Characteristics of implant failures in patients with a history of oral bisphosphonate therapy

Clinical and radiologic treatment outcomes of implant presence tirggered-MRONJ: Systematic review of literature

BACKGROUND

The present systematic review evaluated clinical and radiographic features and treatment outcomes of peri-implantitis-induced medication-related osteonecrosis of the jaws (Pi-MRONJ).

MATERIALS AND METHODS

Literature search was performed in PubMed/MEDLINE, Cochrane CENTRAL, Web of Science, and Scopus databases. Studies reporting Pi-MRONJ were included. No time restrictions were applied.

RESULTS

In total, 571 articles were retrieved, and 24 articles were included in the final review. Study population consisted of 111 patients (70% pharmacologically treated for osteoporosis and 30% for oncologic disease). Pi-MRONJ was characterized by pain, bone exposure and suppuration, and involved a single implant in 55 cases, two implants in 37 cases, three implants in 10 cases, and more than four implants in nine cases. Most of the lesions were assigned Stage II and III. MRONJ developed on average 46.5 ± 33.2 months following implant placement. Sixty-one lesions were surgically treated with implant removal and debridement of the surrounding necrotic bone. Complete wound healing was observed in 85% of cases.

CONCLUSIONS

The presence of dental implants in patients treated with antiresorptive drugs should be considered as a potential risk factor for MRONJ onset. In cases of periimplantitis with delayed wound healing following nonsurgical therapy, the clinician should rule out the presence of Pi-MRONJ.

Dental implant considerations in patients with systemic diseases: An updated comprehensive review

BACKGROUND

Various medical conditions and the drugs used to treat them have been shown to impede or complicate dental implant surgery. It is crucial to carefully monitor the medical status and potential post-operative complications of patients with systemic diseases, particularly elderly patients, to minimize the risk of health complications that may arise.

AIM

The purpose of this study was to review the existing evidence on the viability of dental implants in patients with systemic diseases and to provide practical recommendations to achieve the best possible results in the corresponding patient population.

METHODS

The information for our study was compiled using data from PubMed, Scopus, Web of Science and Google Scholar databases and searched separately for each systemic disease included in our work until October 2023. An additional manual search was also performed to increase the search sensitivity. Only English-language publications were included and assessed according to titles, abstracts and full texts.

RESULTS

In total, 6784 studies were found. After checking for duplicates and full-text availability, screening for the inclusion criteria and manually searching reference lists, 570 articles remained to be considered in this study.

CONCLUSION

In treating patients with systemic conditions, the cost-benefit analysis should consider the patient's quality of life and expected lifespan. The success of dental implants depends heavily on ensuring appropriate maintenance therapy, ideal oral hygiene standards, no smoking and avoiding other risk factors. Indications and contraindications for dental implants in cases of systemic diseases are yet to be more understood; broader and hardcore research needs to be done for a guideline foundation.

Does hormone replacement therapy impact implant osseointegration in females- A systematic review and meta-analysis

Background

This review aimed to comprehensively investigate the impact of Hormone Replacement Therapy (HRT) on implant osseointegration and bone loss. The study considered factors such as HRT type, osteoporosis, smoking, and diabetes mellitus, and analysed the available literature to provide insights into the association between HRT and implant outcomes.

Methods

Multiple databases were utilized, and studies with diverse designs and methodologies were included that examined the relationship between HRT and implant osseointegration. The selected studies were analyzed and relevant data on implant success rates, bone loss, and other correlations was extracted.

Results

The review findings indicate that HRT has a detrimental impact on implant osseointegration, as evidenced by lower implant success rates and increased bone loss in HRT-treated individuals. The odds ratio analysis further strengthens this association, with significant values of 0.59 (95% CI: 0.50-0.70) and 0.64 (95% CI: 0.54-0.76), indicating a higher likelihood of implant failure in HRT-treated patients., highlighting the need for caution when considering HRT as a treatment option in patients undergoing implant procedures. Smoking and diabetes mellitus were also found to significantly affect implant outcomes, emphasizing the importance of addressing these factors in patient management.

Conclusion

The assessments demonstrate that HRT adversely affects implant osseointegration and increases bone loss. The results suggest the importance of considering the potential negative impact of HRT on implant outcomes and the need for thorough patient evaluation and management. Further research is warranted to explore the underlying mechanisms, assess the impact of specific HRT types and dosages, and evaluate preventive strategies to mitigate the detrimental effects of HRT on implant success.

