants.

16. 16 Example of an implant-assisted denture. The denture gains support and retention from the two implants connected by a metal bar. Plastic clips help the denture attach to the implant bar. But the denture also relies on the posterior ridges of the mouth for support. Example of an implant-assisted denture. The denture gains support and retention from the two implants connected by a metal bar. Plastic clips help the denture attach to the implant bar. But the denture also relies on the posterior ridges of the mouth for support.

17. 17 This is also an implant assisted complete denture. The most common treatment of an edentulous patient with dental implants is the placement of two implants in the lower arch. The abutments in this case are pegs over which denture “O” ring attachments snap. The denture is removable by the patient, but provides much greater stability and retention than a traditional mandibular denture. Bone is also preserved in the mandible with this restorative treatment. This is also an implant assisted complete denture. The most common treatment of an edentulous patient with dental implants is the placement of two implants in the lower arch. The abutments in this case are pegs over which denture “O” ring attachments snap. The denture is removable by the patient, but provides much greater stability and retention than a traditional mandibular denture. Bone is also preserved in the mandible with this restorative treatment.

18. 18 Implant Restoration OptionsFor Complete Overdentures 2. Implant-supported restorations: The denture gains all of its support from the dental implants and attached structures.

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22. 22 Overdenture: Removable by Dentist

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24. 24 Concerns About Recommending Dental Implants for the Elderly Fact or Fiction… Longer healing time Inadequate osseointegration of implants Loss of implants due to inadequate oral hygiene Patient’s desire and expectations for dental implants may differ with age Are dental offices including the option of dental implants for elderly clients as frequently as they are for younger clients? Is there a perception that implants will not be as successful in the older population due to these unfounded concerns? Are dental offices including the option of dental implants for elderly clients as frequently as they are for younger clients? Is there a perception that implants will not be as successful in the older population due to these unfounded concerns?

25. 25 Patient’s Expectations Increased resistance to implant surgery - “I’m too old”. Long-term edentulous patients may be more tolerant to ill-fitting conventional dentures. Recommendations for implant-assisted restorations should occur early in edentulism. Elderly patients may take a greater period of time to adapt to a new prosthesis. Elderly patients who have been edentulous for a long period of time may be tolerant of ill-fitting, traditional dentures and not desire improved performance. Recommendations for implants should occur soon after teeth are lost. Patients that lose their teeth rapidly or at an early age will have more difficulty with traditional denture fit and comfort than a patient who has lost their teeth over a long period of time. Even with improved function, elderly patients may take a longer period of time to adapt to the new prostheses because the muscular learning process takes longer.Elderly patients who have been edentulous for a long period of time may be tolerant of ill-fitting, traditional dentures and not desire improved performance. Recommendations for implants should occur soon after teeth are lost. Patients that lose their teeth rapidly or at an early age will have more difficulty with traditional denture fit and comfort than a patient who has lost their teeth over a long period of time. Even with improved function, elderly patients may take a longer period of time to adapt to the new prostheses because the muscular learning process takes longer.

26. 26 Success Rate of Implant Placement Success rate of implants in the healthy elderly population is the same as that of younger age groups. Degree of osseointegration with healthy geriatric patients is comparable to that of the younger population.

27. 27 Mandibular Overdentures Improve the stability and retention of the denture. Can be placed over tooth roots or over implants. Tooth roots provide sensory feedback but can decay or lose support due to periodontal disease or fracture. Both tooth roots or implants will help retain the bone in the mandibular ridge.

28. 28 Tooth replacement with implant-supported or assisted dentures provides greater patient satisfaction with comfort and chewing. Stability and retention of denture is improved. Two categories of restorations can be described: Implant-Supported Overdenture - A removable prosthesis that is totally supported by implants and the attached superstructure. It derives no support from the mucosal tissue but may contact the tissue. 2) Implant-Assisted Overdenture - A removable prosthesis that has some support provided by the implants and the superstructure, but is also dependent on the mucosal tissue for support.Two categories of restorations can be described: Implant-Supported Overdenture - A removable prosthesis that is totally supported by implants and the attached superstructure. It derives no support from the mucosal tissue but may contact the tissue. 2) Implant-Assisted Overdenture - A removable prosthesis that has some support provided by the implants and the superstructure, but is also dependent on the mucosal tissue for support.

