reading

The German National Library has listed this publication in the German National Bibliography. Detailed bibliographical data are available at http://dnb.ddb.de.

All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, whether electronic, mechanical, photocopying, or otherwise, without prior written permission of the publisher.

The materials offered in the ITI Treatment Guide are for educational purposes only and intended as a stepby-step guide to treatment of a particular case and patient situation. These recommendations are based on conclusions of the ITI Consensus Conferences and, as such, in line with the ITI treatment philosophy. These recommendations, nevertheless, represent the opinions of the authors. Neither the ITI nor the authors, editors, or publishers make any representation or warranty for the completeness or accuracy of the published materials and as a consequence do not accept any liability for damages (including, without limitation, direct, indirect, special, consequential, or incidental damages or loss of profits) caused by the use of the information contained in the ITI Treatment Guide. The information contained in the ITI Treatment Guide cannot replace an individual assessment by a clinician, and its use for the treatment of patients is therefore in the sole responsibility of the clinician.

The inclusion of or reference to a particular product, method, technique or material relating to such products, methods, or techniques in the ITI Treatment Guide does not represent a recommendation or an endorsement of the values, features, or claims made by its respective manufacturers.

All rights reserved. In particular, the materials published in the ITI Treatment Guide are protected by copyright. Any reproduction, whether in whole or in part, without the publisher’s prior written consent is prohibited. The information contained in the published materials can itself be protected by other intellectual property rights. Such information may not be used without the prior written consent of the respective intellectual property right owner.

Some of the manufacturer and product names referred to in this publication may be registered trademarks or proprietary names, even though specific reference to this fact is not made. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain.

The tooth identification system used in this ITI Treatment Guide is that of the FDI World Dental Federation.

“… to promote and disseminate knowledge on all aspects of implant dentistry and related tissue regeneration through education and research to the benefit of the patient.”

Preface

With the previous eight volumes of this series, the ITI Treatment Guides have established their place as a valuable reference work for practitioners in the field of implant dentistry. Having dealt with all the classical aspects of implant therapy in those eight volumes, volume 9 closes the life-cycle loop by addressing the situation of the elderly and ailing patient.

It is a fact that the demographics of society today reflect a significant change: not only do we live much longer while still retaining high expectations in terms of health and quality of life, but the ratio of old to young people has also shifted, with the older generation significantly outnumbering the younger.

This has brought with it a new set of demands on implant dentistry and on its practitioners, who more routinely encounter elderly patients. The treatment of these patients is subject to certain limitations and requires compromises. And along with elderly patients who still lead an active life, there are also those who are more frail, whose health has been compromised, or who require special dental care. This changing situation requires well-considered and adequate solutions.

Volume 9 of the ITI Treatment Guide series addresses the situation and needs of the elderly patient, from systemic changes and physical and mental limitations to considerations of quality of life, and also illustrates these using well-chosen clinical cases.

Acknowledgment

We would like to express our gratitude to Ms. Juliane Richter (Quintessence Publishing) for the typesetting and for the coordination of the production workflow, Mr. Per N. Döhler (Triacom Dental) for the editing support and Ms. Ute Drewes for the excellent illustrations. We also acknowledge Straumann AG, the corporate partner of the ITI, for their continuing support.

Editors and Authors

Contributors

Some readers may wonder what has this to do with the ITI. Is not geriatric dentistry usually all about no treatment? Why would we need a Treatment Guide for this?

After a very successful series of eight previous Treatment Guides, it would seem logical to think about our patients’ destiny as they become old, very old, and finally frail and dependent on care. This book is testament to the ITI’s holistic approach to implant dentistry and the professional responsibility it takes—not only for those patients who have aged with implant restorations but also those who have reached an advanced age and may now benefit from the progress in materials and techniques that implant dentistry has to offer today, until late in their lives.

Implants have become an integral part of restorative dental care, and the number of implants placed increases steadily. Worldwide, an estimated 15 million implants are inserted per year to replace missing teeth, mostly in the adult and young elderly age groups. Economic growth and technological advances in almost all domains of our lives have led to a more exigent attitude of adult patients, who increasingly demand higher levels of functional and esthetic outcomes from restorative dentistry. Consequently, any treatise on implant therapy in the elderly population cannot be restricted to options for edentulous jaws.

