Dental Implant Treatment in Medically Compromised Patients [1st ed. 2020] 978-3-030-28556-2, 978-3-030-28557-9

Table of contents :
Front Matter ....Pages i-xi
Introduction (Ya-qian Chen, Quan Yuan)....Pages 1-10
Medically Compromised Patients: A Biological and Social Challenge (Lin Xiang, Ya-qian Chen, Quan Yuan)....Pages 11-20
The Role of Substance Abuse in Dental Implant Treatment (Yan Huang, Ping Gong)....Pages 21-35
Organ Diseases and Dental Implant Treatment (Dan Zhao, Qiu-chan Xiong, Shigehiro Ono, Yoshiaki Ninomiya, Masaaki Takechi)....Pages 37-72
Bone Diseases and Dental Implant Treatment (Yu-chen Guo, Quan Yuan)....Pages 73-101
Dental Implant Treatment for Diabetic Patients (Yun-shu Wu, Yuan Wang, Quan Yuan)....Pages 103-127
Immune System-Related Diseases and Dental Implant Treatment (Xiao-fei Zheng, An-chun Mo)....Pages 129-147
Drug-Induced Disorders and Dental Implant Treatment (Chinhua Hsiao, Hai Qing)....Pages 149-183
Dental Implant and Oral Diseases (Xing-ying Qi, Lei Sui, Wei-qing Liu)....Pages 185-209
Other Conditions Affecting Dental Implant Treatment (Xiao-bo Duan, Kazuya Doi, Quan Yuan, Shi-wen Zhang)....Pages 211-253

Citation preview

Dental Implant Treatment in Medically Compromised Patients Quan Yuan Editor

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Dental Implant Treatment in Medically Compromised Patients

Quan Yuan Editor

Dental Implant Treatment in Medically Compromised Patients

Editor Quan Yuan West China School of Stomatology Sichuan University Chengdu China

ISBN 978-3-030-28556-2    ISBN 978-3-030-28557-9 (eBook) https://doi.org/10.1007/978-3-030-28557-9 © Springer Nature Switzerland AG 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Preface

As global aging society is coming, more and more people live with diverse diseases or conditions such as systemic disorders, renal system disorders, and psychiatric issues. Consecutively, when these patients are encountering tooth loss, we should keep in mind that these patients are usually with adverse conditions like bleeding disorders, bone metabolism disorders, and/or immunosuppressive medication. Furthermore, it is well-established that tooth loss caused by periodontitis and implant failure triggered by peri-implantitis have been largely reported in smokers and diabetic patients. Besides, special consideration should also be kept in mind when we treat patients with head and neck cancer. Although implant-supported restorations have been considered the most comfortable prosthesis and patients are often satisfied with the function, dentists must pay more attention when treating medically compromised patients because they may not have a good condition for osseointegration and soft tissue healing around implants. Hence, I want to edit a reference book for practitioners to find suggestions on how to make decisions when the medically compromised patients come for implant treatment and to improve the results of treatment procedures in these patients. It is our effort to elucidate a thorough background of the possible diseases that would have an influence on the outcome of oral implants placed in these patients. More specifically, we would like to explain in detail in each chapter about the general success rate of oral implants in the medically compromised patients, their possible related changes in oral environment, their treatment consideration (including surgical and prosthodontic procedures), as well as the pharmacological considerations and oral hygiene maintenance. As Confucius once said: “One should learn and unceasingly.” I hope this book will help the readers to make decisions on their daily practice and improve their treatment outcome, leading to improved care and patient satisfaction. I would like to thank Qi-wen Li, Jun-ru Wen, Shuang Jiang, Wei-min Lin, Xiao-­ han Zhang, and Cao-jie Liu for their help during the writing of this book. Thanks also to Yun-shu Wu for her assistance in the manuscript preparation. Finally, my deepest gratitude goes to all authors for sharing their knowledge and experience in this book. Chengdu, China

Quan Yuan

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Contents

1 Introduction������������������������������������������������������������������������������������������������   1 Ya-qian Chen and Quan Yuan 2 Medically Compromised Patients: A Biological and Social Challenge����������������������������������������������������������������������������������  11 Lin Xiang, Ya-qian Chen, and Quan Yuan 3 The Role of Substance Abuse in Dental Implant Treatment������������������  21 Yan Huang and Ping Gong 4 Organ Diseases and Dental Implant Treatment��������������������������������������  37 Dan Zhao, Qiu-chan Xiong, Shigehiro Ono, Yoshiaki Ninomiya, and Masaaki Takechi 5 Bone Diseases and Dental Implant Treatment����������������������������������������  73 Yu-chen Guo and Quan Yuan 6 Dental Implant Treatment for Diabetic Patients������������������������������������ 103 Yun-shu Wu, Yuan Wang, and Quan Yuan 7 Immune System-Related Diseases and Dental Implant Treatment ���������������������������������������������������������������� 129 Xiao-fei Zheng and An-chun Mo 8 Drug-Induced Disorders and Dental Implant Treatment���������������������� 149 Chinhua Hsiao and Hai Qing 9 Dental Implant and Oral Diseases������������������������������������������������������������ 185 Xing-ying Qi, Lei Sui, and Wei-qing Liu 10 Other Conditions Affecting Dental Implant Treatment ������������������������ 211 Xiao-bo Duan, Kazuya Doi, Quan Yuan, and Shi-wen Zhang

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Editors and Contributors

About the Editor  uan  Yuan  is a professor of oral implantology, and Q Chair of Department of Prosthodontics at West China School of Stomatology, Sichuan University, which is the most prestigious dental school in mainland China. He received his D.D.S. degree and accomplished his postgraduate program of oral implantology at West China School of Stomatology. He then pursued international trainings at Hiroshima University, Harvard School of Dental Medicine, and UCLA School of Dentistry to acquire most advanced knowledge and skills. Dr. Yuan shows special interest and great ability in the field of implant dentistry and bone biology. His work focuses on the integration of clinic, research and education of implant dentistry. He has published over 70 peer-reviewed papers and delivered academic lectures in international conferences. He also serves as vice editor or editorial board member for eight scientific journals (including Chinese journals). Last year, he was elected as Changjiang-endorsed youth scholar issued by the Chinese Ministry of Education, which is the highest academic award for university faculties. Dr. Yuan is dedicated to devote his work and passion to promote the development of dental implantology. He is an Executive Committee Member of Dental Implant section, Chinese Stomatological Association, and the president-elected of Sichuan provincial section. He is also an ITI fellow, and has been awarded two research grants from International Team of Implantology.

