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journal of dentistry 41 (2013) 195206

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Review

Dental implants in the medically compromised patient

Pedro Diz a,*, Crispian Scully b, Mariano Sanz c


a
Grupo de Investigacion en Odontologa Medico-Quirurgica (OMEQUI), School of Medicine and Dentistry, University of Santiago de
Compostela, Spain
b
University College London, UK
c
Grupo de Investigacion en Etiologa y Terapeutica Periodontal (ETEP), School of Dentistry, Complutense University of Madrid, Spain

article info abstract

Article history: Objective: It has been suggested that some local and systemic factors could be contra-
Received 14 December 2011 indications to dental implant treatment. The objective of this paper was to evaluate whether
Received in revised form success and survival rates of dental implants are reduced in the medically compromised
3 December 2012 patient.
Accepted 27 December 2012 Data/sources: An extensive literature search was conducted using PubMed/Medline, Scopus,
Scirus and Cochrane databases up to November 8, 2012.
Conclusions: There are very few absolute medical contraindications to dental implant
Keywords: treatment, although a number of conditions may increase the risk of treatment
Dental implants failure or complications. The degree of systemic disease-control may be far more
Osseointegration important that the nature of the disorder itself, and individualized medical control
Systemic diseases should be established prior to implant therapy, since in many of these patients
Contraindication the quality of life and functional benefits from dental implants may outweigh any
risks.
# 2013 Elsevier Ltd. All rights reserved.

The longer term outcome of implant therapy can be


1. Introduction affected by local or systemic diseases or other compromising
factors, in fact, it has been suggested that some local and
In medically healthy patients, the success rates of some dental systemic factors could represent contraindications to DI
implant (DI) systems have reported to be between 90 and 95% treatment.710
at 10 years.1 DI may fail, however, due to a lack of
osseointegration during early healing, or when in function
due to breakage, or infection of the peri-implant tissues 2. Dental implants in medically compromised
leading to loss of implant support. Early complications after patients
implant installation, can include pain, infection or occasion-
ally neuropathy.1 Severe early complications such as hae- The impact of health risks on the outcome of implant therapy
morrhage (e.g. in the floor of the mouth) or descending is unclear, since there are few if any randomized controlled
necrotizing mediastinitis are rare.26 trials (RCTs) evaluating health status as a risk indicator. In

* Corresponding author at: Stomatology Department, School of Medicine and Dentistry, Santiago de Compostela University, c/Entrerros
sn, 15782 Santiago de Compostela, La Coruna, Spain. Tel.: +34 881812344.
E-mail address: pedro.diz@usc.es (P. Diz).
0300-5712/$ see front matter # 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jdent.2012.12.008
196 journal of dentistry 41 (2013) 195206

principle, only patients with an ASA (American Society of on contraindications to DI therapy in medically compromised
Anaesthesiologists) grade I or II should qualify for an elective patients. Contraindications are mainly based on both the risk
surgical procedure, such as DI placement and the patients of medical complications related to implant surgery (e.g.
surgical risks should be weighed against the potential benefits haemorrhage risk in patients with bleeding disorders) and the
offered by the DI.11 rate of DI success in medically compromised patients (e.g. in
Even though there are statements in the implant literature patients with head and neck cancer receiving radiotherapy).
such as: certain conditions such as uncontrolled diabetes, bleeding This review, hence, summarizes this evidence applying
disorders, a weakened immune system, or cognitive problems that recognized evidence-based criteria.14
interfere with postoperative care increase the risk of implant failure
(http://www.dentalphobia.com/lsd-procedures_im-
plants.htm) these are un-substantiated by scientific evidence. 3. Alcoholism
Other authors have recommended as relative contra-
indications for DI, certain patient groups or conditions7: We could not identify any reliable evidence indicating that
alcoholism might be a contraindication to DI. Negative effects
 Children & adolescents of alcohol intake on bone density and osseointegration in
 Epileptic patients animal models, however, have been demonstrated.15,16 In
 Severe bleeding tendency humans, there is evidence of increased peri-implant marginal
 Endocarditis risk bone loss and DI failures in patients with high levels of alcohol
 Osteoradionecrosis risk consumption.17,18In general terms, however, it is worth
 Myocardial infarction risk considering before implants are placed that alcoholism:

