ReviewDental implants in the medically compromised patientPedro Diz a,*, Crispian Scully b, Mariano Sanz caGrupo de Invest...
principle, only patients with an ASA (American Society ofAnaesthesiologists) grade I or II should qualify for an electives...
Table 1 – Dental implants (DI) in medically compromised patients.Condition Evidence conditionis an absolute/relativecontra...
effective in preventing post-operative bleeding.23Oral antico-agulant discontinuation is thus not recommended for dentoal-...
BRONJ is a real issue for patients treated with intravenousBPs but the occurrence of BRONJ in patients receiving oral BPsm...
implant failure rates between the groups.77Moreover, inseveral retrospective DI cohort studies where data regardinglocal a...
Anecdotally, a case report has been published on aninnovative saliva electrostimulation device fixed on a DI,placed in the ...
patients may lead to complications. Therefore, the success oforal rehabilitation depends fundamentally on appropriatepatie...
18. Alissa R, Oliver R. Influence of prognostic risk indicators onosseointegrated dental implant failure: a matched case–co...
53. Memon S, Weltman RL, Katancik JA. Oral bisphosphonates:early endosseous dental implant success and crestal bonechanges...
implant survival: a long-term retrospective evaluation ofpatients followed for up to 10 years. Implant Dentistry2010;19:57...
123. Grecchi F, Zingari F, Bianco R, Zollino I, Casadio C, CarinciF. Implant rehabilitation in grafted and native bone inp...
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Dental implants in the medically compromised patient

  1. 1. ReviewDental implants in the medically compromised patientPedro Diz a,*, Crispian Scully b, Mariano Sanz caGrupo de Investigacio´n en Odontologı´a Me´dico-Quiru´ rgica (OMEQUI), School of Medicine and Dentistry, University of Santiago deCompostela, SpainbUniversity College London, UKcGrupo de Investigacio´n en Etiologı´a y Terape´utica Periodontal (ETEP), School of Dentistry, Complutense University of Madrid, Spain1. IntroductionIn medically healthy patients, the success rates of some dentalimplant (DI) systems have reported to be between 90 and 95%at 10 years.1DI may fail, however, due to a lack ofosseointegration during early healing, or when in functiondue to breakage, or infection of the peri-implant tissuesleading to loss of implant support. Early complications afterimplant installation, can include pain, infection or occasion-ally neuropathy.1Severe early complications such as hae-morrhage (e.g. in the floor of the mouth) or descendingnecrotizing mediastinitis are rare.2–6The longer term outcome of implant therapy can beaffected by local or systemic diseases or other compromisingfactors, in fact, it has been suggested that some local andsystemic factors could represent contraindications to DItreatment.7–102. Dental implants in medically compromisedpatientsThe impact of health risks on the outcome of implant therapyis unclear, since there are few if any randomized controlledtrials (RCTs) evaluating health status as a risk indicator. Inj o u r n a l o f d e n t i s t r y 4 1 ( 2 0 1 3 ) 1 9 5 – 2 0 6a r t i c l e i n f oArticle history:Received 14 December 2011Received in revised form3 December 2012Accepted 27 December 2012Keywords:Dental implantsOsseointegrationSystemic diseasesContraindicationa b s t r a c tObjective: It has been suggested that some local and systemic factors could be contra-indications to dental implant treatment. The objective of this paper was to evaluate whethersuccess and survival rates of dental implants are reduced in the medically compromisedpatient.Data/sources: An extensive literature search was conducted using PubMed/Medline, Scopus,Scirus and Cochrane databases up to November 8, 2012.Conclusions: There are very few absolute medical contraindications to dental implanttreatment, although a number of conditions may increase the risk of treatmentfailure or complications. The degree of systemic disease-control may be far moreimportant that the nature of the disorder itself, and individualized medical controlshould be established prior to implant therapy, since in many of these patientsthe quality of life and functional benefits from dental implants may outweigh anyrisks.# 2013 Elsevier Ltd. All rights reserved.* Corresponding author at: Stomatology Department, School of Medicine and Dentistry, Santiago de Compostela University, c/Entrerrı´ossn, 15782 Santiago de Compostela, La Corun˜ a, Spain. Tel.: +34 881812344.E-mail address: (P. Diz).Available online at www.sciencedirect.comjournal homepage:$ – see front matter # 2013 Elsevier Ltd. All rights reserved.
