A Role in Geriatric Dentistry for the General Practice?

For the majority of the population, the clinical success of dental implant therapy has improved such that some clinicians consider it to be a form of standard of care.  However provocative this assessment may be, clinicians should not ignore the role of implant therapy to support the oral rehabilitation of the elderly population and of other medically compromised patients. The patient, caregiver, family and clinical team need to weigh the inherent advantages and costs of implant therapy. Tooth replacement therapy can vary from single-tooth replacement with conventional or implant-supported restorations to full-arch replacement with individual implants/tooth-to-implant–supported overdentures. Each of these options (including no tooth replacement) has advantages and costs that must be weighted in a multifactorial consideration of patients’ desires, understanding, resources and perspectives.  The predictable esthetic and functional outcomes of care depend on a comprehensive diagnostic evaluation and treatment planning.

Patients who undergo implant therapy face medical and surgical risks that are similar to those of outpatient oral surgical intraosseous procedures. The surgical team should evaluate the patient for systemic conditions that may compromise healing (for example, immunocompromised states, uncontrolled diabetes) and the systemic effects of medications. In general, the survival rates of dental implants in older patients can be affected by certain systemic conditions associated with aging, including long-term smoking, diabetes and postmenopausal estrogen therapy. In addition, the use of multiple medications influencing bone metabolism (for example, steroids, bisphosphonates) has the potential to alter the outcomes of implant therapy.  For instance, investigators recently have become concerned about surgical interventions in patients with osteoporosis who receive long-term oral bisphosphonate therapy. As part of a careful informed consent process, the dentist needs to provide the patient and his or her family with an accurate assessment of the procedures, the length of treatment time, risks and alternatives to implant treatment (including no tooth replacement and conventional fixed or removable prostheses).

Investigators often point to the ability of bone to heal in the older patient as a concern with regard to implant outcomes. Researchers have addressed this question through the clinical assessment of implants placed in the anterior mandible, a region of the oral cavity that does not experience significant age-associated osteopenia. Implants placed, restored and functioning in areas of predominantly trabecular bone (for example, atrophic maxilla) are at a higher risk of experiencing complications.Implant interfaces are maintained through dynamic modeling and remodeling processes within the bone of these regions. (“Modeling” refers to any net change in bone shape, whereas “remodeling” refers to the continuous turnover of bone without a net change in shape or size.) These processes (referred to as “the adaptive capacity” by Stanford and Brand ), in turn, allow bone to respond to the clinical procedures and occlusion over long periods.

Patient assessment. The predictable esthetic and functional outcomes of implant treatment for geriatric patients require comprehensive diagnosis and treatment planning.  The clinician should assess the patient’s medical and dental history for bruxism, periodontal disease, tobacco use, uncontrolled diabetes mellitus and metabolic diseases of bone.  Some investigators have reported elevated complications related to smoking after controlling for age and other medical conditions. Diabetes, especially type 2, is a disease of increasing concern in which control (as measured by hemoglobin A_1C levels < 7.0 percent) is considered important for successful long-term outcomes of implant therapy. Throughout the surgical and prosthetic phases of implant reconstruction, the general dentist should review the treatment with the patient and any key significant others and obtain comprehensive written and oral informed consent from the patient. It may be helpful to have a private discussion with the patient to assess his or her specific needs and desires and balance them with those of the caregiver.

To improve treatment outcomes, the dentist should design and compose the proposed prosthesis during the diagnostic phase. Planning will include issues such as the type of prosthesis (removable, fixed or a combination). Clinicians should consider the use of implants in combination with removable partial dentures in a compromised dentition to provide greater support, esthetics and potential function for the partial denture.¹⁹ On the basis of the acquired diagnostic information, the dentist can use a surgical guide or denture to indicate the desired implant position, angulation and need for hard- and/or soft-tissue augmentation before or during implant placement. The clinician should carefully evaluate the patient’s soft- and hard-tissue changes to encourage realistic patient expectations.

For geriatric patients who have a single edentulous arch or a partially edentulous arch, there is a balancing of treatment options that include fixed partial dentures (FPDs), adhesive resin restorations and single or short-span implant restorations, as well as no tooth replacement. The final decision is made after considering the patient’s desires, treatment objectives, clinical capability of the clinician, dentist’s expertise and training, treatment costs, treatment time and potential morbidity. Occasionally, given a stable occlusion, the dentist might consider a rigid tooth-to-implant fixed prosthesis (a design that does not allow any movement between the two retainers)^20,21 (Figure 1). Preoperative planning helps to achieve rational, functional and esthetic goals by ensuring that the final restorative therapy is in the patient’s best interests.²² As part of the informed consent process, the clinician should discuss with the patient treatment plan alternatives with regard to the ability to control esthetics and function with the various methods of tooth replacement.

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