Dental treatment of the medically compromised patient: are dental implants an option?
In short: In healthy patients, dental implants have evolved to be a common therapy to address issues related to stability and retention of dentures, as well as to replace compromised teeth. Although dental implants are applied to medically compromised patients, it is often not known whether this therapy is feasible in these patients, whether the risk of implant failure and development of infection (peri-implantitis) is increased, and what specific preventive measures, if any, should be taken when applying dental implants to these patients. In general with regard to the placement of dental implants in patients with general disorders, in some disorders implant survival may be lower, and the risk of peri-implant health damage and complications are higher. For patients the greatest risk is on decompensation of the underlying disease, not due to dental implant treatments. Thus, because dental implant treatment is accompanied by significant functional benefits and improved oral health-related quality of life, dental implant therapy is a feasible treatment in almost any medically compromised patient when the necessary preventive measures are taken and follow-up care is taken at a high level.
ARE THERE ANY ABSOLUTE CONTRAINDICATIONS?
There are very few absolute contraindications to the placement of dental implants, but certain medical conditions may increase the risk of treatment failure or increase the risk of perioperative problems. For example, recent myocardial infarction and stroke, organ transplant or prosthetic valve surgery, profound immunosuppression, severe bleeding problems, active treatment of malignancy and its post-treatment sequelae, alcohol and drug abuse, mental illness, mucosal disease, osteoporosis, and intravenously administered bisphosphonates and other antiresorptive drugs have all been suggested as absolute or relative contraindications. To date, there is still little or no evidence to support or refute these presumed contraindications. However dental implant treatment is worthwhile and comes with a low or acceptable health risk, especially in terms of the great benefit in improving oral function and oral health-related quality of life. However, despite the generally positive sentiment that dental implant prosthodontics is feasible in medically compromised patients, there are some medically compromised conditions that must be respected, as implant placement is an elective procedure. Dental implant treatment can always be delayed until a patient is in a more stable condition (e.g. sometime after a heart attack) or the condition has been controlled (e.g. in patients with bleeding disorders) or should preferably be applied early in the treatment process (e.g. implant placement during ablative surgery in the head and neck cancer patient or at the start of intravenous administration of bisphosphonates).
ARE THE RELATIVE CONTRAINDICATIONS NEGLIGIBLE?
As mentioned in the previous paragraph, there are in fact no absolute contraindications for dental implant treatment. At most, treatment should be postponed or carried out early or alternative implant materials should be used. The latter applies in very rare cases for titanium allergy. Even when this allergy is confirmed, these patients can be treated with alternative implant materials, e.g. zirconium oxide dental implants. Although dental implant treatment seems feasible in almost any medically compromised patient, certain precautions may be necessary. However, for some of these conditions, there is now more information about whether the risk of implant failure is indeed increased or what steps need to be taken to make implant placement in the medically compromised patient more feasible and with a lower risk of complications.
VICIOUS HABITS AND GENERAL MEDICAL CONDITIONS
It is questionable whether medical habits and conditions such as alcoholism, bleeding disorders, cardiovascular disease, neuropsychiatric disorders and smoking could affect dental implant survival and the health of pre-implant tissues. Alcohol itself does not reduce implant survival, but it is not uncommon for subjects with high alcohol consumption to smoke and have poor oral care. As a result, periodontitis, a condition that is also linked to increased loss of dental implants and the development of peri-implantitis, is also linked to alcoholism as well as smoking. Smoking also increases the risk of implant failure and the risk of peri-implantitis. Bleeding may complicate implant placement, but is not a contraindication. Even in haemophilia, dental implants can be placed with a high success rate.
Regarding cardiovascular disease and neuropsychiatric disorders, it is important to know that cardiovascular disease is stable (implant placement can be delayed until there is a stable condition!), homeostasis control is at a level that allows implant placement (for patients with anticoagulants and haemophilia) and oral health is at an appropriate level. Occasionally, especially in patients with neuropsychiatric conditions, help from relatives is needed to ensure an adequate level of oral care.
DENTAL IMPLANTS AND BONE DISEASES
There are so far very few reports, although usually successful, on the use of dental implants in patients with osteogenesis imperfecta, rheumatoid arthritis and ankylosing spondylitis. In patients with rheumatoid arthritis, the results of implant treatment are also favourable. A more common disease affecting the bones is osteoporosis. Generally speaking, there is no contraindication to applying dental implants to patients with osteoporosis; the implant survival rate is comparable to that seen in healthy patients. However, the rate of peri-implant bone loss might be slightly higher in patients with osteoporosis, but for this observation long-term follow-up is needed. A recent study showed that regardless of the area where the implant was placed, marginal bone loss was comparable in diabetic patients and controls. Because bone density in patients with osteoporosis is lower, a longer healing time was recommended before prosthetic work was started. An issue in terms of risks accompanying dental implant treatment is the drugs used to treat osteoporosis or bone metastases. The use of antiresorptive drugs, such as bisphosphonates (Zometa, Fosfamax, Actonel, ZOLEDRONIC ACID), is accompanied by an increased risk of developing so-called drug-related osteonecrosis of the jaws, especially when given intravenously or combined with glucocorticoids. Not only does dental implant surgery increase the risk on osteonecrosis in these patients, but also the presence of dental implant and superstructure in the oral cavity. The latter is especially true in case of inadequate oral hygiene maintenance. When oral hygiene maintenance is at an adequate level, marginal bone loss is comparable to that seen in healthy patients. Finally, perioperative antibiotic prophylaxis is strongly recommended in patients taking antiresorptive medications and bone augmentation surgery should be avoided when possible. In summary, with precautionary measures dental implant treatment is feasible in patients using oral administration of antiresorptive drugs. However, when administered intravenously, dental implants should be placed earlier after the start of antiresorptive drug treatment; otherwise, the risk for osteonecrosis may become too great.
