Int. J. Oral Maxillofac. Surg.

2021; 50: 96–103

https://doi.org/10.1016/j.ijom.2020.03.014, available online at https://www.sciencedirect.com

Meta-Analysis
Dental Implants

Is there an association between C. C. G. Silva1, M. S. dos Santos1,

J. L. G. C. Monteiro1,
S. C. de Aguiar Soares Carneiro2,
B. C. do Egito Vasconcelos1
the use of antidepressants and 1
Department of Oral and Maxillofacial
Surgery, School of Dentistry, University of
Pernambuco, Pernambuco, Brazil; 2Service of

complications involving dental Oral and Maxillofacial Surgery, Hospital da

Restauração, Recife, Pernambuco, Brazil

implants? A systematic review

and meta-analysis
C. C. G. Silva, M. S. dos Santos, J. L. G. C. Monteiro, S. C. de Aguiar Soares Carneiro,
B. C. do Egito Vasconcelos: Is there an association between the use of antidepressants
and complications involving dental implants? A systematic review and meta-analysis.
Int. J. Oral Maxillofac. Surg. 2021; 50: 96–103. ã 2020 Published by Elsevier Ltd on
behalf of International Association of Oral and Maxillofacial Surgeons.

Abstract. The aim of this systematic review was to evaluate published evidence on the
association between the use of antidepressants and complications involving dental
implants. Two reviewers independently performed electronic searches of the
MEDLINE/PubMed, Cochrane Library, and Scopus databases for relevant articles
published up to May 30, 2019. This review was conducted in accordance with the
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)
guidelines. The Newcastle–Ottawa Scale was used for the appraisal of the
methodological quality of the studies included. A meta-analysis was performed to
determine the risk of dental implant failure in individuals taking antidepressants.
Five comparative observational studies were selected for this review; these included
a total of 2056 participants with 5302 implants. The results suggest a risk ratio of
3.73 (95% confidence interval 1.85–7.52, P = 0.0002) for implant failure in
Key words: dental implants; antidepressants;
antidepressant users submitted to oral rehabilitation when compared to non-users. meta-analysis.
However, these studies did not present methodological rigour or standardize the
drugs used. Thus, there is insufficient evidence for an association between Accepted for publication 18 March 2020
antidepressant use and dental implant complications. Available online 11 June 2020

Current global trends indicate that the life-
expectancy of the general population is
increasing throughout the world. Such
demographic changes are associated with
an increase in the prevalence of chronic
diseases and consumption of medications.
Moreover, there has been an increase
in the demand for oral rehabilitation pro-
cedures involving the placement of dental
implants in partially or completely
edentulous individuals among the popula-
tion of seniors1–3.
Some systemic disorders and the med-
ications used to manage these disorders
have an effect on bone metabolism,

0901-5027/01096 + 08 ã 2020 Published by Elsevier Ltd on behalf of International Association of Oral and Maxillofacial Surgeons.

