Knowledge and attitude of elderly persons towards dental implants

Or ig ina l a r t i c l e

Knowledge and attitude of elderly persons towards dentalimplants

Frauke Muller1,2, Kamel Salem1, Cindy Barbezat1, Francois R. Herrmann2 and MartinSchimmel1

1Division of Gerodontology and Removable Prosthodontics, University of Geneva, Geneva, Switzerland; 2Department for Rehabilitation and

Geriatrics, University Hospitals of Geneva, Geneva, Switzerland

Gerodontology 2011; doi: 10.1111/j.1741-2358.2011.00586.x

Knowledge and attitude of elderly persons towards dental implants

Background: Despite their unrivalled place in restorative treatment, dental implants are still scarcely used

in elderly patients.

Introduction: The aim of this survey was therefore to identify potential barriers for accepting an implant

treatment.

Materials and methods: Participants were recruited from a geriatric hospital, two long-term-care facil-

ities and a private clinic. The final study sample comprised 92 persons, 61 women and 31 men with an

average age of 81.2 ± 8.0 years. In a semi-structured interview, the participants’ knowledge of implants

and attitude towards a hypothetical treatment with dental implants were evaluated.

Results: Twenty-seven participants had never heard of dental implants, and another 13 participants could

not describe them. The strongest apprehensions against implants were cost, lack of perceived necessity and

old age. Univariate and multiple linear regression analysis identified being women, type and quality of

denture, having little knowledge on implants and being hospitalised as the risk factors for refusing im-

plants. However, old age as such was not associated with a negative attitude.

Conclusion: The acceptance of dental implants in the elderly population might be increased by providing

further information and promoting oral health in general. Regardless of the age, dental implants should be

placed when patients are still in good health and live independently.

Keywords: knowledge, attitude, age, risk factor analysis, dental implants.

Accepted 4 September 2011

Introduction

In spite of progress in oral health promotion and

restorative techniques, tooth loss is still a reality in

old age, and there is widespread need for tooth

replacement in the elderly population1. However,

the prevalence of dental implants in the elderly and

especially in the very old and institutionalised

population is low2,3. According to the national

health survey in Switzerland of 2002, 89.5% of the

population between 65 and 74 years were reha-

bilitated with dental restorations, of those 13.1%

with complete dentures4. The prevalence of dental

restorations increases with age and reaches 97.4%

in the age group of 85 years and above. Never-

theless, the prevalence of dental implants in that

representative population sample was lower than

1% in the patients with removable dentures3. In

Europe, the highest frequency of dental implants in

the edentulous population was found in Sweden,

but did still not exceed 8%5.

Improvements in orofacial function with

implant-supported dental reconstructions are

largely documented, especially for edentulous

subjects with upper complete dentures and lower

implant-supported overdentures6. Besides the pro-

tection of the peri-implant bone through reduced

atrophy7, they comprise increased biting force8,

larger chewing cycles, better coordination of the

chewing sequence9 and improved masticatory

efficiency and ability10. Furthermore, the positive

impact of supporting complete dentures with den-

tal implants on oral health-related quality of life

(OHRQoL) has been demonstrated11.

� 2011 The Gerodontology Society and John Wiley & Sons A/S 1

Nevertheless, a substantial number of patients

are reluctant to receive implant treatment. In a

Swedish study, cost was the main factor for refus-

ing hypothetical implant treatment, followed by

the fear of the surgical procedure12. Even after

removing the cost factor from the decision process

through offering free implant treatment whilst

recruiting for a study, Walton and MacEntee found

36% of their edentulous study sample refusing

such therapy13. This fact was mainly attributed to

concerns about the surgical procedure. Further-

more, older patients seem to refuse implant treat-

ment if they are satisfied with their conventional

denture and at the same time they seem to tolerate

poor dentures better than younger patients14,15. In

a more recent qualitative approach, fear of pain,

complications and social embarrassment were

revealed as factors explaining implant refusal by

elderly patients16.

