The relationship between implant stability and bone health markers in post-menopausal women with bisphosphonate exposure

Bone Augmentation With Alloplastic Graft Material in a Patient Under Bisphosphonate Therapy: A Case Report and Literature Review

Cases of relatively safe dental implant treatment in patients with low-volume bisphosphonate (BP) have been gradually reported. Although bone augmentation is commonly used when the bone volume is insufficient for implant placement, the studies and case reports regarding the safety of bone augmentation in patients treated with BP remain insufficient. Herein, we report a case wherein bone augmentation was performed after BP treatment with bone healing realized according to imaging, and we review the literature regarding BP and bone augmentation. A 67-year-old Japanese woman requested implant treatment for a hopeless lower right second molar. She had been taking minodronic acid hydrate (50 mg/4 wk) for 18 months to treat steroid-induced osteoporosis. After obtaining informed consent, tooth extraction and bone augmentation within the extraction socket were performed. The tooth was extracted atraumatically to preserve the surrounding alveolar bone, and the extraction socket was intensely curetted. Subsequently, the socket was filled with carbonate apatite granules and covered with a biodegradable membrane, and the wound was sutured without tension. Although protracted wound healing without any symptoms of infection was observed, the wound healed completely. No clinical symptoms were observed, the color of the mucosa at the site was healthy, and imaging findings at 6 months postoperation indicated that osteogenesis had progressed uneventfully.

Evaluation of oral implant survival rate in postmenopausal women with osteopenia/osteoporosis. A retrospective pilot study

BACKGROUND

Implant placement is a common part of dental rehabilitation in older individuals. The role of diminished bone mineral density on the healing of dental implants remains to be elucidated.

OBJECTIVE

The aim of this study was to assess the implant survival rate in postmenopausal women with osteopenia/osteoporosis.

METHODS

A retrospective cohort study was conducted of postmenopausal women treated with dental implants and stratified into two groups: those receiving antiresorptive therapy (W ≥ 50 years S) or those not receiving treatment (W ≥ 50 years U). The predictor variable was osteopenia/osteoporosis treatment. The outcome variable was implant failure rate at stage two uncovering. Other study variables included: age, implant location, and bone graft placement. T-test, chi-square test, and univariate and multivariate logistic regression were computed. A p-value<0.05 was considered statistically significant.

RESULTS

The sample was composed of 93 W ≥ 50 years U (197 implants) and 114 W ≥ 50 years S (189 implants). W ≥ 50 years U showed a statistically higher implant failure rate with chi-square testing compared to W ≥ 50 years S (p=0.022). However, univariate, and multivariate logistic regression between age, location, bone grafting, and implant failure did not demonstrate significant associations.

CONCLUSION

Both groups integrated dental implants successfully, with a low failure rate. Implant location, bone grafting, and osteopenia/osteoporosis treatment did not significantly affect osseointegration at uncovering.

Root canal treatment of compromised teeth as alternative treatment for patients receiving bisphosphonates: 60-month results of a prospective clinical study

AIM

This 60-month prospective study aimed to evaluate tooth survival and healing rates after root canal treatment in patients taking bisphosphonates (BPs). Secondary outcomes were complications and clinical variables observed during and after treatment.

METHODS

Root canal treatment was performed using manual K-file canal instrumentation and a carrier-based filling technique with an epoxy resin-based sealer. Teeth without adequate root/crown integrity were restored by trained operators at the tissue level (TL group) to prevent occlusal/mechanical stress and to enable periapical lesion healing without the risk of root fracture. Other teeth were restored with normal occlusal contacts (OC group). Healthy patients who had undergone one or more root canal treatments of the same type constituted the control group. The relationships of the following variables to survival and health status were examined (chi-squared test and multivariate analysis, P = 0.05): age, gender, smoking habit, tooth location, treatment type, BPs treatment, BPs exposure, initial periapical index (PAI) and occlusal restoration. Survival curves were constructed using Kaplan-Meier analysis, with extraction serving as the end-point.