Other reported relative contraindications include: adoles-  is often associated with tobacco smoking,
cence, ageing, osteoporosis, smoking, diabetes, positive  may via liver disease, cause bleeding problems,
interleukin-1 genotype, human immunodeficiency virus posi-  may cause osteoporosis,
tivity, cardiovascular disease, hypothyroidism and Crohn  may impair the immune response,
disease.8,9  may impair nutrition, especially folate and B vitamins.
Suggested absolute contraindications include: recent myo-
cardial infarction and cerebrovascular accident, transplant or In summary, although there is no evidence that alcoholism
valvular prosthesis surgery, profound immunosuppression, is a contraindication to implants, these patients may be at
severe bleeding issues, active treatment of malignancy, drug increased risk of complications (Table 1).
abuse, psychiatric illness, as well as intravenous bispho-
sphonate use10 but there is, however, little or no evidence to
support most of these contentions. 4. Bleeding disorders
It is, therefore, the aim of this review to evaluate the
scientific evidence through PubMed/Medline, Scopus, Scirus Even though haemorrhage can be a relatively common
and Cochrane databases searches up to November 8, 2012, complication in DI placement,19 there is no reliable evidence
using as keywords: implants, contraindications, and the to suggest that bleeding disorders are a contraindication to the
following disease categories, which had been highlighted as placement of implants: even haemophiliacs have successfully
possible contraindications in more than one publication12,13: been treated with DI.20 Nevertheless, any oral surgical
procedure may lead to haemorrhage and blood loss and, if
 Alcoholism this bleeding reaches the fascial spaces of the neck, it can
 Bleeding disorders hazard the airway. In fact, upper airway obstruction second-
 Bone disease ary to severe bleeding in the floor of the mouth is a rare but
 Cancer patients potentially life-threatening complication of DI placement.4
 Cardiac disease Usually arterial impingement is produced when perforating
 Corticosteroids the lingual cortical plate affecting the lingual arteries or the
 Diabetes inferior alveolar canal, affecting the inferior alveolar vessels.6
 Hyposalivation DI placed in the first mandibular premolar position are the
 Immunocompromised patients higher risk for this bleeding complication.21
 Mucosal disease In patients with bleeding disorders, haemorrhage associated
 Neuro-psychiatric disorders with implant surgeries is more common and can be pro-
 Titanium allergy longed,22 particularly with warfarin or acenocoumarol. In these
patients, the current recommendation is to undertake the
This evidence has been drawn from a wide range of implant surgical procedure without modifying the anticoagula-
sources, ranging from case reports to controlled cohort tion, provided the INR is less than 3 or 3.5.22 In this context,