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Editors and Contributors

Contributors Ya-qian  Chen  State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China Kazuya  Doi  Department of Advanced Prosthodontics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan Xiao-bo  Duan  State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China Ping Gong  Department of Oral Implantology, West China Hospital of Stomatology, Sichuan University, Chengdu, China Yu-chen  Guo  State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China Chinhua  Hsiao  Maurice H.  Kornberg School of Dentistry, Temple University, Philadelphia, PA, USA Yan Huang  OMFS-IMPATH, Department of Imagining & Pathology, K.U. Leuven, Leuven, Belgium Department of Oral Implantology, West China Hospital of Stomatology, Sichuan University, Chengdu, China Wei-qing  Liu  State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China An-chun  Mo  Department of Oral Implantology, West China Hospital of Stomatology, Sichuan University, Chengdu, China Yoshiaki  Ninomiya  Department of Oral and Maxillofacial Surgery, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan Shigehiro  Ono  Department of Oral and Maxillofacial Surgery, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan Xing-ying  Qi  State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China Hai Qing  Private Practice at Bucks Dental Health and Esthetics, LLC, New Britain, PA, USA

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Adjunct Faculty, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA, USA Lei Sui  Tianjin Medical University School and Hospital of Stomatology, Tianjin, China Masaaki  Takechi  Department of Oral and Maxillofacial Surgery, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan Yuan Wang  State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China Yun-shu  Wu  State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China Lin Xiang  Department of Oral Implantology, West China Hospital of Stomatology, Sichuan University, Chengdu, China Qiu-chan  Xiong  State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China Quan Yuan  State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China Department of Oral Implantology, West China Hospital of Stomatology, Sichuan University, Chengdu, China Shi-wen  Zhang  State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China Dan Zhao  Discipline of Periodontology & Implant Dentistry, Faculty of Dentistry, The University of Hong Kong, Hong Kong, Hong Kong SAR, China State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China Xiao-fei  Zheng  Department of Stomatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China

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Introduction Ya-qian Chen and Quan Yuan

1.1

I ndications for Dental Implants, Inclusion Criteria for Patients

It is commonly known that having healthy teeth affects one’s oral health and whole body health. Tooth loss can affect one’s quality of life due to reduced aesthetics, chewing ability, and speaking ability. Despite the significant progress that has been made to improve oral health, tooth loss still remains a dental public health problem [1]. Tooth loss may be due to various reasons. However, the most common reasons for tooth extractions are dental caries, periodontal disease, impacted teeth, orthodontic treatment, and prosthetic purposes [2]. Some studies suggested that periodontal diseases are the most common reason for tooth loss, while others reported that deep carious lesions are highly linked with tooth extraction [3, 4]. Tooth loss can have a large influence on health-related quality of life, which was shown to be even greater than having cancer or hypertension when one patient had fewer than nine teeth in mouth [5]. Tooth loss will cause functional impairment with regard to chewing and esthetics. Loss in posterior alveolar will significantly decrease chewing efficiency while anterior tooth loss is more related to esthetics; both might ultimately affect the quality of life. Moreover, edentulism leads to residual ridge resorption, impaired masticatory

Y.-q. Chen State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China Q. Yuan (*) State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China Department of Oral Implantology, West China Hospital of Stomatology, Sichuan University, Chengdu, China e-mail: [email protected] © Springer Nature Switzerland AG 2020 Q. Yuan (ed.), Dental Implant Treatment in Medically Compromised Patients, https://doi.org/10.1007/978-3-030-28557-9_1

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and speech function, poor facial appearance, and reduced self-confidence, which together result in a poor oral health-related quality of life [6]. Therapeutic options for tooth loss of each specific patient depend on the three elements of evidence-based dentistry (EBD): external evidence, internal evidence, and patients’ needs and preferences [7]. External evidence can be construed as the most acceptable scientific criteria and treatment outcomes reported in the literature review, while internal evidence means the clinical expertise of the professionals. Besides, it is also fundamentally important to take patients’ needs and preferences into consideration when deciding the most suitable treatment plan for the individuals [8]. On the other hand, as dental implantology develops rapidly, dental implants are now a popular option for replacement of tooth loss with high long-term survival rates [9, 10]. Implant treatment has explicit advantages over fixed partial dentures and removable dentures such as to avoid tooth preparation and possible sequelae, to avoid mechanical risks of conventional bridges, desirable retention, and support for the upper denture. It’s reported that single-implant treatment is more likely to be indicated than removable partial dentures (RPD) in highly educated patients, and also more likely to be chosen as therapy than fixed dental prosthesis (FDP) in patients with intact adjacent natural teeth [11]. Another study revealed that most dentists perceived implants as a treatment superior to conventional prostheses because of the advantages mentioned above [12]. Dental implantology is evolving rapidly. Although dental implants offer us many advantages, it is also important to bury in mind that now, more and more complications and failures of dental implants are challenging practitioners. Implant failures can be classified into early failures and late failures. Complications include biological complication, mechanical complication, and esthetic complication. We should always bear in mind that we should not lose the balance of the inclusion criteria and exclusion criteria for patients. On account of continuous modifying of implant design and surgical techniques, the literature contains reports of high success rates with the use of dental implants. Therefore, the range of indications for dental implants has been less strict than before [13]. Since the 1990s, the most frequent indication for implant placement was patients with edentulous mandible [14]. In a recent study, Busenlechner et al. reported that almost half of the implants (46.3%) were placed in partially edentulous patients other than fully edentulous patients [15]. Basic patient inclusion criteria contain a good general oral hygiene, the presence of edentulous maxilla or mandible, and the vertical distance of at least 7 mm of occlusal–gingival space to assure predictable prosthodontic outcome. Bone quality used to be a crucial factor when considering patient inclusion. However, recent studies have revealed that the osseointegration and clinical treatment outcome are compatible between osteoporosis patients and healthy patients [16]. So is the case with bone height in the posterior maxilla. Sinus floor augmentation techniques are important surgical ways when managing posterior maxillary tooth loss. Traditional view takes the attitude that when the residual bone height is more than 4 or 5 mm, it is suggested to insert implants. Because of the particularity of implant placement in this area, complications such as perforation of the sinus membrane and infection of graft could happen [17, 18]. However, as recent clinical studies confirm a positive treatment result of

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short implants, bone augmentation procedures are required less frequently in posterior maxilla and bone height appears to be no longer a limit of implant placement [19]. For some dentists, short implants might be a preferable selection to vertical bone augmentation procedures given the higher number of increased morbidity, more financial costs, and surgical time associated with placement of longer dental implants with bone graft [20, 21]. As for some other risk factors such as diabetes, smoking, and periodontal diseases, we will discuss them in detail in each individual chapter. But most of all, a dental implantology practitioner should explain all the treatment choices and their advantages as well as disadvantages to their patients. Patients’ acceptance of the failure and complication risk, cost, and long therapy period of dental implants should be the prerequisite before all the inclusion.

