You are on page 1of 13

journal of dentistry 41 (2013) 195206

Available online at

journal homepage:


Dental implants in the medically compromised patient

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

Grupo de Investigacion en Odontologa Medico-Quirurgica (OMEQUI), School of Medicine and Dentistry, University of Santiago de
Compostela, Spain
University College London, UK
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
# 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: (P. Diz).
0300-5712/$ see front matter # 2013 Elsevier Ltd. All rights reserved.
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
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
Impaired immunity
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
Osteoporosis Similar (2a) Sinus lifts may be
Osteoporosis and Similar (1b)
oral bisphosphonates
Cancer and intravenous Contraindicated (5) Reduced (4)
Head & neck cancer Reduced (1b) (following Cancer prognosis Surgery best carried
patients radiotherapy) out 21 days before
Similar (3b) (following Hyperbaric oxygen
chemotherapy) should be given if
>50 Gy used
Defer DI for 9 months
Consider antimicrobial
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
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
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
In patients allergic to
other metals long-term
clinical and radiographic
follow-up is recommended
Adapted from Scully et al.12
OCEBM Levels of Evidence Working Group.14
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 ( 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

oral rehabilitation depends fundamentally on appropriate
patient selection141 and adequate medical advice should be
seeked prior to implant therapy (Table 1).139 1. Spiekermann H, Jansen VK, Richter EJ. A 10-year follow-up
study of IMZ and TPS implants in the edentulous mandible
using bar-retained overdentures. International Journal of Oral
14. Titanium allergy and Maxillofacial Implants 1995;10:23143.
2. Li KK, Varvares MA, Meara JG. Descending necrotizing
mediastinitis: a complication of dental implant surgery.
Degradation products of metallic biomaterials may result in
Head and Neck 1996;18:1926.
metal hypersensitivity reactions.142 Recently, it has been 3. Mordenfeld A, Andersson L, Bergstrom B. Hemorrhage in
suggested that titanium, formerly considered an inert the floor of the mouth during implant placement in the
material, can induce toxicity or allergic type I or IV reactions edentulous mandible: a case report. International Journal of
in susceptible patients and could play a critical role in Oral and Maxillofacial Implants 1997;12:55861.
implant failure.143,144 In a systematic review including 7 4. Givol N, Chaushu G, Halamish-Shani T, Taicher S.
Emergency tracheostomy following life-threatening
studies it has been shown that titanium allergy develops
hemorrhage in the floor of the mouth during immediate
among patients at every age, the most common clinical
implant placement in the mandibular canine region.
manifestations being dermal inflammatory conditions and Journal of Periodontology 2000;71:18935.
gingival hyperplasia.145 The prevalence of titanium allergy 5. Isaacson TJ. Sublingual hematoma formation during
remains unknown but it has been estimated to be 0.6% immediate placement of mandibular endosseous
among DI patients.146 A significantly higher risk of positive implants. Journal of the American Dental Association
allergic reactions was found in patients showing allergic 2004;135:16872.
6. Kalpidis CD, Setayesh RM. Hemorrhaging associated with
symptoms after implant placement or unexplained implant
endosseous implant placement in the anterior mandible: a
review of the literature. Journal of Periodontology 2004;75:
The risk of an allergy to titanium is increased in patients 63145.
who are allergic to other metals. In these patients, an 7. Sugerman PB, Barber MT. Patient selection for endosseous
evaluation of allergy is recommended, in order to exclude dental implants: oral and systemic considerations.
any problem with titanium medical devices,143 and long-term International Journal of Oral and Maxillofacial Implants
clinical and radiographic follow-up has been recom- 2002;17:191201.
8. Balshi TJ, Wolfinger GJ. Management of the posterior
mended.144 Even in confirmed titanium-allergic patients it
maxilla in the compromised patient: historical, current,
may be possible by using alternative materials (e.g. zirconium and future perspectives. Periodontology 2000 2003;33:6781.
oxide dental implants) to achieve DI rehabilitation.147 9. Hwang D, Wang HL. Medical contraindications to implant
therapy. Part II. Relative contraindications. Implant Dentistry
15. Conclusions 10. Hwang D, Wang HL. Medical contraindications to implant
therapy. Part I. Absolute contraindications. Implant
Dentistry 2006;15:35360.