investigations, including both human and animal studies. implant surgery could be regarded in terms of surgical trauma to
Implant outcome assessment has varied from histological and the extraction of three teeth. There is evidence that antic-
radiographic outcomes, to objective and subjective determi- oagulated patients (INR 24) without discontinuing the antico-
nations of implant and treatment failure. The aim of this study agulant medication do not have a significantly higher risk of
was to evaluate the level of evidence of the available literature post-operative bleeding and, topical haemostatic agents are
journal of dentistry 41 (2013) 195206 197

Table 1 Dental implants (DI) in medically compromised patients.


Condition Evidence condition DI success rate Other considerations Management
is an absolute/relative compared to healthy modifications that
contraindication to DI population (level may be indicated
of evidencea)
Alcoholism Similar (5) Tobacco use These patients may
be at increased risk
of complications
Bleeding
Osteoporosis
Impaired immunity
Malnutrition
Behavioural problems
Bleeding disorder Medical advice should be Similar (3) in oral Possibility of blood These patients may
taken first in congenital anticoagulants and borne infections be at increased risk
bleeding disorders antiplatelet treatment of complications
Bone disease
Rheumatoid arthritis Similar (4) Peri-implantitis
and marginal bone
resorption increase
with concomitant
connective tissue
diseases
Osteoporosis Similar (2a) Sinus lifts may be
contraindicated
Osteoporosis and Similar (1b)
oral bisphosphonates
Cancer and intravenous Contraindicated (5) Reduced (4)
bisphosphonatesb
Head & neck cancer Reduced (1b) (following Cancer prognosis Surgery best carried
patients radiotherapy) out 21 days before
radiotherapy
Similar (3b) (following Hyperbaric oxygen
chemotherapy) should be given if
>50 Gy used
(controversial)
Defer DI for 9 months
Consider antimicrobial
cover
No immediate loading
Cardiac disease Medical advice should be Similar (5) May be anticoagulated Avoid general
taken first anaesthesia
Poor risk for general Consider endocarditis
anaesthesia prophylaxis
Corticosteroid therapy Similar (5) May be impaired Corticosteroid cover
immunity
Antibiotic prophylaxis
Diabetes mellitus Slightly reduced in Microvascular disease HbA1c level for patient
bad metabolic control selection
patients (2a)
Similar in good metabolic Osteoporosis Avoid hypoglycaemia
control patients (2b)
Impaired immunity Use chlorhexidine
Antibiotic prophylaxis
Hyposalivation Similar (4)
Immunocompromised Medical advice should be Similar in organ May be blood borne Use chlorhexidine
patients taken first transplantation infections
patients (4)
Similar in HIV Antibiotic prophylaxis
infected
patients (3a)
Mucosal disease Similar (4)
Neuropsychiatric Medical advice should Similar (4) Behavioural Consider general
disorders be taken first anaesthesia
198 journal of dentistry 41 (2013) 195206

