Osteoporosis and Dental Implant Outcomes
Osteoporosis is a skeletal condition in which mineral is lost from bones, resulting in an increased risk of fracture. Bone resorption and bone deposition occur physiologically throughout life.
Osteoporosis results from resorption outpacing deposition, and changes in structural integrity make fracture more likely. Patients with osteoporosis have a bone mass density (BMD) at least 2.5 standard deviations below the benchmark, which is the BMD of a healthy 30-year-old of the same gender.1Pitts NB, Zero DT, Marsh PD, Ekstrand K, Weintraub JA, Ramos-Gomez F, Tagami J, Twetman S, Tsakos G, Ismail A. Dental caries. Nat Rev Dis Primers 2017;25(3):17030.,2JD. The caries balance: the basis for caries management by risk assessment. Oral Health Prev Dent 2004;2(Suppl 1):259-64. This is represented as a T-score of ≤-2.5 versus the benchmark. Osteopenia is an intermediate condition between normal bone density and osteoporosis, and is defined as a T-score between ≤-1 to >-2.5.2Featherstone JD. The caries balance: the basis for caries management by risk assessment. Oral Health Prev Dent 2004;2(Suppl 1):259-64. As a result of its potential impact in the maxilla and mandible, the effect of osteoporosis on the placement and long-term survival of dental implants has been examined.3Shuler CF. Inherited risks for susceptibility to dental caries. J Dent Educ 2001;65(10):1038-45. Given the low BMD seen with osteoporosis, there has been concern that the rate of bone-to-implant contact, bone support and implant survival may be impaired in patients with osteoporosis.4Opal S, Garg S, Jain J, Walia I. Genetic factors affecting dental caries risk. Aust Dent J 2015;60:2-11.,5Bretz WA, Corby PM, Melo MR, Coelho MQ, Costa SM, Robinson M, Schork NJ, Drewnowski A, Hart TC. Heritability estimates for dental caries and sucrose sweetness preference. Arch Oral Biol 2006;51(12):1156-60.,6Nibali L, Di Iorio A, Tu YK, Vieira A. Host genetics role in the pathogenesis of periodontal disease and caries. J Clin Periodontol 2017;44:S18:52-78.,7Lips A, Antunes LS, Pintor AVB, dos Santos DAB, Bachinski R, Küchler EC, Alves GG. Salivary protein polymorphisms and risk of dental caries: a systematic review. Braz Oral Res 2017;31:e41.
Implant survival rates and marginal bone loss
Figure 1. Mean marginal bone loss in women with and without osteoporosis3Shuler CF. Inherited risks for susceptibility to dental caries. J Dent Educ 2001;65(10):1038-45.
Other reviews and studies have also failed to find evidence for osteoporosis as an absolute or relative contraindication for implant placement, including a recent qualitative review in which the implant survival rate was similar for patients with and without osteoporosis.10Papapostolou A, Kroffke B, Tatakis DN, Nagaraja HN, Kumar PS. Contribution of host genotype to the composition of health-associated supragingival and subgingival microbiomes. J Clin Periodontol 2011;38:517-24.,11Gomez A, Espinoza JL, Harkins DM, Leong P, Saffery R, Bockmann M, Torralba M, Kuelbs C, Kodukula R, Inman J, Hughes T, Craig JM, Highlander SK, Jones MB, Dupont CL, Nelson KE. Host genetic control of the oral microbiome in health and disease. Cell Host Microbe 2017;22:269-78 e263.,12Shaffer JR, Wang X, McNeil DW, Weyant RJ, Crout R, Marazita ML. Genetic susceptibility to dental caries differs between the sexes: a family-based study. Caries Res 2015;49:133-40.,13Stahringer SS, Clemente JC, Corley RP, Hewitt J, Knights D, Walters WA, Knight R, Krauter KS. Nurture trumps nature in a longitudinal survey of salivary bacterial communities in twins from early adolescence to early adulthood. Genome Res 2012;22:2146-52. One study has also assessed peri-implantitis, finding no significant differences in the percentage of implants with peri-implantitis, evaluated for up to 10 years after insertion, for patients with and without osteoporosis.14Momeni SS, Whiddon J, Cheon K, Ghazal T, Moser SA, Childers NK. Genetic diversity and evidence for transmission of streptococcus mutans by DiversiLab rep-PCR. J Microbiol Methods 2016;128:108-17.