Clinical Impact on Dental Implant Survival in Patients Taking Antiresorptive Medications: A Systematic Review and Meta-Analysis

Dental implants are a predictable option to replace missing teeth. Patients on antiresorptive medications used to treat disorders associated with bone resorption may need dental implants to replace missing teeth. The data on implant failure in patients on antiresorptive medication requiring dental implants, is conflicting and limited. This systematic review aims to investigate if antiresorptive medications have any clinical impact on dental implant survival. Electronic databases were searched until May 2020. The focus question (PICOS): Participants: humans, Interventions: implant placement surgery in patients on antiresorptive medication, Comparisons: patients on antiresorptive medication vs control (patients not on antiresorptive medication), Outcomes: implant survival, and Study design: clinical studies. The protocol of this systematic review was registered in PROSPERO (CRD42020209083). Fourteen nonrandomized studies were selected for data extraction and risk of bias assessment using the ROBINS-1 tool. Only studies with a control were included for the meta-analysis, 8 articles were included in the meta-analysis using implant-level data, and 5 articles were included in the meta-analysis using patient-level data. There was no statistical significance between the 2 groups at the patient level based on 265 patients. However, there was a statistically significant difference at the implant level based on 2697 implants. Therefore, antiresorptive medications, mainly bisphosphonates (BPs), may significantly contribute to implant failure. Antiresorptive medications, especially BPs may reduce implant survival and impair the osseointegration of dental implants. Failed implants in patients on BPs may not lead to osteonecrosis and may be replaced with success.

Fabrication of a micro/nanocomposite structure on the surface of high oxygen concentration titanium to promote bone formation

This study investigated the properties of the micro/nano composite structure on the surface of high oxygen concentration titanium (HOC-Ti) after anodic oxidation modification (HOC-NT) and evaluated its biocompatibility as a dental implant material in vitro and in vivo. HOC-Ti was produced by titanium powders and rutile powders using the powder metallurgy method. Its surface was modified by anodic oxidation. After detecting the electrochemical characteristics, the surface properties of HOC-NT were investigated. MC3T3 and MLO-Y4 cells were employed to evaluate the biocompatibility of HOC-NT and cocultured to study the effects of the changes in osteocytes induced by HOC-NT on osteoblasts. While, its possible mechanism was investigated. In addition, osseointegration around the HOC-NT implant was investigated through in vivo experiments. The results showed that a unique micronano composite structure on the HOC-Ti surface with excellent hydrophilicity and suitable surface roughness was created after anodic oxidation promoted by its electrochemical characteristics. The YAP protein may play an important role in regulating bone remodeling by β-catenin and Rankl/OPG Signaling Pathways. An in vivo study also revealed an accelerated formation rate of new bone and more stable osseointegration around the HOC-NT implant. In view of all experimental results, it could be concluded that the unique morphology of HOC-NT has enhanced physicochemical and biological properties. The promotion of bone formation around implants indicated the feasibility of HOC-NT for applications in oral implants.

Is medication related osteonecrosis of the jaw around implants a rare entity? A case series with a focus on etiopathophysiology

OBJECTIVES

Medication Related Osteonecrosis of the Jaw (MRONJ) around dental implants is a rare complication of antiresorptive drug (ARD) treatment. MRONJ has been described in patients with implants placed before, during or after ARD treatment. The aim of this study was to review our cases and to discuss a preventive approach to avoid the risk of MRONJ around implants.

MATERIALS AND METHODS

In a retrospective analysis of the 168 MRONJ seen in our department from 2005 to 2021, we searched for cases of patients with MRONJ around dental implants.

RESULTS

Six patients (4 females, 2 males) presented with MRONJ around 17 implants. Median age was 64 (50-83) years. Four patients received ARD treatment for osteoporosis and 2 for cancer. The maxilla was more affected than the mandible. Six implants were placed after the initiation of ARD treatment and eleven were placed before initiation of ARD treatments. Eight implants were managed surgically while 9 implants were managed conservatively.

CONCLUSION

In this series, implants were placed before or after starting ARD treatment. Despite initial successful osseointegration, MRONJ occurred months or years after initiation of ARD treatment. The role of periimplantitis should be discussed as well as the role of microcracks in the bone following implant loading. Less is known over the effect of ARD treatment after implant osseointegration. Implants could be a risk factor for MRONJ and must be checked regularly (every 3 months). It is important to check the healthy and biomechanical harmony of the implant system during the pre-treatment assessment.