Elderly persons’ knowledge on dental implants is

difficult to assess. Tepper et al.17 reported that only

4% of their representative population sample felt

very well informed about dental implants, whereas

42% felt not at all informed. Main discriminating

factors were the size of the hometown and level of

education. About a third of their participants would

be interested to receive more information about

implant treatment and would prefer their dentist as

source of information. A Norwegian study18 showed

that advanced age, being women, a rural place of

residence as well as low income and educational

level predicted a negative opinion towards implant.

There is well-established evidence on implant

survival as well as improvements in orofacial

function with implant-supported overdentures.

Therefore, elderly patients’ refusal of an implant

treatment remains intriguing. Identifying barriers

could help to improve acceptance rates and

understand patients’ reluctance towards an implant

treatment. The aim of the present study was

therefore to evaluate the knowledge and awareness

of dental implants in an elderly population and to

identify barriers such as age, gender, general and

oral health as well as life circumstances.

Material and methods

Approval from the University Hospital of Geneva

Ethics committee was obtained (06-020/PSY

06-002).

Study sample

Participants were recruited from the Geriatric

University Hospital of Geneva (HOGER), the resi-

dents of two long-term care facilities in the canton

of Geneva (LTC) and community-dwelling patients

from a private dental practice (DOM) in the Lake

Geneva region, Switzerland. Inclusion required an

age of 65 years or over; exclusion criteria were

severe cognitive impairment, ongoing dental

treatment or previous treatment with dental

implants. The patients of HOGER and LTC were

contacted by the nursing staff to participate. HO-

GER patients were hospitalised mostly for chronic

diseases and expressed many co-morbidities19; the

average length of stay in HOGER was 48.8 days in

200820. Participants without current treatment

from DOM were selected from the private practice’s

patient pool to fit the inclusion criteria. Written

informed consent was obtained from all study

participants.

Dental state and general health

A short clinical examination was performed. In

denture wearers, the condition of removable pros-

theses was judged according to Marxkors as ‘very

good’ (free of defaults), ‘good’ (minor default

which requires chair-side correction), ‘acceptable’

(major defaults which can be corrected by dental

technician) or ‘poor’ (denture should be

renewed)21. Evaluations were made by two den-

tists (KS and CB). Further, participants were asked

to judge their own oral health as ‘satisfactory’,

‘better…’, ‘equal…’, ‘worse than the others of my

age’ or ‘unsatisfactory’ and indicate the number of

drugs taken per day.

Screening for cognitive impairment

A clock-drawing test was used to screen for cogni-

tive impairment. The task is to draw a clock on a

sheet of paper with 12 numbers and two separate

indicators. The latter shall indicate a predefined

time. The drawing is evaluated according to the

presence of the 12 numbers, to their correct posi-

tioning, to the existence of two separate indicators

and to the correctness of time they display.

Accordingly, a score from 0 to 4 is attributed22. For

the participation in this study, a minimum score of

2 had to be achieved (Fig. 1).

Oral health-related quality of life (OHRQoL)

The French version of a shortened Oral Health

Impact Profile (OHIP-Edent)23,24 was used to

evaluate the OHRQoL. The original 49-item OHIP

was developed and validated by Slade and Spencer

in 199425. The OHIP-Edent contains 20 items in

� 2011 The Gerodontology Society and John Wiley & Sons A/S

2 F. Muller et al.

seven domains (functional limitation, physical

pain, psychological discomfort, physical disability,

psychological disability, social disability and hand-

icap), and subjects are asked how frequently they

have experienced the event during the last month.

Responses are given on a scale (0 – never, 1 –

rarely, 2 – occasionally, 3 – frequently, 4 – very

frequently, 5 – always). Thus, a higher OHIP score

indicates a lower OHRQoL (range 0–100). Items

that were not applicable were counted as zero, and

no weighting of the items was performed.

Knowledge about dental implants

To evaluate the knowledge on dental implants, a

semi-structured questionnaire was developed. If

the participant had never heard about dental

implants, it was briefly described that the interview

dealt with artificial roots to replace missing teeth.

Answers were graded as true or false, and the sum

of correct answers from five questions was calcu-

lated further analysis. Then, a brief one-page

information sheet was read out to the participants

with basic information on the indication, clinical

procedures, delays, risks and the success rates of a

dental implant treatment.