A raised awareness for the biological and physiological value of natural teeth also increases the desirability of prostheses that protect the neighboring dental tissues and avoid the unfavorable side effects of removable appliances. Despite the cost involved and the physiological limitations of implant therapy, such treatment can fulfil the high demands of the elderly generation. Progress in terms of implant materials and design and also in surgical techniques, including regenerative procedures such as bone grafting, means that almost any partially or fully edentulous patient can be restored with a fixed implant-supported restoration, provided that he or she accepts the costs, time, and burden of treatment procedures involved.

But what is the future of these complex restorations when the patient ages? And what treatment concepts do we offer patients whose lives are already dominated by age, frailty, and multimorbidity? Treatment concepts for the elderly have to consider their physical and cognitive functions, their motivation, and their ability to manipulate and clean a sophisticated implant restoration.

For over 25 years, the ITI has produced numerous publications in its mission to promote and disseminate knowledge in all aspects of implant dentistry and related tissue regeneration through research, development, and education. ITI Consensus Conferences have produced systematic reviews of the latest research resulting in treatment guidelines, distilling the science into practical advice and recommendations for the busy clinician. The widespread use of the SAC Classification and the adoption (sometimes in modified form) of this tool by national implant and dental organizations bears witness to the value of the hard work done by the scientists and clinicians of the ITI for the benefit of both the patient and the practitioner. Books such as the Glossary of Oral and Maxillofacial Implants, an impressive reference volume with over 2,000 definitions of terms, further help establish common standards that facilitate more sharing of information and a better understanding of the fascinating field in which we work.

The ITI Treatment Guides have made a major contribution to further education. This ninth volume addresses an aspect of implant dentistry that has received far less attention than others: implant therapy in the elderly patient.

It has long been known that age alone is not a barrier to implant placement and that the process of osseointegration can be as successful in an older person as in a young adult. There is a growing awareness that in all fields of healthcare, chronological age alone does not govern the health status of an individual; rather, aging is a biological process that may progress at a variable rate, which can be affected by genetic and environmental factors and result in a considerable discrepancy between calendar age and biological age.

This is an increasingly relevant fact with a growing elderly global population. Advances in all fields of healthcare mean that people live longer, often with conditions that would previously have been life-limiting. Elderly patients frequently have multiple chronic conditions treated with a complex regime of multiple medications. This can bring them a longer period of healthy living in their communities. Quite reasonably, they want and need this to be accompanied by good oral health, function, and appearance, so that they may continue to enjoy life and preserve their self-esteem. It is possible to provide dental implants for the elderly and to replace missing teeth; a comfortable and effective tooth replacement is also an important aspect in the maintenance of good nutrition.

There is considerable evidence to support these statements. Many publications testify to the success and usefulness of dental implants in older persons. There is also an, albeit smaller, body of literature that examines the situation of elderly and geriatric patients who, having received dental implants at a younger, healthier age, now require care for their prostheses in times of advancing age, frailty, and declining health.

Few dental treatments last forever. Biological and technical complications will inevitably occur with all dental prostheses—whether implant- or tooth-supported. The treatment can be more challenging in the case of implant complications—even when the patient can be seen in an ideal facility. The management of complications in cases where there are issues of physical or mental health, access to healthcare, and other social or economic considerations may be quite different.

Implant therapy has been a common, successful, and accepted treatment modality for over 30 years. It is time to consider the aspects highlighted above. The aim of this Treatment Guide is to raise awareness of the inevitability of increasing demands on the profession to provide care and treatment for a growing population of patients who, having benefitted from our successes in implant treatment over the past decades, are now growing older with different care needs.

Implants are used to replace missing teeth. It seems intuitive that their prevalence should be highest in the group of patients with the highest number of missing teeth. However, the prevalence of implants in old and geriatric patients is still negligible compared to tooth replacement using conventional fixed or removable dental prostheses. This is even more surprising in that almost 9 out of 10 persons aged 85 years or over are wearing removable prostheses in Switzerland, with well-documented functional and esthetic shortcomings (Zitzmann and coworkers 2007). Limited financial resources, a negative attitude towards both tooth replacement and implants themselves, a lack of knowledge, and reluctance to undergo invasive surgery may be amongst the factors that could explain this situation.