1.2

Survival and Success Criteria for Dental Implants

It is fairly well known that the survival rate stands for whether the implant still physically exists in the mouth or has been taken out [22]. However, the technical improvements in contemporary dental implantology, along with high expectations of treatment outcome from patients, underline a more integrated understanding and comprehensive definition of success criteria for dental implant as a prosthodontic treatment. Therefore, evaluating a dental prosthesis only by its survival rate seems insufficient in perceiving the implant/prosthesis as a whole. We suggest dental implantology practitioners evaluate the clinical efficiency of implant prosthesis in multiple aspects rather than the physical existence of the implants. The most globally accepted criteria for the evaluation of implant success were first put forward by Albrektsson and colleagues: (1) when examined clinically, implant was immobile; (2) radiograph examination did not demonstrate any evidence of peri-implant radiolucency; (3) crestal bone loss was less than 0.2  mm annually after the implant’s first year of function; and (4) absence of signs and symptoms such as pain, infection, neuropathies, and paresthesia [23]. To identify clinical evidence of successful osseointegration as well as survival of implants, the primary criteria for assessing implant are the mobility, pain, and healthy tissue around the implants [24]. Nowadays, the academic term “lack of mobility” is used as a description to judge whether the implant is integrated in most occasions. Nevertheless, lack of clinical mobility does not imply the true absence of movement. A well-osseointegrated implant may have a movement range from 0 to 75 μm which is not detectable clinically [25]. The marginal bone around the implant crestal region is commonly perceived as a significant indicator of implant health. Most dentists consider it necessary to detect the marginal bone loss annually. The other criteria described by Albrektsson and colleagues are addressing the healthy surrounding tissue around the implant such as no peri-implant radiolucency or pain and infection. However, this criterion does not consider the amount of marginal bone loss during the first year after loading. In addition, these descriptions illustrate an ideal implant quality of health from a clinician’s perspective, but do not address the implants and the prosthesis as a whole.

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Over the past decades, new parameters have been put forward to assess the success of implant prosthodontic treatments. An implant quality of health scale was established by James in 1993, and further developed by Misch [26]. The publication reported four clinical categories that described conditions of implant success, survival, and failure. Among the four conditions, survival conditions contain two different categories: firstly, satisfactory survival condition indicates an implant with less than ideal conditions, but does not require any clinical management; secondly, compromised survival condition demonstrates implants with less than ideal conditions, which needs clinical management to prevent it from developing to an implant failure. Implant failure is the term to manifest the implants that require removal or have already been lost. The success category describes ideal condition for implants: no pain is observed with palpation or percussion examination, the implant is in good function, no clinical implant mobility is detected with loads less than 500 g in any direction, and importantly less than 2 mm of crestal bone loss is observed by parallel radiological X-ray compared with that after the implant insertion surgery; what’s more, the implant has no history of exudate. Later on, Gallucci et al. proposed that success criteria for implant fixed complete dental prosthesis should be based on four aspects: implant, prosthodontic, peri-implant tissues, and subjective parameters [27]. The prosthesis was considered as successful when a total of four or fewer complications (mild or moderate severity) occurred. Moreover, the success criteria also include patient satisfaction with overall treatment; only when it was rated good, then the treatment outcome should be considered successful. This developing success criterion is more comprehensive than the old ones. A systematic review showed that among all implant-supported fixed partial dentures, 38.7% of the patients may suffer from complications during a 5-year observation period or longer [28]. A well-­ rounded success criterion should include possible complications as well as taking the patients’ satisfaction into account [29]. Recently, a comprehensive review of dental implant success criteria has been published [30]. This review highlighted the importance of including implant health status, vividness of peri-implant soft tissues, as well as prosthodontic parameters, esthetics evaluation, and patient satisfaction in analyses of the overall success of implant dentistry [31, 32]. Authors suggested evaluating the treatment outcome from four perspectives: the implant level, prosthetic level, peri-implant soft-tissue level, and patient level. The review listed all the parameters used to assess clinical efficiency of implant prosthesis by published literature. The most frequently mentioned criteria for assessing success at the implant level were implant mobility, radiolucency, pain, and peri-implant bone loss; as for peri-implant soft-tissue level, the parameters were suppuration, bleeding, and probing pocket depth. The criteria used to evaluate success at the prosthetic level were prosthetic maintenance, occurrence of technical complications, predictable function, and esthetics outcome. The evaluation indicators facilitated to assess at patient level were satisfaction with appearance, discomfort, and ability to function. This review gives us an enlightenment that we should not view success from one perspective and we should think it from the four different levels which are implant, prosthesis, peri-implant soft tissue, and patient’s subjective evaluation. It seems that this current understanding of

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success criteria should be comprehensive. Some dentists may ignore the patient’s satisfaction level because of their vast professional knowledge; however, it is obviously inappropriate. For example, regarding the evaluation of esthetic outcomes, although objective criteria such as Pink Esthetic Scores (PES) and White Esthetic Scores (WES) have been proposed, these criteria do not directly reflect the patient’s subjective assessment [33, 34]. Besides, sometimes the clinician’s objective evaluation is from a professional perspective, and may not be in accordance with the subjective perception of a successful outcome from patients [35]. As seen above, we learn that the assessment for dental implant prosthesis is becoming diverse and more comprehensive and behind this we believe the reason is the rapid evolving surgical and prosthodontic techniques as well as the high demand of the patients. Through the years, multiple progress has been made to include more parameters such as esthetics and patients’ satisfaction as an aspect to measure success. The focus has moved from concerning implant survival to the creation of vivid implant restorations along with natural-looking healthy peri-implant soft tissues. Another issue that needs to be addressed is patient’s subjective satisfaction with prosthesis; it is always to remember that behind the teeth, there is a person.

