Too Old for Dental Implants
Ageism, Autonomy, and Ethics
Is this patient too old to get dental implant treatment?
Even asking the question seems vaguely morbid. It seems like we’re saying: “This patient is likely to die soon, and I will feel like a money hungry monster if I charge them my standard fee for treatment. Why put them through any procedure when they are so very, very old? And after all, shouldn’t that money go to their children and grandchildren?” On the other hand — how committed are we to one of our pillars of medical ethics: patient autonomy? Do we decide what our patients get to do with their lives and money, or do they? Choose one: Are we greedy bandits robbing our older patients, or are we petty tyrants withholding the best treatment because of our ageist bias? Is our treatment more likely to fail due the patient’s advanced age and (often) multiple medical conditions? Ghoulishness aside, there is a legitimate question of ethics to be dealt with, namely: do the functional and psychosocial benefits of implant treatment for elderly patients outweigh the associated risks and justify the associated costs?
We’ll have to sort out the former, more metaphysical questions on our own, with the help of a well formed conscience, and perhaps some reading more geared to religion, philosophy, and other subjects of (slightly) deeper importance than dental implant treatment.
As for the latter questions, we do have recent research to answer that. Intrepid researchers in Sweden, Turkey, Austria, and Switzerland put their minds and data together to look at implant survival and bone loss for patients older than 65 with at least 5 years of follow up.
How old is old for implant therapy in terms of implant survival and marginal bone levels after 5-11…
The high implant survival rate (95.4%), low mean MBL evel (1.24 mm) and low frequency of maximum MBL oss ≥ 5 mm (0.5%)…
No getting around it; the data look good. 218 implants with 5–11 years of follow up (mean 6.2 years), 95.4% implant survival, maximum bone loss 1.48 ± 1.0 mm, >5mm bone loss in only 0.5% of all cases, and — counterintuitively — age presented a slightly protective effect as it related to bone loss. In other words, the older patients had slightly LESS bone loss than the younger ones. Looking at clinical parameters, implants did just fine in older patients.
≥ 65 years old, > 5 years follow up — 95.4% implant survival
The usual warning regarding retrospective data applies here: there is no way to avoid the possibility of selection bias in retrospective data sets. If the clinicians intentionally (or unintentionally) weeded out patients with more serious risks of failure by dint of their clinical judgment, then these data will be naturally skewed toward success. Still, in a case like this where the independent variable is the patient’s age, it is useful to imagine what a control group might look like — younger with fewer medical conditions seems the likeliest answer. So to assess if these results are outlandish, it is valuable to know what data from those younger populations look like. Are they wildly different, suggesting skewed results? No, happily they are similar. 95.4% survival rate is squarely in line with overall implant survival rates reported in very large and diverse data sets. For what it’s worth, this result is not obviously high or low by comparison. What then, to make of the medical conditions question? The study reviewed here does not stratify the data based on medical history or diseases, so we cannot speak to that here. We’ll have another post on that subject shortly…
What it Means for You
With the selection bias caveat, it seems that age should not be a factor in our treatment planning decisions for dental implants. There’s an obvious way in which this makes sense using the analogue of dental extraction. (N.B.: that some notion makes sense does NOT necessarily mean it is clinically true or correct.) We wouldn’t consider a patient’s age in deciding whether to extract a tooth when that treatment is indicated. And aren’t we asking bone to heal in the case of an implant much like an extraction?
…age should not be a factor in our treatment planning decisions for dental implants.
So in this case, it makes sense AND the data show it to be reasonable. We can confidently treat elderly patients with dental implants, and (if our fee schedule is reasonable) not worry too much about being rapacious fiends. Implants clinically perform as well in older patients as they do in younger ones. So if we believe the benefits justify the costs of implant treatment for our younger patients, we ought to believe the same for our older patients.