29. 29 Risk Factors for DentalImplant Success in the Elderly Oral Hygiene Xerostomia Cardiovascular disease Diabetes Osteoporosis Cancer Most patients who can tolerate any dental surgery are acceptable candidates for the implant placement surgery, but the use of implants in the treatment plan may carry substantial risk factors. Because it is important to know and recognize these risk factors, detailed medical history and evaluation are important prior to treatment. The success of implant therapy is greatly influenced by systemic conditions, and many older patients who are in need of this type treatment have one or more of these conditions. The overall health and well-being of the patient is of primary concern when treating this population.Most patients who can tolerate any dental surgery are acceptable candidates for the implant placement surgery, but the use of implants in the treatment plan may carry substantial risk factors. Because it is important to know and recognize these risk factors, detailed medical history and evaluation are important prior to treatment. The success of implant therapy is greatly influenced by systemic conditions, and many older patients who are in need of this type treatment have one or more of these conditions. The overall health and well-being of the patient is of primary concern when treating this population.

30. 30 Lessened Manual Dexterity and Visual Acuity May Affect Oral Self Care Oral Hygiene Success rate may be comparable to younger age groups when… Appropriate modifications of oral health aids are made. When adequate instruction and recall intervals are maintained. Less complicated designs of implant abutments are utilized. It is necessary to consider the patient's present and future ability to accomplish oral hygiene procedures. Elderly patients may have decreased manual dexterity and must be evaluated regarding their ability to maintain good oral health. In patients with decreased ability to perform adequate oral hygiene, design of an implant-assisted or -supported case may need to be simplified. Very complex cases have the potential to present hygiene problems in the future. It is necessary to consider the patient's present and future ability to accomplish oral hygiene procedures. Elderly patients may have decreased manual dexterity and must be evaluated regarding their ability to maintain good oral health. In patients with decreased ability to perform adequate oral hygiene, design of an implant-assisted or -supported case may need to be simplified. Very complex cases have the potential to present hygiene problems in the future.

31. 31 Xerostomia Salivary flow declines with age. Many medications prescribed to the elderly will reduce salivary flow. Condition enhances the accumulation of periopathogenic bacteria that could cause peri-implantitis. Oral tissues are more fragile and may cause difficulty wearing appliances that rest on oral mucosa. Implant-supported restorations may decrease the contact of traditional dentures on the oral mucosa.Implant-supported restorations may decrease the contact of traditional dentures on the oral mucosa.

32. 32 Cardiovascular Disease Dental implants are not contraindicated if the disease is controlled. Examples of cardiovascular disease include: Hypertension Angina pectoris Myocardial infarction (MI) Congestive heart failure Bacterial endocarditis Moderate to severe hypertension should be corrected prior to implant surgery. Mild hypertension may be controlled with anti-anxiety measures. Patients with angina should be treated in a hospital setting. Elective implant procedures should be delayed for a minimum of 12 months following the MI or until the patient's physician gives consent for implant surgery. Patients with congestive heart failure may be treated depending upon the severity of the disease. Patients with prosthetic heart valves, valvular damage or joint replacement may require systemic antibiotic prophylaxis prior to the placement of any dental implants.Moderate to severe hypertension should be corrected prior to implant surgery. Mild hypertension may be controlled with anti-anxiety measures. Patients with angina should be treated in a hospital setting. Elective implant procedures should be delayed for a minimum of 12 months following the MI or until the patient's physician gives consent for implant surgery. Patients with congestive heart failure may be treated depending upon the severity of the disease. Patients with prosthetic heart valves, valvular damage or joint replacement may require systemic antibiotic prophylaxis prior to the placement of any dental implants.

33. 33 Diabetes Patients with well-controlled diabetes can have successful implant therapy. In long term care settings, it is very important that the patient’s oral hygiene must be monitored. Patients are at greater risk of infection. Dental implants contraindicated in uncontrolled diabetics. Type I Diabetes has a higher risk factor then Type II Diabetes for implant therapy; however, neither is an absolute contraindication if the blood sugar level is controlled by diet and/or medication. Much of the long-term success of implant treatment in these patients is dependent upon the patient’s willingness and ability to manage his/her condition. Diabetic patients are at high risk for infection and in uncontrolled situations can demonstrate poor healing of infected sites. Complete denture wearers have a greater risk for ulceration of the oral tissues.Type I Diabetes has a higher risk factor then Type II Diabetes for implant therapy; however, neither is an absolute contraindication if the blood sugar level is controlled by diet and/or medication. Much of the long-term success of implant treatment in these patients is dependent upon the patient’s willingness and ability to manage his/her condition. Diabetic patients are at high risk for infection and in uncontrolled situations can demonstrate poor healing of infected sites. Complete denture wearers have a greater risk for ulceration of the oral tissues.

