Hagiwara et al.

International Journal of Implant Dentistry

https://doi.org/10.1186/s40729-021-00340-z
(2021) 7:53
International Journal of
Implant Dentistry

RESEARCH Open Access

Dental implant status in elderly individuals

requiring domiciliary dental care in Japan
Yoshiyuki Hagiwara1* , Tetsuo Ohyama2, Hiroyasu Yasuda2, Keisuke Seki3 and Takayuki Ikeda4

Abstract
Background: The presence of implants is a significant burden not only for dentists but also for caregivers and
families of elderly individuals requiring nursing and domiciliary dental care. However, few reports have assessed the
status of domiciliary dental care or measures employed to deal with related issues. Hence, we aimed to evaluate
the dental implant status in elderly patients requiring nursing and domiciliary dental care and to determine the
suitable measures for overcoming the associated limitations. A questionnaire was mailed to 1000 dentists who
provided domiciliary dental care in the Tokyo metropolitan area of Japan. The questions were classified into three
categories: basic information of the dentists, actual implant status of patients requiring domiciliary dental care, and
implants in an aging society.
Results: The response rate was 36.5%. Approximately 2% of patients requiring domiciliary dental care were implant
patients. Many implant-related problems were associated with insufficiency or difficulty in cleaning around the
implant, resulting in peri-implantitis. Prosthetic and more serious complications such as implant body fracture or
loss were reported and frequently managed by routine follow-ups, cleaning the area around the implant, scaling
and polishing, and/or pharmacological modalities. Oral care mainly involved simple toothbrushing instructions,
which was not adequate.
Conclusions: Our findings suggest the necessity of simplifying the oral environment and making oral care a simple
task before aging individuals require nursing and domiciliary dental care.
Keywords: Dental implant, Domiciliary dental care, Questionnaire, Elderly individuals, Complications

Background years and ≥75 years who required care were 4.2% and
Implant treatment has shown long-term success by 29.2%, respectively [3].
regular follow-ups of patients in a dental office. Recently, Common reasons for the need of care at home or fa-
there has been an increase in the number of implant pa- cilities for elderly individuals include advanced age, cere-
tients who cannot visit a dental clinic for follow-up ap- brovascular disease, and dementia. These conditions
pointments due to their increasing age. The Japanese affect not only the quality of oral care provided to pa-
population has the highest life expectancy worldwide, tients but also their general health [4–7]. Costa et al. [8]
and in 2007, Japan was declared the world’s first “super- reported an increase in the incidence of peri-implantitis
aging” society [1]. In 2017, the percentage of elderly in- owing to the inadequate care of implants in patients
dividuals (≥65 years, WHO definition [2]) in Japan was who are unable to maintain oral hygiene. Visser et al. [9,
23.8%, while the percentages of individuals aged 65–74 10] also reported implant-related problems in patients
with dementia. However, these articles do not report
unilaterally denied implant treatments in the elderly and
* Correspondence: [email protected]
state that the use of implant prostheses in the elderly
1
Department of Fixed Prosthodontics, Nihon University School of Dentistry, has contributed significantly to improving masticatory
1-8-13 Kandasurugadai, Chiyoda-ku, Tokyo 101-8310, Japan function and quality of life [4–10]. Although, in the
Full list of author information is available at the end of the article

© The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
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Hagiwara et al. International Journal of Implant Dentistry (2021) 7:53 Page 2 of 7

