What are some of the implant complications associated with systemic disorders and medications?

This summary is based on information found in Dental Implant Complications: Etiology, Prevention, and Treatment, 2 (Wiley Publishing, 2015)

Key messages

• Patient selection is the critical factor for implant success and survival in any medically complex situation.
• When medical conditions are managed wisely, most patients have improved overall health with fixed replacements as opposed to removable appliances.
• Exceptional care must be taken so that any implants placed will be successful and safe for the clinician and the patient.
• It is essential to routinely review the literature and expect that protocols for patients with systemic diseases or taking medications will be regularly updated as our knowledge of dental implants advances.

• Although dental implants have been a successful option for replacement of lost dentition for nearly five decades, their use in the medical and dental treatment plan is still in its youth.
• With patient selection being the critical factor for implant success or survival, the medical condition, pharmacologic implications, and overall health of the patient cannot be overemphasized.
• When medical conditions are managed wisely, most medically-compromised patients enjoy far better overall health if they enjoy the comfort and confidence of fixed prostheses rather than the struggle, discomfort, and self-awareness of dentures in an age where esthetics and self-esteem have never been more highly valued.

Cardiovascular Disease, Stroke and Myocardial Infarction

• CVD and stroke do not directly impact on the success or failure of dental implants. The concerning complications are directly related to management of these medically complex patients. The clinician needs to be vigilant with monitoring blood pressure, patient stress, and interactions of medications.
• Appointments should be kept short, efficient, personable, and relaxed.
• Vital signs should be monitored, have profound anesthesia for additional patient comfort.
  Review emergency procedures with staff well in advance and be mindful of head position and airway freedom on a stroke patient to prevent aspiration of objects or saliva.

Valvular prosthesis placement

• Valvular heart disease does not directly affect implant outcome; still, the heightened risk of infection needs to be recognized.
• In case the implant becomes infected and does not quickly respond to antibiotics, remove the implant and proceed accordingly.
• The primary focus is to prevent bacteremia and to be mindful of changes in premedication protocols.
• Chlorhexidine mouthrinses should be considered before dental procedures as a further precaution.

Osteoporosis

• The concern is grounded in the assumption that the bones of the mandible and maxilla are similarly affected to other bones in the body by impaired bone metabolism (44).
• Another concern is the assumption that impaired bone metabolism as it occurs in osteoporosis may affect osseointegration of implants (44).

Paget’s disease

• Complications for patients with Paget’s disease and dental implants mirror the complications indicated for bisphosphonate drug side effects.
• Unlike patients with other systemic diseases that do not directly affect implant success, PDB patients have compromised bone density and may be contraindicated for dental implant surgery.
• With intelligent management of the patient with PDB, it is possible for them to enjoy the benefits of fixed prostheses. Consult with the patient’s physician to receive guidance needed to incorporate short-term bisphosphonate cotherapy, in order to strengthen bone and increase density before implant surgery and ensure maximum success.

Psychiatric disorders

• Common-sense approaches to psychiatric disorders must be first and foremost in the mind of dental clinicians, with or without implants in the proposed treatment plan.
• Patient expectations, understanding of implant treatment, and comprehension related to informed consent can be directly linked to successful management of dental implants in the long term.

Alzheimer’s disease

• Visiting the dentist may be complicated for both the patient with Alzheimer’s disease and the caregiver (76).
• The goal of dental care is to prevent loss of oral health function despite the loss of cognitive function. Aggressive prevention of dental problems is critical to the success of the patient’s oral health.
• Thoroughly review prescribed medications along with evaluating caregiver commitment and responsibility.
• Postsurgical oral hygiene, management of drug-induced xerostomia, and regular preventive maintenance are critical for the long-term success of the patient with Alzheimer’s.
• Although there is no reason to deny Alzheimer’s patients access to dental implants, a responsible patient agent needs to be included in the treatment plan and management strategy.

Parkinson’s disease

• PD patients have great difficulties in adjusting to the use of complete dentures.
• PD patients are slower in accomplishing most common tasks and are seriously stressed if someone is not patient with their inability to move at normal speed.
• The treating clinician should be compassionate in scheduling their appointments and not rush them while they are in the chair.
• Helping PD patients with fine motor skills related to oral hygiene around dental implants and suggesting oral hygiene supplies designed for disabled individuals along with caries-preventive therapeutics are additionally helpful.