1.3

Overall Survival Rate for Dental Implants

Due to the advantages we discussed in Sect. 1.1, implant-supported prostheses are worldwide accepted as a reliable treatment choice for the replacement of single or multiple missing teeth. In this section, we review the literature published on implant survival, implant failure, and complications. Recently, Pjetursson et al. published a systematic review which had included the studies from 1990 to 2012; they identified 139 prospective and retrospective studies on implant-supported prostheses and divided the studies into two groups according to the publishing time: group 1 contains 31 older studies published in the year 2000 or before and group 2 includes 108 newer studies published after the year 2000 [36]. The overall annual implant 5-year survival rate was 98.6% summarized by literature before 2000. The survival rates for implant-supported single crown and fixed dental prosthesis were 97.1% and 93.8%, respectively. For studies after 2000, the overall annual implant 5-year survival rate was 98.1%, and for single crown and fixed dental prosthesis was 97.2% and 96.1%. There was only a minor difference without statistical significance regarding to the survival rates of single crowns between older publications and newer publications. However, significantly less implant failures were reported in the newer studies for the implant-supported fixed dental prosthesis and the 5-year implant survival rate increased to 96.1% compared with 93.8% in the older studies. More specifically, Zembic and colleagues reported that the implant abutment survival after 5-year loading was 97.5% for ceramic abutments and 97.6% for metal abutments [37]. For longer follow-up period, Stuart et al. reported a 100% implant survival rate and a 96.4% implant success rate 8.5 years after implant placement [38]. Another study with a follow-up of at least 10 years reported that in a total amount of 506 inserted dental implants in 250 patients, the survival rate at implant

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level was 99.7% and at patient level was 99.4% with a 10-year observing period [39]. Despite high survival rate we obtain from this literature review, one thing we should bear in mind that as mentioned in Sect. 1.2, we should evaluate the implantsupported prosthesis from different perspective rather than only focusing on the mobility of the fixture. Therefore, we should re-regard the high survival rate cautiously. Gallucci et al. proposed success criteria based on implant, peri-implant tissues, prosthodontic, and subjective parameters. And a 95.5% survival rate was reported whereas an 86.7% success rate was recalculated when their proposed success criteria were adopted [27]. Besides implant survival rate, another focus for us dental implantology practitioners is the incidence rate of implant-prosthesis complications. Implant-prosthesis complications can be classified into three categories: biological complications, esthetic complications, and technical complications [37]. Biologic complications basically contain peri-implant mucositis and peri-implantitis [40]. Zembic et  al. reported an overall rate of 6.4% 5-year rate for biologic complications [37]. Biological complications can be induced by various reasons and treatment guidance is suggested by different literature [41, 42]. Esthetic complication can be manifested as the margin of abutment exposure, shrinkage of the papilla between two restorations, and so on [37, 43]. Pjetursson reported in their review that for implant-­ supported single crowns, there were 12 out of 37 studies discussing the esthetic outcome of the treatment. In the studies published before 2000, the 5-year esthetic complication rate of implant-supported single crowns was 15.9%. In the studies published after 2000, the 5-year esthetic complication rate was reduced to 5.4% [36]. The management of esthetic complications is sometimes a great challenge for dentists and the best way to prevent it is to think beforehand and avoid all the possible risks [44, 45]. The last category is technical complications which include abutment or screw loosening, abutment or screw fracturing, veneering material fracturing, implant fracturing, framework fracturing, and loss of retention [46, 47]. The 5-year complication rate of the total number of reported technical complications in the older publications (before 2000) ranged from 10.9% to 33.3% for cemented restoration and screw-retained restorations, respectively. For the new publications (after 2000) the rates are 16.3% and 31.1% [36]. Thus, taking all of this into account, it is significant for dental implantology practitioners to identify and carefully deal with different types of complications. Throughout the evolutionary history of dental implantology, great efforts have been made to improve implant survival and success rate. The modification of implant surface is one of them. Roughened-surface implants have proved to obtain higher survival rates than machined-surface implants [48]. Recently, several studies supported that the implants with a hydrophilic surface had a decisive effect on osseointegration in healthy animals as well as in humans [49, 50]. Researches have reported that these implants behaved similarly not only in well-glycemic-controlled patients but also in poorly glycemic-controlled patients comparatively to healthy patients due to its specific hydrophilia and wettability [51, 52]. What’s more, the introduction of platform switching together with inward shifting of the connection

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micro-gap has also been proved to reduce crestal bone remodeling in a large number of studies [53, 54]. In addition, advanced technologies such as surgical navigation and endoscopic surgery help to perform implant surgeries in a less invasive but more accurate way [55–57]. This chapter demonstrated that although literatures display a high survival rate of implant-supported prostheses and substantial improvements within implant dentistry have been achieved over time, the success rate is not satisfactory when evaluating the prosthesis in a different perspective and biologic, esthetic, and technical complications are still frequent. This, in turn, means that dentists still have to spend a substantial amount of chair time to manage all the complaints and possible complications. Therefore, it is of utmost importance that all the scientific community and clinicians universally should work together to identify and learn from failures and complications in implant dentistry and develop as well as sharing more effective solutions that make implant treatment an even more reliable and predictable option for more and more people.