In the institutionalized elderly, a loss of autonomy and the consequently complex logistics for access to health care may further limit access to more complex dental treatment. There is considerable published literature suggesting that chronological age in itself is not a barrier to successful implant osseointegration in healthy individuals or in older people with controlled medical conditions (de Baat 2000; Ikebe and coworkers 2009). However, to focus only on the success of osseointegration and the ongoing survival of individual implants, which is often the level of evidence used, fails to consider the wider implications of such treatment. Other important considerations include patients’ experience and their subjective opinion of the treatment and its benefits, how technical and biological maintenance and complications are managed in aging patients who are becoming progressively infirm, and the objective oral and general health implications, both favorable and unfavorable, of implant-supported prostheses.

Of at least equal importance are the holistic care of old patients and the need for a proper understanding of the physiology of aging and its effect on general health and well-being. Today’s progress in health care enables elderly patients to survive with conditions that only relatively recently would have caused death at an earlier age (Fig 1). This in turn leads to an increasingly aged population that acquires more conditions, in turn leading to a higher prevalence of disability as well as to multiple chronic conditions, known as multimorbidity (Barnett and coworkers 2012). Consequently, these patients are placed on longer and more complex medication regimes, known as polypharmacy (Hajjar and coworkers 2007; Mannucci and coworkers 2014).

Besides the classic “geriatric giants” (immobility, instability, incontinence, and impaired intellect/memory), many other age-related features have been described, such as neurodegenerative diseases, sensory decline, adverse drug events or medication non-compliance, frailty, and the multiple organ or systemic diseases mentioned above. We have a role to play not only in the essential consideration of how these conditions may affect our treatment but also vice versa. We must also be aware and vigilant in order for us, as healthcare providers, to contribute to the general care of our population in its later years.

This chapter gives a brief overview of the current state of the literature at the time of writing. Readers should be aware that limited high-level evidence is available; only recently has there been a growing awareness of the need for further well-designed studies into many of these aspects.

Thanks to improved oral-health education, better preventive intervention, minimally invasive dentistry, and the increased quality of medical and dental care available to the populations of many developed countries, as well as increasing financial resources and social security, more and more people reach an advanced and very advanced age with their natural teeth. They often have fixed tooth-supported prostheses or, increasingly, fixed and removable implant-assisted prostheses (Joshi and coworkers 1996; Petersen 2003). The shift in oral health is reflected in the Swiss health survey: while in the 1992/1993 survey, the 65- to 74-year-old age group was missing on average 15.4 teeth, the same age group was missing only 10.4 teeth 10 years later (Zitzmann and coworkers 2008b; Fig 2). Thanks to the newly introduced age group of 85 years and over in this health survey, we know that 97.4% of this population group are wearing dentures, of which 11.5% are fixed and 85.9% are removable (Table 1). The percentage of complete-denture wearers in this age group is still 37.2%. A similar situation has been reported for most developed countries, where tooth loss also occurs later in life (Mojon 2003; Müller and coworkers 2007).

Despite the progress in oral health promotion and restorative techniques, tooth loss is still a reality in old age; there is a widespread need for tooth replacement in the elderly population (Müller and coworkers 2007). Nevertheless, implants in elderly adults are disproportionately rare, especially in the very old and institutionalized population (Visser and coworkers 2011; Zitzmann and coworkers 2007). The prevalence of implants in a representative Swiss population sample was 4.4% (Zitzmann and coworkers 2008a); in Germany, it was 2.6% in the 65- to 74-year-old adult population (Micheelis and Schiffner 2006). In Europe, the highest frequency of implants in the edentulous population was found in Sweden, but despite substantial financial support from the public health system, it did not exceed 8% (Osterberg and coworkers 2000).

Evaluation of the awareness of implants in elderly persons is difficult, as there may be many factors involved in the dissemination of patient information, including the benefits of implant treatment. In a marketing-related study of the Austrian population, 42% of the cohort investigated was poorly informed and only 4% felt well informed. Approximately one-third of the study participants indicated a desire to receive more information and would prefer it to be provided by their dentist (Tepper and coworkers 2003).