  2. 2. principle, only patients with an ASA (American Society ofAnaesthesiologists) grade I or II should qualify for an electivesurgical procedure, such as DI placement and the patient’ssurgical risks should be weighed against the potential benefitsoffered by the DI.11Even though there are statements in the implant literaturesuch as: ‘‘certain conditions such as uncontrolled diabetes, bleedingdisorders, a weakened immune system, or cognitive problems thatinterfere with postoperative care increase the risk of implant failure’’( these are un-substantiated by scientific evidence.Other authors have recommended as relative contra-indications for DI, certain patient groups or conditions7: Children adolescents Epileptic patients Severe bleeding tendency Endocarditis risk Osteoradionecrosis risk Myocardial infarction riskOther reported relative contraindications include: adoles-cence, ageing, osteoporosis, smoking, diabetes, positiveinterleukin-1 genotype, human immunodeficiency virus posi-tivity, cardiovascular disease, hypothyroidism and Crohndisease.8,9Suggested absolute contraindications include: recent myo-cardial infarction and cerebrovascular accident, transplant orvalvular prosthesis surgery, profound immunosuppression,severe bleeding issues, active treatment of malignancy, drugabuse, psychiatric illness, as well as intravenous bispho-sphonate use10but there is, however, little or no evidence tosupport most of these contentions.It is, therefore, the aim of this review to evaluate thescientific evidence through PubMed/Medline, Scopus, Scirusand Cochrane databases searches up to November 8, 2012,using as keywords: implants, contraindications, and thefollowing disease categories, which had been highlighted aspossible contraindications in more than one publication12,13: Alcoholism Bleeding disorders Bone disease Cancer patients Cardiac disease Corticosteroids Diabetes Hyposalivation Immunocompromised patients Mucosal disease Neuro-psychiatric disorders Titanium allergyThis evidence has been drawn from a wide range ofsources, ranging from case reports to controlled cohortinvestigations, including both human and animal studies.Implant outcome assessment has varied from histological andradiographic outcomes, to objective and subjective determi-nations of implant and treatment failure. The aim of this studywas to evaluate the level of evidence of the available literatureon contraindications to DI therapy in medically compromisedpatients. Contraindications are mainly based on both the riskof medical complications related to implant surgery (e.g.haemorrhage risk in patients with bleeding disorders) and therate of DI success in medically compromised patients (e.g. inpatients with head and neck cancer receiving radiotherapy).This review, hence, summarizes this evidence applyingrecognized evidence-based criteria.143. AlcoholismWe could not identify any reliable evidence indicating thatalcoholism might be a contraindication to DI. Negative effectsof alcohol intake on bone density and osseointegration inanimal models, however, have been demonstrated.15,16Inhumans, there is evidence of increased peri-implant marginalbone loss and DI failures in patients with high levels of alcoholconsumption.17,18In general terms, however, it is worthconsidering before implants are placed that alcoholism: is often associated with tobacco smoking, may via liver disease, cause bleeding problems, may cause osteoporosis, may impair the immune response, may impair nutrition, especially folate and B vitamins.In summary, although there is no evidence that alcoholismis a contraindication to implants, these patients may be atincreased risk of complications (Table 1).4. Bleeding disordersEven though haemorrhage can be a relatively commoncomplication in DI placement,19there is no reliable evidenceto suggest that bleeding disorders are a contraindication to theplacement of implants: even haemophiliacs have successfullybeen treated with DI.20Nevertheless, any oral surgicalprocedure may lead to haemorrhage and blood loss and, ifthis bleeding reaches the fascial spaces of the neck, it canhazard the airway. In fact, upper airway obstruction second-ary to severe bleeding in the floor of the mouth is a rare butpotentially life-threatening complication of DI placement.4Usually arterial impingement is produced when perforatingthe lingual cortical plate affecting the lingual arteries or theinferior alveolar canal, affecting the inferior alveolar vessels.6DI placed in the first mandibular premolar position are thehigher risk for this bleeding complication.21In patients with bleeding disorders, haemorrhage associatedwith implant surgeries is more common and can be pro-longed,22particularly with warfarin or acenocoumarol. In thesepatients, the current recommendation is to undertake theimplant surgical procedure without modifying the anticoagula-tion, provided the INR is less than 3 or 3.5.22In this context,implantsurgerycouldberegardedintermsofsurgicaltraumatothe extraction of three teeth. There is evidence that antic-oagulated patients (INR 2–4) without discontinuing the antico-agulant medication do not have a significantly higher risk ofpost-operative bleeding and, topical haemostatic agents arej o u r n a l o f d e n t i s t r y 4 1 ( 2 0 1 3 ) 1 9 5 – 2 0 6196