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12. Lang-Hua BH, Lang NP, Lo EC, Mcgrath CP. Attitudes of general dental practitioners towards implant dentistry in an environment with widespread provision of implant therapy. Clin Oral Implants Res. 2013;24:278–84. 13. Romero-Pérez MJ, Mang-de la Rosa Mdel R, López-Jimenez J, Fernández-Feijoo J, Cutando-­ Soriano A. Implants in disabled patients: a review and update. Med Oral Patol Oral Cir Bucal. 2014;19:e478–82. 14. Brügger OE, Bornstein MM, Kuchler U, Janner SF, Chappuis V, Buser D. Implant therapy in a surgical specialty clinic: an analysis of patients, indications, surgical procedures, risk factors, and early failures. Int J Oral Maxillofac Implants. 2015;30:151–60. 15. Busenlechner D, Fürhauser R, Haas R, Watzek G, Mailath G, Pommer B. Long-term implant success at the academy for oral implantology: 8-year follow-up and risk factor analysis. J Periodontal Implant Sci. 2014;44:102–8. 16. Ellen Cristina GJ, Joel Ferreira SJ, Marcelo Coelho G, Eduardo Piza P, Osvaldo MF, Elerson Gaetti JJ. Dental implants in patients with osteoporosis: a clinical reality? J Craniofac Surg. 2011;22:1111–3. 17. Taschieri S, Lolato A, Testori T, Francetti L, Del Fabbro M. Short dental implants as compared to maxillary sinus augmentation procedure for the rehabilitation of edentulous posterior maxilla: three-year results of a randomized clinical study. Clin Implant Dent Relat Res. 2017;20(Suppl 1):9–20. 18. Lopez Torres JA, Gehrke SA, Calvo Guirado JL, Aristazábal LFR. Evaluation of four designs of short implants placed in atrophic areas with reduced bone height: a three-year, retrospective, clinical and radiographic study. Br J Oral Maxillofac Surg. 2017;55:703. 19. Marco E, Roberto P, Carlo B, Pietro F. Three-year results from a randomised controlled trial comparing prostheses supported by 5-mm long implants or by longer implants in augmented bone in posterior atrophic edentulous jaws. Eur J Oral Implantol. 2014;7:383–95. 20. Olmedo-Gaya MV, Manzano-Moreno FJ, Cañaveral-Cavero E, De DL-dCJ, Vallecillo-Capilla M. Risk factors associated with early implant failure: a 5-year retrospective clinical study. J Prosthet Dent. 2016;115:150–5. 21. Thoma DS, Zeltner M, Hüsler J, Hämmerle CHF, Jung RE. Short implants versus sinus lifting with longer implants to restore the posterior maxilla: a systematic review. Clin Oral Implants Res. 2015;26:154–69. 22. Raikar S, Talukdar P, Kumari S, Panda SK, Oommen VM, Prasad A.  Factors affecting the survival rate of dental implants: a retrospective study. J Int Soc Prevent Communit Dent. 2017;7:351–5. 23. Fugazzotto PA. Success and failure rates of 1,344 6- to 9-mm-length rough-surface implants placed at the time of transalveolar sinus elevations, restored with single crowns, and followed for 60 to 229 months in function. Int J Oral Maxillofac Implants. 2017;32:1359. 24. Jimbo R, Albrektsson T. Long-term clinical success of minimally and moderately rough oral implants: a review of 71 studies with 5 years or more of follow-up. Implant Dent. 2015;24:62–9. 25. Gilad BG, Mordechai LA, Orith H, Eldad S, Ami S. Existing concepts and a search for evidence: a review on implant occlusion. Compend Contin Educ Dent. 2013;34:26–31. 26. Misch CE. The implant quality scale: a clinical assessment of the health—disease continuum. Oral Health. 1998;88:15–20, 23–5. 27. Gallucci GO, Doughtie CB, Hwang JW, Fiorellini JP, Weber HP.  Five-year results of fixed implant-supported rehabilitations with distal cantilevers for the edentulous mandible. Clin Oral Implants Res. 2010;20:601–7. 28. Sailer I, Pjetursson B, Zwahlen M, Hammerle C. A systematic review of the survival and complication rates of all-ceramic and metal-ceramic reconstructions after an observation period of at least 3 years. Part II: fixed dental prostheses. Clin Oral Implants Res. 2010;18:86–96. 29. Eckert SE, Choi YG, Sanchez AR, Koka S.  Comparison of dental implant systems: quality of clinical evidence and prediction of 5-year survival. Int J Oral Maxillofac Implants. 2005;20:406–15. 30. Papaspyridakos P, Chen CJ, Singh M, Weber HP, Gallucci GO.  Success criteria in implant dentistry: a systematic review. J Dent Res. 2012;91:242–8.

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31. Meijer HJ, Stellingsma KL, Raghoebar GM.  A new index for rating aesthetics of implant-­ supported single crowns and adjacent soft tissues—the implant crown aesthetic index. Clin Oral Implants Res. 2010;16:645–9. 32. Annibali S, Bignozzi I, La Monaca G, Cristalli MP. Usefulness of the aesthetic result as a success criterion for implant therapy: a review. Clin Implant Dent Relat Res. 2012;14:3–40. 33. Vidigal GM Jr, Groisman M, Clavijo VG, Barros Paulinelli Santos IG, Fischer RG. Evaluation of pink and white esthetic scores for immediately placed and provisionally restored implants in the anterior maxilla. Int J Oral Maxillofac Implants. 2017;32:625–32. 34. Esposito M, Tallarico M, Trullenque-Eriksson A, Gianserra R. Endodontic retreatment vs dental implants of teeth with an uncertain endodontic prognosis: 1-year results from a randomised controlled trial. Eur J Oral Implantol. 2017;10:293–308. 35. Arunyanak SP, Pollini A, Ntounis A, Morton D. Clinician assessments and patient perspectives of single-tooth implant restorations in the esthetic zone of the maxilla: a systematic review. J Prosthet Dent. 2017;118:10–7. 36. Pjetursson BE, Dent DM, Asgeirsson MAG, Zwahlen DM, Sailer PI, Dent DM. Improvements in implant dentistry over the last decade: comparison of survival and complication rates in older and newer publications. Int J Oral Maxillofac Implants. 2014;29(Suppl 1):308. 37. Jung RE, Zembic A, Pjetursson BE, Zwahlen M, Thoma DS. Systematic review of the survival rate and the incidence of biological, technical, and aesthetic complications of single crowns on implants reported in longitudinal studies with a mean follow-up of 5 years. Clin Oral Implants Res. 2012;23:2–21. 38. Froum SJ, Khouly I. Survival rates and bone and soft tissue level changes around one-piece dental implants placed with a flapless or flap protocol: 8.5-year results. Int J Periodont Rest Dent. 2017;37:327–37. 39. van Velzen FJ, Ofec R, Schulten EA, Ten Bruggenkate CM. 10-year survival rate and the incidence of peri-implant disease of 374 titanium dental implants with a SLA surface: a prospective cohort study in 177 fully and partially edentulous patients. Clin Oral Implants Res. 2015;26:1121–8. 40. Figuero E, Graziani F, Sanz I, Herrera D, Sanz M. Management of peri-implant mucositis and peri-implantitis. Periodontology. 2014;66:255–73. 41. Moldovan O, Rudolph H, Luthardt RG. Biological complications of removable dental prostheses in the moderately reduced dentition: a systematic literature review. Clin Oral Investig. 2018;7:1–23. 42. Poli PP, Cicciã M, Beretta M, Maiorana C. Peri-implant mucositis and peri-implantitis: current understanding of their diagnosis, clinical implications and a report of treatment using a combined therapy approach. J Oral Implantol. 2017;43:45–50. 43. Visser A, Raghoebar GM, Meijer HJ, Meijndert L, Vissink A. Care and aftercare related to implant-retained dental crowns in the maxillary aesthetic region: a 5-year prospective randomized clinical trial. Clin Implant Dent Relat Res. 2011;13:157–67. 44. Chaar EE, Oshman S. Soft tissue grafting for implant site development: diagnosis and treatment planning, esthetic evaluation. In: Toistunov L, editor. Horizontal alveolar ridge augmentation in implant dentistry: a surgical manual. Hoboken, NJ: Wiley; 2016. p. 261–70. 45. Ravidà A, Saleh M, Muriel MC, Maska B, Wang HL.  Biological and technical complications of splinted or nonsplinted dental implants: a decision tree for selection. Implant Dent. 2018;27:89–94. 46. Kreissl M, Gerds TR, Heydecke G, Strub J.  Technical complications of implant-supported fixed partial dentures in partially edentulous cases after an average observation period of 5 years. Clin Oral Implants Res. 2010;18:720–6. 47. Brägger U, Karoussis I, Persson R, Pjetursson B, Salvi G, Lang N. Technical and biological complications/failures with single crowns and fixed partial dentures on implants: a 10-year prospective cohort study. Clin Oral Implants Res. 2010;16:326–34. 48. Mangano FG, Iezzi G, Shibli JA, Pires JT, Luongo G, Piattelli A, et al. Early bone formation around immediately loaded implants with nanostructured calcium-incorporated and machined surface: a randomized, controlled histologic and histomorphometric study in the human posterior maxilla. Clin Oral Investig. 2017;21:2603–11.