Awareness of dental implants is not necessarily correlated with a correct understanding of the nature and benefits of treatment. Various studies indicate that approximately 70% of elderly patients questioned are aware of the existence of dental implants as a treatment option. The number of interviewees who had received information direct from a dentist appears to vary for reasons not fully understood. In the Tepper study, 68% had received an explanation from a dentist, whereas in a US-based study the level was 17% (Tepper and coworkers 2003; Zimmer and coworkers 1992). Similar results were found in a survey of Swiss adults in both in geriatric-care facilities and living at home (Müller and coworkers 2012a). The authors confirmed that in the elderly population, knowledge of dental implants is limited: almost half of the study participants had never heard of implants or could not describe them (Fig 3). Only one out of the 92 participants knew that implants were made of titanium (Fig 4). The rate of objection to implant treatment was high, mostly based on cost, the surgical nature of the therapy, and other psychological factors. A limited knowledge of implants as well as a poor state of general health—but not old age in itself—were not associated with a negative attitude toward implant treatment. Identifying further barriers and understanding patients’ reluctance towards implant treatment could improve the acceptance of implant therapy in the elderly population. Providing further information in appropriate formats, with clearly worded and printed text complemented by simple illustrations, would help elderly patients to reflect on the novel information provided and give informed consent to implant treatment. Furthermore, the development of less invasive surgical techniques is another possible measure that could contribute to a greater uptake of an implant treatment.

Of potentially greater concern is the awareness and understanding of implants and related prostheses by the caregivers of patients unable to access regular dental care or to manage adequate self-performed oral hygiene (Holtzman and Akiyama 1985). It has been suggested that in many elderly-care institutions, few staff members recognize an implant-supported prosthesis, let alone know how to handle and clean it. Even with a seemingly simple and straightforward overdenture supported by two implants, if the patient can no longer remove the denture, it is likely that nursing staff will not know how to help, and the denture may end up falling into disuse (Visser and coworkers 2011).

Considering the acceptance of proposed implant treatment, many elderly patients do not consider implants a preferred treatment option for reasons of cost. However, cost may not be the only issue, as demonstrated in a study showing that over one-third of patients with edentulous mandibles declined free treatment with an implant-supported overdenture. Elderly patients often object to surgical intervention, but may also consider any denture “improvement” unnecessary (Walton and MacEntee 2005). When presented with different treatment options for the replacement of missing teeth, they are frequently more conservative in their preferences and may be more tolerant of simpler solutions that the clinician may consider a compromise (Ikebe and coworkers 2011).

The infinite variability of site- and patient-specific factors, implant and prosthetic designs, study methodologies and confounding factors, and many other interrelated considerations imply that considerations of age alone as a success factor in implant therapy are difficult to determine (Wood and coworkers 2004). A large part of the currently available literature is based on the treatment of the edentulous jaw, often with overdentures, and this does not fully reflect the emerging situation of a partially edentulous population with an increasing demand for implant treatment, historically restricted to younger age groups (Dudley 2015). There are also only few studies available that address the rate of biological and technical complications in geriatric patients who have previously had implants and prostheses for decades and who are now more infirm; perhaps more importantly, neither is there a body of literature outlining the issues of providing remedial treatment in such situations.

As previously mentioned, age alone appears to be unrelated to the success or failure of initial implant integration, with success rates similar to younger age groups but with a seemingly greater incidence of problems in adapting to a new prosthesis (Andreiotelli and coworkers 2010; Engfors and coworkers 2004). Osseointegration at an advanced age was well documented in an 83-year-old patient, who received four implants in the edentulous mandible. After passing away 12 years later, Lederman, Schenk and Buser had the opportunity to investigate the osseointegration histologically (Ledermann and coworkers 1998; Figs 5a-e). A close-up view confirms the intimate contact of the bone with the titanium implant surface.

Very few studies have directly compared implant survival in young and old patients. Bryant and Zarb compared peri-implant marginal bone loss in 26- to 49-year-old patients with a cohort of 60- to 74-year-olds with fixed or removable restorations and found no difference over 17 years (Bryant and Zarb 2003; Fig 6). Hoeksema and coworkers, in a 10-year prospective study, followed a group of 52 young patients (age 35 to 50 years) and compared implant survival rates with those of 53 elderly edentulous wearers of overdentures (age 60 to 80 years). Despite the obvious larger dropout in the older cohort, due in part to death and health reasons, they found no statistical difference in implant survival and marginal bone loss between the two groups (Hoeksema and coworkers 2015). Even very old age—80 years and older—resulted in survival rates for fixed implant-supported prostheses that were similar to those of patients below 80 years over a 5-year observation period (Engfors and coworkers 2004).