In conclusion there are very few absolute contraindications to
11. Meijer GJ, Cune MS. Surgical dilemmas. Medical
DI treatment, although a number of conditions may increase restrictions and risk factors. Nederlands Tijdschrift Voor
the risk of treatment failure or complications. However, due to Tandheelkunde 2008;115:64351.
the scarcity of prospective studies the impact of health risks 12. Scully C, Hobkirk J, Dios PD. Dental endosseous implants in
on implant outcome remains unclear and well-designed the medically compromised patient. Journal of Oral
observational studies are needed. Rehabilitation 2007;34:5909.
13. Alsaadi G, Quirynen M, Komarek A, van Steenberghe D.
The degree of disease-control may be far more important
Impact of local and systemic factors on the incidence of
that the nature of the systemic disorder itself, and individu-
late oral implant loss. Clinical Oral Implants Research 2008;19:
alized medical control should be procured prior to implant 6706.
therapy, since in many of these patients the quality of life and 14. OCEBM Levels of Evidence Working Group. The Oxford
functional benefits of dental implants may outweigh any 2009 Levels of Evidence. Oxford Centre for Evidence-Based
risks. Medicine.
As in any clinical decision in dentistry, the range of [accessed November 2011].
15. Koo S, Konig Jr B, Mizusaki CI, Allegrini Jr S, Yoshimoto M,
treatment options and their relative advantages and dis-
Carbonari MJ. Effects of alcohol consumption on
advantages should be carefully assessed in relation to the osseointegration of titanium implants in rabbits. Implant
patients needs and wishes. In patients with systemic Dentistry 2004;13:2327.
conditions, it is important to weigh carefully the cost-benefit 16. Marchini L, de Deco CP, Marchini AP, Barbara MA,
analysis with the patients quality of life and life expectancy Vasconcellos LM, Rocha RF, et al. Negative effects of alcohol
and it is very important to undertake the implant surgical intake and estrogen deficiency combination on
osseointegration in a rat model. Journal of Oral Implantology
procedures with strict asepsis, minimal trauma, and avoiding
2011. April 19 [Epub ahead of print].
stress and undue haemorrhage. Equally it is very important in
17. Galindo-Moreno P, Fauri M, Avila-Ortiz G, Fernandez-
these patients to ensure proper maintenance therapy with Barbero JE, Cabrera-Leon A, Sanchez-Fernandez E.
optimal standards of oral hygiene, without smoking and with Influence of alcohol and tobacco habits on peri-implant
avoidance of any other risk factors that may affect the marginal bone loss: a prospective study. Clinical Oral
outcome of dental implants. Implants Research 2005;16:57986.
journal of dentistry 41 (2013) 195206 203

18. Alissa R, Oliver R. Influence of prognostic risk indicators on peri-implant findings. Journal of Clinical Periodontology
osseointegrated dental implant failure: a matched case 2010;37:92836.
control analysis. Journal of Oral Implantology 2011;38:5161. 36. Weinlander M, Krennmair G, Piehslinger E. Implant
19. Goodacre CJ, Bernal G, Rungcharassaeng K, Kan JY. Clinical prosthodontic rehabilitation of patients with rheumatic
complications with implants and implant prostheses. disorders: a case series report. International Journal of
Journal of Prosthetic Dentistry 2003;90:12132. Prosthodontics 2010;23:228.
20. Gornitsky M, Hammouda W, Rosen H. Rehabilitation of a 37. Glosel B, Kuchler U, Watzek G, Gruber R. Review of dental
hemophiliac with implants: a medical perspective and case implant rat research models simulating osteoporosis or
report. Journal of Oral and Maxillofacial Surgery 2005;63: diabetes. International Journal of Oral and Maxillofacial
5927. Implants 2010;25:51624.
21. Kalpidis CD, Konstantinidis AB. Critical hemorrhage in the 38. Blomqvist JE, Alberius P, Isaksson S, Linde A, Hansson BG.
floor of the mouth during implant placement in the first Factors in implant integration failure after bone grafting:
mandibular premolar position: a case report. Implant an osteometric and endocrinologic matched analysis.
Dentistry 2005;14:11724. International Journal of Oral and Maxillofacial Surgery
22. Scully C. Medical problems in dentistry. 6th ed. London: 1996;25:638.
Elsevier; 2010. 39. Alsaadi G, Quirynen M, Komarek A, van Steenberghe D.
23. Madrid C, Sanz M. What influence do anticoagulants have Impact of local and systemic factors on the incidence of
on oral implant therapy? A systematic review. Clinical Oral oral implant failures, up to abutment connection. Journal of
Implants Research 2009;20:96106. Clinical Periodontology 2007;34:6107.