  3. 3. Table 1 – Dental implants (DI) in medically compromised patients.Condition Evidence conditionis an absolute/relativecontraindication to DIDI success ratecompared to healthypopulation (levelof evidencea)Other considerations Managementmodifications thatmay be indicatedAlcoholism – Similar (5) Tobacco use These patients maybe at increased riskof complicationsBleedingOsteoporosisImpaired immunityMalnutritionBehavioural problemsBleeding disorder Medical advice should betaken first in congenitalbleeding disordersSimilar (3) in oralanticoagulants andantiplatelet treatmentPossibility of bloodborne infectionsThese patients maybe at increased riskof complicationsBone diseaseRheumatoid arthritis – Similar (4) Peri-implantitisand marginal boneresorption increasewith concomitantconnective tissuediseases–Osteoporosis – Similar (2a) – Sinus lifts may becontraindicatedOsteoporosis andoral bisphosphonates– Similar (1b) –Cancer and intravenousbisphosphonatesbContraindicated (5) Reduced (4) – –Head neck cancerpatients– Reduced (1b) (followingradiotherapy)Cancer prognosis Surgery best carriedout 21 days beforeradiotherapySimilar (3b) (followingchemotherapy)Hyperbaric oxygenshould be given if50 Gy used(controversial)Defer DI for 9 monthsConsider antimicrobialcoverNo immediate loadingCardiac disease Medical advice should betaken firstSimilar (5) May be anticoagulated Avoid generalanaesthesiaPoor risk for generalanaesthesiaConsider endocarditisprophylaxisCorticosteroid therapy – Similar (5) May be impairedimmunityCorticosteroid coverAntibiotic prophylaxisDiabetes mellitus – Slightly reduced inbad metabolic controlpatients (2a)Microvascular disease HbA1c level for patientselectionSimilar in good metaboliccontrol patients (2b)Osteoporosis Avoid hypoglycaemiaImpaired immunity Use chlorhexidineAntibiotic prophylaxisHyposalivation – Similar (4) – –ImmunocompromisedpatientsMedical advice should betaken firstSimilar in organtransplantationpatients (4)May be blood borneinfectionsUse chlorhexidineSimilar in HIVinfectedpatients (3a)Antibiotic prophylaxisMucosal disease – Similar (4) – –NeuropsychiatricdisordersMedical advice shouldbe taken firstSimilar (4) Behavioural Consider generalanaesthesiaj o u r n a l o f d e n t i s t r y 4 1 ( 2 0 1 3 ) 1 9 5 – 2 0 6 197
  4. 4. effective in preventing post-operative bleeding.23Oral antico-agulant discontinuation is thus not recommended for dentoal-veolar surgery, such as implant placement, provided that thisdoes not involve autogenous bone grafts, extensive flaps orosteotomy preparations extending outside the bony envelope.In a recently published case series involving 50 consecutivepatients receiving oral anticoagulant therapy (warfarin) with-out interruption or modifications to their therapy, it was shownthat a standard protocol of local haemostasis in dental implantsurgery is able to prevent bleeding complications in patients onoral anticoagulants, allowing these surgical procedures to beperformed on an outpatient basis.24The bleeding risk is also low in patients treated withheparin.25In patients on single or dual antiplatelet therapy,the frequency of oral bleeding complications after invasivedental procedures is low to negligible and, therefore, the risksof altering or discontinuing use of the antiplatelet medications– increased risk of thromboembolism – far outweigh the lowrisk of haemorrhage.26In summary, there is no evidence that any bleedingdisorders are an absolute contraindication to DI surgery,although these patients may be at risk of prolonged haemor-rhage and blood loss, and medical advice should be taken firstespecially in congenital bleeding disorders (Table 1).5. Bone diseasesThere are few reported cases in the literature of DI placementand subsequent rehabilitation of patients with these bonediseases such as osteogenesis imperfecta,27–32polyarthritis,33or ankylosing spondylitis,34and to our knowledge no relevantcase series have been published up to date. On the contrary, atleast two retrospective series on dental implants outcomesinvolving 34 and 22 females suffering from autoimmunerheumatoid arthritis with or without concomitant connectivetissue diseases have been published, the authors concludingthat a high implant and prosthodontic success rate can beanticipated in rheumatoid arthritis patients, but peri-implantmarginal bone resorption and bleeding are more pronouncedin those with