RESULTS

In total, 65 patients with 109 root canal-treated teeth who were taking BPs were included. At 60 months, data from 57 patients (52F, 5M; median age 65.7 ± 8.6 years) who had undergone 96 root canal treatments were analysed (drop-out rate = 16.9%). The survival rate was 85%, and the success rate was 76%. The control group consisted of 46 patients (21F, 25M; median age 60.3 ± 7.2 years) who had undergone 102 root canal treatments. The survival rate was 88%, with 12 teeth lost during follow-up. The success rate was 73%. In the BP group, 55 teeth were restored normally (OC group) and 41 teeth were restored at the tissue level (TL group). No difference in the success or survival rate was observed between the BP and control groups (P > 0.05). Univariate Kaplan-Meier analysis revealed that only tooth type significantly affected survival status in the BP group. The analysis revealed the clinical relevance of smoking, tooth location and initial PAI on patients' health status (P < 0.05).

CONCLUSION

Root canal treatments and post-endodontic restoration with tissue-level filling procedures represent a safe approach for severely damaged teeth in patients receiving BPs having comparable results to root filled teeth restored with occlusal contacts and to the control group.

Sustained Release of Melatonin from GelMA Liposomes Reduced Osteoblast Apoptosis and Improved Implant Osseointegration in Osteoporosis

A reduction in bone mass around an implant is the main cause of implant loosening, especially in postmenopausal osteoporosis patients. In osteoporosis, excessive oxidative stress, resulting in osteoblast apoptosis, largely contributes to abnormal bone remodeling. Melatonin (MT) synthesized by the pineal gland promotes osteoblast differentiation and bone formation and has been effectively used to combat oxidative stress. Therefore, we hypothesized that MT attenuates osteoblast apoptosis induced by oxidative stress, promotes osteogenesis in osteoporosis, and improves bone mass around prostheses. Moreover, considering the distribution and metabolism of MT, its systemic administration would require a large amount of MT, increasing the probability of drug side effects, so the local administration of MT is more effective than its systemic administration. In this study, we constructed a composite adhesive hydrogel system (GelMA-DOPA@MT) to bring about sustained MT release in a local area. Additionally, MT-reduced apoptosis caused by hydrogen peroxide- (H₂O₂-) induced oxidative stress and restored the osteogenic potential of MC3T3-E1 cells. Furthermore, apoptosis in osteoblasts around the implant was significantly attenuated, and increased bone mass around the implant was observed in ovariectomized (OVX) rats treated with this composite system. In conclusion, our results show that GelMA-DOPA@MT can inhibit osteoblast apoptosis caused by oxidative stress, thereby promoting osteogenesis and improving bone quality around a prosthesis. Therefore, this system of local, sustained MT release is a suitable candidate to address implant loosening in patients with osteoporosis.

The effect of antiresorptive drugs on implant therapy: Systematic review and meta-analysis

OBJECTIVES

A considerable portion of the adult population has received and/or is receiving treatment with antiresorptive drugs (ARDs). It is thus relevant to assess possible side effects of ARD intake in connection to various aspects of implant therapy. The aim of this study was to answer the focused question "In patients with systemic intake of ARDs, what is the outcome and complication rate of implant therapy including associated bone grafting procedures comparing to patients without systemic intake of ARDs?"

MATERIALS AND METHODS

Original studies fulfilled predefined inclusion criteria (e.g., case series, cohort studies, case-control studies, and controlled and/or randomized controlled clinical trials; retro- or prospective design; and ≥10 patients with systemic intake of ARDs). Various patient-, medication-, and intervention-related parameters [i.e., implant loss, grafting procedure complication/failure, peri-implant marginal bone levels/loss, medication-related osteonecrosis of the jaws (MRONJ), and peri-implantitis] were extracted, and meta-analyses and quality assessment were performed.