Objection towards a hypothetical implant treatment

Subsequently, a second questionnaire with 10 pre-

worded statements on the attitude towards a

hypothetical implant treatment was developed

based on the answers from a previously used open

interview14. The participant could agree or disagree

to each statement on a 100-mm visual analogue

scale (VAS) after a short training in the use the

VAS. For analysis, the VAS scores in mm were

added and expressed as percentages to objectify a

possible objection towards implant treatment. Both

newly developed questionnaires had previously

been tested on six elderly volunteers (HOGER) for

wording and comprehension, but no change was

necessary. All interviews took place in a private and

calm atmosphere, and the interviewer was always

available for questions or assistance.

Statistical analysis

Data were analysed descriptively. In addition, dif-

ferences between groups were tested using the

non-parametric Mann–Whitney and Kruskal–

Wallis tests for unpaired samples. Correlations were

tested with Spearman’s rank correlation. A uni-

variate and multiple linear regression (stepwise

backward selection) models were used to predict

factors for a negative attitude towards an implant

treatment. The Stata Statistical Software, release

11.1, was used (Stata Corporation, College Station,

TX, USA). The level of significance a was set at 5%

(p < 0.05).

Results

Study sample

Initially, 96 patients were recruited. One woman

from HOGER and one from LTC had to be excluded

because they failed the clock-drawing test. Two

further participants were excluded because they

had dental implants but were unaware of it. The

final study sample comprised 92 persons, 61

women and 31 men with an average age of 81.2 ±

8.0 years (Table 1). Seventy-four of the partici-

pants wore removable prostheses, of which 39

were complete dentures. The condition of the

prostheses21 was judged 29 times as ‘good’, 36

times as ‘acceptable’ and eight times as ‘poor’. Only

one of the prostheses was graded ‘very good’. The

number of drugs taken per day varied significantly

between the three types of residence. Participants

living at home took 3.3 ± 0.98, those from LTC

4.6 ± 1.13 and those from HOGER 4.9 ± 1.36

different drugs (p < 0.0001, Kruskal–Wallis). Of the

92 participants, 61 judged their oral health as

‘satisfactory’, nine as ‘better than others of my age’,

17 as ‘like others of my age’, four as ‘unsatisfac-

tory’, and only one as ‘worse than others of my

age’. The OHIP-20 sum score for all participants

was 20.1 ± 11.54 (median 17.0, range 6–68). There

was neither a difference in sum scores among dif-

ferent types of residence (n.s., Kruskal–Wallis) nor

a correlation with age (Spearman’s correlation).

However, there was a significant higher OHIP-20

score in the presence of removable prostheses [with

Figure 1 Examples of the clock-drawing test; drawing

(a) fulfils the inclusion criteria, whereas drawing (b)

excludes the participant.


Knowledge and attitude towards implants in the elderly 3

removable prostheses: 21.9 ± 12.1; without: 13.3 ±

5.6; p = 0.002 (Mann–Whitney)], indicating a

lower OHRQoL.

Knowledge about dental implants

The majority of participants had already heard of

dental implants (n = 65; 70.7%). These participants

mentioned as source of their information their so-

cial environment (n = 34), their dentist (n = 26),

written media (n = 4) and others (n = 1). No par-

ticipant had heard about dental implants via the

television. Thirty-four of the participants who

knew implants had an acquaintance who had

received implant treatment.

Those participants who had already heard about

implants (n = 65) were asked to describe them.

One-fifth (n = 13) stated that they could not de-

scribe an implant although they had heard about

them; seven thought implants were a pin, 15 a nail

and 30 a screw (Fig. 2).

With regard to the longevity of dental implants,

five participants thought they are kept for life, 21

stated that they last up to 20 years, 12 said several

years and 54 had no idea at all. Also, a variety of

materials was proposed for dental implants (Fig. 3).

When asked to specify how implants are anchored,

47 participants did not know; further answers were

grafted (n = 1), glued (n = 3), planted (n = 13) and

screwed (n = 28). For the osseointegration time,

the majority of interviewees did not know or have

never heard of it (n = 77), four assumed that im-

plants integrated immediately to the bone, whereas

11 thought that the osseointegration took several

months.