concomitant connective tissue diseases.35,36In summary, a number of bone disorders may potentiallyinfluence the outcome of DI, but few studies have evaluatedscientifically this risk (i.e. DI in patients with rheumatoidarthritis),35being most of the published investigations relatedto the relationship between bone density and implant success.Osteoporosis is the most studied bone-related disease. It isa common condition characterized by generalized reductionin bone mass with no other bone abnormality. Whenevaluating whether DI in osteoporotic patients have adifferent long-term outcome, even though failure rates havebeen reportedly higher in animal models37and patients,38,39asystematic review revealed no association between systemicbone mineral density (BMD) status, mandibular BMD status,bone quality, and implant loss, concluding that the use of DI inosteoporosis patients is not contraindicated.40In a cross-sectional study no relation was found between osteoporosisand peri-implantitis41and even patients with severe osteopo-rosis have been successfully rehabilitated with DI-supportedprostheses.42,33There are, however, some case–control stud-ies reporting a weak association between osteoporosis and therisk of implant failure43and some authors have alluded to acorrelation between BMD of the mandible with BMD measure-ments at other skeletal sites.44It is, therefore, recommendedto thoroughly evaluate the jawbone quality prior implantplacement, rather than undertaking systemic BMD andosteoporotic status assays.43,45Dentists should perform anaccurate analysis of bone quality by means of tomography andmodify treatment planning if indicated (e.g. using largerimplant diameter and with surface treatment).46A further potential complication in osteoporotic patientsis the possible effect on bone turnover at the DI interfaceof systemic anti-resorptive medication. This risk inpatients using bisphosphonates (BPs) is well recognized,47in terms of bisphosphonate-related osteonecrosis of the jaws(BRONJ).48–50The largest series of patients developing BRONJfollowing DI published to date involved 27 patients on BPs, 11orally and 16 intravenously. BRONJ developed after meanperiods of 68 months, 16 months, and 50 months in patientson alendronate, zoledronic acid, and pamidronate, respec-tively. There was a mean duration of 16 months fromimplants placement until the appearance of BRONJ.51Recently, in a series of BRONJ following DI involving 14patients on BPs, 5 orally and 9 intravenously, it has beensuggested that posteriorly placed implants seem to be ofhigher risk of BRONJ development.52Table 1 (Continued )Condition Evidence conditionis an absolute/relativecontraindication to DIDI success ratecompared to healthypopulation (levelof evidencea)Other considerations Managementmodifications thatmay be indicatedTitanium allergy – Reduced (4) Allergic symptomsafter implantplacement orunexplained implantfailuresUse alternativematerialsIn patients allergic toother metals long-termclinical and radiographicfollow-up is recommendedAdapted from Scully et al.12aOCEBM Levels of Evidence Working Group.14bTo reduce skeletal-related morbidity.j o u r n a l o f d e n t i s t r y 4 1 ( 2 0 1 3 ) 1 9 5 – 2 0 6198
  5. 5. BRONJ is a real issue for patients treated with intravenousBPs but the occurrence of BRONJ in patients receiving oral BPsmedication is minimal. The use of oral BPs at the time ofimplant placement and during healing do not seems to affectearly implant success.53In a retrospective survey of 115patients on oral BPs receiving DI (72 returned to the clinic forevaluation), oral bisphosphonate therapy did not appear tosignificantly affect implant success and no cases of BRONJwere registered54and similarly, in a large survey performed inSouth Australia the estimated prevalence of BRONJ in patientsunder oral BPs was less than 1%.55In 2007, the American Association of Oral and Maxillofa-cial Surgeons56produced guidelines for patients treatedwith oral BPs, based on the clinical situation of the patientand the length of treatment with the drug, indicating thatgreater caution prior and subsequent to surgery should betaken during 3 years after discontinuing BP treatment. Asystematic review analysing one prospective and threeretrospective series (217 patients) showed that the place-ment of a DI in patients with chronic intake of oral-BPs didnot lead to BRONJ and did not influence short-term (1–4years) implant survival rates. This study concluded that DImight be considered a safe procedure in patients taking oralBPs for 5 years.57Similarly, in another review that included12 studies (7 case reports and 5 retrospective studies), theauthors concluded that dental implants can osseointegrateand remain functionally stable in patients treated withbisphosphonates.58In summary, there is a consensus on contraindicatingimplants