While medical conditions exist that are considered relative contraindications that may affect successful osseointegration, the relative levels of associated risk may vary in different patients. There is a greater incidence of multimorbidity and polypharmacy in the older age group, and combinations of risk factors may increase the risk of an adverse outcome.

The most relevant factor of implant success may actually be the quantity and quality of the bone at the surgical site—and these may in part be age-related, reflecting changes in bone structure and quite simply the length of time that teeth had been diseased or missing (Bryant 1998).

A significant confounding factor in attempts to evaluate implant success is the lack of consistency amongst studies regarding what constitutes success. Indeed, many studies actually report implant survival, which is of course based only on the singular fact that the implant remains in situ. Different criteria exist for qualifying success, which generally include the following factors (Buser and coworkers 1990):

•Absence of persistent subjective complaints, such as pain, foreign body sensation and/or dysesthesia.

However, success at the implant level is not a measure of treatment success, only of the biological achievement of osseointegration. Success has to be also measured at the prosthesis level and, perhaps most importantly, at the patient level—the patient should remain our prime concern. The possibility of autonomous management of the implant-supported denture, including proper oral hygiene, should therefore be added to the outcome measures.

Nor can we be reassured by short-term success. Given the increasing life expectancy of the middle-aged and young-old patients who have received implant treatment, the rehabilitation will inevitably require both maintenance and repair or replacement. Furthermore, with the growing number of healthy and fit very old persons, implant treatment should not be withheld, even at a very high age, if close monitoring of the patient’s denture management and oral hygiene are assured and the attachments can be removed easily if necessary.

There is ample evidence that the accumulation of bacterial plaque on the surfaces of implants and associated restorations can lead to inflammation of the soft tissues and, in susceptible sites and individuals, to peri-implant bone loss (Zitzmann and Berglund 2008b). Concerning the susceptibility of an individual to periodontal disease, Mombelli considered whether or not there are specific age-related changes in the oral microbiota that may affect the progression of periodontal disease. He concluded that other age-related general and oral health conditions might have a greater impact (Mombelli 1998). Declining manual dexterity and visual acuity may be associated with a reduced ability to maintain adequate plaque control. Several studies have observed that osseointegration can be maintained even under conditions of poor or moderately successful self-performed or caregiver-assisted oral hygiene procedures (Isaksson and coworkers 2009; Olerud and coworkers 2012). The impact of immunosenescence on the reaction of the peri-implant tissues to substantial bacterial load remains to be investigated. It is also recognized that the host response is as important a factor in peri-implant disease as it is in periodontal disease (Heitz-Mayfield 2008), and that the risk of biological complications in periodontitis-susceptible patients is greater than in less susceptible individuals (Ong and coworkers 2008). Given the greater difficulty of treating such complications in patients with compromised oral hygiene and general health, it would be unwise to be complacent in situations of inadequate oral hygiene.

It is recognized that the role of staff and caregivers in maintaining oral health in such patients is important (Ettinger and Pinkham 1977; Mersel and coworkers 2000) and is an essential part of general healthcare, particularly in multimorbid and fragile elderly patients. An example of this is the prevention of complications such as aspiration pneumonia precipitated by oral pathogens (Quagliarello and coworkers 2005; Sjögren and coworkers 2008; van der Maarel-Wierink and coworkers 2011; Yoneyama and coworkers 1999).

As mentioned above, the awareness of care providers, relatives, and occasionally even patients of the presence and maintenance requirements of implants and related prostheses is low (Kimura and coworkers 2015; Sweeney and coworkers 2007). In the multimorbid and fragile elderly, adequate oral hygiene may not be the most important factor for the general well-being of the patient, especially when chronic disease and disability dominate daily life. However, the neglect of oral health can have serious implications, caused for example by the inability of some caregivers to as much as recognize the presence of implants. Examples are given of food refusal and weight loss in patients unable to inform the staff of oral discomfort from overdenture abutments where the overdenture is no longer worn (Visser and coworkers 2011). Adequate nutrition and weight are of vital importance for the morbidity and mortality of elders, and such incidents can have consequences of greater significance than oral health alone (Weiss and coworkers 2008).