24. Bacci C, Berengo M, Favero L, Zanon E. Safety of dental 40. Slagter KW, Raghoebar GM, Vissink A. Osteoporosis and
implant surgery in patients undergoing anticoagulation edentulous jaws. International Journal of Prosthodontics
therapy: a prospective casecontrol study. Clinical Oral 2008;21:1926.
Implants Research 2011;22:1516. 41. Dvorak G, Arnhart C, Heuberer S, Huber CD, Watzek G,
25. Hong CH, Napenas JJ, Brennan MT, Furney SL, Lockhart PB. Gruber R. Peri-implantitis and late implant failures in
Frequency of bleeding following invasive dental postmenopausal women: a cross-sectional study. Journal of
procedures in patients on low-molecular-weight heparin Clinical Periodontology 2011;38:9505.
therapy. Journal of Oral and Maxillofacial Surgery 2010;68:975 42. Friberg B, Ekestubbe A, Mellstrom D, Sennerby L.
9. Branemark implants and osteoporosis: a clinical
26. Napenas JJ, Hong CH, Brennan MT, Furney SL, Fox PC, exploratory study. Clinical Implant Dentistry and Related
Lockhart PB. The frequency of bleeding complications after Research 2001;3:506.
invasive dental treatment in patients receiving single and 43. Bornstein MM, Cionca N, Mombelli A. Systemic conditions
dual antiplatelet therapy. Journal of the American Dental and treatments as risks for implant therapy. International
Association 2009;140:6905. Journal of Oral and Maxillofacial Implants 2009;24:
27. Zola MB. Staged sinus augmentation and implant 1227.
placement in a patient with osteogenesis imperfecta. 44. Dao TT, Anderson JD, Zarb GA. Is osteoporosis a risk factor
Journal of Oral and Maxillofacial Surgery 2000;58:4437. for osseointegration of dental implants? International
28. Lee CY, Ertel SK. Bone graft augmentation and dental Journal of Oral and Maxillofacial Implants 1993;8:13744.
implant treatment in a patient with osteogenesis 45. Holahan CM, Wiens JL, Weaver A, Assad D, Koka S.
imperfecta: review of the literature with a case report. Relationship between systemic bone mineral density and
Implant Dentistry 2003;12:2915. local bone quality as effectors of dental implant survival.
29. Binger T, Rucker M, Spitzer WJ. Dentofacial rehabilitation Clinical Implant Dentistry and Related Research 2011;13:
by osteodistraction, augmentation and implantation 2933.
despite osteogenesis imperfecta. International Journal of Oral 46. Gaetti-Jardim EC, Santiago-Junior JF, Goiato MC, Pellizer EP,
and Maxillofacial Surgery 2006;35:55962. Magro-Filho O, Jardim Junior EG. Dental implants in
30. Prabhu N, Duckmanton N, Stevenson AR, Cameron A. The patients with osteoporosis: a clinical reality? Journal of
placement of osseointegrated dental implants in a patient Craniofacial Surgery 2011;22:11113.
with type IV B osteogenesis imperfecta: a 9-year follow-up. 47. Starck WJ, Epker BN. Failure of osseointegrated dental
Oral Surgery Oral Medicine Oral Pathology Oral Radiology and implants after diphosphonate therapy for osteoporosis: a
Endodontics 2007;103:34954. case report. International Journal of Oral and Maxillofacial
31. Payne MA, Postlethwaite KR, Smith DG, Nohl FS. Implant- Implants 1995;10:748.
supported rehabilitation of an edentate patient with 48. Ferlito S, Liardo C, Puzzo S. Bisphosphonates and dental
osteogenesis imperfecta: a case report. International Journal implants: a case report and a brief review of literature.
of Oral and Maxillofacial Implants 2008;23:94752. Minerva Stomatologica 2011;60:7581.
32. Wannfors K, Johansson C, Donath K. Augmentation of the 49. Flichy-Fernandez AJ, Balaguer-Martnez J, Penarrocha-
mandible via a tent-pole procedure and implant Diago M, Bagan JV. Bisphosphonates and dental implants:
treatment in a patient with type III osteogenesis current problems. Medicina Oral Patologa Oral y Ciruga Bucal
imperfecta: clinical and histologic considerations. 2009;14:E35560.
