Maintenance considerations in elderly dependent patients with implants

Background Self-care and professional care of implants may prove difficult for elderly people who require nursing care. However, the actual state of care and problems remains unknown. In this study, we investigated the actual state of implant problems in elderly people living in their own home or in a nursing home who received visiting dental treatment. Methods We mailed questionnaire survey forms to 2339 representatives or specialists who were members of the Japanese Society of Oral Implantology, the Japanese Society of Gerodontology or the Japan Prosthodontic Society. We narrowed down the respondents to those who provided visiting dental treatment, and analyzed the actual state of implants observed during visiting dental treatment (type, care, problems, countermeasures, etc.). Results Of the 924 dentists who responded to the questionnaire survey, 291 (22%) provided visiting dental treatment . While the majority of implant types encountered in the previous 12 months were root-form implants, there were still a certain number of blade and subperiosteal implants. Daily implant care involved mostly cleaning with a toothbrush + auxiliary tools. The most frequent implant problems encountered in the past were difficulty in cleaning and peri-implantitis. Medication and antiphlogistic treatment were most frequently adopted as countermeasures to implant problems, followed by observation. When we classified the results into those for the dentists who provided implant treatment and those for the dentists who did not, we found that many of the dentists who did not provide implant treatment opted for observation or medication, while those who provided implant treatment also implemented removal of superstructure, retightening of screws, repair and so forth. Conclusions We found that many of the implant troubles encountered by dentists who provided visiting dental care were difficulty in cleaning or peri-implantitis, and that the actions taken against these troubles varied depending on the experience of the dentist performing the implant treatment. Our study also revealed that dentists who provide visiting dental care need to acquire knowledge and skills of implant treatment, to have actions prepared in case they encounter such cases, or to closely coordinate with dentists who specialize in implants.

about implants by their patients. The rate of dentists who continued providing care through visits was approximately 80%. However, 40% of the dentists did not grasp the trends of the patients after implant treatment. Approximately 3% of the patients receiving visiting dental treatment had implants (mainly confirmed by visual examination). More than 50% of the dentists who provided implant treatment did not use implant cards, and even when the cards were used, they lacked consistency. It is necessary to expand the provision of continuous care after implant treatment, and we consider that the popularization of cards under a unified standard is essential for achieving this.
In this study, we narrowed down the survey respondents to dentists who provided visiting dental treatment and we analyzed the data on the implant care and problems encountered as well as the countermeasures in order to elucidate the actual state of implants in elderly people requiring nursing care.

Methods
The survey was conducted as a questionnaire for a period of three months from August to October 2015, with the survey respondents' names entered. The questionnaire forms were distributed and collected in mail [4]. Table 1 shows the questions that were asked in the questionnaire.
Questionnaire forms were distributed to 2339 representatives or specialists who were members of the Japanese Society of Oral Implantology, the Japanese Society of Gerodontology or the Japan Prosthodontic Society, and we received 924 completed (40% collection rate). We then narrowed down the respondents to those who provided visiting dental treatment and analyzed the data for the following three matters. The 96 dentists mentioned above responded that the types of daily implant care provided by dentists, facility staff and so forth in the past 12 months included: brushing with a toothbrush only (49.0%, 47 dentists), combination of a toothbrush and an auxiliary tool (88.5%, 85 dentists), gum massage (39.6%, 38 dentists), salivary gland massage (21.9%, 21 dentists), moisturizing (33.3%, 32 dentists), cleaning with gauze (12.5%, 12 dentists), dedicated care (10.4%, 10 dentists), mouthwash (2.1%, 2 dentists) and others (7.3%, 7 dentists).

Actual state of implant problems
Of the 360 patients revealed by the questionnaire, the types and numbers of implant troubles that were encountered in the past were as follows: difficulty of cleaning (45%, 170 patients), periimplantitis (39%, 139 patients) and fracture of facing material (16%, 59 patients) (Fig. 3).

Actual state of countermeasures for implant problems
The actions that were taken against implant troubles in the past for the 360 patients were as follows: patients) (Fig. 4). When these cases are classified by dentists who provided implant treatments and those who did not, the dentists who provided implant treatments conducted the following actions: superstructure removal (22%, 12 patients), tighten screw (20%, 11 patients), and superstructure repair (19%, 10 patients), whereas the dentists who did not often resorted to observation (53%, 17 patients) (p<0.01) and medication (53%, 17 patients) (Fig. 5).