All studies reporting on technical complications observe that while implant survival rates are high, there is a considerable rate of technical complications with all implant-retained prostheses that increases with the length of time in service (Albrektsson and coworkers 2012; Berglundh and coworkers 2002; Brägger and coworkers 2005; Zembic and coworkers 2014a). This has an impact on the health economics of implant treatment and requires considerable chairside time. This may be particularly relevant for a patient who is no longer able to access the dental office and/or who may no longer be able to afford the maintenance for an implant-supported denture to which they committed when in a more privileged financial situation.

Technical complications may in fact be more prevalent with overdentures than with fixed reconstructions, especially regarding the overdenture attachment system (Bryant and coworkers 2007). However, addressing such issues with an implant overdenture may be considerably more straightforward than with a complex fixed prosthesis in an elderly patient with general or mental health conditions that preclude care in a conventional clinical setting.

As the population of elderly patients increases, the average age of that population also increases. Improved health care in developed countries reduces the proportion of edentulous patients, and this trend is expected to continue (Müller and coworkers 2007). However, there are indications that the growing elderly population will still result in many edentulous adults to treat and that these patients may benefit from implant therapy rather than being constrained to removable complete dentures (Turkyilmaz and coworkers 2010). We know that clinicians and patients often view the efficacy of treatment differently (Heydecke and coworkers 2003b) and that the acceptance of complete dentures by patients varies considerably, with some adapting better than others (Boerrigter and coworkers 1995a; Müller and Hasse-Sander 1993). Even among those patients who do not report high levels of chewing ability, there are many who do not consider such functional limitations any handicap (Allen and coworkers 2001).

It is frequently said that implant-retained overdentures are “better” than conventional complete dentures. However, it is important to distinguish between maxillary and mandibular prostheses, as much of the available literature relates to mandibular implant-retained overdentures. Indeed, many reviews of the literature do not explicitly differentiate these two distinct clinical situations.

It has been suggested that implant-supported maxillary complete overdentures have few advantages over conventional maxillary complete dentures (Watson and coworkers 1997). There is evidence that the simpler overdenture approach is favored by patients over a complex fixed bridge on implants, or even that there is no advantage of an implant-supported complete maxillary prosthesis over a conventional complete denture (de Albuquerque Júnior and coworkers 2000). Few studies include sufficient long-term follow-up to evaluate the differences between implant and prosthetic success, or between different types of restoration. It is inevitable that the design of a prosthesis will affect the ease of cleaning and the rate of technical complications, even though there appears to be no correlation between designs and implant survival/success over relatively short observation periods (Bryant and coworkers 2007).

Nor is there any reliable evidence for an optimal number of implants to support an overdenture (Roccuzzo and coworkers 2012). However, there is evidence that implant-supported mandibular prostheses are associated with improved clinical and patient-related outcomes compared to mandibular complete dentures. While wellmade replacement conventional complete dentures can provide improvements in speech, appearance, and comfort, there is frequently little or no improvement in function (Awad and coworkers 2003), and this is especially so in elderly patients (Allen and McMillan 2003).

The use of two implants in the interforaminal region of the mandible to support an overdenture is well documented. There is reliable evidence for the benefits of this treatment modality and its cost-effectiveness (Heydecke and coworkers 2005). Indeed, the two-implant mandibular overdenture is now regarded the first-choice standard of care (Feine and coworkers 2002; Thomason and coworkers 2009) and that a conventional mandibular complete denture may be inadequate in terms of comfort and function, with masticatory performance being less than 20% of that achieved with a natural dentition (Heath 1982; Kapur 1964).

A recent review from Andreotelli and coworkers confirmed excellent survival rates for implant-supported overdentures (Andreiotelli and coworkers 2010). The majority of studies in this review concerned mandibular implants placed in the interforaminal region to retain removable overdentures. Observation periods in four of the studies analyzed reached the critical 10-year mark, indicating implant survival rates between 93% and 100%. Although the quality of the available evidence often precludes combining the individual study outcomes within a meta-analysis, it seems that neither the number of implants used nor the attachment system chosen, or splinting the implants, has a significant impact on the treatment success (Meijer and coworkers 2004; Naert and coworkers 2004).