Dental Implant Placement in Patients With a History of Medications Related to Osteonecrosis of the Jaws: A Systematic Review

The present systematic review evaluates the safety of placing dental implants in patients with a history of antiresorptive or antiangiogenic drug therapy. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. PubMed, Cochrane Central Register of Controlled Trials, Scopus, Web of Science, and OpenGrey databases were used to search for clinical studies (English only) to July 16, 2019. Study quality was assessed regarding randomization, allocation sequence concealment, blinding, incomplete outcome data, selective outcome reporting, and other biases using a modified Newcastle-Ottawa scale and the Joanna Briggs Institute critical appraisal checklist for case series. A broad search strategy resulted in the identification of 7542 studies. There were 28 studies reporting on bisphosphonates (5 cohort, 6 case control, and 17 case series) and 1 study reporting on denosumab (case series) that met the inclusion criteria and were included in the qualitative synthesis. The quality assessment revealed an overall moderate quality of evidence among the studies. Results demonstrated that patients with a history of bisphosphonate treatment for osteoporosis are not at increased risk of implant failure in terms of osseointegration. However, all patients with a history of bisphosphonate treatment, whether taken orally for osteoporosis or intravenously for malignancy, appear to be at risk of "implant surgery-triggered" medication-related osteonecrosis of the jaw (MRONJ). In contrast, the risk of MRONJ in patients treated with denosumab for osteoporosis was found to be negligible. In conclusion, general and specialist dentists should exercise caution when planning dental implant therapy in patients with a history of bisphosphonate and denosumab drug therapy. Importantly, all patients with a history of bisphosphonates are at risk of MRONJ, necessitating this to be included in the informed consent obtained before implant placement.

Success Rate and Safety of Dental Implantology in Patients Treated With Antiresorptive Medication: A Systematic Review

There is no agreement of data on the subject of implant failure and the development of osteonecrosis in patients receiving antiresorptive agents. The purpose of this systematic review is to evaluate whether dental implants placed in patients on antiresorptive medication have an increased failure rate and whether the implant placement or the implant existence are risk factors for developing medication-related osteonecrosis of the jaw (MRONJ). An electronic search was conducted in PubMed/Medline, and all publications fulfilling the inclusion criteria were included. The search was completed by a hand research of the references cited in all electronic identified publications, resulting in 411 articles. Based on the inclusion criteria, 32 studies were included, with a total of 5221 patients, 12 751 implants, 618 cases of implants loss, and 136 cases of MRONJ analyzed. Because of the small number of studies, most of which were characterized by a low level of quality, it cannot be established that the use of antiresorptive medication affects dental implant survival rates. The risk of MRONJ as an early or late complication is also not well established. Therefore, successful dental implant procedures in patients receiving antiresorptive medication might be possible, but more studies need to be carried out in the future to verify this topic. Apart from intravenous antiresorptive drugs, which remain an absolute contraindication, the use of antiresorptive medication is not a contraindication to dental implantology, but it must be accompanied by careful treatment planning, informing patients about possible complications, and essential long follow-up periods.

Osseointegration Pharmacology: A Systematic Mapping Using Artificial Intelligence

Clinical performance of osseointegrated implants could be compromised by the medications taken by patients. The effect of a specific medication on osseointegration can be easily investigated using traditional systematic reviews. However, assessment of all known medications requires the use of evidence mapping methods. These methods allow assessment of complex questions, but they are very resource intensive when done manually. The objective of this study was to develop a machine learning algorithm to automatically map the literature assessing the effect of medications on osseointegration. Datasets of articles classified manually were used to train a machine-learning algorithm based on Support Vector Machines. The algorithm was then validated and used to screen 599,604 articles identified with an extremely sensitive search strategy. The algorithm included 281 relevant articles that described the effect of 31 different drugs on osseointegration. This approach achieved an accuracy of 95%, and compared to manual screening, it reduced the workload by 93%. The systematic mapping revealed that the treatment outcomes of osseointegrated medical devices could be influenced by drugs affecting homeostasis, inflammation, cell proliferation and bone remodeling. The effect of all known medications on the performance of osseointegrated medical devices can be assessed using evidence mappings executed with highly accurate machine learning algorithms.

Are There Contraindications for Placing Dental Implants?