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49. Buser D, Broggini N, Wieland M, Schenk RK, Denzer AJ, Cochran DL. Enhanced bone apposition to a chemically modified SLA titanium surface. J Dent Res. 2004;83:529–33. 50. Mardas N, Schwarz F, Petrie A, Hakimi AR, Donos N. The effect of SLActive surface in guided bone formation in osteoporotic-like conditions. Clin Oral Implants Res. 2015;22:406–15. 51. Cabrera-Domínguez J, Castellanos-Cosano L, Torres-Lagares D, Machuca-Portillo G. A prospective case-control clinical study of titanium-zirconium alloy implants with a hydrophilic surface in patients with type 2 diabetes mellitus. Int J Oral Maxillofac Implants. 2017;32:1135. 52. Khandelwal N, Oates TW, Vargas A, Alexander PP, Schoolfield JD, Alex MC. Conventional SLA and chemically modified SLA implants in patients with poorly controlled type 2 diabetes mellitus—a randomized controlled trial. Clin Oral Implants Res. 2013;24:13–9. 53. Nayak R, Devanna R, Dharamsi AM, Shetty J, Mokashi R, Malhotra S.  Crestal bone loss around dental implants: platform switching vs platform matching-a retrospective study. J Contemp Dent Pract. 2018;19:574–8. 54. Alrabeah GO, Knowles JC, Petridis H. Reduction of tribocorrosion products when using the platform-switching concept. J Dent Res. 2018;97:995–1002. 55. Ma L, Jiang W, Zhang B, Qu X, Ning G, Zhang X, et al. Augmented reality surgical navigation with accurate CBCT-patient registration for dental implant placement. Med Biol Eng Comput. 2018;57:47–57. 56. Kersten-Oertel M, Jannin P, Collins DL. The state of the art of visualization in mixed reality image guided surgery. Comput Med Imaging Graph. 2013;37:98–112. 57. Nam KY, Kim JB.  Treatment of dental implant-related maxillary sinusitis with functional endoscopic sinus surgery in combination with an intra-oral approach. J Korean Assoc Oral Maxillofac Surg. 2014;40:87–90.

2

Medically Compromised Patients: A Biological and Social Challenge Lin Xiang, Ya-qian Chen, and Quan Yuan

2.1

Introduction

As we have elaborated in Chap. 1, dental implants have been regarded as a reliable therapy for replacing missing teeth. However, the clinical trials reporting dental implant survival and success rates often recruited patients with suitable inclusion criteria such as no systemic diseases and medication history which may affect tissue healing around implants [1]. As we all know, 10-year implant survival in healthy patients is very satisfactory, but implant failure and peri-implantitis still cause the loss of implants early after they were placed or on a longer term [2, 3]. While in health-compromised subjects, is this therapy still predictable and will the risk of implant failure and related complications increase? That is our main concern, especially in today’s society. Implant treatment procedures include preoperative planning, surgery performing, restoration treatment, and post-maintenance. These three stages jointly guarantee the key factor of the success—osseointegration between surrounding bone tissue and endosseous implant surface. This inter-tissular integration ensures long-term survival of dental implants and reduces marginal bone loss around L. Xiang Department of Oral Implantology, West China Hospital of Stomatology, Sichuan University, Chengdu, China Y.-q. Chen State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China Q. Yuan (*) State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China Department of Oral Implantology, West China Hospital of Stomatology, Sichuan University, Chengdu, China e-mail: [email protected] © Springer Nature Switzerland AG 2020 Q. Yuan (ed.), Dental Implant Treatment in Medically Compromised Patients, https://doi.org/10.1007/978-3-030-28557-9_2

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implant shoulder. To obtain well-deserved osseointegration, a prerequisite is to acquire favorable primary stability which requires operators to insert implants within enough cortical and cancellous bone. Poor fixation may cause micromovements during osseointegration resulting in fibrous encapsulation. Therefore, the quantity and degree of corticalization and density of mineralization of cancellous bone in implant area should be carefully assessed in medically compromised patients before surgery. Various health issues are troubling more people today because of the environment deterioration, such as air pollution and water contamination, and increasing life pressure for people living in big cities. People with these conditions are mounting a biological challenge to clinical practitioners. Besides, aging is also one of the reasons. On the one hand, life expectancy was 65  years in the more developed regions of the world and 42 years in the less developed regions in 1950, while currently life expectancy is 78  years in the developed countries and 68  years in the developing world. On the other hand, there has been a decline in population growth rate [4]. This increasing life expectancies and decreasing fertility rate have resulted in faster growing of older population than younger individuals. The United Nations Population Division reported that the global share of people aged 60 years or over increased from 8% in 1950 to 12% in 2013, and will reach an estimated 21% by 2050, which indicates a social challenge to dental clinicians [5]. As a consequence, the incidence of tooth loss will be significantly enhanced. All the current situations indicate that we, dentists practicing implant dentistry, will face the upcoming challenge that more and more patients who desire an implant restoration may be medically compromised. They may suffer from chronic diseases such as cardiovascular diseases and diabetes or some contagious diseases and so on. One thing we should bear in mind is that some diseases will in deed affect patients’ bone metabolism, further influencing osseointegration around dental implants. Therefore, it is of great importance to be aware of the survival and failure risk accompanying implant placement in medically compromised patients, as well as whether the medication of these patients will impede the healing of dental implants based on existing evidence-based medicine. As discussed by Diz et al., so far there are actually very few absolute contraindications of dental implant treatment [6]. However, plenty of work has been reported to illustrate that the risk of implant failure and complications could increase in certain medically compromised populations and there are some precautions that we must bear in mind. Accordingly, authors strive to elucidate these issues in the following chapters, aiming to provide a practical and comprehensive guideline for clinical practitioners.