International Journal of Oral and Maxillofacial Implants 50. Wang HL, Weber D, McCauley LK. Effect of long-term oral
2009;24:11448. bisphosphonates on implant wound healing: literature
33. Eder A, Watzek G. Treatment of a patient with severe review and a case report. Journal of Periodontology
osteoporosis and chronic polyarthritis with fixed implant- 2007;78:58494.
supported prosthesis: a case report. International Journal of 51. Lazarovici TS, Yahalom R, Taicher S, Schwartz-Arad D,
Oral and Maxillofacial Implants 1999;14:58790. Peleg O, Yarom N. Bisphosphonate-related osteonecrosis of
34. Barker D, Nohl FS, Postlethwaite KR, Smith DG. Case report the jaw associated with dental implants. Journal of Oral and
of multiple implant failure in a patient with ankylosing Maxillofacial Surgery 2010;68:7906.
spondylitis. European Journal of Prosthodontics and Restorative 52. Jacobsen C, Metzler P, Rossle M, Obwegeser J, Zemann W,
Dentistry 2008;16:203. Gratz KW. Osteopathology induced by bisphosphonates
35. Krennmair G, Seemann R, Piehslinger E. Dental implants in and dental implants: clinical observations. Clinical Oral
patients with rheumatoid arthritis: clinical outcome and Investigations 2012. [Epub ahead of print].
204 journal of dentistry 41 (2013) 195206

53. Memon S, Weltman RL, Katancik JA. Oral bisphosphonates: 71. Kahnberg KE. Functional rehabilitation using orthognathic
early endosseous dental implant success and crestal bone surgery, bone transplants and implants after irradiation of
changes. A retrospective study. International Journal of Oral malignancy in early childhood. Swedish Dental Journal
and Maxillofacial Implants 2012;27:121622. 2002;26:99106.
54. Grant BT, Amenedo C, Freeman K, Kraut RA. Outcomes of 72. Landes CA, Kovacs AF. Comparison of early telescope
placing dental implants in patients taking oral loading of non-submerged ITI implants in irradiated and
bisphosphonates: a review of 115 cases. Journal of Oral and non-irradiated oral cancer patients. Clinical Oral Implants
Maxillofacial Surgery 2008;66:22330. Research 2006;17:36774.
55. Goss A, Bartold M, Sambrook P, Hawker P. The nature and 73. Granstrom G. Radiotherapy, osseointegration and
frequency of bisphosphonate-associated osteonecrosis of hyperbaric oxygen therapy. Periodontology 2000 2003;33:
the jaws in dental implant patients: a South Australian 14562.
case series. Journal of Oral and Maxillofacial Surgery 2010;68: 74. Coulthard P, Patel S, Grusovin GM, Worthington HV,
33743. Esposito M. Hyperbaric oxygen therapy for irradiated
56. Advisory Task Force on Bisphosphonate-related patients who require dental implants: a cochrane review of
Ostenonecrosis of the Jaws. American Association of Oral randomised clinical trials. European Journal of Oral
and Maxillofacial Surgeons. American Association of Oral Implantology 2008;1:10510.
and Maxillofacial Surgeons position paper on 75. Kovacs AF. Influence of chemotherapy on endosteal
bisphosphonate-related osteonecrosis of the jaws. Journal implant survival and success in oral cancer patients.
of Oral and Maxillofacial Surgery 2007;65:36976. International Journal of Oral and Maxillofacial Surgery
57. Madrid C, Sanz M. What impact do systemically 2001;30:1447.
administrated bisphosphonates have on oral implant 76. Karr RA, Kramer DC, Toth BB. Dental implants and
therapy? A systematic review. Clinical Oral Implants Research chemotherapy complications. Journal of Prosthetic Dentistry
2009;20:8795. 1992;67:6837. [Review].
58. Javed F, Almas K. Osseointegration of dental implants in 77. Khadivi V, Anderson J, Zarb GA. Cardiovascular disease
patients undergoing bisphosphonate treatment: a and treatment outcomes with osseointegration surgery.
literature review. Journal of Periodontology 2010;81:47984. Journal of Prosthetic Dentistry 1999;81:5336.
59. Otomo-Corgel J. Osteoporosis and osteopenia: implications 78. Moy PK, Medina D, Shetty V, Aghaloo TL. Dental implant
for periodontal and implant therapy. Periodontology 2000 failure rates and associated risk factors. International Journal
2012;59:11139. of Oral and Maxillofacial Implants 2005;20:56977.