cases of elderly people who need long-term care, they metropolitan area in 2017. The participants were ran-
emphasize concerns about poor oral hygiene and peri- domly selected using a table of random numbers from
implantitis. Consequently, there is an increase in the registered dentists who provided domiciliary dental care.
need for domiciliary dental care [11–13] whereby den- The questionnaire comprised 13 questions (Table 1)
tists or dental hygienists provide dental treatment and classified under the following three categories: basic in-
specialized oral care by visiting the homes, care facilities, formation of the dentists (3 questions), actual implant
or hospitals of patients who cannot visit dental clinics status of patients requiring domiciliary dental care (5
for physical or psychological reasons. However, the vis- questions), and implants in an aging society (5 ques-
ited location is usually not equipped with dental infra- tions). This study was performed after obtaining ap-
structure; hence, the treatment provided primarily proval from the ethics committee of Nihon University
includes simple caries treatment, adjustment and repair School of Dentistry (No. 2016-18).
of dentures, and oral care. However, global awareness
about domiciliary dental care is inadequate, and the sys- Results
tem differs according to the medical insurance system, In total, 365 dentists (36.5%) responded to the question-
number of dentists, geographical requirements, and pa- naire. The mean duration of clinical experience was 27.5
tient populations in different countries and regions [11– years (median 22.5 years), while the mean duration of
13]. experience in providing domiciliary dental care was 11
The oral condition of patients requiring domiciliary years (median 7.5 years). Of the 365 respondents, 189
dental care is generally poor, and there are various limi- (51.7%) confirmed that they performed implant treat-
tations in the dental equipment that are used for this ment in their own clinics. The types of facilities visited
mode of treatment. These patients need treatment in an for domiciliary dental care and the number of implant
environment that is completely different from that in a patients encountered are shown in Table 2. Six types of
dental clinic; therefore, the presence of implants be- facilities were visited for domiciliary dental care: pa-
comes a significant burden not only for dentists but also tients’ homes, special nursing home for the elderly
for caregivers and families and impedes adequate oral (SNHs), long-term care health facilities (LCHFs), private
care. However, few reports have assessed the current sta- nursing homes for the elderly (PNHs), hospitals, and day
tus of this modality or the measures employed to deal care services (DCSs) for individuals with dementia. Im-
with related issues [14, 15]. plant patients accounted for 2% of the total number of
Hence, the purpose of this study was to determine the patients receiving domiciliary dental care. The percent-
status of implants placed in elderly individuals requiring age differed across facilities, being higher in homes,
long-term nursing and domiciliary dental care in Japan PNHs, and DCSs.
and to investigate the suitable measures for overcoming
the associated limitations. Actual implant status of patients requiring domiciliary
dental care
Methods The most common implant superstructure encountered
A questionnaire was sent via mail to 1000 dentists pro- was a fixed prosthesis (crowns and bridges). Patients
viding domiciliary dental care within the Tokyo with exposed implant abutments and broken

Table 1 Summary of the questionnaire sent to dentists who provided domiciliary dental care
Basic information of the dentists Q1. Years of clinical experience
Q2. Years of experience providing domiciliary dental care
Q3. Provision of implant treatment in the respondent’s own clinic
Actual implant status of patients requiring Q4. Type of facilities visited for domiciliary dental care and the number of implant patients
domiciliary dental care
Q5. Types or status of implant prostheses encountered in domiciliary dental care
Q6. Types of implant-related complications encountered
Q7. Countermeasures/treatment for implant-related problems and complications
Q8. Oral care/care instructions provided in domiciliary dental care
Implants in an aging society Q9. Whether there is a necessity of implants (prostheses) in patients requiring domiciliary dental care
Q10. Indications for implants (prostheses) in domiciliary dental care
Q11. Necessity of consulting services (from implant societies or dental associations or universities) for
implant problems/complications in domiciliary dental care
Q12. Whether implant treatment history/information provided by patients was useful
Hagiwara et al. International Journal of Implant Dentistry (2021) 7:53 Page 3 of 7

Table 2 Types of facilities visited for domiciliary dental care in the Tokyo metropolitan area and the number of implant patients in
these facilities
Type of facility Number of facilities Total number of Number of implant patients (percentage of total
visited patients patients)
Patient’s homes 2857 3637 90 (2.5%)
Special nursing home for the elderly 410 1024 11 (1.1%)
Long-term care health facilities 60 671 8 (1.2%)
Private nursing homes for the elderly 291 170 9 (5.3%)
Hospitals 32 240 3 (1.3%)
Daycare services for individuals with 6 36 1 (2.8%)
dementia
Total 3656 5878 122 (2.1%)

superstructures that were left untreated were also evalu- Moreover, many respondents preferred to manage im-
ated, and we found that these problems were difficult to plants using measures such as implant overdentures, im-
manage via domiciliary dental care (Fig. 1). Many plant removal, or conversion to sleeping (submerged)
implant-related complications were associated with in- implants before patients reached the stage of requiring
sufficiency or difficulty in cleaning around the implant, nursing and domiciliary dental care (Fig. 5). Additionally,
ultimately resulting in peri-implantitis. In addition to 88% of the respondents stated that consulting services
prosthetic complications such as chipping or fracture of were necessary for implant-related problems, and 90%
veneering materials, loosening or fracture of abutment stated that information regarding the implant treatment
screws, and loss of cement retention, serious complica- (position of implant placement, implant system used,
tions such as implant fracture or loss were also found retained methods of superstructure) was necessary.
(Fig. 2). These complications were frequently managed
by routine follow-ups. Several patients underwent pas- Discussion
sive treatments, such as cleaning the area around the im- The response rate for the survey in this study was 36.5%,
plant, scaling and polishing, and/or pharmacological which is slightly lower than the typical response rate for
modalities; this highlights the difficulties associated with postal surveys [16]. This was a fact-finding survey per-
proactive management of implants via domiciliary dental taining to implant patients requiring domiciliary dental
care (Fig. 3). Oral care primarily involved routine tooth- care. Accordingly, if we assume the presence of bias due
cleaning methods using equipment, such as tooth- to factors such as the lack of survey completion because
brushes, interdental brushes, and dental floss; no aggres- of no implant patients or no experience or interest in
sive intervention was used. Oral hygiene instructions implant treatment, the actual implant status of patients
were provided to the families or caregivers (Fig. 4). requiring nursing and domiciliary dental care could be
worse than that suggested by the results of this survey.
Implants in an aging society
Regarding the need for implant treatments in patients Domiciliary dental care
requiring nursing care, 73% of the respondents opined This survey found that approximately 62% of patients
that implants were not necessary in such patients. who received domiciliary dental treatment/care resided