Table 1 (Continued )
Condition Evidence condition DI success rate Other considerations Management
is an absolute/relative compared to healthy modifications that
contraindication to DI population (level may be indicated
of evidencea)
Titanium allergy Reduced (4) Allergic symptoms Use alternative
after implant materials
placement or
unexplained implant
failures
In patients allergic to
other metals long-term
clinical and radiographic
follow-up is recommended
Adapted from Scully et al.12
a
OCEBM Levels of Evidence Working Group.14
b
To reduce skeletal-related morbidity.

effective in preventing post-operative bleeding.23 Oral antico- scientifically this risk (i.e. DI in patients with rheumatoid
agulant discontinuation is thus not recommended for dentoal- arthritis),35 being most of the published investigations related
veolar surgery, such as implant placement, provided that this to the relationship between bone density and implant success.
does not involve autogenous bone grafts, extensive flaps or Osteoporosis is the most studied bone-related disease. It is
osteotomy preparations extending outside the bony envelope. a common condition characterized by generalized reduction
In a recently published case series involving 50 consecutive in bone mass with no other bone abnormality. When
patients receiving oral anticoagulant therapy (warfarin) with- evaluating whether DI in osteoporotic patients have a
out interruption or modifications to their therapy, it was shown different long-term outcome, even though failure rates have
that a standard protocol of local haemostasis in dental implant been reportedly higher in animal models37 and patients,38,39 a
surgery is able to prevent bleeding complications in patients on systematic review revealed no association between systemic
oral anticoagulants, allowing these surgical procedures to be bone mineral density (BMD) status, mandibular BMD status,
performed on an outpatient basis.24 bone quality, and implant loss, concluding that the use of DI in
The bleeding risk is also low in patients treated with osteoporosis patients is not contraindicated.40 In a cross-
heparin.25 In patients on single or dual antiplatelet therapy, sectional study no relation was found between osteoporosis
the frequency of oral bleeding complications after invasive and peri-implantitis41 and even patients with severe osteopo-
dental procedures is low to negligible and, therefore, the risks rosis have been successfully rehabilitated with DI-supported
of altering or discontinuing use of the antiplatelet medications prostheses.42,33 There are, however, some casecontrol stud-
increased risk of thromboembolism far outweigh the low ies reporting a weak association between osteoporosis and the
risk of haemorrhage.26 risk of implant failure43 and some authors have alluded to a
In summary, there is no evidence that any bleeding correlation between BMD of the mandible with BMD measure-
disorders are an absolute contraindication to DI surgery, ments at other skeletal sites.44 It is, therefore, recommended
although these patients may be at risk of prolonged haemor- to thoroughly evaluate the jawbone quality prior implant
rhage and blood loss, and medical advice should be taken first placement, rather than undertaking systemic BMD and
especially in congenital bleeding disorders (Table 1). osteoporotic status assays.43,45 Dentists should perform an
accurate analysis of bone quality by means of tomography and
modify treatment planning if indicated (e.g. using larger
5. Bone diseases implant diameter and with surface treatment).46
A further potential complication in osteoporotic patients
There are few reported cases in the literature of DI placement is the possible effect on bone turnover at the DI interface
and subsequent rehabilitation of patients with these bone of systemic anti-resorptive medication. This risk in
diseases such as osteogenesis imperfecta,2732 polyarthritis,33 patients using bisphosphonates (BPs) is well recognized,47
or ankylosing spondylitis,34 and to our knowledge no relevant in terms of bisphosphonate-related osteonecrosis of the jaws
case series have been published up to date. On the contrary, at (BRONJ).4850 The largest series of patients developing BRONJ
least two retrospective series on dental implants outcomes following DI published to date involved 27 patients on BPs, 11
involving 34 and 22 females suffering from autoimmune orally and 16 intravenously. BRONJ developed after mean
rheumatoid arthritis with or without concomitant connective periods of 68 months, 16 months, and 50 months in patients
tissue diseases have been published, the authors concluding on alendronate, zoledronic acid, and pamidronate, respec-
that a high implant and prosthodontic success rate can be tively. There was a mean duration of 16 months from
anticipated in rheumatoid arthritis patients, but peri-implant implants placement until the appearance of BRONJ.51
marginal bone resorption and bleeding are more pronounced Recently, in a series of BRONJ following DI involving 14
in those with concomitant connective tissue diseases.35,36 patients on BPs, 5 orally and 9 intravenously, it has been
In summary, a number of bone disorders may potentially suggested that posteriorly placed implants seem to be of
influence the outcome of DI, but few studies have evaluated higher risk of BRONJ development.52
journal of dentistry 41 (2013) 195206 199