60. Maurer P, Sandulescu T, Kriwalsky MS, Rashad A, Hollstein 79. Taguchi T, Fukuda K, Sekine H, Kakizawa T. Intravenous
S, Stricker I, et al. Bisphosphonate-related osteonecrosis of sedation and hemodynamic changes during dental
the maxilla and sinusitis maxillaris. International Journal of implant surgery. International Journal of Oral and Maxillofacial
Oral and Maxillofacial Surgery 2011;40:28591. Implants 2011;26:13038.
61. Kim DD, Ghali GE. Dental implants in oral cancer 80. Romano MM, Soares MS, Pastore CA, Tornelli MJ, de
reconstruction. Dental Clinics of North America 2011;55:871 Oliveira Guare R, Adde CA. A study of effectiveness of
82. midazolam sedation for prevention of myocardial
62. Nelson K, Heberer S, Glatzer C. Survival analysis and arrhythmias in endosseous implant placement. Clinical Oral
clinical evaluation of implant-retained prostheses in oral Implants Research 2012;23:48995.
cancer resection patients over a mean follow-up period of 81. Bencharit S, Reside GJ, Howard-Williams EL. Complex
10 years. Journal of Prosthetic Dentistry 2007;98:40510. prosthodontic treatment with dental implants for a
63. Barrowman RA, Wilson PR, Wiesenfeld D. Oral patient with polymyalgia rheumatica: a clinical report.
rehabilitation with dental implants after cancer treatment. International Journal of Oral and Maxillofacial Implants
Australian Dental Journal 2011;56:1605. 2010;25:12415.
64. Jokstad A. Patients undergoing craniofacial tumour 82. Keller JC, Stewart M, Roehm M, Schneider GB.
ablation surgery may benefit from having the implants Osteoporosis-like bone conditions affect osseointegration
placed simultaneously instead of waiting. Evidence Based of implants. International Journal of Oral and Maxillofacial
Dentistry 2010;11:523. Implants 2004;19:68794.
65. Korfage A, Schoen PJ, Raghoebar GM, Roodenburg JL, 83. Fujimoto T, Niimi A, Sawai T, Ueda M. Effects of steroid-
Vissink A, Reintsema H. Benefits of dental implants induced osteoporosis on osseointegration of titanium
installed during ablative tumour surgery in oral cancer implants. International Journal of Oral and Maxillofacial
patients: a prospective 5-year clinical trial. Clinical Implant Implants 1998;13:1839.
Dentistry and Related Research 2010;21:9719. 84. Nicholson G, Burrin JM, Hall GM. Peri-operative steroid
66. Linsen SS, Martini M, Stark H. Long-term results of supplementation. Anaesthesia 1998;53:1091104.
endosteal implants following radical oral cancer surgery 85. Thomason JM, Girdler NM, Kendall-Taylor P, Wastell H,
with and without adjuvant radiation therapy. Clinical Weddel A, Seymour RA. An investigation into the need for
Implant Dentistry and Related Research 2012;14:2508. supplementary steroids in organ transplant patients
67. Harrison JS, Stratemann S, Redding SW. Dental implants undergoing gingival surgery. A double-blind, split-mouth,
for patients who have had radiation treatment for head cross-over study. Journal of Clinical Periodontology
and neck cancer. Special Care in Dentistry 2003;23:2239. 1999;26:57782.
68. Javed F, Al-Hezaimi K, Al-Rasheed A, Almas K, Romanos 86. Dowell S, Oates TW, Robinson M. Implant success in
GE. Implant survival rate after oral cancer therapy: a people with type 2 diabetes mellitus with varying glycemic
review. Oral Oncology 2010;46:8549. control: a pilot study. Journal of the American Dental
69. Wagner W, Esser E, Ostkamp K. Osseointegration of dental Association 2007;138:35561.
implants in patients with and without radiotherapy. Acta 87. Michaeli E, Weinberg I, Nahlieli O. Dental implants in the
Oncologica 1998;37:6936. diabetic patient: systemic and rehabilitative
70. Mancha de la Plata M, Gas LN, Dez PM, Munoz-Guerra M, considerations. Quintessence International 2009;40:63945.
Gonzalez-Garca R, Lee GY, et al. Osseointegrated implant 88. Anner R, Grossmann Y, Anner Y, Levin L. Smoking,
rehabilitation of irradiated oral cancer patients. Journal of diabetes mellitus, periodontitis, and supportive
Oral and Maxillofacial Surgery 2012;70:105263. periodontal treatment as factors associated with dental
journal of dentistry 41 (2013) 195206 205

implant survival: a long-term retrospective evaluation of 107. Porter SR, Scully C, Luker J. Complications of dental surgery
patients followed for up to 10 years. Implant Dentistry in persons with HIV disease. Oral Surgery Oral Medicine and
2010;19:5764. Oral Pathology 1993;75:1657.