Fig. 1 Q5. Types or status of implant prostheses encountered in domiciliary dental care (multiple answers were allowed)
Hagiwara et al. International Journal of Implant Dentistry (2021) 7:53 Page 4 of 7

Fig. 2 Q6. Types of implant-related complications encountered (multiple answers were allowed)

in their homes. Various types of nursing facilities are vis- enable the individual to return home. PNHs are residential
ited for providing domiciliary dental care. SNHs are per- facilities that mainly provide services of daily life, includ-
manent residential facilities for individuals who require ing care services (bathing, toileting, feeding), household
constant care, cannot be cared for at home, and/or have assistance (washing, cleaning), and health and medical
relatively severe systemic conditions, such as immobility care. Generally, patients cover all the expenses for using
or dementia. LCHFs are temporary residential facilities for PNHs. DCSs are day care facilities for patients with de-
elderly individuals requiring medical care or rehabilitation mentia wherein lifestyle care and functional training are
that are primarily centered on rehabilitation measures to provided on an outpatient basis during the day.

Fig. 3 Q7. Countermeasures/treatment for implant-related problems and complications (multiple answers were allowed)
Hagiwara et al. International Journal of Implant Dentistry (2021) 7:53 Page 5 of 7

Fig. 4 Q8. Oral care/care instructions provided in domiciliary dental care (multiple answers were allowed)

Actual implant status of patients requiring domiciliary presence of serious complications such as implant body
dental care fracture or implant loss indicated that the patient or
In this study, 2% of the total number of individuals re- caregiver did not perform oral care in an appropriate
ceiving domiciliary dental care were implant patients. manner. We also found that a passive approach was
This proportion is slightly lower than the proportion of employed for the management of biological complica-
implant treatment in those aged 65 years and more tions. This could be attributed to the unfamiliarity of
(3.8%), according to the Survey of Dental Diseases con- dentists involved in domiciliary dental care with im-
ducted in Japan in 2016 [13]. With regard to the distri- plants. Aggressive interventions and invasive treatments
bution of implant patients according to the type of are difficult because of limitations in the treatment en-
facility, we found the highest percentage in PNHs (5.3%), vironment. Thus, difficulties in providing appropriate
followed by DCSs and homes. Elderly individuals of a dental treatment via domiciliary dental care result in im-
relatively higher socioeconomic group reside in PNHs; properly maintained superstructures and inadequately
consequently, the proportion of implant patients in these repaired prostheses. In this study, regarding the implant
facilities was high. The significant number of patients superstructure (crowns and bridges), a detailed analysis
showing evidence of poor hygiene maintenance around of the prosthetic retention options (screw, cement) and
the implant, resulting in peri-implantitis, as well as the the type of facing material was not possible. However,

Fig. 5 Q10. Indications for implants (prostheses) in domiciliary dental care

Hagiwara et al. International Journal of Implant Dentistry (2021) 7:53 Page 6 of 7