in cancer patients treated with intravenous BPs.57Inpatients with osteoporosis treated with BPs, they should beinformed of the risk of possible implant loss59the risk ofsuffering bony necrosis and a poor outcome from sinus lifts,60and adequate informed consent prior to dental implantsurgery should be obtained (Table 1).6. Head and neck cancer patientsSurgical resection of head and neck cancer can be severelymutilating. DI in oral cancer patients are successfully used fordental rehabilitation after bony reconstruction of the jaws,and for retention of a prosthetic device (e.g.: palatalobturator), used as the primary means of maxillary recon-struction.61,62Combinations of microvascular surgical tech-niques and the use of DI can considerably improve therehabilitation of people with severe head and neck defects,but there may be an increased risk of implant failure inirradiated free flap bone.63It has been suggested that somepatients may benefit from having the placement of DI duringablative tumour surgery.64,65Radiotherapy can significantly affect DI outcomes13mainlyduring the healing period66. Radiotherapy may induce endar-teritis obliterans, and hence can predispose to osteoradione-crosis of the jaw. Twelve studies involving 643 DI placed inadult patients who have received radiotherapy, reported lowersuccess rates, ranging from 40 to 100%.67There are, however,several clinical studies demonstrating that DI can osseointe-grate and remain functionally stable in patients who hadreceived radiotherapy.68In a series of 275 DI placed in 63patients with oropharyngeal squamous cell carcinoma, noincrease in osteoradionecrosis was reported.69It has beensuggested that DI may represent an acceptable option for oralrehabilitation in patients who had suffered previous osteor-adionecrosis (5 year survival rate of 48.3%).70Even successfulDI placed during early childhood in patients treated with fulldose radiation for malignant midface tumours has beenreported.71Other authors have reported successful DI butoccurrence of late complications, such as bone loss andmucosal recession, possible due to altered saliva flow andincreased bacterial colonization.72Several case–control studies have shown evidence ofimproved outcomes in patients with history of radiotherapyand DI with the addition of hyperbaric oxygen therapy (HBO)mainly through reduction in the occurrence of osteoradione-crosis and failing implants.73However, a systematic reviewfound only one RCT comparing HBO with no HBO for DItreatment in irradiated patients and was unable to find anystrong evidence to either support or refute the use of HBOtherapy for improving implant outcome.74To increase implant success in irradiated head neckcancer patients, the following precautions should be consid-ered73 Implant surgery is best carried out 21 days beforeradiotherapy Total radiation dose should be 66 Gy if the risks of ORN areto be minimized or 50 Gy to reduce osseointegrationfailure: avoiding implant site/portals Hyperbaric oxygen should be given if 50 Gy radiation isused No implant surgery should be carried out during radiother-apy No implant surgery should be carried out during mucositis Defer implant placement for 9 months after radiotherapy Use implant-supported prostheses without any mucosalcontact Avoid immediate loading Ensure strict asepsis Consider antimicrobial prophylaxis.In a study of 30 postsurgical oral cancer patients receiving106 dental mandibular implants and adjuvant chemotherapywith either cisplatin or carboplatin plus 5-FU, there was nosignificant difference in implant survival at 10 years follow-upwhen compared with matched controls. None of the patientshad been treated with radiotherapy (Table 1).75To the best ofour knowledge, two case series have been published reportingthat cancer chemotherapy appears not to significantly impairthe success of DI.75,767. Cardiovascular diseaseIt has been suggested that some cardiovascular events such asrecent myocardial infarction, stroke, and cardiovascularsurgery, might represent an absolute contraindication toimplant therapy.10In a retrospective analysis of 246 consecu-tively treated DI patients, including cardiovascular diseasepatients, patients with a history of other systemic disease, andhealthy controls, there were no significant differences inj o u r n a l o f d e n t i s t r y 4 1 ( 2 0 1 3 ) 1 9 5 – 2 0 6 199