exerting an important influence on out-
comes related to dental implants2. System-
ic diseases such as obesity, arthritis, and
other chronic diseases induce systemic
inflammation, which contributes to mar-
ginal bone loss and peri-implant disease.
Moreover, medications such as diuretics,
b-blockers, anti-inflammatory drugs,
proton pump inhibitors, and selective se-
rotonin reuptake inhibitors (SSRIs), also
affect bone metabolism1,4.
Depression and the use of antidepres-
sants have considerable clinical signifi-
cance5,6. According to the World Health
Organization, more than 350 million indi-
viduals around the world suffer from de-
pression or major depressive disorder
(MDD). This psychological disorder is
associated with changes in behaviour
and the neuroendocrine system. There is
no standardization of drugs in the treat-
ment of depression. A variety of drugs are
used for this purpose. SSRIs are the most
often prescribed antidepressants for the
treatment of this condition7.
SSRIs inhibit the reuptake of serotonin
at the synapse level, which leads to an
increase in serotonin concentration, con-
tributing to a sensation of wellbeing and
happiness. However, these medications
have systemic effects and can interfere
with bone metabolism, resulting in a re-
duction in both bone mass and bone min-
eral density4–6. The findings of Koura
et al.8 indicate that fluoxetine, an antide-
pressant, exerts a direct inhibitory effect
on bone cells via an apoptosis-dependent
pathway.
Despite the relatively high success rate
of dental implants in daily practice, fail-
ures can occur and constitute a significant
concern for both patients and dental pro-
fessionals. It is therefore important to
identify patients at greater risk of compli-
cations2,9.
Considering the global trend towards
the use of antidepressants and the need
to replace missing teeth with the instal-
ment of implants, the aim of this study was
to perform a systematic review of the
literature with meta-analysis on the asso-
ciation between the use of antidepressants
and complications involving dental
implants.
Materials and methods
Protocol and registry
This review was structured following the
Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA)
guidelines. The following was the guiding
question: Is there an association between
Antidepressants and dental implants
the use of antidepressants and complica-
tions involving dental implants? This sys-
tematic review has been registered in the
International Prospective Register of Sys-
tematic Reviews (PROSPERO, National
Institute for Health Research, York, UK;
registry number CRD42019119995).
Eligibility criteria
The guiding question was determined
using the PICO strategy, with descriptors
related to the topic designated for each
item: population (P), patients with dental
implants; intervention (I), individuals tak-
ing antidepressants; comparator (C), non-
users of antidepressants; outcome (O),
dental implant failure (primary outcome),
marginal bone loss (secondary outcome),
probing depth (secondary outcome), peri-
implantitis (secondary outcome), and oth-
er complications (secondary outcome).
These descriptors were combined in the
search fields of the databases.
The inclusion criteria were randomized
clinical trials, case–control or cohort ob-
servational studies, and case-series (more
than nine patients), and articles published
in English, Spanish, or Portuguese, with
no restrictions regarding date or time of
publication.
Articles were excluded for the follow-
ing reasons: in vitro studies; studies in-
volving animals; literature reviews; case
reports; other types of documents, such as
letters, abstracts presented at conferences,
and book chapters; studies that did not
evaluate the primary or secondary out-
comes; studies not related to the topic of
interest; and studies for which the full text
was not available in the databases.
Sources of information and search
criteria
The PubMed/MEDLINE, Cochrane Li-
brary, and Scopus databases were
searched for pertinent articles published
up to May 30, 2019. Mendeley Desktop
was used for the management of the refer-
ences and exclusion of duplicates. The
following combination of search terms
was used (with slight changes to adapt
to the interface of each database): ‘‘anti-
depressants’’ OR ‘‘antidepressive’’ OR
‘‘serotonin uptake inhibitors’’ OR ‘‘sero-
tonin reuptake inhibitors’’ OR ‘‘serotonin
inhibits’’ OR ‘‘monoamine oxidase inhi-
bitors’’ AND ‘‘implants’’ OR ‘‘dental
implants’’ OR ‘‘oral implant’’ OR ‘‘den-
tal implantation’’.
An additional search was performed of
the grey literature using Google Scholar.
A hand-search was also conducted in the
97
main journals in the fields of implantology
and oral and maxillofacial surgery to find
relevant articles: Clinical Oral Implants
Research, Clinical Implant Dentistry and
Related Research, International Journal
of Oral and Maxillofacial Implants,
European Journal of Oral Implantology,
International Journal of Oral and Maxil-
lofacial Surgery, Journal of Oral and
Maxillofacial Surgery, British Journal of
Oral and Maxillofacial Surgery, and Jour-
nal of Cranio-Maxillofacial Surgery.
Data collection process
Two independent reviewers (C.C.G.S. and
M.S.S.) who had undergone a calibration
exercise, performed the selection of the
articles in two phases. In phase 1, the two
reviewers performed an independent
blinded analysis of the titles and abstracts
of all references based on the eligibility
criteria. In the case of a divergence of
opinion, a third reviewer (J.L.M.) was
consulted and a discussion was held until
a consensus was reached. Any study that
did not meet the eligibility criteria was
discarded. In this step, inter-evaluator
agreement was calculated using the kappa
statistic to determine the level of agree-
ment in the pre-selection of articles based
on the titles and abstracts. In phase 2, the
same reviewers (C.C.G.S. and M.S.S.)
performed full-text analyses of the
pre-selected articles for the determination
of eligibility and the extraction of relevant
information.
Data extraction
Two reviewers (C.C.G.S. and M.S.S.)
extracted the following data from the se-
lected articles: year of publication, author
(s), country of origin, type of study, sample,
dropouts, mean age, sex, follow-up time,
outcome studied, antidepressant medica-
tion taken, intervention and control, and
the method of evaluation of peri-implant
health or complications.
Meta-analysis
A meta-analysis was performed with the
aid of Review Manager (RevMan version
5.3, 2014; The Nordic Cochrane Centre,
The Cochrane Collaboration, Copenha-
gen, Denmark), and 95% confidence
intervals (CI) were calculated. A P-value
<0.05 was considered indicative of a sta-
tistically significant result. A forest plot
was generated for dental implant failure to
enable the evaluation of global and indi-
vidual results. Heterogeneity among the
studies was determined using the x2 test.
98 Silva et al.