Of all participants, 63 believed that there is a risk

of failure in implant treatment. From these, 27

could not specify what the risk was. Further 12

identified poor gums as failure risk, seven stated

implants could be rejected by the body or there

could be an allergic reaction, a further seven indi-

cated that a failure would be the dentist’s fault, five

attributed a potential failure to bad bone, two to

advanced age and one participant each to poor

general health, oral hygiene or implant material.

Less than half of the 92 participants were con-

vinced that implants could improve their oral

condition or dental appearance (n = 36 and

n = 39, respectively). Slightly over half of the

interviewees believed that there was an age limit

for implants (n = 49). However, only 34 of the

study sample could imagine having an implant

themselves. Of the 52 who could not imagine

Table 1 Gender, age and number of participants from the geriatric hospital (HOGER), a long-term care facility (LTC)

and living freely at home (DOM).

Total HOGER $ HOGER # LTC $ LTC # DOM $ DOM #

Age (mean) 81.2 84.7 81.3 83.7 81.4 76.6 75.1

SD 8.0 8.1 4.6 8.3 8.3 5.1 4.7

Age (min) 65 68 77 71 68 69 65

Age (max) 102 102 87 98 96 86 86

N 92 26 4 21 13 14 14

« What is an implant ? »

screw(n = 30)

nailpin

(n = 7)

(n = 15)

never heard of it(n = 27)

I have heard about it, but cannot describe it

(n = 13)

Figure 2 Answers to the open question ‘what is an

implant’ (n = 92; age 65–103 years).

« From what material are implants made? »

Plastic

Titanium

Steel

Gold

Acrylic

Silver

Porcelain

Don’t know

Metal

n = 27 had not heard of impants

0 10 20 30 40 50 60 [n]

Figure 3 Answers to the open question: ‘Of what

material are implants made?’ (n = 92; age 65–103 years).


4 F. Muller et al.

having implants, 13 thought they would be too

old for such a treatment, 11 thought the treat-

ment would be too expensive, ten did not see a

need, eight would fear the surgical procedure,

seven would fear the implant could be rejected,

two would feel in bad general medical condition

and one participant thought his life expectancy

would be too short. Six patients could not specify

why they could not imagine having an implant

themselves.

Objection towards a hypothetical implant treatment

The agreement to the pre-worded statements

regarding reasons for a hypothetical objection to-

wards implant treatment revealed that cost was a

predominant factor, followed by ‘I don’t see the

need’, ‘I am too old’ and ‘it is not worthwhile’

(Fig. 4). These four main objections did not show a

significant difference between men and women

(Table 2). For the other six statements, women

were significantly more worried than men, in

particular regarding the ‘fear of the operation’ and

the ‘quality of the bone’. The least concern was

raised if acquaintances had bad experience with

implants as well as the length of the integration

period. There was no correlation between the

attitude towards a hypothetical implant treatment

and the OHIP-20 sum scores of the participants.

The refusal rate varied significantly in relation to

the type of residence. The strongest refusal was

seen in hospitalised patients, followed by LTC and

community-dwelling participants (0.01 < p < 0.05,

Mann–Whitney and Kruskal–Wallis, Fig. 5).

Risk factors for an implant refusal

There was a linear and significant correlation

between the VAS sum scores for the objection of a

hypothetical implant treatment and the age of the

participants (p = 0.0002, q = 0.39, Spearman

regression analysis). Yet, this correlation exists no

longer when the results are corrected for con-

founding factors.

I find implants to expensiveI don’t see the necessity

I would not be likely to benefit from dental implants as….

I consider myself too oldit is not worthwhile

I am afraid of the operationmy bone is of bad quality

I fear implant rejectionI fear a foreign body feeling

the integration time is too longI know persons with bad experience

0 20 40 60 80 100VAS ± SD

Figure 4 Attitude towards an

hypothetical implant treatment for

institutionalised and independently

living participants (VAS score

100 = max negative attitude,

0 = max positive attitude).

Table 2 Attitude towards a hypothetical implant treatment. Agreement to 10 pre-worded statements using a visual

analogue scale (0 = max disagreement, 100 = max agreement; Mann–Whitney test for unpaired samples).

