JOMI on CD-ROM, 1995 Jan (74-77 ): Failure of Osseointegrated Dental Implants After… Copyrights © 1997 Quinte…

Failure of Osseointegrated Dental Implants After

Diphosphonate Therapy for Osteoporosis: A Case
Report
William J. Starck, DDS/Bruce N. Epker, DDS, PhD

Late loss of initially integrated endosseous implants has generally been

attributed to implant overload often the result of inappropriate prosthesis
design. Implant placement is rarely contraindicated by preexisting systemic
diseases, and no instances of medication-induced implant failure have been
reported in the literature. This paper reports a case in which a patient lost five
endosseous implants that had successfully osseointegrated and had been
restored with a lower hybrid prosthesis approximately 6 months after
diphosphonate therapy for osteoporosis was started.(Int J Oral Maxillofac
Implants 1995;10:74–78)
Key words: diphosphonate, etidronate disodium, osseointegration, osteoporosis

The concept of osseointegrated dental implants as developed by P.-I. Brånemark in

the mid-1960s has been one of the most remarkable success stories in the history of
prosthetic dentistry. Considering the large number of implants placed each year, it is
remarkable that success rates have consistently remained in the ninetieth percentile
range.1,2 Minor complications include mucosal perforation, gingivitis, gingival
hyperplasia, fistulae, exposed threads, and abutment-screw fracture. Major
complications include injury to adjacent teeth or nerves, implant mobility, implant
fracture, loss of implants (early and late),3 and sublingual hematoma.4
Late loss of implants is generally the result of one or a combination of factors
that result in implant overload. These include inadequate size and number of
implants for the prosthesis, inappropriate design of the prosthesis resulting in the
transmission of unphysiologic loads to the supporting alveolus, and/or abnormal
masticatory loading of the prosthesis, which can occur with any one of several
parafunctional habits. Systemic conditions rarely prohibit placement of implants. In
particular, osteoporosis is not viewed as a contraindication to implant placement.5
Furthermore, there are no published reports of medication-related implant failure.
However, this report describes a patient who experienced loss of an
implant-supported hybrid fixed mandibular prosthesis while taking the
diphosphonate etidronate disodium for osteoporosis.
Case Report
In June of 1989, a 75-year-old Caucasian woman presented with a complaint of
JOMI on CD-ROM, 1995 Jan (74-77 ): Failure of Osseointegrated Dental Implants After… Copyrights © 1997 Quinte…

ill-fitting dentures. She had been edentulous for over 50 years. Her medical history
was significant for osteoporosis, hypothyroidism, nephrolithiasis, thyroidectomy,
cholecystectomy, hysterectomy, an ankle fracture suffered in 1986, and a hip
fracture sustained in 1987 that ultimately resulted in total hip replacement. The
patient was taking thyroid and estrogen replacement, as well as calcium and vitamin
D supplements. Clinical examination revealed severe atrophy of the maxilla and
mandible with virtually no residual alveolar ridges (Fig 1). After she had been
evaluated by her internist and no contraindications for surgery were reported, the
patient underwent placement of five endosseous implants in the anterior mandible
and augmentation of the maxillary residual alveolar ridge with nonresorbable
particulate hydroxyapatite. The date of the original surgery was August 31, 1989.
The surgical sites healed without complication, and the implants were uncovered on
December 6, 1989. The patient was restored with a new complete maxillary denture
and fixed hybrid mandibular prosthesis on January 3, 1990.
The patient returned for five routine recall appointments between May 1990 and
June 1991. Panoramic radiographs taken at these appointments revealed normal
healing (Fig 2). However, approximately 9 months following radiographic
examination, the patient returned complaining of pain in the mandible. A new
panoramic radiograph revealed extensive osteolysis around all five implants (Fig 3).
On questioning, the patient related that she had been placed on etidronate disodium
(Didronel, Norwich Eaton Pharmaceuticals, Norwich, New York) in December of
1991 to “build up her bones.” In addition, the patient had recently started a liquid
diet for weight loss that resulted in loosening of her maxillary denture, which caused
her to clench her teeth in an attempt to retain the denture. Importantly, the
radiographic appearance of uniform radiolucencies around each implant was unlike
anything previously observed or reported in the literature. After consultation with
the patient’s internist, the Didronel was discontinued and she was instructed not to
wear her denture. Unfortunately, the osteolysis resulted in loss of all five implants,
which were removed on April 30th, 1992 (Fig 4).
Discussion
Etidronate disodium (1-hydroxyethylidene or EHDP) is a diphosphonate that affects
bone metabolism. It has been used in the United States for the management of
Paget’s disease, osteoporosis, hypercalcemia of malignancy, and for the treatment of
heterotopic ossification following total hip replacement and spinal trauma. It may be
administered orally or intravenously. Low dose therapy ranges from 2.5 to 10
mg/kg/day, while higher dosage regimens of up to 20 mg/kg/day are reserved for
patients who fail to respond to low-dosage regimens. Didronel-induced osteomalacia
from continuous use in patients with osteoporosis has led to the development of
cyclic therapy regimens; the usual regimen consists of 2 weeks of therapy followed
by 10 to 13 weeks without medication.
Didronel has been demonstrated to arrest bone activation and/or turnover
6
JOMI on CD-ROM, 1995 Jan (74-77 ): Failure of Osseointegrated Dental Implants After… Copyrights © 1997 Quinte…