RESULTS

Twenty-four studies with bisphosphonate (BP) intake (mainly low dose for osteoporosis treatment) and seven studies on hormone replacement therapy (HRT), including ≥10 patients, and controls not taking the medication were identified. Furthermore, seven studies on MRONJ associated with implants were included. Meta-analyses based on four studies reporting on patient level and eight studies reporting on implant level showed no significant differences in terms of implant loss between patients on BPs (mainly low dose for osteoporosis treatment) and controls. Furthermore, low-dose BP intake did not compromise peri-implant marginal bone levels. Based on two studies, no negative effect of HRT was observed on the implant level, while HRT appeared to exert a marginally significant negative effect regarding implant survival on the patient level and regarding peri-implant marginal bone levels. Based on six studies reporting single-patient data, MRONJ in patients on BP for osteoporosis appeared in 70% of the cases >36 months after start of drug intake, while in patients with cancer, MRONJ appeared in 64% of the cases ≤36 months after first BP intake.

CONCLUSION

Low-dose oral BP intake for osteoporosis treatment, in general, does not compromise implant therapy, that is, patients on ARDs do not lose more implants nor get more implant-related complications/failures comparing to implant patients without BP intake. There is almost no information available on the possible effect on implant therapy of high-dose BPs or other widely used ARDs (e.g., denosumab), or on the success or safety of bone grafting procedures. Patients with high-dose ARD intake for management of malignancies, patients on oral BP over a longer period of time, and patients with comorbidities should be considered as high-risk patients for MRONJ.

Immediate implant placement following 1-year treatment with oral versus intravenous bisphosphonates: a histomorphometric canine study on peri-implant bone

OBJECTIVES

Bisphosphonates (BPs) are anti-resorptive medications with inhibitory effects on osteoclasts which decrease bone turnover. The present study aimed to assess the early effects of BPs on peri-implant bone.

MATERIALS AND METHODS

Twelve female mongrel dogs were assigned to one control and two experimental groups as follows: 12 months of oral alendronate (ALN, 3.5 mg/kg/week) or intravenous (IV) pamidronate (PAM, 1 mg/kg/week) for experimental groups. Following 8 weeks after implant insertion, the specimens were sacrificed, histological evaluation was performed, and C-terminal telopeptide of collagen I (CTx) analysis was performed on serums.

RESULTS

PAM demonstrated the greatest marginal bone level (MBL), 2.64 ± 0.48, followed by ALN and control, 2.5 ± 0.4 and 0.66 ± 0.5 respectively. The least bone-implant contact was observed in PAM group (%39 ± 0.03) while it was significantly greater in the control group (p < 0.05). PAM and ALN demonstrated < 10 CTx levels versus > 300 in controls.

CONCLUSION

It is assumed that long-term oral or IV BP therapy decreases marginal bone resorption and osseointegration. These changes were more accentuated in IV BP administration. CTx does not seem to be a precise predictor for bisphosphonate-related osteonecrosis of the jaw.

CLINICAL RELEVANCE

BPs impair peri-implant bone remodeling and this phenomena may be effective for reducing resorption at esthetic zone implants; however, decrease in osseointegration may be a concern for implant treatment in patients receiving BPs.

Immediate Early and Delayed Implants: A 2-Year Prospective Cohort Study of 131 Transmucosal Flapless Implants Placed in Sites With Different Pre-extractive Endodontic Infections

INTRODUCTION

To evaluate clinical outcome of early, immediate, and delayed transmucosal implants placed in patients affected by acute/chronic endodontic lesions.

MATERIALS AND METHODS

Eighty-five consecutive patients received 131 titanium implants with zirconium-oxide blasted surface. Pre-extractive diagnosis represented the main criteria for implant placement timing, following "best treatment" criteria. Implants were placed with flapless transmucosal technique. Hopeless teeth with chronic periapical lesions received atraumatic extraction, and an implant was immediately placed (Immediate Group, n = 29). Teeth with acute periapical lesion/abscess were extracted and implants placed after 8 to 12 weeks (Early Group, n = 29). Implants placed 10- to 12-month after extraction constituted the control group (delayed group, n = 73). Implants were loaded 3 months after insertion with provisional resin crowns and after approximately 15 days with definitive ceramic crowns. Marginal bone loss (MBL) was measured in a single-blind manner on periapical radiographs at 1, 3, 6, 12, and 24 months.