Implant stability
In one study, it was observed that MBL was significantly greater in the maxilla than the mandible for patients with osteoporosis, leading to the conclusion that achieving primary stability may differ for the two jaws.3Shuler CF. Inherited risks for susceptibility to dental caries. J Dent Educ 2001;65(10):1038-45. In a separate study, implant stability was assessed using resonance frequency analysis for 49 patients with and without osteoporosis.15Paglia L, Scaglioni S, Torchia V, De Cosmi V, Moretti M, Marzo G, Giuca MR. Familial and dietary risk factors in early childhood caries. Eur J Paediatr Dent 2016;17:93-9. While statistically significant differences were found for implant stability when comparing patients with osteoporosis to patients with a physiologically healthy BMD, implant osseointegration was achieved for all patient groups. Primary stability measured as the implant stability quotient (ISQ) was 63.3 ± 10.3, 65.3 ± 7.5 and 66.7 ± 8.7 ISQ, respectively, for patients with osteoporosis, osteopenia and without either condition (Figure 2). Following osseointegration, implant stability at the time of abutment placement measured 66.4 ± 9.5, 70.7 ± 7.8, and 72.2 ± 7.2 ISQ, respectively.15Paglia L, Scaglioni S, Torchia V, De Cosmi V, Moretti M, Marzo G, Giuca MR. Familial and dietary risk factors in early childhood caries. Eur J Paediatr Dent 2016;17:93-9.
Figure 2. Primary implant stability and stability at abutment placement (ISQ)
Implant surface morphology
Significantly less MBL has been observed to occur around rough-surface implants compared to machined (smooth surface) implants in patients with osteoporosis.3Shuler CF. Inherited risks for susceptibility to dental caries. J Dent Educ 2001;65(10):1038-45. Further, in a recent systematic review examining the impact of surface coatings on dental implants placed in osteoporotic bone in 6 laboratory studies, bone volume and bone-in-contact (BIC) were found in 5 of the 6 studies to be significantly greater for implants with osteoinductive and osteoproliferative coatings compared to non-coated implants.16Kong Y-Y, Zheng J-M, Zhang W-J, Jiang Q-Z, Yang X-C, Yu M, Zeng SuJ. The relationship between vitamin D receptor gene polymorphism and deciduous tooth decay in Chinese children. BMC Oral Health 2017;17:111. Laboratory studies also indicate that microrough-surface implants result in greater tissue maturation at 3 days and osseointegration at 14 days than is observed for machined surfaces under conditions of reduced BMD.17American Dental Association. Symposium on Early Childhood Caries in American Indian and Alaska Native Children, 2010.
Anti-resorptive therapy in patients with osteoporosis
Conclusions
Osteoporosis is not a contraindication to implant treatment. As populations age, an increasing number of people will require dental implants to maintain oral function, and may present with or subsequently develop osteoporosis. Patients must be informed of the risks, including increased MBL around implants and implant failure.20Acton RT, Dasanayake AP, Harrison RA, Li Y, Roseman JM, Go RCP, Wiener H, Caufield PW. Association of MHC genes with levels of caries-inducing organisms and caries severity in African-American women. Human Immunol 1999;60:984-9. Patients should also be educated about the need for sound oral hygiene practices and regular dental care for on-going evaluation.19Vieira AR, Modesto A, Marazita ML. Caries: review of human genetics research. Caries Res 2014;48:491-506.,20Acton RT, Dasanayake AP, Harrison RA, Li Y, Roseman JM, Go RCP, Wiener H, Caufield PW. Association of MHC genes with levels of caries-inducing organisms and caries severity in African-American women. Human Immunol 1999;60:984-9. Lastly, there is a need for additional, well-designed, longer-duration and larger sample size studies to assess the impact of severity of osteoporosis on implant survival, as well as the effect of comorbidities such as smoking or diabetes mellitus, and the impact of BP therapy.6Nibali L, Di Iorio A, Tu YK, Vieira A. Host genetics role in the pathogenesis of periodontal disease and caries. J Clin Periodontol 2017;44:S18:52-78.,8Wang X, Shaffer JR, Weyant RJ, Cuenco KT, DeSensi RS, Crout R, McNeil DW, Marazita ML. Genes and their effects on dental caries may differ between primary and permanent dentitions. Caries Res 2010;44:277-84.10Papapostolou A, Kroffke B, Tatakis DN, Nagaraja HN, Kumar PS. Contribution of host genotype to the composition of health-associated supragingival and subgingival microbiomes. J Clin Periodontol 2011;38:517-24.,21Bagherian A, Nematollahi H, Afshari JT, Moheghi N. Comparison of allele frequency for hla-dr and hla-dq between patients with ecc and caries-free children. J Indian Soc Pedod Prev Dent 2008;26:18-21.
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