Women (n = 61) Men (n = 31)

p% Mean ±SD % Mean ±SD

I would not be likely to benefit from dental implants as…I find implants too expensive 65.1 32.8 74.5 25.0 n.s.

I don’t see the necessity 54.5 43.9 64.2 46.0 n.s.

I consider myself too old 52.0 42.4 47.7 43.9 n.s.

It is not worthwhile 38.5 43.0 58.4 46.4 n.s.

I am afraid of the surgery 52.7 36.6 9.7 13.0 <0.0001

My bone is of bad quality 31.5 34.7 3.2 6.5 <0.0001

I fear implant rejection 27.9 30.1 6.1 14.8 <0.0001

I fear a foreign body feeling 25.7 30.8 9.0 20.1 <0.0004

The integration time seems too long 17.9 27.1 6.5 12.5 0.0247

I know persons with bad experience 12.3 23.7 5.5 17.0 0.0203

Total 37.8 17.4 28.5 12.8 0.0229



Simple linear regression was used to identify

factors that influence the VAS sum score and thus

a negative attitude of the participants towards an

implant treatment. The age of the participant

explained 14.3% of the objection’s variance. The

older the participant is, the stronger the objection

to a hypothetical implant treatment (p = 0.0002).

Also, the number of drugs taken per day was

associated with 11.2% of the variance in rejection

(p = 0.001). An inverse relationship was found

regarding the knowledge about implants for

which 11.8% of the objection can be predicted by

knowledge of the participants (p = 0.0008), so the

smaller the knowledge, the higher the rejection

towards a hypothetical implant treatment. As a

second negative factor, the condition of the

prosthesis explained 8.0% of refusal (p = 0.006).

The judgement of their own health was also

associated with attitudes towards dental implants

and bad self-judgement was associated with 4.4%

of refusal, but that prediction was less reliable

(p = 0.045).

After applying univariate linear regression mod-

els, a multiple model with stepwise backward

variables selection identified the variables most

significantly associated with the VAS sum score.

This model did not include age and showed that

33.2% of refusal is explained by the following

selected factors (female gender, type and condition

of the prosthesis, knowledge about implants, being

hospitalised).

In summary, according to the analysis, certain

factors predict a significantly higher refusal

1. Gender: women > men.

2. The type of removable dentures: tempo-

rary > definitive.

3. Condition of dentures: poor > good condition.

4. Knowledge about implants: low > high.

5. Place of residence: hospital > domiciliary or LTC.

After adjusting for confounding factors, age did

not play a role in denial of a hypothetical implant

treatment. The factor age is only indirectly linked

via other factors. In this study sample, women were

older than men (p = 0.0260, Mann–Whitney),

denture wearers were older than non-denture

wearers (n.s.), and the condition of the prosthesis

was judged worse in older people (p = 0.0004,

Kruskal–Wallis). In addition, participants living at

home were significantly younger (p < 0.0001,

Kruskal–Wallis). Furthermore, there was no cor-

relation between knowledge about implants and

age of the participant (n.s., Spearman’s non-para-

metric rank correlation n.s.).

Discussion

Critique of method

The study design has some inherent shortcom-

ings, which have to be born in mind when

interpreting the results. Firstly, the study sample

was not representative of the population as par-

ticipants of HOGER, LTC and DOM represented

about one-third each. In contrast, only 5% of the

Swiss population above the age of 65 years are

institutionalised26. Another shortcoming is the

convenience sample. Although screening included

dementia, it has to be born in mind that the

reported sensitivity of the clock-drawing test is

around 85%22 so that despite an additional con-

sultation of the medical records, some participants

might have a mild cognitive impairment. As for

the interviews, a shortcoming is related to the

two questionnaires that were developed for this

study. They were tested beforehand on a small

focus group but not validated in a large popula-

tion sample.

Knowledge

In this study, 71% of the participants had already

heard about dental implants, but a correct and

detailed description remained a challenge for about

two-thirds of interviewees. The high prevalence of

‘half-knowledge’ may be related to the source of

information, which was in 37% the social envi-

ronment. Only five of the participants had their

information from the media, who are more likely

to report on negative outcomes18. About a third of

1000

VA

S s

cale 600

800

200

400

0

p < 0.01

n = 30

p < 0.0001

HOSPITAL

DOMICILE

LTC

p < 0.05

n = 34 n = 28

Figure 5 Sum of VAS scores for the objection towards

implant treatment correlated with place of residence of

participants. The sum scores vary significantly between

groups (Mann–Whitney, Kruskal–Wallis tests).