There are few absolute contraindications to dental implant placement. Relative contraindications include cognitive decline, American Society of Anesthesiology patient status IV or higher categories, or medical conditions that may jeopardize the life or lifespan of the patient. Precautions for placing dental implants should be viewed with respect to the evidence-based exposures that can contribute to risk of failure, including but not limited to local, behavioral, and medical factors. Risk for dental implant failure increases in association with (1) past history of periodontal disease, (2) bruxism, (3) smoking, and (4) radiation therapy.

Sex hormone replacement therapy in periodontology-A systematic review

OBJECTIVE

To analyse whether sex hormone replacement therapy (HRT) improves periodontal parameters and dental implants osseointegration in humans.

MATERIALS AND METHODS

Electronic databases and hand searches were performed from June to August 2018 in SciELO, LILACS and PubMed/MEDLINE. Human observational and interventional studies that evaluated the following parameters were included: clinical attachment loss (CAL), probing pocket depth (PPD), bleeding on probing (BOP), radiographic bone loss (RBL) or osseointegration.

RESULTS

Initial search retrieved 1,282 non-duplicated articles. Fifteen studies were selected after inclusion criteria were applied. All studies were performed in postmenopausal women. Mean differences for PPD reduction ranged from 0.02 to 0.2 mm in HRT-positive patients; mean CAL gain -0.18 to 0.54 mm; mean RBL reduction -0.87 to 0.15 mm; and mean BOP reduction 9%-30.3%. Failure rate of dental implants increased -5.5% to 11.21% when HRT was used.

CONCLUSIONS

Very low but consistent evidence suggests a reduction in BOP and no impact on RBL in postmenopausal women receiving HRT. There are inconsistent reports that suggest that HRT in postmenopausal women: (a) improves or does not impact PPD reduction and CAL gain; and (b) does not impact or increase implant loss. In summary, there is no evidence to support HRT prescription for either men or women for periodontal/implant placement purposes.

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.

Development of Antiresorptive Agent-Related Osteonecrosis of the Jaw After Dental Implant Removal: A Case Report

Dental implant treatment is a highly predictable therapy, but when potentially lethal symptoms or complications occur, dentists must remove the implant fixture. Recently, reports on antiresorptive agent-related osteonecrosis of the jaw have increased in the field of dental implants, although the relationship between dental implant treatment and antiresorptive agents remains unclear. Here, we report a case of antiresorptive agent-related osteonecrosis of the jaw that developed after dental implant removal. A 67-year-old Japanese woman with a medical history of osteoporosis and 7 years of oral bisphosphonate treatment was referred to our hospital with a chief complaint of painful right mandibular bone exposure. A family dentist removed the dental implants from the right mandible using a trephine drill without flap elevation in August 2016. However, the healing was impaired; she was referred to our hospital 3 months after the procedure. We performed a sequestrectomy of the mandible under general anesthesia. In conclusion, this patient's course has two important implications: First, the removal of dental implants from patients who are prescribed oral bisphosphonates for long durations can cause antiresorptive agent-related osteonecrosis of the jaw. Second, meticulous procedures are required to prevent and treat the development of antiresorptive agent-related osteonecrosis of the jaw after dental implant removal.

Comparison of early osseointegration between laser-treated/acid-etched and sandblasted/acid-etched titanium implant surfaces

This study was designed to compare the early osseointegration of titanium surfaces prepared via laser-treated/acid-etched (LA) and sandblasted/acid-etched (SLA) in dogs. Titanium implants were divided into two groups: Surfaces of the experimental group were treated via LA, while in the control group, surfaces were treated via SLA. The physical and chemical properties of LA and SLA surfaces were tested and compared. Sixteen implants with LA or SLA surfaces were placed into the tibias of four beagle dogs, each treatment group received two implants per single tibia. The dogs were sacrificed two and four weeks after implant placement. Scanning electron microscopy showed that both the LA and SLAs surface exhibited rough structures with micro pores sized 1-3 μm. In the LA surface, regular melting points were observed. However, in the SLA surface, the structure was irregular and few oxide aluminum particles still remained. Only titanium and a small amount of titanium compounds were detected on LA surfaces, while Al was found of SLA surfaces. The LA surface roughness was above that of SLA surfaces (LA: Ra: 2.1 μm; SLA: Ra :1.53 μm; P < 0.01). Both groups exhibited good osseointegration and no significant differences were found in the BIC% at two or four weeks between both groups (P > 0.05). Both groups exhibited good osseointegration; however, the LA surface was cleaner and more uniform than the SLA surface, and no significant differences were found between both groups.