Total number Quality

domain + 1 or 2 stars in the comparability domain + 2 or 3 stars in the outcome domain; ‘reasonable quality’: 2 stars in the selection domain + 1 or 2 stars in the comparability domain + 2 or 3 stars in the
Thresholds for conversion of the Newcastle–Ottawa classification to standards of Agency for Health Research Quality (good, reasonable, and poor): ‘good quality’: 3 or 4 stars in the selection
ratinga
A random-effects model was used, due to

Good
Good
Good
Good
Poor
the P-value of <0.10 in the calculation of
heterogeneity. I2 values higher than 50%
indicate ‘substantial heterogeneity’

of stars
and those higher than 75% indicate
‘considerable heterogeneity’. The
Cochrane Handbook for Systematic

8
7
7
8
5
Reviews of Interventions (version 5.1.0)

the non-exposed Ascertainment present at start Implant Prosthetic Assessment of Long-term of follow-up
was used for this interpretation.

follow-up of cohorts
Adequacy
Appraisal of methodological quality of

$
selected studies
Two reviewers (C.C.G.S. and M.S.S.)

Outcome
independently performed the appraisal

outcome domain; ‘poor quality’: 0 or 1 star in the selection domain or 0 stars in the comparability domain or 0 or 1 stars in the outcome domain.
of the methodological quality of the

$
$
$
$
$
studies selected for this review. The
Newcastle–Ottawa Scale was used to
judge the quality of case–control observa-
tional studies10. This scale is widely used

outcome
to assess the methodological quality of

Table 1. Summary of the methodological quality of each study included in the review according to the Newcastle–Ottawa Scale.

$
$
$
$
case–control and cohort studies with
regards to the selection of the study groups
and comparability between the groups and

factors
outcome, with a star awarded for each Comparability

$
item considered adequate. Each study
receives one star for each item fulfilled
in the ‘selection’ and ‘outcome’ catego- failure
ries and a maximum of two stars may be
$
$
$
$
$
awarded for ‘comparability’. The total
possible score ranges from 0 (worst) to
Outcome not

9 (best) stars10.
of study

The minimum score was 5 stars and the

maximum score was 8 stars. For the se-
$
$
$
$

lection category, 4 stars were attributed to

the majority of studies (80%). Regarding
of exposure

comparability, only one study (20%) re-

ceived 2 stars. For the outcome category,
the majority of studies (80%) received 2
stars. Thus, the studies selected for this
$
$
$
$
$

review generally exhibited good method-

Selection

ological quality (Table 1).

Representativeness of Selection of

Results
cohort

In the first phase, 333 publications were

$
$
$
$
$

identified in the database search, 10 of

which were duplicates and were removed.
The analysis of the titles and abstracts led
to the exclusion of 310 studies. In this
the exposed

step, the inter-evaluator kappa coefficient

was 0.81 for the pre-selection of studies to
cohort

be submitted to full-text analysis. No ad-

ditional publications were found through
$
$
$
$
$

Google Scholar, the reference lists of the

Chrcanovic et al. (2017)14

selected studies, or the hand-search of

Alsaadi et al. (2008)12

scientific journals. Full-text analysis was

Deepa et al. (2018)13
Altay et al. (2018)6

performed on 13 articles in the second

Wu et al. (2014)11

Source: Authors.

phase, leading to the elimination of eight

studies. Figure 1 shows the flowchart of
the article selection process.
Five comparative observational studies
Study