6 F. Muller et al.

the participants had received their knowledge from

their dentist, so that one can assume they have

received scientifically sound information. This

percentage was substantially higher in an Austrian

study, where 68% of the 1000 study participants

had received information on implants from their

dentist27. In contrast, only 17% of 109 participants

in an American study had been informed by their

dentists on implants although a similar percentage

had heard about implants as in the present study28.

These differences may be explained by differences

in culture and health care systems. In Switzerland,

the frequency of annual dental visits diminishes

with age, which may be related to a shift in prior-

ities but also to limited financial resources in the

elderly population. The Austrian cohort was not

only larger, but clearly younger and not institu-

tionalised so that a more frequent contact with the

dental profession could be assumed. The low

awareness of implants in the US study from Zim-

mer and co-workers28 might be time-related as this

paper was published in 1992, and the attention

paid to implantology has dramatically risen in the

last two decades. In addition, health insurance is

not compulsory in the United States so that finan-

cial restrictions might have limited the contact with

dental professionals. When interpreting the low

prevalence of knowledge, it needs to be borne in

mind that not all patients are aware of the dental

treatment they receive, and it remains unclear

whether this is a lack of information from the

operator, poor communication, cognitive impair-

ment or simply a lack of interest. For example, two

patients in the present study were post hoc excluded

because they did not know that they already had

implants. Another potential explanation for the

little information patients receive from their den-

tists might be that there is no indication for implant

placement, hence no need to inform the patient. In

the last decades, teeth tend to be retained for longer

and prostheses placed only later in life29. However,

data on the prevalence of missing teeth suggest still

more than a third of the 80-year-old population is

in need of tooth replacement. A recent Swiss health

survey revealed that 70% of the 75- to 84-year-old

population reported wearing removable dentures,

and at 85 years or above, 37% of the population

were edentulous4. Thus, the numbers suggest that

more patients could benefit from dental implants

and its low prevalence in the elderly population

might be attributed to non-identified barriers.

The high prevalence of ‘layman-knowledge’ was

equally reported in the Austrian study27, where

only 20% of the sample answered spontaneously

that ‘implants are a possibility to replace missing

teeth’, while 72% had claimed to have heard about

dental implants when prompted. Whereas it is less

relevant if a patient knows technical details like the

material and osseointegration time, it seems

important for the acceptance of such treatment that

they are informed on the potential risks of failure.

From the two-thirds of participants who stated

there was a failure risk, less than half could specify

what it would be. Suggested failure reasons such as

poor gums, allergic reactions, bad bone, poor gen-

eral health or age suggest that failure is perceived

rather as a fate, which could not be influenced.

Few participants blamed the healthcare provider or

the material for a potential failure. Only one par-

ticipant saw the responsibility for a failure in the

patient’s behaviour as he stated oral hygiene as a

risk factor. The latter was cited more often in other,

much younger study samples as a risk factor27.

Interestingly, in the open question on causes for

implant failure, none of the participants mentioned

smoking. More than half of the participants assume

there is an age limit for receiving implant treat-

ment; therefore, it seems plausible that age is

mentioned frequently as a reason for objection to-

wards such treatment30. However, there is no

scientific evidence supporting age as contraindica-

tion for an implant treatment31.