  6. 6. implant failure rates between the groups.77Moreover, inseveral retrospective DI cohort studies where data regardinglocal and systemic risk factors for implant failure had beenrecorded, hypertension and coronary artery disease were notassociated with a significant increase in either early or lateimplant failures.13,39,78In a recent case–control study, it has been suggested thatintravenous sedation using midazolam and propofol during DIsurgery prevented excessive increases in blood pressure, andstabilized haemodynamics,79which could be useful inpatients with cardiovascular disease. However intravenousmidazolam does not prevent the myocardial arrhythmias thatmay arise during DI placement.80We could find no evidence that cardiac disorders are acontraindication to DI but it is important to consider otherissues such as the occurrence of bleeding, or cardiac ischaemicduring DI insertion in these patients, and therefore, medicaladvice should be procured before DI surgery (Table 1).228. Corticosteroid therapyCorticosteroid adverse effects include reduced bone density,increased epithelial fragility and immunosuppression.22Inconsequence, the use of systemic glucocorticoids mightcompromise DI osseointegration and peri-implant healing.81In animal models, osseointegration of implants in rabbitsunder experimental osteoporosis-like bone induced by gluco-corticoids appeared to be compromised, which could affectbiomechanical stability of implants.82However, in most ofthese studies implants were placed in extraoral bones (i.e.femur or tibia), and it has been suggested that steroidadministration could have less effect on the osseointegrationof titanium implants in the mandible than in the skeletalbone.83To the best of our knowledge no relevant series havebeen published to demonstrate if DI failure rate and/orperioperative morbidity may increase in patients undersystemic corticosteroids.There is no evidence that corticosteroid therapy is acontraindication to DI, but it is important to consider thatsystemic corticosteroids can cause suppression of thehypothalamo–pituitary–adrenal axis and therefore, stan-dard recommendations for any oral surgery in patients onsteroid therapy should be implemented.22The MedicinesControl Agency still advise in patients who have finished acourse of systemic corticosteroids of less than 3 weeksduration and might be under stresses such as trauma,surgery or infection and who are at risk of adrenalinsufficiency, to receive systemic corticosteroid coverduring these periods ( In patients on less than 10 mg prednisolone daily(as recommended by Nicholson et al),84no significant eventshave been reported after oral surgery without steroidcover.85In summary, although there is no evidence that cortico-steroid therapy is a contraindication to DI, medical adviceshould be procured in these patients prior to DI and medico-legal and other considerations suggest that steroid covershould be provided (Table 1).9. Diabetes mellitusMost caseseries, cohort studies, andsystematicreviews supportthat DI in diabetics with good metabolic control have similarsuccess rates when compared to matched healthy controls,86–89maintenance programme receiving conventional or advancedimplant surgery (sinus floor elevation, immediate loading, andguided bone regeneration).90However, impaired implant inte-gration has been reported in relation to hyperglycaemicconditions in diabetic patients91and in animal models.37,92Ina systematic literature search including 18 studies published upto 2009, the authors concluded that poorly controlled diabetesnegatively affects implant osseointegration.93This fact isconsistent with the known effects of hyperglycaemic stateson impaired immunity, microvascular complications and/orosteoporosis.Paradoxically,inarecentcriticalreviewithasbeensuggested that clinical evidence is lacking for the association ofglycaemic control with implant failure, because the identifica-tion and reporting of glycaemic control was insufficient orlacking in most of the published studies.94In summary, there is no evidence that diabetes is acontraindication to DI therapy, but as HbA1C (glycosylatedhaemoglobin) may represent an independent factor correlatedwith postoperative complications90and due to the knowneffects of hyperglycaemic states on healing, medical adviceand strict glycaemic control before and after DI therapy arerecommended (Table 1).22,87,95,96Antimicrobial cover usingpenicillin, amoxicillin, clindamycin or metronidazole shouldbe provided during the implant surgery.97These patientsshould also quit smoking, optimize oral hygiene measures anduse antiseptic mouthrinses to prevent the occurrence ofperiodontal and peri-implant infections.88,93,95As implantsurgery is never a matter of urgency, it has been suggested thatpatients should be conjointly selected and prepared by bothdental practitioner and diabetes clinician.9510. HyposalivationTheoretically DI may help prosthesis retention in patientswith dry mouth (hyposalivation). Although cases withhyposalivation have been successfully managed with DI98,99and even 7 out of 8 patients with Sjo¨gren syndrome improvedtheir oral comfort levels with implant-retained prostheses,100there are no systematic studies evaluating the outcomes of DItherapy in these patients (Table 1).A retrospective study