89. Turkyilmaz I. One-year clinical outcome of dental implants 108. Scully C, Watt-Smith P, Dios P, Giangrande PLF.
placed in patients with type 2 diabetes mellitus: a case Complications in HIV-infected and non-HIV-infected
series. Implant Dentistry 2010;19:3239. hemophiliacs and other patients after oral surgery.
90. Tawil G, Younan R, Azar P, Sleilati G. Conventional and International Journal of Oral and Maxillofacial Surgery
advanced implant treatment in the type II diabetic patient: 2002;31:63440.
surgical protocol and long-term clinical results. 109. Stevenson GC, Riano PC, Moretti AJ, Nichols CM,
International Journal of Oral and Maxillofacial Implants Engelmeier RL, Flaitz CM. Short-term success of
2008;23:74452. osseointegrated dental implants in HIV-positive
91. Oates TW, Dowell S, Robinson M, McMahan CA. Glycemic individuals: a prospective study. Journal of Contemporary
control and implant stabilization in type 2 diabetes Dental Practice 2007;8:110.
mellitus. Journal of Dental Research 2009;88:36771. 110. Oliveira MA, Gallottini M, Pallos D, Maluf PS, Jablonka F,
92. Wang F, Song YL, Li DH, Li CX, Wang Y, Zhang N, et al. Type Ortega JL. The success of endosseous implants in human
2 diabetes mellitus impairs bone healing of dental implants immunodeficiency virus-positive patients receiving
in GK rats. Diabetes Research and Clinical Practice 2010;88:79. antiretroviral therapy: a pilot study. Journal of the American
93. Javed F, Romanos GE. Impact of diabetes mellitus and Dental Association 2011;142:10106.
glycemic control on the osseointegration of dental 111. Ahmadian L, Monzavi A, Arbabi R, Hashemi HM. Full-
implants: a systematic literature review. Journal of mouth rehabilitation of an edentulous patient with
Periodontology 2009;80:171930. Papillon-Lefevre syndrome using dental implants: a
94. Oates TW, Huynh-Ba G, Vargas A, Alexander P, Feine J. A clinical report. Journal of Prosthodontics 2011. October 4
critical review of diabetes, glycemic control, and dental [Epub ahead of print].
implant therapy. Clinical Oral Implants Research 2011. [Epub 112. Diz Dios P, Ocampo Hermida A, Fernandez Feijoo J.
ahead of print]. Quantitative and functional neutrophil deficiencies.
95. Marchand F, Raskin A, Dionnes-Hornes A, Barry T, Dubois Medicina Oral 2002;7:20621.
N, Valero R, et al. Dental implants and diabetes: conditions 113. Candel-Marti ME, Ata-Ali J, Penarrocha-Oltra D,
for success. Diabetes & Metabolism 2012;38:149. Penarrocha-Diago M, Bagan JV. Dental implants in patients
96. Courtney Jr MW, Snider TN, Cottrell DA. Dental implant with oral mucosal alterations: an update. Medicina Oral
placement in type II diabetics: a review of the literature. Patologa Oral y Ciruga Bucal 2011;16:e78793.
Journal of the Massachusetts Dental Society 2010;59:124. 114. Rad AS, Siadat H, Monzavi A, Mangoli AA. Full mouth
97. Beikler T, Flemmig TF. Implants in the medically rehabilitation of a hypohidrotic ectodermal dysplasia
compromised patient. Critical Reviews in Oral Biology and patient with dental implants: a clinical report. Journal of
Medicine 2003;14:30516. Prosthodontics 2007;16:20913.
98. Payne AG, Lownie JF, Van Der Linden WJ. Implant- 115. Kirmeier R, Gluhak C, Marada P, Wegscheider WA, Eskici A,
supported prostheses in patients with Sjogrens syndrome: Jakse N. Oral rehabilitation of adult twins with severe lack
a clinical report on three patients. International Journal of of bone due to hypohidrotic ectodermal dysplasia a 12-
Oral and Maxillofacial Implants 1997;12:67985. month follow-up. Journal of Oral and Maxillofacial Surgery
99. Binon PP. Thirteen-year follow-up of a mandibular 2009;67:18994.
implant-supported fixed complete denture in a patient 116. Kearns G, Sharma A, Perrott D, Schmidt B, Kaban L,
with Sjogrens syndrome: a clinical report. Journal of Vargervik K. Placement of endosseous implants in children
Prosthetic Dentistry 2005;94:40913. and adolescents with hereditary ectodermal dysplasia. Oral
100. Isidor F, Brondum K, Hansen HJ, Jensen J, Sindet-Pedersen Surgery Oral Medicine Oral Pathology Oral Radiology and
S. Outcome of treatment with implant-retained dental Endodontics 1999;88:510.
prosthesis in patients with Sjogren syndrome. International 117. Guckes AD, Scurria MS, King TS, McCarthy GR, Brahim JS.
