Introduction

“Older adult” or “elderly” are terms conventionally referred to individuals older than 65 years of age [1]. The World Health Organization estimates an increase in the elderly population from 900 million to 2 billion by 2050 worldwide; an increase from 12 to 22% of the total global population (WHO) [2]. Not only is this age group increasing in number, but also exhibits a notable increase in life expectancy, educational level, and personal wealth, factors that play a role in overall health. The impact of social determinants of health such as these, in oral and overall health should be considered when treatment planning a patient affected by any combination of the factors. On the other hand, geriatric dental patients are biologically compromised adults, that may or may not be older than 65, with one or more chronic, debilitating, physical, or mental illness [3]. Older adults as well as geriatric patients can present with unique challenges that impact treatment planning for implant prosthodontics rehabilitation. Even though treatment planning for these cohorts of patients has been recognized more so now than in the past, including greater emphasis in dental school curriculum, providing ideal and safe care with long‐term clinical and patient outcomes is still a challenge. The concept of rationale treatment planning applies to this patient population when considering dental implants as long‐term solution in oral rehabilitation.

From an oral health perspective, an increase in chronological age has traditionally been associated with an increase in tooth loss and partial edentulism [4–6], and prevalence of total edentulism ranging from 1.3 to 78% worldwide (Figure 20.1) [7–9]. Prevalence of edentulism in most developed countries has shown a dramatic decline more recently [10]. Between 1990 and 2010, a decrease in global age‐standardized prevalence of complete edentulism in individuals decreased from 4.4 to 2.4%, respectively [7]. This decrease is notable in developed countries as a result of various public health initiatives. However, when considering age, there exists a steep increase in prevalence of edentulism around the seventh decade of life. Reasons may include low utilization of dental services by this cohort, the lack of financial support from the government or third‐party payment systems, and absence of relevant oral health policies [11]. The data indicates that even with a clear decline in edentulism, there will continue to be a need for replacement of teeth in the future, most especially among older patients. Dental care in the elderly can no longer be limited to removable complete prostheses. Retaining natural teeth in the older patient population has inadvertently led to dentistry’s achievement of an adverse “consequence of success” as described by Joshi et al in 1996 [12]. With the increased retention of natural teeth in the elderly population, there is also an increased risk for developing periodontal disease or dental caries as well as increased need and demand for complex restorative care that provides not only function and form, but also includes expectations for esthetic outcomes. Furthermore, treatment planning for partially edentulous patients is a complex challenge as compared to edentulous patients, further necessitating the use of dental implants in a practitioner’s armamentarium.

Studies have shown that tooth loss results in a reduced quality of life. Notable consequences of tooth loss include compromised masticatory ability with subsequent poor nutrition [13, 14], as well as restriction on social activities or psychological well‐being are observed [15]. With the advent of implant‐retained and implant–supported prostheses, there has been a significant shift in treatment strategies to help improve stability and support in removable prostheses in edentulous patients and improve esthetics and function in partially edentulous patients. As patients’ demand for more complex, multidisciplinary interventions increase, along with dental training in implant dentistry, it can be expected elderly individuals in high‐income countries will choose the aforementioned to address their oral quality of life [6, 16, 17]. In the United States, implant dentistry was the only prosthodontic procedure that increased per capita from 1992 to 2007 and from prevalence of 0.7% in 1999–2000 to 5.7% in 2015–2016 [18, 19]. The largest absolute increase in prevalence of dental implants was observed among 65‐ to 75‐year‐old individuals [19]. In 2020, North America accounted for 38.2% revenue share, leading the worldwide implant market [20]. Driving forces include increased geriatric population with high oral healthcare needs and increased awareness of dental implants as well as introduction of advanced technologies and digital workflows [20].

Review of peer‐reviewed scientific literature overwhelmingly supports the use dental implants as a reliable, predictable treatment modality for replacement of missing teeth in elderly patients [6, 21–24]. Studies have shown high implant survival rates in patients 65 years and older. However, implant and prosthesis maintenance have become an important factor impacting long‐term success that needs further investigation with increased use of implants surgically placed and restored using various prosthodontic designs. An elderly patients’ ability to (i) maintain dental implants long‐term considering their co‐morbidities, (ii) perform oral hygiene habits, (iii) seek and obtain regular supportive care, and (iv) manage care of fixed and removable prostheses associated with the implants are important aspects reviewed in this chapter.