34. 34 Osteoporosis Potential for patients with osteoporosis have a greater risk of implant failure. Presence of osteoporosis in one site of the body does not mean it will affect another site. Evaluate bone density at the implant site. Osteoporosis is primarily a disease of long bones and tends not to affect the bones of the oral cavity.Osteoporosis is primarily a disease of long bones and tends not to affect the bones of the oral cavity.

35. 35 Oral Cancer Fifty percent of oral cancer is diagnosed in age 60 or older. Post-radiation and post-chemotherapy patients should be evaluated with care. Implants helpful in replacement of both soft and hard tissues lost as a result of cancer surgery. Post-radiation patients often have Xerostomia.Post-radiation patients often have Xerostomia.

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37. 37 Absolute Contraindications for Dental Implants Recent valvular prosthesis Recent MI Severe renal disorder Uncontrolled diabetes Secondary osteoporosis in oral cavity Alcoholism Osteomalacia Active radiation therapy Severe hormone deficiency Drug addiction Heavy smoking Active periodontal disease4 Recent valvular prosthesis - (within 18 months) increased risk of infection from elective surgery 2) Recent MI - The risk of an additional MI is statistically much greater in a patient with a history of a recent MI. After 12 months, the risk of another MI during a surgical procedure drops to around five percent. Elective implant procedures should be postponed to at least 12 months after an MI. 3) Severe renal disorder. 4) Uncontrolled diabetes - delayed healing and decreased resistance to infection. 5) Osteoporosis in oral cavity - bone may not be dense enough to support implant. 6) Alcoholism - delayed healing, possible clotting disorders and poor oral hygiene. 7) Osteomalacia - bone not strong enough. 8) Active radiation therapy - inadequate healing. 9) Severe hormone deficiency 10) Drug addiction - inability to provide consistent adequate home care. 11) Heavy smoking - inadequate healing, periodontal disease. 12) Active periodontal disease - increased chance of implant failure from infection.4 Recent valvular prosthesis - (within 18 months) increased risk of infection from elective surgery 2) Recent MI - The risk of an additional MI is statistically much greater in a patient with a history of a recent MI. After 12 months, the risk of another MI during a surgical procedure drops to around five percent. Elective implant procedures should be postponed to at least 12 months after an MI. 3) Severe renal disorder. 4) Uncontrolled diabetes - delayed healing and decreased resistance to infection. 5) Osteoporosis in oral cavity - bone may not be dense enough to support implant. 6) Alcoholism - delayed healing, possible clotting disorders and poor oral hygiene. 7) Osteomalacia - bone not strong enough. 8) Active radiation therapy - inadequate healing. 9) Severe hormone deficiency 10) Drug addiction - inability to provide consistent adequate home care. 11) Heavy smoking - inadequate healing, periodontal disease. 12) Active periodontal disease - increased chance of implant failure from infection.4

38. 38 Relative Contraindications for Dental Implants HIV/AIDS Long-term steroid use Blood disorders Active chemotherapy Renal/pancreatic disorders Psychological disorders Smoking Heavy smokers do not heal well, and often they have both poor oral hygiene and overall oral health.Heavy smokers do not heal well, and often they have both poor oral hygiene and overall oral health.

39. 39 Conclusions Dental implants and implant-assisted or implant-supported fixed and removable restorations remain a valuable treatment option for the geriatric patient. Reduced ability to maintain oral hygiene due to age is not a contraindication to implant therapy. The patient’s overall health should be considered first. There exists a greater likelihood of medical complications in this population.

40. 40 Biography Dr. Elizabeth S. Pilcher is an Associate Professor of Fixed Prosthodontics in the College of Dentistry at the Medical University of South Carolina. Her special interests are the development and analysis of web-based distance learning, dental education programs and research into dental diamonds. She also serves as a member of the Governor's Council on Developmental Disabilities and lectures on treatment of patients with Down Syndrome.