Attitude

Of the 92 participants, slightly over a third could

imagine receiving an implant treatment them-

selves. When compared with similar studies on

younger cohorts30, the acceptance rate is much

lower in the present elderly cohort. Berge18 stated

that 57% of the Norwegian participants would

accept an implant treatment, while 23% would

not. In Tepper’s Austrian study27, even 61% of

those who knew implant would accept such treat-

ment. Finally, the US study of Zimmer and

co-workers28 reported that of 84 participants who

know about dental implants, 51 would accept the

possibility of such treatment, 17 would refuse and

16 did not know. They also reported a clear corre-

lation between age and implant acceptance. It is

important to bear in mind that questionnaire-based

findings do not necessarily reflect a clinical situa-

tion. In the present study, the participants judged

on a situation that may have not yet or will never

arrive. Even then, a third of edentulous patients

who have had the experience of functional

impairment with complete dentures refused im-

plants within the context of a Canadian RCT on

one or two implant-supported lower overden-

tures13. In a survey by Salonen15, 85% of edentu-



lous patients experiencing functional stability

problems with their recently renewed complete

dentures were not interested in implant-retained

overdentures. Whereas participation in Walton and

MacEntee’s study13 was mainly motivated by

improvement in function, refusal was most fre-

quently related to the surgical risk or the lack of

necessity. Surely, the objection to implant treat-

ment is multifactorial. Elderly patients often weigh

decisions against their remaining life expectancy

and consider it not worthwhile to invest time,

effort and money on sophisticated dental treat-

ments. In the present study, participants men-

tioned costs, lack of perceived need or simply

feeling too old as main objections. These have

changed remarkably little over the years12. Other

preoccupations such as fear of surgery, fear of

having a bone of poor quality or fear of rejection

were significantly higher concerns in the female

participants. It is true that women have a higher

prevalence of osteoporosis, which may explain

their reluctance32. However, do women really fear

more the operation than men or are they simply

more openly admitting it?33 Most participants

stated finding an implant treatment to expensive.

But even when cost was removed in the above-

mentioned Canadian Study, the refusal rate was

high13.

The multiple linear regression model with

stepwise backward variables selection identified

predictors for implant refusal and age as such was

not amongst them. At first, this seemed surprising,

as a simple linear regression showed a close corre-

lation between age and the refusal sum score. Age

was also previously reported to influence the

patients’ attitude towards implants28. Several other

parameters such as gender, place of residence, the

presence and condition of a removable denture as

well as little knowledge about implant treatment

were identified as significant predictors. Thus, age

only indirectly predicted a negative attitude as it is

inevitably linked to other factors predicting refusal

such as reduced general health and loss of auton-

omy. The model further revealed poor condition of

the denture as a predictor for a negative attitude

towards implants. Palmqvist et al.34 confirmed that

subjects with the best dental conditions showed the

highest subjective need for implant treatment, and

those with the poorest conditions claimed the least

interest. Such findings reflect the known pattern of

uptake of dental services, which is less frequent in

persons with a poor dental state35. The importance

attributed to the own oral health and oral func-

tioning may go along with a more open-minded

approach towards proposed dental interventions.

Another predictor for a negative attitude was

knowledge of implants. It seems somewhat intui-

tive that an unknown treatment modality elicits

less support than a well-known one. Nevertheless,

there seems to be a socio-demographic coincidence

as Berge18 reported persons with a high education

as being more open to an oral implant treatment.

Last but not least, the refusal rate can significantly

be predicted by the type of residence (HOGER,

EMS, and DOM), which reflects the participants’

general health state as well as their degree of

dependency. Again, this finding is intuitive, as with

decreasing health and autonomy priorities change

and a poor oral health condition may be over-

shadowed by multiple other health problems.

Summary and conclusions

In the elderly population, knowledge of dental

implants is limited and the rate of objection

towards an implant treatment is high. Cost, psy-

chological reasons and the surgical intervention

were the strongest objections. Univariate and

multiple linear regression analysis identified being

a woman, wearing a poor denture, having little

knowledge of implants and being hospitalised as

the main predictors for refusing implants. However,

old age as such was not associated with a negative

attitude.

In conclusion, the acceptance of dental implants

in the elderly population might be increased by

providing further information and promoting oral

health in general. Less-invasive operation tech-

niques should be developed. Regardless of age,

dental implants should be placed when patients are

still in good health and live independently so that

they can benefit from the functional advantages

until late in life.

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Correspondence to:

Dr Frauke Muller, Dental Section, Division of

Gerodontology and Removable Prosthodontics,

Medical Faculty, University of Geneva, 19, rue

Barthelemy-Menn, CH-1205 Geneva, Switzerland.

Tel.: +412 23794060

Fax: +412 23794052

E-mail: [email protected]


10 F. Muller et al.

Documents

Knowledge and attitude of elderly persons towards dental implants