BRONJ is a real issue for patients treated with intravenous patients with oropharyngeal squamous cell carcinoma, no
BPs but the occurrence of BRONJ in patients receiving oral BPs increase in osteoradionecrosis was reported.69 It has been
medication is minimal. The use of oral BPs at the time of suggested that DI may represent an acceptable option for oral
implant placement and during healing do not seems to affect rehabilitation in patients who had suffered previous osteor-
early implant success.53 In a retrospective survey of 115 adionecrosis (5 year survival rate of 48.3%).70 Even successful
patients on oral BPs receiving DI (72 returned to the clinic for DI placed during early childhood in patients treated with full
evaluation), oral bisphosphonate therapy did not appear to dose radiation for malignant midface tumours has been
significantly affect implant success and no cases of BRONJ reported.71 Other authors have reported successful DI but
were registered54 and similarly, in a large survey performed in occurrence of late complications, such as bone loss and
South Australia the estimated prevalence of BRONJ in patients mucosal recession, possible due to altered saliva flow and
under oral BPs was less than 1%.55 increased bacterial colonization.72
In 2007, the American Association of Oral and Maxillofa- Several casecontrol studies have shown evidence of
cial Surgeons56 produced guidelines for patients treated improved outcomes in patients with history of radiotherapy
with oral BPs, based on the clinical situation of the patient and DI with the addition of hyperbaric oxygen therapy (HBO)
and the length of treatment with the drug, indicating that mainly through reduction in the occurrence of osteoradione-
greater caution prior and subsequent to surgery should be crosis and failing implants.73 However, a systematic review
taken during 3 years after discontinuing BP treatment. A found only one RCT comparing HBO with no HBO for DI
systematic review analysing one prospective and three treatment in irradiated patients and was unable to find any
retrospective series (217 patients) showed that the place- strong evidence to either support or refute the use of HBO
ment of a DI in patients with chronic intake of oral-BPs did therapy for improving implant outcome.74
not lead to BRONJ and did not influence short-term (14 To increase implant success in irradiated head & neck
years) implant survival rates. This study concluded that DI cancer patients, the following precautions should be consid-
might be considered a safe procedure in patients taking oral ered73
BPs for <5 years.57 Similarly, in another review that included
12 studies (7 case reports and 5 retrospective studies), the  Implant surgery is best carried out >21 days before
authors concluded that dental implants can osseointegrate radiotherapy
and remain functionally stable in patients treated with  Total radiation dose should be <66 Gy if the risks of ORN are
bisphosphonates.58 to be minimized or <50 Gy to reduce osseointegration
In summary, there is a consensus on contraindicating failure: avoiding implant site/portals
implants in cancer patients treated with intravenous BPs.57 In  Hyperbaric oxygen should be given if >50 Gy radiation is
patients with osteoporosis treated with BPs, they should be used
informed of the risk of possible implant loss59 the risk of  No implant surgery should be carried out during radiother-
suffering bony necrosis and a poor outcome from sinus lifts,60 apy
and adequate informed consent prior to dental implant  No implant surgery should be carried out during mucositis
surgery should be obtained (Table 1).  Defer implant placement for 9 months after radiotherapy
 Use implant-supported prostheses without any mucosal
contact Avoid immediate loading
6. Head and neck cancer patients  Ensure strict asepsis
 Consider antimicrobial prophylaxis.
Surgical resection of head and neck cancer can be severely
mutilating. DI in oral cancer patients are successfully used for In a study of 30 postsurgical oral cancer patients receiving
dental rehabilitation after bony reconstruction of the jaws, 106 dental mandibular implants and adjuvant chemotherapy
and for retention of a prosthetic device (e.g.: palatal with either cisplatin or carboplatin plus 5-FU, there was no
obturator), used as the primary means of maxillary recon- significant difference in implant survival at 10 years follow-up
struction.61,62 Combinations of microvascular surgical tech- when compared with matched controls. None of the patients
niques and the use of DI can considerably improve the had been treated with radiotherapy (Table 1).75 To the best of
rehabilitation of people with severe head and neck defects, our knowledge, two case series have been published reporting
but there may be an increased risk of implant failure in that cancer chemotherapy appears not to significantly impair
irradiated free flap bone.63 It has been suggested that some the success of DI.75,76
patients may benefit from having the placement of DI during
ablative tumour surgery.64,65
Radiotherapy can significantly affect DI outcomes13 mainly 7. Cardiovascular disease
during the healing period66. Radiotherapy may induce endar-
teritis obliterans, and hence can predispose to osteoradione- It has been suggested that some cardiovascular events such as
crosis of the jaw. Twelve studies involving 643 DI placed in recent myocardial infarction, stroke, and cardiovascular
adult patients who have received radiotherapy, reported lower surgery, might represent an absolute contraindication to
success rates, ranging from 40 to 100%.67 There are, however, implant therapy.10 In a retrospective analysis of 246 consecu-
several clinical studies demonstrating that DI can osseointe- tively treated DI patients, including cardiovascular disease
grate and remain functionally stable in patients who had patients, patients with a history of other systemic disease, and
received radiotherapy.68 In a series of 275 DI placed in 63 healthy controls, there were no significant differences in
200 journal of dentistry 41 (2013) 195206