Journal of Oral and Maxillofacial Implants 1999;14:73643. Prospective clinical trial of dental implants in persons with
101. Ami S, Wolff A. Implant-supported electrostimulating ectodermal dysplasia. Journal of Prosthetic Dentistry
device to treat xerostomia: a preliminary study. Clinical 2002;88:21599.
Implant Dentistry and Related Research 2010;12:6271. 118. Penarrocha M, Serrano C, Sanchis JM, Silvestre FJ, Bagan JV.
102. Sakakura CE, Marcantonio Jr E, Wenzel A, Scaf G. Influence Placement of endosseous implants in patients with oral
of cyclosporin A on quality of bone around integrated epidermolysis bullosa. Oral Surgery Oral Medicine Oral
dental implants: a radiographic study in rabbits. Clinical Pathology Oral Radiology and Endodontics 2000;90:58790.
Oral Implants Research 2007;18:349. 119. Larrazabal-Moron C, Boronat-Lopez A, Penarrocha-Diago
103. Heckmann SM, Heckmann JG, Linke JJ, Hohenberger W, M, Penarrocha-Diago M. Oral rehabilitation with bone graft
Mombelli A. Implant therapy following liver and simultaneous dental implants in a patient with
transplantation: clinical and microbiological results after epidermolysis bullosa: a clinical case report. Journal of Oral
10 years. Journal of Periodontology 2004;75:90913. and Maxillofacial Surgery 2009;67:1499502.
104. Gu L, Yu YC. Clinical outcome of dental implants placed in 120. Penarrocha M, Rambla J, Balaguer J, Serrano C, Silvestre J,
liver transplant recipients after 3 years: a case series. Bagan JV. Complete fixed prostheses over implants in
Transplant Proceedings 2011;43:267882. patients with oral epidermolysis bullosa. Journal of Oral and
105. Gu L, Wang Q, Yu YC. Eleven dental implants placed in a Maxillofacial Surgery 2007;65:1036.
liver transplantation patient: a case report and 5-year 121. Esposito SJ, Camisa C, Morgan M. Implant retained
clinical evaluation. Chinese Medical Journal (English) overdentures for two patients with severe lichen planus: a
2011;124:4725. clinical report. Journal of Prosthetic Dentistry 2003;89:610.
106. Dijakiewicz M, Wojtowicz A, Dijakiewicz J, Szycik V, 122. Garagiola U, Maiorana C, Ghiglione V, Marzo G, Santoro F,
Rutkowski P, Rutkowski B. Is implanto-prosthodontic Szabo G. Osseointegration and guided bone regeneration in
treatment available for haemodialysis patients? Nephrology ectodermal dysplasia patients. Journal of Craniofacial Surgery
Dialysis Transplantation 2007;22:27224. 2007;18:1296304.
206 journal of dentistry 41 (2013) 195206

123. Grecchi F, Zingari F, Bianco R, Zollino I, Casadio C, Carinci 135. Lopez-Jimenez J, Romero-Domnguez A, Gimenez-Prats MJ.
F. Implant rehabilitation in grafted and native bone in Implants in handicapped patients. Medicina Oral
patients affected by ectodermal dysplasia: evaluation of 78 2003;8:28893.
implants inserted in 8 patients. Implant Dentistry 136. Kubo K, Kimura K. Implant surgery for a patient with
2010;19:4008. Parkinsons disease controlled by intravenous midazolam:
124. Sweeney IP, Ferguson JW, Heggie AA, Lucas JO. Treatment a case report. International Journal of Oral and Maxillofacial
outcomes for adolescent ectodermal dysplasia patients Implants 2004;19:28890.
treated with dental implants. International Journal of 137. Ekfeldt A. Early experience of implant-supported
Paediatric Dentistry 2005;15:2418. prostheses in patients with neurologic disabilities.