Medication-Related Osteonecrosis of the Jaw and Dental Implants Failures: A Systematic Review

No well-established evidence supporting safe use of bisphosphonates (BPs) or other antiresorptive agents prior, during, or after dentoalveolar surgery, are currently available; moreover, the real risk of osteonecrosis of the jaw (ONJ) development is still unknown. The aim of the present systematic review was to assess the scientific literature concerning the implants placement in antiresorptive agent users and the related risk of implants failure and ONJ development. English papers published from January 2003 until December 2014 were identified on the MEDLINE database. Titles and abstracts retrieved form electronic search were screened separately by 2 examiners; thus, original studies dealing with dental implants placement during or before bone antiresorptive agent therapy and the relative risk of implant failure or development of osteonecrosis were evaluated. Due to the heterogeneity of the included studies and the high risk of bias, there is no evidence of the safe use of oral antiresorptive agents prior or after dental implant surgery. Indeed, implant failure and ONJ development can occur and represent a devastating side effect that should be considered during treatment. Within the limitation of the present systematic review, high quality studies are needed to provide an adequate level of evidence regarding the safety of dentoalveolar surgery during or before bone resorption inhibition therapy and the increase predisposition to osteonecrosis of the jaw (ONJ) development. Therefore, antiresorptive agent therapy should be considered a risk factor until further evidence is prospectively obtained.

General Diseases Influence on Peri-Implantitis Development: a Systematic Review

OBJECTIVES

To systematically review the influence of systemic diseases or medications used in their treatment on the dental implant therapy success.

MATERIAL AND METHODS

The search strategy was implemented on the National Library of Medicine database (MEDLINE) (Ovid) and EMBASE electronic databases between January 2006 and January 2016. Human studies with available English articles analysing the relationship between dental implant therapy success and systemic diseases, such as diabetes mellitus, AIDS/HIV, rheumatoid arthritis, osteoporosis, Crohn's disease, cardiovascular diseases, scleroderma, Sjögren's syndrome, lichen planus, ectodermal dysplasia, post-transplantation status, were included in present review according to the PRISMA guidelines. The review protocol was registered on PROSPERO system with the code CRD42016033662.

RESULTS

Present review included forty one retrospective and prospective follow-up studies, case-control studies, case report series and cohort studies. Despite some limitations this study reveals positive results of implantation in most systemic conditions that should be interpreted with caution. Influence of cardiovascular diseases on the dental implantation success should be explored deeply, because of controversial results and likelihood of comorbidity expressed by a history of cardiovascular diseases and periodontitis. There is only a weak relationship with bone density in osteoporosis and implant failure. All the other diseases did not show significant effect on implantation success.

CONCLUSIONS

Recent studies with low strength of evidence and controversy show that systemic diseases may have potential effect on the success of implantation, but further detailed studies are needed to provide these findings.

Bisphosphonate treatment and dental implants: A systematic review

Background

To analyze articles that studied patients submitted to diphosphonates therapy and who received dental implants before, during or after bisphosphonate (BP) treatment, compared to healthy patients, analyzing the increase of failure and loss of implants or bisphosphonate related osteonecrosis of the jaw (BRONJ) incidence.

Material and Methods

The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement was used in this study. The clinical question in “PICO” format was: In patients under bisphosphonate therapy, do dental implants placement, compared to healthy patients, increase the failure and loss of implants or bisphosphonate related osteonecrosis of the jaw incidence? PubMed/MEDLINE was searched for articles published up until April 15, 2015 using a combination of MeSH terms and their Entry terms.

Results

The search resulted in 375 articles. After selection according to the eligibility criteria, 15 studies fulfilled were included (eight retrospective, one prospective and six case series), with a total of 1339 patients analyzed, 3748 implants placed, 152 loss of implants and 78 cases of BRONJ.

Conclusions

Due to the lack of randomized clinical trials looking at this theme, further studies with longer follow-up are needed to elucidate the remaining questions. Thus, it is wise to be careful when planning dental implant surgery in patients undergoing bisphosphonate therapy because of the risk of developing BRONJ as well as occurring failure of implant. Moreover, complete systemic condition of the patient must be also taking into considering when such procedures are performed.

Key words:Bisphosphonates, diphosphonates, dental implants, osteonecrosis.