implant failure rates between the groups.77 Moreover, in


several retrospective DI cohort studies where data regarding 9. Diabetes mellitus
local and systemic risk factors for implant failure had been
recorded, hypertension and coronary artery disease were not Most case series, cohort studies, and systematic reviews support
associated with a significant increase in either early or late that DI in diabetics with good metabolic control have similar
implant failures.13,39,78 success rates when compared to matched healthy controls,8689
In a recent casecontrol study, it has been suggested that maintenance programme receiving conventional or advanced
intravenous sedation using midazolam and propofol during DI implant surgery (sinus floor elevation, immediate loading, and
surgery prevented excessive increases in blood pressure, and guided bone regeneration).90 However, impaired implant inte-
stabilized haemodynamics,79 which could be useful in gration has been reported in relation to hyperglycaemic
patients with cardiovascular disease. However intravenous conditions in diabetic patients91 and in animal models.37,92 In
midazolam does not prevent the myocardial arrhythmias that a systematic literature search including 18 studies published up
may arise during DI placement.80 to 2009, the authors concluded that poorly controlled diabetes
We could find no evidence that cardiac disorders are a negatively affects implant osseointegration.93 This fact is
contraindication to DI but it is important to consider other consistent with the known effects of hyperglycaemic states
issues such as the occurrence of bleeding, or cardiac ischaemic on impaired immunity, microvascular complications and/or
during DI insertion in these patients, and therefore, medical osteoporosis. Paradoxically, in a recent critical review it has been
advice should be procured before DI surgery (Table 1).22 suggested that clinical evidence is lacking for the association of
glycaemic control with implant failure, because the identifica-
tion and reporting of glycaemic control was insufficient or
8. Corticosteroid therapy lacking in most of the published studies.94
In summary, there is no evidence that diabetes is a
Corticosteroid adverse effects include reduced bone density, contraindication to DI therapy, but as HbA1C (glycosylated
increased epithelial fragility and immunosuppression.22 In haemoglobin) may represent an independent factor correlated
consequence, the use of systemic glucocorticoids might with postoperative complications90 and due to the known
compromise DI osseointegration and peri-implant healing.81 effects of hyperglycaemic states on healing, medical advice
In animal models, osseointegration of implants in rabbits and strict glycaemic control before and after DI therapy are
under experimental osteoporosis-like bone induced by gluco- recommended (Table 1).22,87,95,96 Antimicrobial cover using
corticoids appeared to be compromised, which could affect penicillin, amoxicillin, clindamycin or metronidazole should
biomechanical stability of implants.82 However, in most of be provided during the implant surgery.97 These patients
these studies implants were placed in extraoral bones (i.e. should also quit smoking, optimize oral hygiene measures and
femur or tibia), and it has been suggested that steroid use antiseptic mouthrinses to prevent the occurrence of
administration could have less effect on the osseointegration periodontal and peri-implant infections.88,93,95 As implant
of titanium implants in the mandible than in the skeletal surgery is never a matter of urgency, it has been suggested that
bone.83 To the best of our knowledge no relevant series have patients should be conjointly selected and prepared by both
been published to demonstrate if DI failure rate and/or dental practitioner and diabetes clinician.95
perioperative morbidity may increase in patients under
systemic corticosteroids.
There is no evidence that corticosteroid therapy is a 10. Hyposalivation
contraindication to DI, but it is important to consider that
systemic corticosteroids can cause suppression of the Theoretically DI may help prosthesis retention in patients
hypothalamopituitaryadrenal axis and therefore, stan- with dry mouth (hyposalivation). Although cases with
dard recommendations for any oral surgery in patients on hyposalivation have been successfully managed with DI98,99
steroid therapy should be implemented.22 The Medicines and even 7 out of 8 patients with Sjogren syndrome improved
Control Agency still advise in patients who have finished a their oral comfort levels with implant-retained prostheses,100
course of systemic corticosteroids of less than 3 weeks there are no systematic studies evaluating the outcomes of DI
duration and might be under stresses such as trauma, therapy in these patients (Table 1).
surgery or infection and who are at risk of adrenal A retrospective study on patients suffering from rheu-
insufficiency, to receive systemic corticosteroid cover matic disorders such as rheumatoid arthritis and other
during these periods (http://www.mca.gov.uk/ourwork/ connective tissue diseases and compromised salivary flow
monitorsafequalmed/currentproblems/volume24- showed high implant survival rates (cumulative 3-year
may.htm). In patients on less than 10 mg prednisolone daily implant success rate of 96.1%). Patients with rheumatoid
(as recommended by Nicholson et al),84 no significant events arthritis demonstrated acceptable marginal bone resorption
have been reported after oral surgery without steroid and good soft tissue conditions, while other connective
cover.85 tissue diseases patients showed increased bone resorption
In summary, although there is no evidence that cortico- and peri-implant soft tissue alterations in scleroderma
steroid therapy is a contraindication to DI, medical advice patients and patients suffering from Sjogren syndrome.36
should be procured in these patients prior to DI and medico- The severity of the salivary flow alteration, together with the
legal and other considerations suggest that steroid cover patients medical condition should be evaluated before
should be provided (Table 1). recommending DI placement.98
journal of dentistry 41 (2013) 195206 201