Pharmacologic considerations

Corticosteroids

• Their use often leads to suppression of a patient’s immune response and makes them more prone to developing bacterial, viral, and fungal infections.
• The clinician should be aware of this when observing the maxilla and mandible (89–92).

Bisphosphonates

• A category of drugs that function as bone resorption inhibitors by depressing osteoclast function.
• Patients under treatment with oral bisphosphonate therapy are at a considerably lower risk for ONJ than patients treated intravenously (97, 101).
• A patient is considered to have bisphosphonate-related ONJ if they have the following three characteristics:
  • current or previous treatment with a bisphosphonate;
  • exposed, necrotic bone in the maxillofacial region that has persisted for more than 8 weeks; and
  • no history of radiation therapy to the jaws.

Anticoagulants

• Treat a number of cardiac or vascular disorders, including atrial fibrillation, ischemic cardiac disease, cardiac valvular disease, prosthetic cardiac valves, post MI, deep venous thrombosis, and pulmonary embolism (105).
• In the past, dentists asked patients not to take oral antithrombotics (such as anticoagulants and antiplatelets) before a procedure because of the fear the medications would increase bleeding. Most experts now agree that antithrombotic regimens should not be routinely stopped or changed (107–109).
• Clinically, the risk of thrombosis formation as a result of stopping therapy outweighs the risk of bleeding for most patients.
• Procedures with high bleeding risk require closer consideration and consultation with the patient’s primary care provider particularly if the patient has only recently started warfarin and adjustments are still being made.

Age

• Patient age in and of itself has not been shown to affect implant complication rates significantly (117).
• However, age is definitely associated with the prevalence of systemic conditions that may affect implant success or complication rates.
• The effect of risk factors for implant complications may become more obvious as a patient ages simply owing to the cumulative effect of the risk factor over time:
  • smoking may increase the risk of implant complications.
  • Hormonal changes occurring with age mainly affect women.
  • the number and variety of medications taken.

Diabetes

• There is relatively little evidence on diabetes as a direct risk factor for dental implant complications or failure.
• If diabetes does negatively affect osseointegration, it is more likely to impact implants placed in regions with a predominance of cancellous bone, such as the maxilla, than in regions with an abundance of cortical bone such as the anterior mandible.

Smoking

• Products of tobacco such as nicotine, carbon monoxide, and hydrogen cyanide alter wound healing by decreasing proliferation of fibroblasts and other reparative cells, decreasing tissue perfusion through vasoconstriction, and increasing platelet adhesion (139).
• Smoking has a deleterious effect on secretory immune functions as well, which may adversely impact healing in the maxillary sinus. Smoking decreases osteoblast activity, resulting in diminished bone mineral density and delayed bone healing after surgery.
• The clinical question remains as to the impact of smoking on actual implant survival and the rate of complications.
• Studies examining data from thousands of implants confirm that overall, implant failure rates are approximately twofold higher in smokers compared with nonsmokers.
• In addition to implant failure implant complications may also occur, including periimplantitis, soft tissue inflammation, and loss of alveolar bone.

Immunodeficiency

• Immunodeficiency can affect a patient’s ability to fight infection and can alter wound healing following trauma or surgery.
• There is little research on dental implant outcomes in patients with HIV.
• Although HIV itself is not a major etiologic factor in implant failure or complications, each HIV patient must be evaluated individually, as comorbid conditions such as hepatitis or other viral infections, blood dyscrasias, opportunistic infections, and certain forms of cancer may contraindicate implant therapy.
• Systemic steroids are often used in the management of autoimmune disorders to suppress the immune response.
• There is little evidence available to determine the impact of intentional immunosuppression on implant survival, failure, or complication rates.

Cancer therapy

• Patients with cancer of the head and neck region are often treated with chemotherapy, radiation therapy, or both, and these treatments have major negative effects on host defenses and on hematopoiesis. Clearly, a patient undergoing active chemotherapy or radiation therapy is not a candidate for dental implant placement.
• Radiation therapy has numerous factors that can affect the risk for implant failure or complications (157).
• When implants are placed following irradiation, the failure rate may be higher if implants are placed a long time after radiation therapy compared with placement at a shorter time from radiation treatment.

List of References (PDF)