“The concept of ‘one size fits all’ cannot be applied to implant dentistry any more”

Iveta Ramonaite, Dental Tribune International

Fri. 29 September 2023

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Because the long-term success of implant treatment depends on various factors, including oral hygiene, lifestyle habits and health conditions, it is vital to tailor treatment to the characteristics and risk profiles of patients. In the run-up to the 2023 EAO–DGI joint meeting, Dental Tribune International spoke with Dr Elena Calciolari, an associate professor in translational dental medicine at Queen Mary University of London in the UK, about some major considerations for dental professionals in treating immunocompromised patients and those with chronic disease.

Dr Calciolari, has your understanding of implant placement in medically compromised patients changed throughout your profession? If so, how?
Research is progressing at an incredibly fast rate. Compared with ten years ago, we are now more aware of the influence of systemic disease and medications on the oral cavity. For instance, thanks to advancements in “-omics” technologies such as transcriptomics and proteomics, we are starting to unravel the biological mechanisms that explain the potentially detrimental effect of diseases such as uncontrolled diabetes or osteoporosis on osseointegration. By knowing which signalling pathways and stages of bone formation are jeopardised by systemic disease, we can design future-targeted treatments to reduce the risk of treatment failures and complications in these challenging patients.

It is important to acknowledge that we are ageing as a society. This means that, going forwards, we will treat more and more patients with chronic or non-communicable diseases, which result from a combination of genetic, physiological, environmental and behavioural factors. Being able to ensure predictable implant therapies in such patients is the future challenge of our profession.

What key factors should dental professionals consider before dental implant placement in high-risk patients?
Needless to say, it is important to take a proper and thorough medical history of the patient and, whenever necessary, to consult with the patient’s physician. Our role is to meet patient expectations. At the same time, we are responsible for informing the patient about the potential risks associated with their medical conditions and offering a safe and predictable therapy.

Once we have defined the risk profile of the patient, we should focus on eliminating all modifiable risk factors before starting any type of implant therapy. This means that we have a responsibility, for instance, to advise our patients to quit smoking and vaping and to refer them to specialised centres for such purposes. Likewise, promoting a healthy lifestyle, proper diet and thorough oral hygiene habits should be an integral part of our treatment strategy.

“It is important to acknowledge that we are ageing as a society.”

As indicated in the European Federation of Periodontology’s S3-level clinical practice guideline published earlier this year, successful, long-term maintenance of peri-implant tissue health encompasses behavioural modification, health monitoring, appropriate preventive interventions and, when necessary, careful treatment planning and execution. This is even more crucial when treating systemically compromised patients.

How can immunodeficiency influence dental implant survival, and how can dental professionals avoid complications that jeopardise the long-term stability of dental implants in this patient group?
The term “immunodeficiency” is very broad and encompasses a large number of diseases that can affect dental implant treatments at different levels. In generic terms, we can say that different diseases, including autoimmune diseases, genetic diseases and chronic diseases with inflammatory pathogenesis, can have a detrimental effect because they can induce an impaired immune response, a deficit in bacterial killing, or non-resolving or exaggerated inflammation, thus increasing the risk of impaired bone and soft-tissue healing.

However, the majority of common chronic diseases, such as Type 2 diabetes, metabolic syndrome and osteoporosis, should not be considered contra-indications for implant placement as long as we work together with the patient’s physician on controlling modifiable risk factors to make sure that the medical condition is under control.

Only a few conditions should be considered absolute contra-indications for implant placement or any other elective surgery. These include myocardial infarction or cerebrovascular accident within the last six months, valvular prosthesis placement or transplant within the last six to 12 months, high risk of bleeding (international normalised ratio of > 3.0–3.5; platelet count of < 50,000/mm³), significant immunosuppression (total white blood cell count of < 1,500–3,000 cells/mm³), active cancer therapy and intravenous bisphosphonate treatment.

What role do medications taken for chronic disease play in implant osseointegration?
Several medications can affect bone metabolism and therefore jeopardise or impair the process of osseointegration. However, it is important to point out that most of the available evidence is of low level, as it comes mainly from retrospective studies or case series with short follow-ups, and it is not always easy to differentiate the role of the medications from other concomitant potential risk factors.

Nevertheless, a systematic review by Chappuis et al. in 2018, performed as part of the sixth International Team for Implantology Consensus Conference, indicated an increased rate of implant failure in patients taking proton pump inhibitors (4.3%, with an odds ratio of 2), based on two studies, and in patients taking selective serotonin reuptake inhibitors (7.5%, with an odds ratio of 3), based again on only two studies. Notably, the same review did not indicate increased implant failure in relation to bisphosphonate intake. However, we know that bisphosphonates, and anti-resorptive medications in general, may lead to an increased risk of developing osteonecrosis of the jaw. This is a very rare complication (< 0.1%) when it comes to the use of oral bisphosphonate for osteoporosis. However, its prevalence increases in patients taking these medications for more than four years and in patients with other concomitant risk factors, such as smoking and corticosteroid intake, which is why clinicians should be aware of this and inform patients accordingly.

Besides the effect of medications on osseointegration, clinicians should be aware that the same medications may impair bone regenerative procedures performed before or in tandem with implant placement, so when planning complex implant rehabilitations that require extensive bone regenerative procedures, all these aspects should be carefully considered.

What are some surgical recommendations for placing dental implants in patients affected by chronic disease?
As a general rule, whenever there is doubt about the medical condition of the patient or their pharmacological treatment, it is best to discuss it with the patient’s physician and to consider the risk of potential adverse events together with the physician. As previously mentioned, we must control for modifiable concomitant risk factors that can affect bone metabolism and bone density, such as vitamin D and calcium deficiency, smoking or alcohol abuse, before embarking on implant rehabilitation.

“The key to the long-term success of our implant treatment greatly relies on respecting biological healing times.”

When dealing with patients who present with a systemic disease that may affect bone metabolism and lead to reduced bone density and/or quality, such as osteoporosis, clinicians should consider the bone equivalent to Type IV according to the Lekholm and Zarb classification, thus porous and on average of poor quality. As such, when preparing the implant site, clinicians might consider under-preparation of the site and allow for longer healing periods before seating the prosthesis.

A large body of research is now involved in optimising implant surfaces to enhance osseointegration, also in challenging scenarios. For example, clinicians could consider hydrophilic micro-rough surfaces when dealing with high-risk patients in order to increase the predictability of the treatment, although more research is needed to understand how to tailor the treatment based on the underlying medical condition of the patient. Also, when dealing with patients taking anti-resorptive medications, such as bisphosphonates, we should prioritise performing minimally invasive surgery, which means reducing the surgical trauma as much as possible and promoting healing to minimise the risk of infection and development of osteonecrosis of the jaw.

The key to the long-term success of our implant treatment greatly relies on respecting biological healing times and on our ability to keep our patients motivated and to intercept problems early. For this reason, all implant patients, particularly patients with systemic conditions, should be placed on strict supportive care programmes.

We are moving more and more towards the development of precision dentistry, which means that we should try to tailor the treatment based on the characteristics and risk profile of our patients. The concept of “one size fits all” cannot be applied to implant dentistry any more. Future research efforts should be focused on better understanding how to personalise the treatments of our patients to ensure predictable outcomes in challenging scenarios.

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