met the inclusion criteria6,11–14. These stud-

a

ies involved a total of 2056 participants and


Fig. 1. PRISMA flow diagram of the study selection process.
all had a control group of non-users of
antidepressants. There was no uniformity
in the use of antidepressant medications.
Two studies, by Wu et al.11 and Chrcanovic
et al.14, used the following medications:
citalopram, dapoxetine, escitalopram,
fluoxetine, fluvoxamine, indalpine, paroxe-
tine, sertraline, venlafaxine, and zimeli-
dine. The study of Altay et al.6 included
the same medications, with the exception of
dapoxetine, indalpine, venlafaxine, and
zimelidine. Alsaadi et al.12 and Deepa
et al.13 did not specify the antidepressant
medications used. Table 2 summarizes the
characteristics of the studies included in this
review.
Dental implant failure
Implant failure was reported in all five
studies. The results of the meta-analysis
Antidepressants and dental implants
of the use or non-use of antidepressants for
the outcome ‘implant failure’ are shown in
Fig. 2. Heterogeneity (determined using
the x2 test) was considered moderate to
substantial (P < 0.03; I2 = 64%). Thus, a
random-effects model was used as the
statistical method. This condition is a
reflection of the diversity of the studies
used as the basis for the analysis. The
forest plot demonstrated a statistically
significant greater occurrence of dental
implant failure among users of antidepres-
sants compared to the control group, with
a risk ratio of 3.73 (95% CI 1.85–7.52,
P = 0.0002).
Appraisal of the methodological quality
of the selected studies
The main sources of bias in the studies
were comparability for prosthetic factors
99
and the adequacy of follow-up of the
cohorts (Fig. 3). The study with the lowest
score (five stars) had a cross-sectional
design13. The studies with the highest
scores (8 out of 9 stars) were those con-
ducted by Alsaadi et al.12 and Altay et al.6
(Table 1).
Discussion
Depression is associated with changes in
behaviour and the neuroendocrine system,
and is seen increasingly at younger ages.
Antidepressants are often prescribed as the
first line of treatment. SSRIs inhibit the
reuptake of serotonin at the synapse level,
which increases the concentration of sero-
tonin, contributing to a sensation of wellbe-
ing and happiness. However, the inhibition
of serotonin reuptake causes an increase
in the differentiation of osteoclasts and a
100 Silva et al.

Clinical follow-up

Analysis of charts

Analysis of charts

Analysis of charts

Analysis of charts
reduction in the proliferation of osteoblasts,
leading to an increased risk of dental
implant failure1,4,6,15–17.
Assessment

In this review, the total sample com-

(controls) method

prised 2056 participants with 5302

implants, and the occurrence of dental
implant failure was significantly higher

11/1946
among patients taking antidepressants.
Implant
failures

12/647

38/822

29/883
(1.8%)

(4.6%)

(3.3%)

(0.6%)

(1.1%)
5/450c
There was no uniformity in the use of
antidepressant medications. Wu et al.11
and Chrcanovic et al.14 reported the use
(10.6%)

(12.5%)
Implant
Antidepressant failures

(3.4%)

(7.3%)

(3.0%)
(users)

7/230c
of the following medications: citalopram,
10/94

8/109
2/59

6/48

dapoxetine, escitalopram, fluoxetine, flu-

voxamine, indalpine, paroxetine, sertra-
line, venlafaxine, and zimelidine. Altay
et al.6 reported the use of citalopram,
medication

escitalopram, fluoxetine, fluvoxamine,

Implant failure SSRIsb
a

Implant failure SSRIsa

Implant failure SSRIs

Implant failure SSRIs

paroxetine, and sertraline, which were

Implant failure NR

the medications for the treatment of

MDD available in Turkey (where the
study was conducted) at the time of the
study. Alsaadi et al.12 and Deepa et al.13
Citalopram, dapoxetine, escitalopram, fluoxetine, fluvoxamine, indalpine, paroxetine, sertraline, venlafaxine, and zimelidine.
time (months) Outcome

did not specify the antidepressants used by

the participants in their studies.
SSRIs are among the most commonly
prescribed antidepressant medications for
the treatment of MDD and are considered
Follow-up

safer than other antidepressants5,6,18.

However, this class of drugs has systemic
164
67

60

60

effects and many studies have been con-

6

ducted to investigate the impact of these

M 198

M 145

M 292

M 150
F 187

F 292

F 155

F 339

F 202

medications on the organism. Diem et al.19

M 96
Sex

reported that the use of SSRIs is associated

with increased rates of bone loss in the
Mean age

hips of women compared to non-users.

(Total implants) Dropouts (years)

Likewise, Richards et al.20 found an asso-

50.80
56.2

56.4

55.9

...

F, female; M, male; NR, not reported; SSRI, selective serotonin reuptake inhibitor.

ciation between the use of SSRIs and

Citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline.

lower bone mineral density, which is re-

Table 2. Description of characteristics of articles included in present review.

lated to an increased risk of fracture. An

observational study conducted by Wil-
...

...