DIABETES AND DENTAL IMPLANTS
Diabetes is the most common endocrine disorder. When blood glucose is well controlled, implant survival is comparable to that of healthy subjects; peri-implant health is good, and bone loss is comparable to that of healthy patients. In subjects with hyperglycemia, i.e. less controlled diabetics, the risk of developing peri-implantitis has been shown to be increased. Antibiotic prophylaxis is recommended in diabetic patients, especially in patients with higher glycaemic levels.
HEAD AND NECK CANCER
Dental implant treatment is a great benefit for patients with head and neck cancer as surgical resection of the tumour can lead to compromised oral health, which makes oral care with conventional means very difficult. In addition, quality of life benefits are also increased due to dental implant treatment. While the application of chemotherapy does not affect dental implant survival and peri-implant health, the outcome of implant survival and peri-implant health in head and neck cancer patients treated with radiotherapy is controversial. Some authors indicate that implant survival and peri-implant health are comparable between controls and irradiated patients, but most studies show that implant survival and peri-implant health are compromised in irradiated patients. Implant placement after radiotherapy is associated with an increased risk of developing osteonecrosis.
IMMUNOCOMPROMISED PATIENTS
Dental implant treatment is contraindicated in patients undergoing immunotherapy or in immunocompromised patients and specific precautions should be taken. As far as immunotherapy is concerned, dental implant treatment can usually be postponed until the end of immunotherapy, as immunotherapy can be accompanied by a wide variety of side effects, often temporary. In immunocompromised patients dental implant treatment is feasible when appropriate precautions are taken, mostly antibiotic prophylaxis.
As for Crohn's disease, older studies indicate that implant survival may be lower than in healthy patients, but more recent studies show that implant survival is comparable. Regarding the use of biologics, which are quite commonly used in immunocompromised patients, it is advisable to discuss with the treating physician whether their administration should be modified or whether specific precautions should be taken. These may be accompanied by a variety of oral side effects.
ORAL MUCOSAL DISEASES
For patients with oral mucosal disease, dental implant treatment is contraindicated and specific precautions must be taken. It is recommended to place the implant under antibiotic prophylaxis and to place implants at a stage when oral mucosal disease manifestations are under control.
MEDICINES AND DENTAL IMPLANTS
A variety of medications can have oral manifestations as a side effect that must be considered when placing dental implants. The most common side effect of medications is their effect on salivary secretion or at least the dry mouth sensation that many patients experience when taking medication. In this regard, it should be noted that for many drugs, it is not yet proven that they actually cause reduced or increased salivary flow or that they only cause the subjective sensation of dry mouth. An increased or decreased salivary secretion as such is not a contraindication for the placement of dental implants. Implant survival is not decreased and soft tissue health is not affected. Accumulation of food debris along the cervical region of teeth and implants is more common in patients with dry mouth and can thus affect soft tissue health. Recently, there are indications that certain groups of drugs may increase dental implant failure.
CONCLUSIONS
In medically compromised patients, dental implants may be a preferred solution for problems with the retention of full dentures or replacement of missing teeth. Dental implant survival and peri-implant health in those patients are mostly comparable to healthy subjects. Occasionally, specific precautions such as antibiotic prophylaxis, or placement of dental implants early in the course of the disease, should be taken. Typically, a high level of care and follow-up should be present in patients with general health problems, as these patients, especially patients with reduced salivary flow or mucosal disease, are prone to develop oral health problems. These problems can be recognized early and treated appropriately when patient follow-up is appropriate. Thus, dental implants can be safely applied to most medically compromised patients when the necessary precautions are taken for the disease from which they are suffering or being treated, immediate implant complications are quickly recognized and treated when necessary, and follow-up is strict and peri-implant health problems are promptly recognized and treated.
References
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Diz, Pedro, et al. "Dental Implants in the Medically Compromised Patient." Journal of Dentistry, vol. 41, no. 3, Mar. 2013, pp. 195-206. DOI.org (Crossref), doi:10.1016/j.jdent.2012.12.008.
Vissink, A., et al. "The Medically Compromised Patient: Are Dental Implants a Feasible Option?" Oral Diseases, vol. 24, no. 1-2, Mar. 2018, pp. 253-60. DOI.org (Crossref), doi:10.1111/odi.12762.
Vissink, A., et al. "The Medically Compromised Patient: Are Dental Implants a Feasible Option?" Oral Diseases, vol. 24, no. 1-2, Mar. 2018, pp. 253-60. DOI.org (Crossref), doi:10.1111/odi.12762.