RESULTS

Multilevel analysis described exploring factors associated with MBL. Survival rate was 100%. MBL after 24 months was 0.78 ± 0.70 (95% confidence interval [CI]: 0.20 to -1.37) at immediate, 0.48 ± 0.70 at early (95% CI: -0.006 to -0.961), and 1.02 ± 1.01 (95% CI: 0.61 to -1.43) at delayed groups. Implant groups (immediate/early/delayed) and location (maxillary/mandibular) showed statistically significant results. Early group showed the lowest MBL values. The immediate group demonstrated less MBL than the delayed group.

CONCLUSION

Early implant placement technique preserves periimplant marginal bone level more than immediate and delayed techniques.

Comparison between inflammation-related markers in peri-implant crevicular fluid and clinical parameters during osseointegration in edentulous jaws

OBJECTIVES

The aim of this study is to improve the understanding of interleukin mechanisms during osseointegration to enhance the monitoring of implant failure and success. Clinical parameters, implant stability, and cytokine levels in peri-implant crevicular fluid (PICF) during early bone healing after implant placement were investigated.

MATERIAL AND METHODS

Sixty narrow implants were placed in mandible anterior region of 30 edentulous patients (67.23 ± 7.66 years). Bone type, insertion torque, and primary stability were registered during surgery. Clinical measurements of peri-implant health and the secondary implant stability quotient (ISQ) were recorded. Samples from the PICF were collected 1, 2, 4, 8, and 12 weeks after surgery and analyzed for IL-1β, IL-6, IL-10, and TNF-α levels using ELISAs.

RESULTS

The gingival index increased significantly during the first week (p = 0.05), while the plaque index increased significantly between 4 to 8 and 8 to 12 weeks (p < 0.05). The probing depth and the ISQ also reduced significantly (p < 0.05) over time. The TNF-α release increased significantly after the 2nd week for non-atrophic patients and 4th week for atrophic patients (p < 0.05). The IL-1β concentrations showed a short-lived peak after 1st week (p = 0.003), specially in atrophic patients and sites with bone type I (p = 0.034; p = 0.007). The IL-6 concentrations peaked during the 1st and 2nd weeks (p < 0.05; p = 0.005) in atrophic patients and in bone type II (p = 0.023; p = 0.003). The IL-10 concentrations increased gradually over time, showing the highest concentrations at the 12th week (p < 0.005). A total of 12 implants failed at different periods.

CONCLUSION

While the clinical measurements presented differences between the evaluation periods, these were not indicative of early dental implant failure or peri-implant diseases. Smoking, bone atrophy, and bone type can greatly influence the cytokines concentrations during the healing time.

Influence of bisphosphonates on the adherence and metabolism of epithelial cells and gingival fibroblasts to titanium surfaces

OBJECTIVES

To evaluate the effects of sodium alendronate (SA) and zoledronic acid (ZA), on the adhesion and metabolism of epithelial cells and gingival fibroblasts to titanium surfaces considering cell functions related to an effective mucosal barrier around the implant.

MATERIALS AND METHODS

Cells were seeded onto titanium discs and incubated for 24 h. Then, serum-free DMEM containing selected bisphosphonates (0, 0.5, 1, or 5 μM) was added for 24 and 48 h. Factors related to the achievement of an effective mechanical and immunological barrier-cell adhesion, viability, collagen epidermal growth factor, and immunoglobulin synthesis-were evaluated. Data were analyzed by Kruskal-Wallis and Mann-Whitney tests as well as by ANOVA and Tukey's tests, (α = 0.05).

RESULTS

The presence of bisphosphonates culminated in lower cell adhesion to the titanium discs, particularly for SA at 5 μM (40%) and ZA at all concentrations (from 30 to 50%, according to increased concentrations). Reduced cell viability occurred after exposing these cells to ZA (40%); however, only 5 μM SA-treated cells had decreased viability (30%). Reduced synthesis of growth factors and collagen was observed when cells were reated with ZA (20 and 40%, respectively), while about 70% of IgG synthesis was enhanced.

CONCLUSION

Bisphosphonates negatively affected the adhesion and metabolism of oral mucosal cells, and this effect was related to the type of bisphosphonate as well as to concentration and period of treatment.

CLINICAL RELEVANCE

The negative effects of bisphosphonates on oral mucosal cells can hamper the formation of an effective biological seal in osseointegrated implants.