...

...

liams et al.21 also demonstrated that SSRIs

0

exert a negative impact on bone mineral

density.
Sample, n

Koura et al.8, in an in vitro study, in-

vestigated the effects of fluoxetine on bone
(2055)
(706)

(916)

(931)

(680)

using mesenchymal stem cells (MSCs)

283

Retrospective cohort 490

Retrospective cohort 300

Retrospective cohort 631

352

derived from rat adipose tissue. MSCs

Only ‘implant failure’ considered in this item.

were left to differentiate into osteopro-

genitor cells. Various concentrations of
fluoxetine were then added to the cells.
Retrospective

The underlying molecular pathways asso-

Prospective

ciated with the effects of fluoxetine on

Type of

bone were investigated. The study results

study

revealed a significant dose-dependent in-

crease in apoptosis in response to in-
Chrcanovic et al. (2017)14

creased dose of fluoxetine, regardless of

serotonin levels. These findings showed
Alsaadi et al. (2008)12

Deepa et al. (2018)13

that fluoxetine exerted a direct inhibitory

Altay et al. (2018)6
Wu et al. (2014)11

effect on bone cells via an apoptosis-

dependent pathway and that this drug is
thus involved in the process of bone loss.
Germany
Country
Authors

Implant failure is generally caused

Sweden
Canada

Turkey

India

by deficient osseointegration, peri-

b
a

implantitis, mechanical overload, or a


Fig. 2. Meta-analysis demonstrating a statistically significant increase in dental implant failure in anti-depressant users compared to non-users.
Fig. 3. Risk of bias in studies included in this review.
combination of these factors. Early fail-
ures occur within a few months or even
weeks after placement and result from an
incapacity to establish close contact be-
tween the bone and implant due to com-
promised repair, contamination of the
implant, or a lack of mechanical stability.
Late failures mainly occur after 2 years of
follow-up and are often caused by peri-
implantitis (progressive marginal bone
loss induced by plaque) or mechanical
overload11,12. In the present study, it
was found that dental implant failure
was 3.73 times more likely to occur in
the antidepressant users than in the non-
users.
In the prospective study conducted by
Alsaadi et al.12, it was not possible to draw
definitive conclusions regarding the use of
antidepressants and implant failure due to
the low number of early failures (1.9%). In
the retrospective cohort study conducted
by Wu et al.11, which included 916 dental
implants in 490 patients (94 implants in 51
patients taking SSRIs), the failure rate was
10.6% among users of SSRIs and 4.6%
among non-users, and the authors con-
cluded that the consumption of SSRIs
was associated with an increased risk of
the failure of osseointegrated implants.
Chrcanovic et al.14 retrospectively an-
alysed the results of therapy involving 931
dental implants in 300 patients and found a
Antidepressants and dental implants
12.5% failure rate among users of SSRIs
compared to a 3.3% failure rate among
non-users. However, multivariate analysis
of the data revealed no statistically signif-
icant difference between the groups, sug-
gesting that the use of SSRIs may not be
associated with an increased risk of dental
implant failure. Similar results were
reported in the retrospective studies con-
ducted by Altay et al.6 and Deepa et al.13,
who found no statistically significant dif-
ference in implant failure among users and
non-users of SSRIs, although the chance
of unsuccessful osseointegration of dental
implants was higher among those taking
SSRIs.
The implant survival rate is also influ-
enced by other factors that affect bone
metabolism, such as age, sex, radiotherapy,
smoking, implant size, surgical conditions,
and other systemic medications1,2,17. In the
studies by Wu et al.11, Chrcanovic et al.14,
and Altay et al.6, the researchers controlled
the participant selection process, excluding
individuals with severe systemic diseases
and those with factors that affect bone
metabolism, resulting in a lower risk of bias
regarding the final values. Alsaadi et al.12
and Deepa et al.13 did not perform this
control of the participant selection process,
which may have generated biased results.
Smoking, especially nicotine, impairs
new bone formation, reduces calcium
101
absorption, and decreases bone mineral
density transiently, harming the osseointe-
gration process of the implant11. In the study
by Wu et al.11, they observed a significant
increase in the risk of dental implant failure
associated with smoking in antidepressant
users. The studies by Alsaadi et al.12 and
Deepa et al.13 found a higher number of
early implant failures in smokers, but did
not make a direct association with antide-
pressant use. In the studies by Altay et al.6
and Chrcanovic et al.14, smoking patients
were excluded due to the interference of