2.2

Dental Implant and Substance Abuse

In this chapter we focus on tobacco consumption and alcoholism. Habitual cigarette smoking is known to all as a well-instituted classical risk factor for soft-tissue inflammation and crestal bone loss around natural teeth and dental implants [7–9].

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Researches have shown that the metabolites of nicotine will upregulate the expression of advanced glycation end products in gingival tissues resulting in increased production of inflammatory cytokines such as interleukin (IL)-6, matrix metalloproteinase (MMP)-1, IL-1 beta, and tumor necrosis factor-alpha (TNF-α) by gingival fibroblasts [10–12]. These inflammatory cytokines contribute to periodontal collagen degradation and inhibit the healing of soft tissue around dental implants [13]. Therefore, tobacco consumption is considered as one of the main habits that would influence dental implant therapy. There have been a large number of studies discussing success and survival rate as well as marginal bone loss in smoker population. We have summarized all the related studies in Chap. 3. To date, most of the studies tend to regard that smokers (especially heavy smokers) tend to suffer from more implant failures and more significant bone loss [14, 15]. Hence we need to develop a more detailed treatment plan for these patients to enhance the survival rate of dental implants. In addition, it is absolutely necessary to warn the patients of this possibility, and make them clearly aware of the risk of failure and sign an informed consent form before the treatment. Besides, giving up smoking should be encouraged for long-term implant success. As for alcoholism, so far there is no significant difference in implant survival rate between alcohol consumption population and nondrinkers. Nevertheless, alcoholism may lead to liver diseases, nutrient absorption disorders, and bleeding disorders, thus increasing the risk of dental implant complications [6]. Furthermore, it is common that subjects with a high alcohol intake amount may have poor self-­ conscious in oral hygiene maintenance [16]. It is necessary to reduce the harmful use of alcohol. For the daily practicing, prevention of peri-implantitis should therefore be taken care as a main priority in implant dentistry. Details of implant treatment for alcohol consumption population will be discussed in Chap. 3.

2.3

Dental Implant and Organ Diseases

The relationship between dental implants and organ diseases has been discussed broadly. In Chap. 4, authors will illustrate the relationship between dental implant success and cardiovascular disease. The most widely studied disease is cardiovascular disease such as hypertension, coronary atherosclerotic heart disease, and acute myocardial infarction. This kind of disease may compromise the blood flow and may impede oxygen or nutrient delivery in the osseous tissue, thus possibly obstructing osseointegration [17, 18]. Consistent with this, Mulinari-Santos et al. hold that hypertension is possibly due to the detriment of osseointegration [19]. Additionally, a cohort study proved the association between antihypertensive drugs and increased survival rate of osseointegrated implants [20]. As for the precautions of this part, it is vital to assess the cardiovascular risk, conduct blood test, monitor blood pressure, supply additional oxygen, and focus on the postoperative issues. When it comes to renal disease, it was associated with bacterial infection, cardiac disorders, and disturbance of bone metabolism [21–23]. All these three problems may increase the risk of dental implant therapy. The preoperative,

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perioperative, and postoperative precautions of renal disease are similar to those of cardiovascular disease. Apart from these, there are some risks accompanied by thyroid disorders and hepatitis. For example, thyroid disorders are sometimes accompanied with low bone turnover, osteoporosis, as well as thyroid crisis. Hepatitis may end up with unmanageable hemorrhage, peri-implantitis, and slow wound healing. Treatment suggestions with regard to antibiotic prophylaxis and anesthesia precautions will also be demonstrated in this chapter. We have summarized relevant published literature to give readers a comprehensive reference.

2.4

Dental Implant and Bone Diseases

The literature reporting cases of dental implants and bone diseases such as osteoporosis, osteogenesis imperfecta, and polyarthritis have been published in the last decade [24–26]. As main concern of dentists, would these related bone disorders influence bone tissue healing around implants? A common disease which was considered to affect the outcome of dental implants is osteoporosis. This disease is featured with a low bone mass and redundant accumulation of adipose tissue in bone marrow [27, 28]. Although clinical studies have demonstrated a comparable survival rate of dental implants in osteoporosis patients and healthy individuals, marginal bone loss for osteoporosis patients may be slightly higher [29, 30]. A recent work reported a mean value of 0.65 mm of marginal bone loss for osteoporosis patients at the fifth-­ year follow-up [31]. Additionally, high rate (76.1%) of peri-implantitis in patients with osteoporosis was reported [32]. As a result, taking the low bone density into mind, a longer healing time and a careful occlusion design are suggested in the treatment plan. To our knowledge, bone disorders are not the absolute contraindication of dental implants therapy. However, patients who are compromised in these related systematic situations, should be informed of the possible risks of early implant failure and excessive marginal bone loss. The suggestions for the treatment are provided in Chap. 5.

2.5

Dental Implant and Diabetic Patients

Diabetes mellitus is becoming one of the most prevalent endocrine disorders all over the world. As far as the authors are concerned, most of the literature agreed on that implant survival rate is comparable in diabetic patients with proper metabolic control to healthy patients [33, 34]. Nevertheless, compromised implant osseointegration has also been reported in diabetic patients [35]. In animal study, hyperglycemia has been found to inhibit osteoblast differentiation and influence parathyroid hormone-mediated regulation of phosphorus and calcium metabolism, as well as negatively affect the growth and accumulation of extracellular matrix of bone tissue [26, 36, 37]. Besides, it has also been raised that the inflammatory response around dental implants was greater in the diabetic rats than that in the controlled rats, which turned out to give rise to an increased bone resorption

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in the diabetic group [38]. Considering the negative effects of hyperglycemic states on bone healing, medical advice and strict glycemic control before and after implant treatment are recommended (more details in Chap. 6). These patients are also suggested to practice hard in maintaining a good oral hygiene, applying antiseptic mouth rinse, etc. to avoid incidental periodontal and peri-implant infections.