Dental implants in patients treated with antiresorptive medication - a systematic literature review

Objective

Bisphosphonate-associated osteonecrosis of the jaws (BP-ONJ) is triggered by inflammatory processes. Typical trigger factors are periodontal disease, denture pressure sores, and surgical interventions such as tooth extractions. Unfortunately there is only little data on how to proceed with implant therapy in patients with bisphosphonate treatment. This topic is not addressed in the German guidelines on medication-associated osteonecrosis. Therefore a systematic literature review was performed.

Methods

The PICO design was used: (Patients) For which subclientel of patients with antiresorptive therapy (intervention) do dental implants have a benefit (control) compared to forgoing dental implants (outcome) in regards to oral rehabilitation and quality of life without having a substantial risk of BP-ONJ development? A PubMed search was performed including all studies dealing with this topic. Case reports and studies with less than 5 cases were excluded.

Results

There is only very little data available, mostly retrospective case series. 50 articles were analyzed in detail. BP-ONJ can be triggered by dental implants and by dentures in patients with benign and malignant primary diseases. In most studies, analyzing osteoporosis patients only, no cases of BP-ONJ were observed in patients with implant therapy in the time span observed. There are no studies about implant therapy in patients with malignant diseases. Many case series analyzing the trigger factors for BP-ONJ describe dentures as one of the main causes. Perioperative antimicrobial prophylaxis has a benefit in the prevention of BP-ONJ development.

Conclusion

Successful implant therapy is possible in patients receiving antiresorptive therapy. The possibility of osteonecrosis development needs to be explained to the patient. An individual risk assessment is essential, taking the primary disease with the medication and further wound-healing-compromising diseases and medications into account. If possible, bone augmentations should be avoided, and a perioperative antimicrobiological prophylaxis is strongly recommended in these patients.

What is the impact of bisphosphonate therapy upon dental implant survival? A systematic review and meta-analysis

OBJECTIVE

A systematic review and meta-analysis are carried out to assess the scientific evidence that bisphosphonate therapy can decrease the success rate of dental implants.

MATERIAL AND METHODS

The PubMed (Medline) database was used to search for articles published up until February 22, 2014. The meta-analysis was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). The Newcastle-Ottawa scale (NOS) was used to assess study quality.

RESULTS

The combinations of search terms resulted in a list of 256 titles. Fourteen finally met the inclusion criteria and were thus selected for inclusion in the systematic review. Eight studies (six retrospective and two prospective) were included in the meta-analysis, with a total of 1288 patients (386 cases and 902 controls) and 4562 dental implants (1090 dental implants in cases and 3472 in controls). The summary odds ratio (OR = 1.43, P = 0.156) indicates that there is not enough evidence that bisphosphonates have a negative impact upon implant survival. According to the number need to harm (NNH), over 500 dental implants are required in patients receiving bisphosphonate treatment to produce a single implant failure.

CONCLUSION

Our results show that dental implant placement in patients receiving bisphosphonates does not reduce the dental implant success rate. On the other hand, such patients are not without complications, and risk evaluation therefore must be established on an individualized basis, as one of the most serious though infrequent complications of bisphosphonate therapy is bisphosphonate-related osteonecrosis of the jaws. Given the few studies included in our meta-analysis, further prospective studies involving larger sample sizes and longer durations of follow-up are required to confirm the results obtained.

Effects of alendronate on the peri-implant bone in rats

OBJECTIVES

The purpose of this study was to determine the effects of alendronate on the peri-implant bone in rat maxillae with the aid of micro-computed tomographic, histologic, and biochemical analyses.

MATERIALS AND METHODS

Thirty-six male Sprague-Dawley rats were used. After extraction of the maxillary first molars, each rat was given periodic subcutaneous injections of either alendronate (alendronate group) or saline (control group). Customized implants were placed bilaterally 4 weeks after these injections. The rats were sacrificed at either 4, 8, or 12 weeks after implantation (4-, 8-, and 12-week groups, respectively; n = 6 rats per group). Microcomputed tomographic and histologic analyses were conducted for all rats. Biochemical analyses were performed at four time points for the 12-week groups.

RESULTS

There were no significant differences between the groups on microcomputed tomographic and histologic analyses. All of the measured biochemical parameters tended to decrease over time, with significant differences among some time points within each group. The serum osteocalcin level was significantly lower in the 12-week alendronate group than in the control group (P < 0.05).