nicotine in bone healing. The study by
Chrcanovic et al.14 was the only study that
also excluded patients with parafunctional
habits (bruxism) from its sample, due to the
deleterious effects of this habit on implant
stability.
The psychological status of the patient
is another factor that may increase the risk
of implant failure. Studies have reported a
greater occurrence of deficient oral hy-
giene in individuals with MDD compared
to the general population, with higher rates
of dental caries, tooth loss, xerostomia,
and soft tissue lesions. This tendency may
be related to lifestyle, poor oral hygiene,
and a failure to seek dental care17,22.
Xerostomia may be related to implant
failure due to the protective effect of saliva
against numerous pathogens. In the study
by Cockburn et al.22, the most frequently
102 Silva et al.
reported side effect in antidepressant users
was dry mouth. Salivary reduction due to
pharmacological treatment with antide-
pressants puts oral health at risk. A study
by Tan et al.23 found that tricyclic anti-
depressants enhance the actions of nor-
adrenaline and serotonin by blocking their
reuptake at the neuronal membrane, but
they also block histamine, a1-adrenergic,
and muscarinic acetylcholine receptors,
resulting in xerostomia.
Altay et al.6 were the only researchers to
investigate the periodontal health of the
participants prior to the placement of the
implants. All patients were submitted to
periodontal therapy and were only consid-
ered ready for implant placement when no
clinical sign of active periodontal disease
was detected. Thus, all patients were con-
sidered clinically healthy in terms of peri-
odontal status at the time of implant
placement. Controlling for this predispos-
ing factor (periodontal disease) enhanced
the validity of the results with regards to
implant failure.
Patient follow-up ranged from 6 months
(Alsaadi et al.12) to 164 months (Chrca-
novic et al.14). Due to the short follow-up
period (6 months), Alsaadi et al.12 only
evaluated the phase of primary stability
prior to the placement of the prosthetic
component. This time factor may have
exerted an influence on the low implant
failure rate in that study (1.9%).
In the study conducted by Wu et al.11,
the implants placed in patients taking
SSRIs were followed up for 67 months
and exhibited favourable primary me-
chanical stability, acceptable bone quan-
tity and quality, and good initial healing.
The main reason for implant failure
among the users of SSRIs was related
to mechanical load on the implants. This
finding is in agreement with data de-
scribed in an in vivo study conducted
by Sibilia et al.4, who demonstrated that
serotonin plays an important role in the
anabolic response of bone to mechanical
load, indicating that SSRIs can cause
bone loss around the implants by inhibit-
ing the bone remodelling process trig-
gered by mechanical load.
Certain limitations of this systematic re-
view should be taken into consideration
when interpreting the findings. Several fac-
tors may have influenced the results of the
studies, including the lack of information on
the type, dose, and duration of SSRI thera-
py, which could not be analysed in detail
due to the inherent limitations of the retro-
spective design of the majority of stud-
ies6,11,13,14. Moreover, the observational
studies would require greater methodologi-
cal rigour and standardization to enable a
uniform comparison of the different drugs
and outcomes.
In conclusion, there is insufficient
evidence to support the association
between antidepressant use and dental
implant complications. Further well-
conducted prospective studies with a sig-
nificant sample size and standardization of
data are needed to provide a better under-
standing of the effects of antidepressants
on dental implant survival.
Funding
This work received financial support from
the Brazilian fostering agencies Coorde-
nação de Aperfeiçoamento de Pessoal de
Nı́vel Superior (CAPES (Coordination for
the Improvement of Higher Education
Personnel)) and Conselho Nacional de
Desenvolvimento Cientı́fico e Tecnoló-
gico (CNPq (National Council for
Scientific and Technological Develop-
ment)). The second and third authors re-
ceived master’s degree scholarships from
CAPES.
Competing interests
The authors declare no conflicts of inter-
est.
Ethical approval
Not applicable.
Patient consent
Not applicable.
Acknowledgements. Richard Boike pro-
vided the English editing of the manu-
script. All authors read and approved the
manuscript.
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Address:
Belmiro Cavalcanti do Egito Vasconcelos
University of Pernambuco
School of Dentistry
Oswaldo Cruz University Hospital
Department of Oral and Maxillofacial
Surgery
Arnóbio Marquês Street
310
Recife
PE
CEP 50100-130
Brazil
Tel.: +55 (81) 988868677
E-mail: belmiro.vasconcelos@upe.br