Rapid Oral Health Deterioration in Elderly Patients

Even though most studies focus on age when grouping patients based on demographic profiles, a functional definition for an elderly adult is at times more appropriate than a chronological one. In 1984, Ettinger and Beck developed a means of categorizing elderly patients based on their functional abilities as opposed to their age alone. The aging population can be categorized in one of three functional groups: functionally independent older adult, frail older adult, or functional dependent older adult [3]. Those persons who are frail and functionally dependent are known to have higher rates of oral disease that develops over time due to the overall decline in their general health and function [25]. The rapid oral health deterioration (ROHD) concept was introduced to help identify patients who experience a decline in general health later in life and subsequently, a decline in oral health [3].

Advanced chronologic age is correlated with age‐related diseases, with 92 age‐related diseases accounting for 51.3% of the adult global burden [26]. According to the World Health Organization (WHO), the most common chronic conditions in the elderly include cardiovascular disease, cancer, respiratory diseases, diabetes mellitus, cirrhosis of the liver, osteoarthritis, and neurocognitive impairments like unipolar depression, Alzheimer’s, and dementia. In addition, polypharmacy is a complex issue for the older population and can result in several oral side effects, such as xerostomia. These systemic diseases can affect oral health including indirect impact on dental implants and prostheses in various ways. For instance, the consequences of systemic disease can reduce a patient’s ability to maintain proper oral hygiene, especially in those with dementia, depression, arthritis, and stroke; or predispose patients to more aggressive oral disease as seen with those with diabetes; and finally, diminish the effects of protective factors by reducing salivary flow as in patients with medication‐induced xerostomia [27].

Social determinants can also lead to a reduction in access to needed care and ultimately, place a patient at risk for ROHD [3, 28–30]. The World Health Organization defines social determinants of health as “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems.” [31] Our goal as clinicians is to provide the optimal care not just for today but for years to come, thus aiming for a patient‐centered long‐term outcome as opposed to mere procedure‐centered outcomes. As best stated by Marchini and colleagues, it is critical to “look at a patient as a moving picture rather than a snapshot” [27].

Evidence‐based risk factors for ROHD (Figure 20.2) should be reviewed when assessing a patient for any implant–supported or implant‐retained treatment. A thorough medical and social history will ultimately help ascertain data relative to general health, social support, and oral conditions that may contribute to ROHD risk. Providers can categorize patients within one of four stages:

• Stage 1: Risk factors for ROHD not present
• Stage 2: Patient is at risk of ROHD, but not currently experiencing ROHD
• Stage 3: Patient is currently experiencing ROHD
• Stage 4: ROHD has happened

Evaluating and assessing a patient for stages of ROHD ultimately enables a clinician to properly formulate a treatment plan, while also planning for failures and determining the complexity or aggressiveness nature for a proposed preventive plan. Again, the goal is to envision the patient as a moving picture. For instance, if a patient is a well‐controlled diabetic via medication (HbA1c level of 6.5% or less), this condition is unlikely to affect the treatment plan for implant therapy and restorations at this point of time. In this example, diabetes is not considered a risk factor and does not impact implant survival up to five years after implant loading based on current evidence available [32]. In contrast, if a patient has been recently diagnosed with dementia, reports indicate that these types of patients have lower motivation to perform regular oral hygiene maintenance along with diminished cognitive and manual skills to perform adequate hygiene maintenance protocol [33]. Thus, without consistent home‐care support, the long‐term outcome of the implant and prostheses may be at risk. Implant and prosthesis maintenance should be taken into consideration at the time of treatment planning. In addition, long‐term maintenance costs should be considered and included as part of the treatment plan discussion [34].

Treatment Modalities

Treatment plans should be formulated based on a thorough medical and dental evaluation of elderly patients and customized to everyone following the patient‐centered approach to assess the possibilities for medical and oral deterioration [27]. There are multiple terminologies referring to this decision‐making process of formulating a treatment plan. Examples include cost‐effective care, minimally invasive dentistry, and rational dental care. In medicine, alternative treatment strategies have been proposed to develop “best sequence” treatment decisions in order to optimize long‐term outcomes with both present and delayed benefits [35]. The concept of rational dental care applies to the elderly patient population when considering treatment plans that incorporate the use of implants for long‐term clinical outcomes. Rational care, as described by Ettinger and Beck, is not a new concept; it emphasizes the importance of making thoughtful decisions with regards to patient treatment plans while considering modifying factors that will play a large role in the patient’s systemic and oral health (Figure 20.2). Rational dental care has been described as clinical decision‐making based on a patient’s characteristics and consideration for modifying factors to formulate the best, individualized treatment plan [36]. Rational treatment plans can range from complex treatment, limited treatment, and emergency care to decisions that reflect no treatment for the individual. The plan should also include preventive and therapeutic treatments. Recall and professional maintenance regimen should be prescribed and individualized based on the soft and hard tissue risk assessment and supportive care [37].