on patients suffering from rheu-matic disorders such as rheumatoid arthritis and otherconnective tissue diseases and compromised salivary flowshowed high implant survival rates (cumulative 3-yearimplant success rate of 96.1%). Patients with rheumatoidarthritis demonstrated acceptable marginal bone resorptionand good soft tissue conditions, while other connectivetissue diseases patients showed increased bone resorptionand peri-implant soft tissue alterations in sclerodermapatients and patients suffering from Sjo¨ gren syndrome.36The severity of the salivary flow alteration, together with thepatient’s medical condition should be evaluated beforerecommending DI placement.98j o u r n a l o f d e n t i s t r y 4 1 ( 2 0 1 3 ) 1 9 5 – 2 0 6200
  7. 7. Anecdotally, a case report has been published on aninnovative saliva electrostimulation device fixed on a DI,placed in the lower third molar area.10111. Immunocompromised patientsIt would be reasonable to assume that DI might be contra-indicated in immunocompromised patients. In fact, in animalmodels it has been shown that ciclosporin impairs peri-implant bone healing and implant osseointegration.102How-ever, many patients receiving organ transplantation (mainlyliver and kidney) with long-term ciclosporin therapy, have hadsuccessful DI therapy.103–106Similarly, no significant problems after dento-alveolarsurgery have been reported in HIV-positive patients.107,108Ina series of 20 HIV-positive subjects with mean CD4 count of467 cells/mm3(range: 132–948), two dental implants wereplaced in the anterior mandible to support an overdenture,and the short-term (6 months) success rate was 100%.109In arecently published case–control series of HIV-positive patientsreceiving different regimens of highly active anti-retroviraltherapy, after assessing peri-implant health at 6 and 12months, the authors concluded that DI may represent areasonable treatment option in HIV-positive patients, regard-less of CD4 cell count, viral load levels and type of antiretrovi-ral therapy.110It seems that DI are well tolerated and havepredictable short-term outcomes for HIV-infected individuals,but published evidence is scarce and the predictability of thelong-term success remains unknown. It would seem prudentto carry out DI when CD4 rates are high and the patient is onantiretroviral therapy.Crohn’s disease has also been suggested as a relativecontraindication for DI.8Crohn’s disease is associated withnutritional and immune defects, and hence, it may impair DIsuccess.39However, in a retrospective study 11 of 12 DI placedin Crohn’s disease patients integrated successfully.13Severe periodontitis is frequent in patients with congenitalneutrophil deficiencies and therefore, high occurrence of peri-implant infection should be expected when implants areplaced in these patients. There are, however, some casereports of successful implant placement in patients withPapillon-Lefevre syndrome111and von Gierke syndrome.112In summary, there is no evidence that immunoincompe-tence is a contraindication to DI therapy, but medical adviceshould be procured before considering DI therapy and strictanti-infective measures should be enforced when treatingthese patients (Table 1).2212. Mucosal diseaseThere are numerous case reports and case series documentingthe success of DI in patients with a range of mucosalconditions113including ectodermal dysplasia,114–117epider-molysis bullosa118–120and in lichen planus (Table 1).121DI is often the treatment of choice in patients withectodermal dysplasia with severe oligodontia or hypodontia.The largest published series report outcomes in 51 and 33patients, with 264 and 186 implants respectively.118,122Presence of a limited amount of bone was a common finding,particularly in the upper arch, and often requires extensivebone regenerative procedures. Some case-series have shownthat results of DI and bone grafts in adult patients affected byectodermal dysplasia were similar to those achieved inunaffected patients.123Most series demonstrate an excellent implant success ratein adults with ectodermal dysplasia,113although resultsreported in children and adolescents mainly when implantswere placed in the maxilla or the symphyseal region of theanterior mandible have been less encouraging.124,125The mostappropriate age for dental implant treatment in growingchildren remains controversial.117,126A recent review, included 7 studies describing 17 patientswith epidermolysis bullosa receiving 102 implants and beingfollowed for 12 to 108 months: the implant success rate wasclose to 100%.127In a small case series DI showing dehiscenceor fenestration were placed simultaneously with particulatedbone grafts to cover exposed threads, all implants survivingafter a minimum follow-up of 12 months.128The mainreported complication during the implant surgical