CONCLUSIONS

Three approaches were utilized in evaluating the effects of alendronate. It appears serum osteocalcin levels may serve as an adjuvant marker for this purpose, although further studies are required to confirm this.

Alendronate-associated osteonecrosis of the jaws: a review of the main topics

Bisphosphonates is a group of inorganic pyrophosphates analogues that suppress bone resorption by inducing osteoclast inactivation, being frequently used for management of diseases affecting bone metabolism, bone metastases and bone tumors. However, since 2003 many cases describing the presence of necrotic bone exposures in the jaws have been described in patients receiving these drugs, what represent a significant complication of bisphosphonates treatment. The overall incidence of bisphosphonate-related osteonecrosis of the jaws is low, ranging from 0.7% to 12%, mainly observed in those patients receiving intravenously treatment. Osteonecrosis of the jaws associated to oral bisphosphonate, particularly alendronate, has also been reported by a number of authors. Considering that alendronate is one of the most used drugs worldwide, specially for treatment of osteoporosis, a better understanding of osteonecrosis of the jaws related to its use and how to manage these patients is extremely important. Therefore, in the current manuscript the authors aim to review the most important topics related to this pathological presentation.

Key words:Bisphosphonates, alendronate, bisphosphonate-related osteonecrosis of the jaws, osteonecrosis.

Osseointegration of dental implants and osteonecrosis of the jaw in patients treated with bisphosphonate therapy: a systematic review

Bisphosphonate (BP) drugs are a commonly prescribed group of medications used in the treatment of metabolic and oncologic bone disorders. The aim of this study was to conduct a systematic review in order to evaluate whether patients on BP therapy are appropriate candidates for dental implants as compared to patients not taking BP drugs with respect to successful implant osseointegration and the risk of developing bisphosphonate-related osteonecrosis of the jaw. Based on the current literature, a history of oral or intravenous BP use is not an absolute contraindication for dental implant placement, and dental implants can osseointegrate successfully in this patient population. Importantly, the studies currently available on this topic are of moderate to weak strength of evidence with inherent bias and limitations, and hence results must be interpreted in this context. Well-controlled studies with higher strength of evidence and larger population sizes are required to address this topic more accurately in the future.

Oral bisphosphonate-related osteonecrosis of the jaws in dental implant patients: a case series

Bisphosphonates have been associated with a serious adverse reaction known as bisphosphonate-related osteonecrosis of the jaws (BRONJ). The aim of this study was to describe its clinical characteristics in patients with dental implants who were taking bisphosphonates orally. We made a retrospective multicentre study in 3 hospitals in Galicia, Spain. The medical records and clinical and radiological follow-up of the oral cavity were reviewed for those patients given bisphosphonates and diagnosed with BRONJ after the placement of dental implants within the previous 3 years. The series comprised 9 white patients (mean age 66 years). The bisphosphonates were alendronate (n=6), ibandronate (n=2), and risedronate (n=1), and the most common indication was osteoporosis (n=7). The mean interval between the initiation of treatment and the onset of BRONJ lesions was 60 months. Most of the lesions were located around the mandibular implants (n=8). The mean interval between placement of dental implants and the onset of BRONJ was 34 (range 1-96) months. After treatment 7/9 patients recovered completely. The prevalence of BRONJ secondary to treatment with bisphosphonates taken orally after placement of dental implants may be higher than expected in a particular geographical region, but to date specific risk factors have not been identified. Clinical characteristics and the outcomes of treatment of lesions are similar to those seen in patients with BRONJ that is unrelated to placement of dental implants.

In vivo comparison between laser-treated and grit blasted/acid etched titanium

OBJECTIVE

Laser profiling of titanium has been of considerable interest in the field of oral implantology. However, very few pre-clinical and clinical studies have been performed with laser-treated implants, especially focusing on isotropic roughness topography. The aim of the study was to compare the cortical bone response of Ti-implants discs treated with pico-sec pulsed laser (LAS) and conventional grit-blasted/acid-etched (GAE) method.

MATERIALS AND METHODS

Prior to the in vivo experiment, in vitro cell viability testing of the LAS surface treatment was preformed. Then, 5 mm diameter Titanium (Ti) discs treated with LAS and GAE method were implanted in a pre-validated rabbit tibia cortical bone model and assessed with histology and histomorphometric measurements. In total, eight New Zealand White adult female rabbits were used.