(remodeling).6 This attenuates the remodeling response of bone, making it unable to

respond effectively to mechanical stimuli such as those that occur continuously
around teeth and osseointegrated dental implants. Two related diphosphonates,
clodrinate and pamidronate, are associated with fewer adverse effects than
etidronate. Pamidronate was not approved by the Federal Drug Administration in
1989, and clodrinate has not been approved by the FDA for use in the United States.
In addition to Didronel therapy, the patient acquired the parafunctional clenching
habit secondary to rapid weight loss. It is our hypothesis that Didronel induced arrest
of bone turnover, which, combined with increased physiologic loads, contributed to
the abrupt loss of implants that had been successfully integrated for a period of 1⁄
years. Therefore, it is advisable to avoid diphosphonate therapy in patients who have
previously undergone implant placement, and to avoid implant placement in patients
who require diphosphonate therapy as part of the medical management of their
disease.
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1. Adell R, Lekholm U, Rockler B, Brånemark P-I. A 15 year study of osseointegrated

implants in the treatment of the edentulous jaw. Int J Oral Surg 1981;10:387–
416.
2. Albrektsson T, Zarb GA, Worthington PW, Eriksson AR. The long term efficacy of
currently used dental implants: A review and proposed criteria of success. Int J
Oral Maxillofac Implants 1986;1:11–25.
3. Lekholm U, Adell R, Brånemark P-I. Complications. In: Brånemark P-I, Zarb GA,
Albrektsson T (eds). Tissue-Integrated Prostheses: Osseointegration in Clinical
Dentistry. Chicago: Quintessence, 1985: 233–240.
4. ten Bruggenkate CM, Krekeler G, Kraaijenhagen HA, Foitzik C, Oosterbeek HS.
Hemorrhage of the floor of the mouth resulting from lingual perforation during
implant placement. Int J Oral Maxillofac Implants 1993;8:329–334.
5. Dao TTT, Anderson JD, Zarb GA. Is osteoporosis a risk factor for osseointegration
of dental implants? Int J Oral Maxillofac Implants 1993;8:137–143.
6. Jee WSS, Tang L, Ke HZ, Setterberg RB, Kimmel DB. Maintaining restored bone
with biphosphonate in the ovariectomized rat skeleton: Dynamic
histomorphometry of changes in bone mass. Bone 1993;14:493–498.
JOMI on CD-ROM, 1995 Jan (74-77 ): Failure of Osseointegrated Dental Implants After… Copyrights © 1997 Quinte…

Fig. 1 Original condition of

the maxillary and mandibular residual alveolar ridges.

Fig. 2 Condition of implants

at 1⁄ years prior to institution of etidronate disodium therapy.
JOMI on CD-ROM, 1995 Jan (74-77 ): Failure of Osseointegrated Dental Implants After… Copyrights © 1997 Quinte…

Fig. 3 Massive osteolysis 9

months after institution of etidronate disodium therapy. The patient eventually lost all five
implants 2 months later.

Fig. 4a (Right) Explanted prosthesis.

JOMI on CD-ROM, 1995 Jan (74-77 ): Failure of Osseointegrated Dental Implants After… Copyrights © 1997 Quinte…

Fig. 4b (Below) Resultant

condition of alveolar ridges.