Today’s aged generation presents new challenges in the field of implant dentistry. Implant patients of advanced age often present with functional dependency, systemic medical conditions (comorbidities), and frailty. In addition, the aging of the immune system, termed immunosenescence, may result in a compromised host defense to a bacterial challenge at dental implants which adversely affects peri-implant health.
Furthermore, the presence of systemic conditions and treatment of these conditions may present a risk for implant placement, maintenance of peri-implant health, and ultimately implant survival. The most common systemic conditions in geriatric patients, as reported by the World Health Organization (WHO) in 2015, are cardiovascular disease (CVD), cancer, respiratory diseases, diabetes mellitus, liver cirrhosis, osteoarthritis, and conditions that involve neurocognitive impairment.
This systematic review addressed the focused questions: “In patients undergoing dental implant therapy, what is the effect of advanced age (≥75 years) and/or common systemic medical conditions on implant survival and biologic complication rates?”
The systematic review included evidence from 60 studies, of which 7 provided sufficient information to perform meta-analyses based on the primary outcome - implant survival in geriatric patients (≥75 years). One-year implant survival was based on 7 prospective studies with a mean of 35 implants, and 5-year implant survival was based on 3 prospective studies with a mean of 25 implants.
The remaining 53 studies reported on implant survival in patients with the most common systemic medical conditions and their respective treatments (CVD, radiation therapy, antiresorptive therapy (ART), hyposalivation/dry mouth, diabetes mellitus, and neurocognitive impairment), irrespective of the patients’ age.
Annual mean peri-implant marginal bone loss (PI-MBL) was reported in seven studies.
- Advanced age alone (≥75 years) is not a contraindication for implant therapy.
This statement is based on 7 prospective studies.
- Peri-implant marginal bone loss (PI-MBL) in geriatric patients is low and similar to other age groups after one to 5-year follow-up.
This statement is based on 7 prospective studies, where PI-MBL was calculated to be between 0.1 mm and 0.2 mm annually over a recall period of up to 5 years and 0.51 mm for the first-year after loading.
- Few studies in implantology focus on geriatric patients (≥75 years) and systemic medical conditions (comorbidities) common in old age.
- Evidence suggests, that in patients with cardiovascular disease (CVD), including ischemic heart disease, stroke, and hypertensive heart disease, implant survival is similar to patients without CVD.
This statement is based on one cross-sectional and one cohort study. The calculated implant survival ranges from 98% to 100% in patients with CVD.
- In patients with head and neck cancer, implant survival may be negatively affected by radiotherapy. Treatment protocols for implant placement in irradiated patients have been developed. In oncology patients receiving high-dose antiresorptive therapy (ART), implant surgery carries a high risk for postoperative complications and is contraindicated. High-dose ART is described as any ART treatment administered in oncology patients with bone metastases. In oncology patients, the long-term effects of chemotherapy on oral tissues have not been investigated.
This statement is based on 16 studies on radiotherapy and on two studies on ART focussing on the development of medication-related osteonecrosis of the jaw (MRONJ). No studies reported on the effects of chemotherapy alone.
- Treatment for cancer is commonly associated with hyposalivation. Hyposalivation is also commonly associated with polypharmacy and Sjögren’s syndrome. While implant survival in patients with Sjögren’s syndrome is reported to be very high, the effect of cancer treatment and polypharmacy has not been reported.
This statement is based on 5 studies.
- In adult patients with diabetes mellitus type II, high implant survival rates may be achieved.
This statement is based on 7 studies for patients in the mean age range of 49.5–64 years.
- Patients with conditions involving neurocognitive impairment (unipolar depression, Alzheimer’s disease and other dementias, and Parkinson’s disease) can experience high implant survival rates.
This statement is based on 7 studies, including 4 case reports. The mean age ranged from 44 to 83 years and an observation period of 3–72 months.
- No evidence was identified related to other diseases that are common among the elderly (WHO, 2015) such as liver cirrhosis, respiratory diseases and osteoarthritis, in relation to implant therapy.
- Is there an upper age limit for implant therapy?
In geriatric patients, implant therapy may be considered irrespective of age. Implant and prosthesis maintenance must be assured by the patient and/or care provider.
- Which common comorbidities comprise contraindications for implant placement?
High-dose antiresorptive therapy (ART) poses a serious risk for postoperative complications and is a contraindication for implant surgery. If treated at all, these patients should be managed in a specialist setting.
- Which common comorbidities comprise risks for implant placement?
Comorbidities such as cancer, diabetes mellitus, and conditions involving neurocognitive impairment may carry risks for implant therapy. An individual risk assessment is necessary before considering implant surgery for these patients. Implant patients with comorbidities should be managed in close collaboration with a supervising physician with regular follow-up. In patients with diabetes mellitus, oral hygiene should be closely monitored along with glycemic control and associated comorbidities of the disease.
- Which information must be taken into account when planning implant therapy for geriatric patients with common systemic diseases?
While there is no evidence to preclude geriatric patients (≥75 years) from implant therapy it is advisable to perform an individual risk assessment for patients with comorbidities. In geriatric patients, a holistic approach is required which should include assessment of functional dependency in addition to related limitations for the use of implant-supported prostheses and the ability to perform oral hygiene measures. The progression of existing systemic disease and dependency as well as the patient’s life expectancy should be considered in the context of availability of competent care.
- What are the risks and benefits associated with implant therapy in geriatric patients and patients suffering from the most common diseases in geriatric patients?
Implants may be considered in elderly and medically compromised patients when they can provide substantial functional and psycho-social benefits, which must outweigh the associated risks, cost, and burden of treatment.
- What public health issues are important to consider for successful implant therapy in geriatric patients?
When older patients lose independence, the availability of trained manpower in the caring professions is a potential limiting factor for implant therapy. Opportunities for education and additional training focused on oral health should be provided for those involved in caring for dependent persons.