When an elderly patient is categorized as Stage 1: “Risk factors for ROHD not present,” an advanced treatment approach including a fixed‐retained prosthesis can be proposed to restore form, function, and esthetics. For instance, implant–supported fixed complete dental prostheses have been documented to provide patients with improved function, esthetics, and quality of life [38]. Potential prosthetic complications in this prosthodontic approach include wear, chipping, and fracturing of the prosthetic teeth [39]. High patient satisfaction and oral health‐related quality of life have been documented with favorable outcomes. However, sustained hygienic maintenance of a prosthesis has been reported as the most significant complaint by patients [40].

For a patient in the category of Stage 2: “Patient is at risk of ROHD, but not currently experiencing ROHD,” a more conservative treatment approach [41] should be considered. Changing from a complex, intricate design for an implant–supported prosthesis to a simplistic, straightforward prosthetic design may be needed as the patient ages. As described by Muller, “today’s fixed implant prosthesis should be considered for tomorrow’s overdenture, at first retained by a bar, then a stud‐type attachment, and converting to a lower retention attachment when the patient is in a palliative care setting.” In addition, the prosthetic design should support a cleansable, hygienic environment that will allow a patient and their caregiver to maintain optimal oral health.

When a patient falls in the category of Stage 3: “Patient is currently experiencing ROHD,” oral hypofunction, mastication functions, tongue pressure, tongue, and lip movement function deterioration will most likely be observed [42]. Therefore, a treatment plan involving removable implant‐retained prosthesis may be indicated to provide function and form. Esthetics may not be the top priority for this cohort, but comfort should be [43].

When a patient is determined to be in Stage 4: “ROHD has happened,” the treatment plan should incorporate simple prosthetic design for ideal hygiene maintenance to be managed by the patient and if needed, by caregivers. Planning for an implant‐retained prosthesis with complex and intricate design elements may not be indicated for a patient in the ROHD stage. Alternatively, a conventional prosthesis should be considered for these patients. The maintenance of a healthy intraoral environment and a prosthetic design with relatively easy access to home care cleaning and maintenance should be the primary goals for this cohort. Cognitive deterioration function should be assessed for the patient’s understanding of the treatment plan and maintenance [43]. Finally, home caregivers should be educated and trained in providing care for the elderly, both the oral cavity and the prosthesis.

Recall and Maintenance in Elderly Patients

Routine patient recall appointments, professional hygiene maintenance appointments, and at‐home hygiene maintenance regimens are essential for long‐term success in elderly patients to decrease the frequency of biological, mechanical, and technical complications commonly associated with implant–supported prostheses [44]. Frequent, prescribed dental implant maintenance over a long‐term period has been shown to be critical in implant survival [45]. According to recently published clinical practice guidelines for recall and maintenance of patients with implant–borne dental prostheses, patient recall frequencies should be more often than every six months if patients are considered as higher risk based on their age and ability to perform oral self‐care and potential biological or mechanical complications [44] (Figure 20.3). During professional maintenance appointments, thorough extraoral and intraoral health and dental examinations, intraoral hygiene instructions, and hygiene instructions for cleaning the prostheses and oral hygiene intervention are performed. In addition, the prostheses should be professionally cleaned with established mechanical and chemical debridement and cleaning protocols.

In regards to professional prosthesis maintenance, the prostheses should be evaluated and assessed to determine need for adjustment, repair, replacement, or remake upon evaluation. Lastly, patient education is important for the person to learn about potential for anticipated issues to respond and seek consultation with the dentist, learn use of individualized home care instruments or cleaning aids, and learn cleaning protocol based on their specific needs. The various aspects addressed through the clinical practice guidelines are vital to help oral healthcare providers and caregivers improve clinical outcomes for patients.