procedurewas the formation of bleeding blisters by minimal trauma.During the follow-up period many patients also developedulcers in the areas of prosthesis contact, but these complica-tions did not affect the successful implant outcome. A fixedfull-arch short-expand prostheses supported by four DI hasbeen successfully used in patients with recessive dystrophicepidermolysis bullosa, minimizing oral mucosa surfacecontact and improving the patients’ quality of life. 129It has been suggested that dental implants are not ideal forpatients with oral lichen planus because of the limitedcapacity of the involved epithelium to adhere to the titaniumsurface.7Despite the generalized use of DI, very few casereports have been documented, all of them with successfuloutcome.121,130Recently, two case–control studies including14 and 18 oral lichen planus patients have been published,with no implant failure recorded during the follow-up period(12–53 months).131,132Peri-implant mucositis and peri-implan-titis seem to be slightly more frequent in patients with orallichen planus than in controls, and desquamative gingivitiswas associated with a higher rate of peri-implant mucositis.132Implant placement does not influence the disease manifesta-tions.131As malignant transformation has been observed infew cases of oral lichen planus, careful long-term monitoringof both lesions and dental implants is recommended.11313. Neuro-psychiatric disordersThe literature with respect to DI placement in patients withneuro-psychiatric disorders is sparse and contradictory. Somecase reports and case series have shown DI treatment to besuccessful in some patients with various degrees of bothintellectual and physical disability, including cases of cerebralpalsy, Down syndrome, psychiatric disorders, dementia,bulimia, Parkinson disease and severe epilepsy.133–141Howev-er, poor oral hygiene, oral parafunctions such as bruxism,harmful habits such as repeated introduction of the fingersinto the mouth and behavioural problems are not uncommonin patients with neuro-psychiatric diseases, and DI in suchj o u r n a l o f d e n t i s t r y 4 1 ( 2 0 1 3 ) 1 9 5 – 2 0 6 201
  8. 8. patients may lead to complications. Therefore, the success oforal rehabilitation depends fundamentally on appropriatepatient selection141and adequate medical advice should beseeked prior to implant therapy (Table 1).13914. Titanium allergyDegradation products of metallic biomaterials may result inmetal hypersensitivity reactions.142Recently, it has beensuggested that titanium, formerly considered an inertmaterial, can induce toxicity or allergic type I or IV reactionsin susceptible patients and could play a critical role inimplant failure.143,144In a systematic review including 7studies it has been shown that titanium allergy developsamong patients at every age, the most common clinicalmanifestations being dermal inflammatory conditions andgingival hyperplasia.145The prevalence of titanium allergyremains unknown but it has been estimated to be 0.6%among DI patients.146A significantly higher risk of positiveallergic reactions was found in patients showing allergicsymptoms after implant placement or unexplained implantfailures.146The risk of an allergy to titanium is increased in patientswho are allergic to other metals. In these patients, anevaluation of allergy is recommended, in order to excludeany problem with titanium medical devices,143and long-termclinical and radiographic follow-up has been recom-mended.144Even in confirmed titanium-allergic patients itmay be possible by using alternative materials (e.g. zirconiumoxide dental implants) to achieve DI rehabilitation.14715. ConclusionsIn conclusion there are very few absolute contraindications toDI treatment, although a number of conditions may increasethe risk of treatment failure or complications. However, due tothe scarcity of prospective studies the impact of health riskson implant outcome remains unclear and well-designedobservational studies are needed.The degree of disease-control may be far more importantthat the nature of the systemic disorder itself, and individu-alized medical control should be procured prior to implanttherapy, since in many of these patients the quality of life andfunctional benefits of dental implants may outweigh anyrisks.As in any clinical decision in dentistry, the range oftreatment options and their relative advantages and dis-advantages should be carefully assessed in relation to thepatient’s needs and wishes. In patients with systemicconditions, it is important to weigh carefully the cost-benefitanalysis with the patient’s quality of life and life expectancyand it is very important to undertake the implant surgicalprocedures with strict asepsis, minimal trauma, and avoidingstress and undue haemorrhage. 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