Treatment concepts for the maxilla, single implant mandibular overdentures (Bryant and coworkers 2015; Kronstrom and coworkers 2014; Srinivasan and coworkers 2016), and short or reduced-diameter implants have been less well documented (Müller and coworkers 2015; Srinivasan and coworkers 2014a). Although immediate, early, and conventional loading protocols of mandibular implant dentures are predictable treatment modalities, early and conventional loading tended to reduce failures of osseointegration within the first year (Schimmel and coworkers 2014). From a patient perspective, early loading seems particularly attractive, as the time of discomfort due to provisionalization is limited. There is still sufficient time for wound healing, hence the likelihood of a reline being needed shortly after denture insertion is lower than with immediate-loading concepts. It can be concluded that mandibular implant overdentures are a safe and successful treatment modality and present multiple functional, structural, and psychosocial benefits.

As stated, an increasing number of patients in a growing elderly population retain natural or treated natural teeth well into old age. Failing older dental restorations can of course lead to a partially edentulous situation; it may be desirable to preserve natural teeth as much as possible and to avoid the preparation of teeth adjacent to gaps for tooth-supported fixed prostheses. The greater expectations patients have of dental treatment and their desire to avoid dentures, even partial ones, mean that implants in partially edentulous patients are a practical and beneficial treatment option for many. Especially in severely depleted dentitions, where abutment teeth may be positioned unfavorably, additional abutments in the form of implants may greatly enhance denture kinetics. The literature is replete with evidence that the same patient- and site-specific factors are the main considerations affecting future implant survival and that age alone is not a factor (Kowar and coworkers 2013).

Patient-centered outcomes are an important measure of the “success” of a treatment, both subjectively and objectively, particularly in regard to health economics (Rohlin and Mileman 2000). Clinicians and patients often perceive and evaluate the outcome of treatment differently, and such variation can lead to problems in treatment planning. Involvement of the patient in clinical decision-making can lead to higher levels of satisfaction with treatment (Kay and Nuttall 1995). It is therefore important to consider patient preferences and attitudes to treatment when selecting treatment (Kay and coworkers 1992). It is equally important to accept that elderly patients will often place different values on the potential benefits of treatment than younger adults, based on medical, social, cultural, and economic considerations. It is necessary to respect their decisions when deciding on the use of implants and the type of prosthesis that will produce the most predictable and satisfactory outcome. Respecting the patient’s decision becomes even more relevant in patients who have to be considered vulnerable, as ethical considerations strongly preclude “forcefully convincing” the patient towards accepting a given treatment plan.

Unfortunately, most of the current literature in patient-centered outcomes relates to the treatment of the edentulous older adult (Weyant and coworkers 2004). As older adults retain teeth for longer, perhaps losing teeth later in life and demanding implant-supported partial or complete prostheses, we may need modified assessment tools that are preferably standardized to eliminate heterogeneity in results in order to evaluate the true benefit of treatment at the patient level.

Assessing oral health-related quality of life (OHRQoL) essentially measures the degree to which oral health interrupts the well-being and social functioning of an individual. There are a large variety of instruments that have been used to assess the social impact of dental disease (Hebling and Pereira 2007; Slade 2002).

From the literature, there appear to be two most commonly used indices for evaluating the impact of oral and dental problems on an elderly patient’s quality of life:

•OHIP—Oral Health Impact Profile. Used to evaluate the patient’s perception of the social impact of poor oral health (Slade and Spencer 1994). Within this tool, there are refined questionnaires to assess different specific treatment modalities such as OHIP-EDENT, for edentulous adults.

•GOHAI—Geriatric Oral Health Assessment Index. Used to evaluate the impact of oral health problems in the older population (Atchison and Dolan 1990).

There is evidence to show that after treatment, patient satisfaction with implants is good, even when there is a substantial need for support in daily living that includes assisted oral hygiene (Isaksson and coworkers 2009; Olerud and coworkers 2012; Osterberg and coworkers 2007). Mandibular implant-supported overdentures seem to provide improved patient-centered outcomes from both the patients’ and the clinicians’ perspectives (Boerrigter and coworkers 1995a; Boerrigter and coworkers 1995b; Emami and coworkers 2009; Meijer and coworkers 1999).