There are confounding factors such as systemic health status, transportation, access to care, and financial standing of an elderly patient that may influence the commitment necessary for professional and at‐home maintenance regimens and consequently, compromise outcomes related to tissue health and prosthesis longevity. Advanced age may be related to more difficulties in adapting to the new prostheses, delayed muscular function and adaptation, and post‐insertion problems [22, 46]. Further, deteriorating maintenance conditions, such as reduced dexterity in the elderly [43], may also be observed. This may make it challenging for elderly patients to manage a removable implant prosthesis since proper hygiene maintenance requires patient agility to manage insertion and removal of the prosthesis multiple times during a single day. Deterioration of a patient’s social environment defined as lacking supportive care from either family members or caregivers, can influence access to care and prevent the elderly from receiving adequate professional care and maintenance.

There are some recommendations to promote recall and professional maintenance and preserve the prostheses outcomes in the elderly in anticipation of the patient’s aging. For instance, anticipating or converting an implant–supported or implant‐assisted prosthesis from a fixed‐retained design to a removable prosthesis for ease of cleaning and maintaining is highly recommended [34, 43, 47]. It may be challenging for those elderly in nursing home care with limited access to seek or conduct off‐site professional care or continue self‐care to keep up with their oral health follow‐up and professional maintenance care [48]. Many elderlies in a nursing home or assisted living environments depend on the caregiver and other social services to provide oral hygiene care. Therefore, educating the caregivers with the appropriate information from journals, books, audio‐visual media, and in‐house training should be planned to provide oral health support for the elderly [49]. At the same time, preparing for increased home health and oral health care involving oral health professionals visiting the personal residences, assisted‐living to transitional nursing home facilities, and hospitals for those patients who cannot attend regular maintenance care may be needed to support the elderly oral maintenance care [50].

At the policy level, recommendations to standardize implant components help ensure compatibility of implant instrumentation across various manufacturers, in order to evaluate and perform repair of implant superstructures. In addition, it is important to ensure all oral health providers are competent in providing implant prosthetic maintenance and post‐insertion, and post‐delivery maintenance for their patients, especially those who provide care in nursing homes [43]. At a patient level, the use of a specific manufacturer for an implant system should be selected to ensure the availability to supply component parts over the lifetime of a patient. In addition, if a patient continues to experience natural tooth loss, a record of the implant system and components employed can be recorded on a personalized “implant card.” This documentation of the implant system, component parts, and manufacturer identification codes should be provided to the patient in case they relocate, move, or transfer care elsewhere. In certain situations, it may be prudent as oral healthcare providers to provide the patient their casts or models used to fabricate the implant prostheses so that they may safely retain them for future reference in prostheses maintenance or replacement.

Conclusion

As a person ages, it is important to anticipate potential challenges due to consequences associated with aging when providing implant treatment. The Rapid Oral Health Deterioration staging classification is one means of rationalizing a patient’s current status relative to general health, social support, and intraoral conditions while taking into consideration the potential of future adverse changes.

Key perspectives when considering incorporation of dental implants in treatment planning for elderly patients include the following:

• Life expectancy and quality of life: It is important to note that clinical decision‐making relative to implant–supported prostheses should not be solely based on survival or success rates. The focus should be a patient’s subjective gain of quality of life and overall well‐being as well as anticipated life expectancy based on the patient’s systemic conditions.
• Rational treatment planning: Careful consideration as to the final treatment plan, prosthesis type, and the ability to change from a fixed to a removable restoration or vice versa can be critical especially as the patient’s general health, social support, and oral conditions deteriorate with time.
• Prosthesis design: Clinicians must also take into consideration the type of implant prosthesis and design in addition to a patient’s ability and motivation to wear and/or maintain it as the person ages. An implant may successfully integrated with minimal bone loss; however, if the prosthesis cannot be utilized for its intended purpose due to the patient’s inability to maintain it, then this cannot be considered a successful outcome [41]. Prosthodontic treatment plans should be ultimately designed to be cleansable for long‐term maintenance, but also retrievable, repairable, and replaceable.
• Implant systems and manufacturers: Consideration to utilize one implant system over time for a patient is preferred as opposed to use of multiple implant systems with various implant component manufacturers along with providing the patient with a listing detailing implant specifications.
• Access to care: As the patient ages, their ability to schedule and commit to professional maintenance care may depend on several factors such as transportation and assistance to gain access to care. Identifying an appropriate support system is important for an elderly patient to maintain good oral health for overall health, yet the support system must adapt to increased needs of the patient and/or unexpected complications. Many elderly depend on their caregivers to maintain their oral health and general health. Therefore, educating the caregivers to raise the level of oral health literacy is essential in providing optimal care for the elderly.

Case reports of patients that required implant prostheses management over time, impacting clinical decision‐making.