Anecdotally, a case report has been published on an Presence of a limited amount of bone was a common finding,
innovative saliva electrostimulation device fixed on a DI, particularly in the upper arch, and often requires extensive
placed in the lower third molar area.101 bone regenerative procedures. Some case-series have shown
that results of DI and bone grafts in adult patients affected by
ectodermal dysplasia were similar to those achieved in
11. Immunocompromised patients unaffected patients.123
Most series demonstrate an excellent implant success rate
It would be reasonable to assume that DI might be contra- in adults with ectodermal dysplasia,113 although results
indicated in immunocompromised patients. In fact, in animal reported in children and adolescents mainly when implants
models it has been shown that ciclosporin impairs peri- were placed in the maxilla or the symphyseal region of the
implant bone healing and implant osseointegration.102 How- anterior mandible have been less encouraging.124,125 The most
ever, many patients receiving organ transplantation (mainly appropriate age for dental implant treatment in growing
liver and kidney) with long-term ciclosporin therapy, have had children remains controversial.117,126
successful DI therapy.103106 A recent review, included 7 studies describing 17 patients
Similarly, no significant problems after dento-alveolar with epidermolysis bullosa receiving 102 implants and being
surgery have been reported in HIV-positive patients.107,108 In followed for 12 to 108 months: the implant success rate was
a series of 20 HIV-positive subjects with mean CD4 count of close to 100%.127 In a small case series DI showing dehiscence
467 cells/mm3 (range: 132948), two dental implants were or fenestration were placed simultaneously with particulated
placed in the anterior mandible to support an overdenture, bone grafts to cover exposed threads, all implants surviving
and the short-term (6 months) success rate was 100%.109 In a after a minimum follow-up of 12 months.128 The main
recently published casecontrol series of HIV-positive patients reported complication during the implant surgical procedure
receiving different regimens of highly active anti-retroviral was the formation of bleeding blisters by minimal trauma.
therapy, after assessing peri-implant health at 6 and 12 During the follow-up period many patients also developed
months, the authors concluded that DI may represent a ulcers in the areas of prosthesis contact, but these complica-
reasonable treatment option in HIV-positive patients, regard- tions did not affect the successful implant outcome. A fixed
less of CD4 cell count, viral load levels and type of antiretrovi- full-arch short-expand prostheses supported by four DI has
ral therapy.110 It seems that DI are well tolerated and have been successfully used in patients with recessive dystrophic
predictable short-term outcomes for HIV-infected individuals, epidermolysis bullosa, minimizing oral mucosa surface
but published evidence is scarce and the predictability of the contact and improving the patients quality of life. 129
long-term success remains unknown. It would seem prudent It has been suggested that dental implants are not ideal for
to carry out DI when CD4 rates are high and the patient is on patients with oral lichen planus because of the limited
antiretroviral therapy. capacity of the involved epithelium to adhere to the titanium
Crohns disease has also been suggested as a relative surface.7 Despite the generalized use of DI, very few case
contraindication for DI.8 Crohns disease is associated with reports have been documented, all of them with successful
nutritional and immune defects, and hence, it may impair DI outcome.121,130 Recently, two casecontrol studies including
success.39 However, in a retrospective study 11 of 12 DI placed 14 and 18 oral lichen planus patients have been published,
in Crohns disease patients integrated successfully.13 with no implant failure recorded during the follow-up period
Severe periodontitis is frequent in patients with congenital (1253 months).131,132 Peri-implant mucositis and peri-implan-
neutrophil deficiencies and therefore, high occurrence of peri- titis seem to be slightly more frequent in patients with oral
implant infection should be expected when implants are lichen planus than in controls, and desquamative gingivitis
placed in these patients. There are, however, some case was associated with a higher rate of peri-implant mucositis.132
reports of successful implant placement in patients with Implant placement does not influence the disease manifesta-
Papillon-Lefevre syndrome111 and von Gierke syndrome.112 tions.131 As malignant transformation has been observed in
In summary, there is no evidence that immunoincompe- few cases of oral lichen planus, careful long-term monitoring
tence is a contraindication to DI therapy, but medical advice of both lesions and dental implants is recommended.113
should be procured before considering DI therapy and strict
anti-infective measures should be enforced when treating
these patients (Table 1).22 13. Neuro-psychiatric disorders

The literature with respect to DI placement in patients with


12. Mucosal disease neuro-psychiatric disorders is sparse and contradictory. Some
case reports and case series have shown DI treatment to be
There are numerous case reports and case series documenting successful in some patients with various degrees of both
the success of DI in patients with a range of mucosal intellectual and physical disability, including cases of cerebral
conditions113 including ectodermal dysplasia,114117 epider- palsy, Down syndrome, psychiatric disorders, dementia,
molysis bullosa118120 and in lichen planus (Table 1).121 bulimia, Parkinson disease and severe epilepsy.133141 Howev-
DI is often the treatment of choice in patients with er, poor oral hygiene, oral parafunctions such as bruxism,
ectodermal dysplasia with severe oligodontia or hypodontia. harmful habits such as repeated introduction of the fingers
The largest published series report outcomes in 51 and 33 into the mouth and behavioural problems are not uncommon
patients, with 264 and 186 implants respectively.118,122 in patients with neuro-psychiatric diseases, and DI in such
202 journal of dentistry 41 (2013) 195206

patients may lead to complications. Therefore, the success of references


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