125. Bergendal B, Ekman A, Nilsson P. Implant failure in young International Journal of Prosthodontics 2005;18:
children with ectodermal dysplasia: a retrospective 1328.
evaluation of use and outcome of dental implant 138. Oczakir C, Balmer S, Mericske-Stern R. Implant-prosthodontic
treatment in children in Sweden. International Journal of Oral treatment for special care patients: a case series study.
and Maxillofacial Implants 2008;23:5204. International Journal of Prosthodontics 2005;18:3839.
126. Percinoto C, Vieira AE, Barbieri CM, Melhado FL, Moreira 139. Addy L, Korszun A, Jagger RG. Dental implant treatment
KS. Use of dental implants in children: a literature review. for patients with psychiatric disorders. European Journal
Quintessence International 2001;32:3813. of Prosthodontics and Restorative Dentistry 2006;14:
127. Feijoo JF, Bugallo J, Limeres J, Penarrocha D, Penarrocha M, 902.
Diz P. Inherited epidermolysis bullosa: an update and 140. Cune MS, Strooker H, Van der Reijden WA, de Putter C,
suggested dental care considerations. Journal of the Laine ML, Verhoeven JW. Dental implants in persons with
American Dental Association 2011;142:101725. severe epilepsy and multiple disabilities: a long-term
128. Penarrocha-Oltra D, Aloy-Prosper A, Ata-Ali J, Penarrocha- retrospective study. International Journal of Oral and
Diago M, Penarrocha-Diago M. Implants placed Maxillofacial Implants 2009;24:53440.
simultaneously with particulated bone graft in patients 141. Feijoo JF, Limeres J, Diniz M, Del Llano A, Seoane J, Diz P.
diagnosed with recessive dystrophic epidermolysis bullosa. Osseointegrated dental implants in patients with
Journal of Oral and Maxillofacial Surgery 2012;70:e517. intellectual disability: a pilot study. Disability and
129. Penarrocha-Oltra D, Penarrocha-Diago M, Balaguer- Rehabilitation 2012;34:202530.
Martnez J, Ata-Ali J, Penarrocha-Diago M. Full-arch fixed 142. Basko-Plluska JL, Thyssen JP, Schalock PC. Cutaneous and
prosthesis supported by four implants in patients with systemic hypersensitivity reactions to metallic implants.
recessive dystrophic epidermolysis bullosa. Oral Surgery Dermatitis 2011;22:6579.
Oral Medicine Oral Pathology Oral Radiology and Endodontics 143. Evrard L, Waroquier D, Parent D. Allergies to dental metals.
2011;112:e410. Titanium: a new allergen. Revue Medicale de Bruxelles
130. Reichart PA. Oral lichen planus and dental implants. 2010;31:449.
Report of 3 cases. International Journal of Oral and 144. Siddiqi A, Payne AG, De Silva RK, Duncan WJ. Titanium
Maxillofacial Surgery 2006;35:23740. allergy: could it affect dental implant integration? Clinical
131. Czerninski R, Eliezer M, Wilensky A, Soskolne A. Oral Oral Implants Research 2011;22:67380.
lichen planus and dental implants a retrospective study. 145. Javed F, Al-Hezaimi K, Almas K, Romanos GE. Is titanium
Clinical Implant Dentistry and Related Research 2011. [Epub sensitivity associated with allergic reactions in patients
ahead of print]. with dental implants? A systematic review. Clinical Implant
132. Hernandez G, Lopez-Pintor RM, Arriba L, Torres J, de Dentistry and Related Research 2011. [Epub ahead of print].
Vicente JC. Implant treatment in patients with oral lichen 146. Sicilia A, Cuesta S, Coma G, Arregui I, Guisasola C, Ruiz E,
planus: a prospective-controlled study. Clinical Oral et al. Titanium allergy in dental implant patients: a clinical
Implants Research 2012;23:72632. study on 1500 consecutive patients. Clinical Oral Implants
133. Rogers JO. Implant-stabilized complete mandibular Research 2008;19:82335.
denture for a patient with cerebral palsy. Dental Update 147. Oliva X, Oliva J, Oliva JD. Full-mouth oral rehabilitation in a
1995;22:236. titanium allergy patient using zirconium oxide dental
134. Ambard A, Mueninghoff L. Rehabilitation of a bulimic implants and zirconium oxide restorations. A case report
patient using endosteal implants. Journal of Prosthodontics from an ongoing clinical study. European Journal of Esthetic
2002;11:17680. Dentistry 2010;5:190203.
2013 Elsevier