many mechanical complications were answered, includ- stage of requiring nursing and domiciliary dental care.
ing veneering material chipping/fracture, screw loosen- However, if we consider the mental and financial condi-
ing/fracture, loss of retention (crown detachment), and tions of patients, obtaining consent for changing the im-
implant body fracture associated with these types of su- plant prosthesis, removing the implant, or converting
perstructures. In addition, because of economic limita- the implant to a sleeping one (while the patients are still
tions associated with aging, the patients may not be able healthy) would be difficult. Furthermore, many implant
to afford expensive dental treatments. patients have natural teeth as well as implant prostheses;
Furthermore, we found that oral care around the im- hence, oral care for both the natural teeth and implant
plant primarily involved the use of toothbrushes, inter- prostheses is required. The following factors were issues
dental brushes, and dental floss, accompanied by faced by domiciliary dentists/dental hygienists and care-
cleaning strategies, such as wiping with gauze and mois- givers: (1) little knowledge about dental implants, (2) dif-
turizing. This indicates that the maintenance of cleanli- ficulty in identifying implant-supported fixed prostheses,
ness around implants was prioritized, even if aggressive and (3) not familiar with special oral hygiene procedures
treatment for peri-implantitis could not be performed. for implants.
However, the patient’s family or caregiver barely re-
ceived instructions regarding oral hygiene maintenance, Conclusions
resulting in inadequate routine oral care. As many eld- With the limitation of low response rate to the question-
erly individuals depend on their families or caregivers naire in this study, we found that approximately 2% of
for oral care, educational activities that will enable the patients requiring domiciliary dental care in the Tokyo
caregivers to provide a certain level of oral care to metropolitan area in Japan are implant patients; this is
dependent individuals with oral implants are necessary. close to the overall percentage of implant patients in
Japan. Many implants are restored using fixed pros-
Relationship between an aging society and implant theses, and various prosthetic and biological complica-
treatment tions, primarily peri-implantitis, are treated using simple
In this study, 73% of dentists responded that implants symptomatic measures or are left untreated. These find-
were not necessary for patients requiring nursing care, ings suggest the necessity of simplifying the oral envir-
with reasons including difficulty in providing oral care, onment and making oral care a simple task before aging
need for invasive treatment, and difficulty in managing individuals require nursing and domiciliary dental care.
the prosthetic aspects of the implants. This opinion was
Abbreviations
generalized not only among dentists, but also among SNHs: Special nursing home for the elderly; LCHFs: Long-term care health
family members and caregivers of the patients. The par- facilities; PNHs: Primary nursing homes; DCSs: Day care services
ticipants of this study were randomly selected, and the
Acknowledgements
respondents were not grouped according to their age or
Not applicable
clinical experience, although there was a tendency for
relatively experienced dentists to provide domiciliary Authors’ contributions
dental care. Additionally, there was no disagreement re- YH conceived and designed the study, performed the experiments, and
wrote the manuscript. TO and HY performed the experiments, and KS and TI
garding the problem of implants in an aging society and performed the data analysis. TO and TI participated in the manuscript
the importance/difficulty of domiciliary dental care de- preparation. All authors read and approved the final manuscript.
pending on the clinical experience (age) of dentists. The
Funding
long-term success of implants is dependent on regular The authors acknowledge the grant from the 8020 Promotion Foundation
checkups at dental clinics and routine oral hygiene (2017).
maintenance. This is based on the premise that the pa-
Availability of data and materials
tient is healthy and able to visit dental clinics in the long All data generated or analyzed during this study are included in this
term. Accordingly, measures for the management of im- published article.
plant patients in the current super-aging society are es-
sential. Müller and Schimmel [14] used the term “back- Declarations
off” to advocate a shift from fixed prosthesis to a more Ethics approval and consent to participate
simplified and easy-to-manage oral environment toward This research was approved by the Ethics Committee of Nihon University
School of Dentistry (No.2016-18).
the end of life. This not only simplifies the provision of
oral care but also prevents the build-up of biofilm and Consent for publication
reduces the risk of aspiration pneumonia. Many respon- Not applicable
dents opined that measures such as implant-supported
Competing interests
overdentures, implant removal, or sleeping (submerged) Yoshiyuki Hagiwara, Tetsuo Ohyama, Hiroyasu Yasuda, Keisuke Seki and
implants should be employed before patients reach the Takayuki Ikeda declare that they have no competing interests.
Hagiwara et al. International Journal of Implant Dentistry (2021) 7:53 Page 7 of 7

Author details
1
Department of Fixed Prosthodontics, Nihon University School of Dentistry,
1-8-13 Kandasurugadai, Chiyoda-ku, Tokyo 101-8310, Japan. 2Department of
Partial Denture Prosthodontics, Nihon University School of Dentistry, 1-8-13
Kandasurugadai, Chiyoda-ku, Tokyo 101-8310, Japan. 3Department of
Comprehensive Dentistry and Clinical Education, Nihon University School of
Dentistry, 1-8-13 Kandasurugadai, Chiyoda-ku, Tokyo 101-8310, Japan.
4
Department of Complete Denture Prosthodontics, Nihon University School
of Dentistry, 1-8-13 Kandasurugadai, Chiyoda-ku, Tokyo 101-8310, Japan.

Received: 7 February 2021 Accepted: 1 April 2021

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