Illustrations:	Ute Drewes, Basel (CH),
	www.drewes.ch
Copyediting:	Triacom Dental, Barendorf (DE),
	www.dental.triacom.com
Graphic concept:	Wirz Corporate AG, Zürich (CH)
Production:	Juliane Richter, Berlin (DE)

1	Introduction
	F. Müller, S. Barter
2	Implant Treatment in Old Age: Literature Review
	S. Barter, F. Müller
3	Aging: a Biological, Social, and Economic Challenge
	F. Müller
4	The Benefits of Implant-supported Prostheses in the Elderly Patient
	F. Müller
5	Medical Considerations for Dental Implant Therapy in the Elderly Patient
	S. Barter
5.1	Introduction
5.1.1	Aging and Multimorbidity
5.1.2	Polypharmacy
5.1.3	Frailty
5.1.4	Taking the Patient’s Medical History
5.2	Cardiovascular System
5.2.1	Age-related Changes
5.2.2	Treatment Considerations
5.2.3	Pharmacological Considerations
5.3	Hematological System
5.3.1	Age-related Changes
5.3.2	Treatment Considerations
5.3.3	Pharmacological Considerations
5.4	Hematopoietic System
5.4.1	Age-related Changes
5.4.2	Treatment Considerations
5.5	Respiratory System
5.5.1	Age-related Changes
5.5.2	Treatment Considerations
5.5.3	Pharmacological Considerations
5.6	Alimentary System
5.6.1	Treatment Considerations
5.6.2	Pharmacological Considerations
5.7	Hepatobiliary System
5.8	Renal System
5.8.1	Age-related Changes
5.8.2	Treatment Considerations
5.8.3	Pharmacological Considerations
5.9	Endocrine System
5.9.1	Age-related Changes
5.9.2	Pharmacological Considerations
5.10	Musculoskeletal System
5.10.1	Age-related Changes
5.10.2	Treatment Considerations
5.10.3	Pharmacological Considerations
5.11	Neurosensory System
5.11.1	Age-related Changes
5.11.2	Treatment Considerations
5.11.3	Pharmacological Considerations
5.12	Cancer
5.12.1	Osteoradionecrosis
5.13	Conclusions
6	Features of Removable Prostheses for the Old
	F. Müller
7	Implants and Partial-denture Design
	F. Müller
8	Implant-supported Overdentures for the Edentulous Patient
	F. Müller
9	Surgical Considerations in the Aging Patient
	S. Barter
10	Oral Hygiene in Geriatric Implant Patients
	F. Müller
11	The Ailing Patient
	F. Müller
12	Management of Technical and Biological Complications
	S. Barter
13	Clinical Case Presentations
13.1	Improving an Existing Implant-supported Denture in an Alzheimer Patient with Bipolar Affective Disorder with Moderate Depression and Dementia
	U. Webersberger
13.2	Maxillary Complete Denture and Mandibular Overdenture on Two Implants with Universal Design
	R. Leesungbok
13.3	Improving a Centenarian’s Quality of Life
	M. Schimmel
13.4	Oral Rehabilitation of an Elderly Edentulous Patient with Osteoarthritis Using an Implant-supported Mandibular Prosthesis with Locator Abutments
	G. McKenna
13.5	Maxillary Implant-supported Full-arch Removable Dental Prostheses for a Geriatric Patient: Sequencing the Treatment for an Optimal Outcome
	A. Dickinson
13.6	Mandibular Overdenture Supported by a CAD/CAM-milled Bar with Long Distal Extensions on Two Conventionally Loaded Implants
	M. Srinivasan
13.7	Flapless Guided Surgery: Bar-supported Overdenture on Four Implants
	R. J. Renting
13.8	Prosthodontic Solution for Two Angulated 6-mm Implants Supporting a Removable Partial Denture in a 74-year-old Patient
	U. Webersberger
13.9	Rehabilitation of a Mandibular Distal Extension Situation in a 89-year-old Patient with an Implant-supported Fixed Dental Prosthesis
	D. Buser
13.10	Minimally Invasive Treatment of a Patient in Her Nineties After Removing Implants Affected by Severe Peri-implantitis
	M. Roccuzzo
13.11	Implant-retained Rehabilitation after Mandibular Rim Resection
	S. Shahdad
13.12	Four Immediately Loaded Mini-implants Supporting a Mandibular Overdenture
	S. Esfandiari
14	Conclusions
	S. Barter, F. Müller
15	References

2	Implant Treatment in Old Age: Literature Review
	S. Barter, F. Müller

Preface

Acknowledgment

Editors and Authors

Contributors

Table of Contents

1

Introduction

F. Müller, S. Barter

2

Implant Treatment in Old Age: Literature Review

S. Barter, F. Müller