Discussion
Our previous report [4] revealed the state of implant treatment provision, state of visiting dental treatment, trends in patients after implant treatment, actual state of implants in visiting dental treatment, and actual state of implant card utilization as well as awareness of it, and indicated that it was essential to expand the provision of continuous care after implant treatment and that popularization of the implant cards under a unified standard was necessary to achieve this.
In this report, we narrowed down the survey respondents to dentists who provided visiting dental treatment, and analyzed the actual state of implant care and problems encountered as well as the countermeasures in order to elucidate the actual state of implants in elderly people requiring nursing care.

1.
Actual conditions of implants in visiting care patients and actual conditions of daily care While most of the implants encountered (87.2%) were root forms, certain quantities of the blade type and subperiosteal types were also present ( Fig. 1). Adoption of blade implants started decreasing around 1985 [5], and the use of subperiosteal implants is assumed to have also declined [6].
However, they are still present in some patients, and thus it is considered that education on these systems is still necessary.

Actual state of implant problems
Since many cases involved difficulty in cleaning or peri-implantitis according to the types and numbers of implant troubles that were encountered in the past, we found that there were many troubles related to oral cavity cleaning. It is therefore important to ensure professional care and management. It is also necessary for the dentists to install implant prostheses while taking into consideration the cleaning properties and modifiability of the prosthetic devices.
We consider it favorable that toothbrush + auxiliary tools (such as interdental brushes) accounted for a majority of daily implant care. However, this study was not able to clarify who provides this care and how, or whether such care is properly implemented. Implant treatment itself has achieved sufficient success rates even in elderly people [7] (Dudly, 2015) and people with disabilities [8] ( (2011) [10] stated that it was important to ask, "Is the patient supported by a well-functioning oral (self) care assisting network? Is it possible for the patient to regularly see an oral health care professional and is oral health care easily accessible in case of an emergency?" Due to the fact that the rate of people who were incapable of self-care was quite high at 56% [4], it seems that professional care and management are more important, even though there is also an issue of manpower [11][12][13]. We await the results of more detailed fact-finding studies on oral care in the future.

Actual state of countermeasures for implant problems
Since we found differences in actions taken against implant troubles by dentists who provide visiting dental care depending on their experience and knowledge in implant treatment, it is desirable to expand pre-graduate education on implants, the system for introduction to implant experts, and so forth.
The fact that many of the dentists who did not provide implant treatment opted for observation or medication while those who provided implant treatment also implemented removal of the upper structure, retightening of screws, repair and so forth suggests that those who did not provide implant treatment found it difficult to take appropriate measures due to insufficient knowledge or skills related to implants. Even though student education on implants has become more substantial in recent years [14], further coverage is desired, including oral care for patients living in a nursing home including elderly people and patients receiving home treatment, comprehension and management of systemic conditions, coordination with other occupations and so forth. In addition, since it is not practical to presume that all dentists providing visiting dental treatment would be capable of sufficient measures regarding implants, coordination with implant specialists should also be examined.
In addition, the fact that there is insufficient evidence for actions against implant troubles in visiting dental care is a problem. While position papers by experts [15,16] are beginning to be published, the accumulation of evidence and establishment of guidelines are also necessary. To do this, we need to conduct more surveys on actual conditions in visiting dental care, in order to determine the relationship between individual patients and level of trouble, such as the degree of autonomy of the patient and the level of peri-implantitis [4]. It is also necessary to examine the situation that the handling of implant troubles is not covered by health insurance, which is unique to Japan. Efforts to achieve public consensus will be necessary while also taking into account the increase in medical expenses.

Conclusion
While field surveys will be required in the future since the present survey was done by questionnaire, we were able to clarify the following points: 1.
The most frequent implant troubles encountered by dentists were difficulty of cleaning and peri-implantitis.

2.
While many of the dentists who did not provide implant treatments resorted to observation or medication, those who provided implant treatments also removal of implant, repair and so forth.

3.
Dentists who provide visiting dental care need to either acquire knowledge and skills in implant treatment or consider coordinating with implant experts.

Declarations
Ethics approval and consent to participate The study design and consent forms for all procedures performed on the study subjects were approved by the ethics committee for human subjects at Japanese Society of Oral Implantology in accordance with the Helsinki Declaration of 1975 as revised in 2008.

Consent for publication
Not applicable

Availability of data and materials
The data that support the findings of this study are included in this published article and its    Daily implant care implemented in the previous 12 months Toothbrush + auxiliary tools (such as interdental brushes) accounted for the majority of cases.

Figure 3
Implant problems encountered in the past Most frequent problems were difficulty in cleaning and peri-implantitis.

Figure 4
Countermeasures for implant problems taken in the past Medication and antiphlogistic treatment were most frequently adopted, followed by observation.