RESULTS

The in vitro cell viability testing with osteoblast-like cells confirmed cytocompatibility of the LAS surface treatment. Further, the rabbit experiment demonstrated a bone-to-implant contact of 68% (±17) for the laser-treated discs and 49% (±21) for the GAE discs 8 weeks after the implantation, which was statistically not different.

CONCLUSION

Laser surface treatment gives the same results to the grit-blasting/acid-etched method and thus is a valid alternative to conventional roughening for dental implant materials.

Correlating macrophage morphology and cytokine production resulting from biomaterial contact

The morphological and inflammatory responses of adherent macrophages are correlated to evaluate the biocompatibility of surfaces. Monocyte-derived macrophage (MDM), THP-1, and THP-1 cells expressing GFP-actin chimeric protein were seeded onto glass, polyurethane (PU), and glass surface modified with quaternary ammonium salt functionalized chitosan (CH-Q) and hyaluronic acid (HA). Using confocal microscopy, the surface area, volume and 3D shape factor of adherent macrophages was quantified. For comparison, functional consequences of cell-surface interactions that activate macrophages and thereby elicit secretion of a proinflammatory cytokine were evaluated. Using an enzyme linked immune sorbent assay, tumor necrosis factor-alpha (TNF-α) was measured. On glass, macrophages exhibited mainly an amoeboid shape, exhibited the largest surface area, volume, and 3D shape factor and produced the most TNF-α. On PU, macrophages displayed mainly a hemispherical shape, exhibited an intermediate volume, surface area and 3D shape factor, and produced moderate TNF-α. In contrast, on CH-Q and HA surfaces, macrophages were spherical, exhibited the smallest volume, surface area, and 3D shape factor, and produced the least TNF-α. These studies begin to validate the use of GFP-actin-modified MDM as a novel tool to correlate cell morphology with inflammatory cell response.

Osteopathology induced by bisphosphonates and dental implants: clinical observations

OBJECTIVES

Although there are many reports about risk factors for the development of BP-associated osteonecrosis of the jaws, the role of dental implants as a local risk factor is still discussed, especially in patients with oral BP treatment. Until now, a few case reports and surveys display a possible minor risk in patients with oral BP therapy, whereas the avoidance of implant placement is generally accepted in patients with intravenous BP therapy.

PATIENT AND METHODS

In this study, the cases of 14 patients with osteonecrosis of the jaws in association with BP therapy and dental implant placement were analyzed carefully with a detailed literature review.

RESULTS

Of 14 patients, nine had underlying malignant disease and five patients had osteoporosis. In ten patients, implants were placed either in the posterior mandible or maxilla; the mean interval between implant insertion and disease onset was 20.9 months. Pain (n12) and signs of infection (n10) were the most common symptoms. Histologically, signs of infection were found in nine of 11 analyzed patients with presence of Actinomyces in six patients. Two patients turned out to have infiltration of underlying malignant disease.

CONCLUSIONS

Posteriorly placed implants seem to be of higher risk of development of osteonecrosis of the jaws. Not only the implant placement but also the inserted implant itself seems to be a continuous risk factor.

CLINICAL RELEVANCE

The herein elaborated risk factors help dentists plan dental rehabilitation with implants in this high-risk group of patients and indicate careful and regular dental recall.

Effect of alendronate on healing of extraction sockets and healing around implants

OBJECTIVES

The purpose of this study was to evaluate the effect of alendronates on healing of extraction sockets and healing around implants in the maxilla of rats.

MATERIALS AND METHODS

Twenty-four Sprague-Dawley rats were used. The rats in bisphosphonate group were subcutaneously injected with alendronate (5.0 mg kg(--1)) three times a week for 4 weeks. Both sides of the maxillary first molars were extracted, and customized titanium implants (Ø1.5 × 2.0 mm) were placed immediately into one side. Rats were killed at 3, 7, 14, or 28 days following surgery.

RESULTS

New bone formation in extraction sockets, bone area around the implant site, and bone-implant contact were not delayed in the bisphosphonate group. The tartrate-resistant acid phosphatase positive cell count did not differ between bisphosphonate and control groups; however, empty lacunae were observed significantly more in bisphosphonate group. The differences in empty lacunae were shown at different time points between the implant sites and extraction sites: at 7 days after extraction, and at 14 and 28 days after implantation.

CONCLUSIONS

Alendronates seemed to decrease bone resorption but not to decrease bone formation. Empty lacunae were observed significantly more at later time points in implant sites compared to extraction sockets.