2.6

Dental Implant and Immune System-Related Diseases

A favorable surrounding tissue healing requires a benign immune system response. Therefore, in patients with immune system disorders, healing may be compromised. In Chap. 7, we will discuss dental implant therapy with rheumatologic disorders and immunosuppressive conditions. Rheumatologic disorders could affect dental implant treatment outcome in different ways. Take rheumatoid arthritis as an example. A study has reported that rheumatoid arthritis increases bone resorption around implants [39]. One reason is the extensive use of corticosteroids which may induce osteoporosis and may lower local bone density, thus increasing the risk of bone fracture and prolonging healing periods [40]. Additionally, the administration of steroid may also lead to potential infection [41]. On this condition, it is more possible that peri-implantitis occurs, which may end up with failure of dental implant therapy. With regard to the immunosuppressive conditions, we will discuss dental implants placed in organ-transplantation patients and HIV-positive patients. Cautions of dental implants in patients under long-term immunosuppressive treatment are similar to those of “organ diseases.” This will be well elucidated with additional measures for dental implant practitioners.

2.7

Dental Implant and Drug-Induced Disorders

In this chapter, we pay close attention to patients who take drugs such as bisphosphonates, anticoagulants, and corticosteroids. Bisphosphonates are often used in osteoporosis patients and are known to suppress the osteoclast function. The use of these anti-resorptive drugs, such as bisphosphonates, is accompanied by an increased risk of medication-related osteonecrosis of the jaws (MRONJ) [42, 43]. However, a systematic review showed that dental implants in patients with chronic intake of oral bisphosphonates did not lead to MRONJ and did not influence short-term (1–4  years) implant survival rates, but perioperative antibiotic prophylaxis was recommended in these patients [44]. As for patients with cardiovascular disorders, anticoagulants such as warfarin are often subscribed. Hemorrhage happening during implant surgeries can be prolonged, which may even end up with significant hemorrhage [45]. A cohort study by Gboyega et al. reported many major bleeding cases (2.8–6% per 100 patient-years) after application of anticoagulants [46]. Corticosteroids are used to suppress chronic inflammatory diseases, such as rheumatoid arthritis, autoimmune diseases, and asthma. However, long-term use of

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oral glucocorticoids is associated with serious side effects, including osteoporosis and adrenal insufficiency. Precautions for these drug-induced disorders include obtaining a comprehensive history, reducing invasive procedures, and testing some markers if necessary. In these patients, we will give more recommendation regarding implant surgical procedures in Chap. 8.

2.8

Dental Implant and Oral Diseases

The relationship of dental implants and related oral diseases including head and neck cancers, Sjögren’s syndrome, and oral lichen planus is investigated in Chap. 9. Adjuvant hyperbaric oxygen therapy, radiology therapy, and chemotherapy are common treatments for cancer patients. However, dental implant survival is controversial in cancer patients [47, 48]. It was found out that high-dose radiation (cumulative dose >50  Gy) was about to raise the risk of dental implant [49–51]. The potential mechanisms may be the loss of osseointegration caused by bone vascularity reduction, and bone substance and soft tissues (such as periosteum and connective tissue of the mucosa) are impaired in the meanwhile [49, 52, 53]. In Chap. 9, we will display relevant literature over the years in much detail and list precaution or guidelines for treating these patients. Furthermore, it would be reasonable to hypothesize that dental implant healing is compromised in patients with mucosal diseases. These patients concomitantly suffer from greater mental stress and may be expressed as anxiety, sleep disorders, and irritability. The related advice and treatment plan will be displayed in Chap. 9. Except for the disorders mentioned above, we will also illustrate the relationship between dental implants and other conditions such as psychiatric disorders, titanium allergy, and genetic diseases in this book. What is more, due attention is also paid to those elder citizens under dental implant treatment.

2.9

Conclusion

To date, there is no absolute contraindication for dental implant therapy. However, with a possibility that we will face more medically compromised patients in the near future, it is in urgent need that we keep in mind the influences that systemic conditions or disorders exert on implants. We should be aware of the failure risk, complication incidence, precautions before and during as well as after treatment such as antibiotic prophylaxis, or time of implant placement, and we should also make it clear that whether we are able to handle the possible complications when they happen. Only in this way we can decrease the failure risk of dental implants in compromised patients. The knowledge we discussed is essential for dentists performing implant-based prosthodontics in medically compromised patients. The mind map for risks in medically compromised patients and related precautions is listed as follow.

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To wam the patients of the risk Soft tissue inflammation

Tobacco consumption

To sign an informed consent form

Precautions Crestal bone loss

Dental Implant and Substance Abuse

To encourage giving up smoking To reduce the harmful use of alcohol

Periodontiss Alcoholism

Precautions

Peri-implant mangial bone loss

To prioritize prevention of peri-implantitis

General condition eveluation Functional capacity evaluation Cardiovascular risk assessment Blood tests

Preoperative Period

Residual bone evaluation Eliminating oral infections Antibiotic prophylaxis Planning for the implant surgery Monitaring blood pressure

Periodontal disease Cardiovascular disease

Precautions

Influence of blood supply

Oral antisepsis Additional oxygen supply Perioperative Period

Anesthesia and sedation Hemostatic measures Minimally invasive procedures Regular adivice for patients Antibiotic treatment

Postoperative Period

Analgesics and anti-inflammatory drugs Cordiovascular risk assessment General condition evaluation Blood tests Residual bone evaluation

Dental Implant and Organ Diseases

Preoperative Period

Eliminating oral infections Planning for the implant surgery

Loss of poriodontal bone Renal disease

Gingival enlargement

Antibiotic prophylaxis

Precautions

Refer to “Cardiovascular Diseases” except for “Additional oxygen supply”

Disturbance of bone metabolism

Perioperative Period

Regular advice for patients Antibiotic treatment

Postoperative Period

Analgesics and anti-inflammatory drugs To check numerical value of the thyroid hormone

Untreated hypothyroidism Thyroid disorders

To confirm a state of the control in the thyroid function

Precautions

Hypothyroidism related osteoporosis

To perform the confirmation of the oral medicine

Thyroid hormones influences

To maintain close contact with the family doctor

Unmanageable hemorrhage Hepatitis

Slowing down wound healing

To avoid acidic anti-inflammatory analgesics

Precautions

To avoid nosocomial infections

Cirrhosis

Dental Implant Treatment in the Medically Compromised Patients

To obtain a comprehensive history To pay attention to hormone and bisphosphonates usage To choose optimum implant

Marginal bone loss

Perioperative anti-microbial prophylaxis

Peri-implantitis

Ostecporosis

Precautions

Risk associated with pharmacological interventions

A safe dosage of local anesthesia To avoid bone augmentotions if possible

Periodontitis

Minimally invasive procedures

Dental Implant and Bone Diseases

To provide through postoperative instructoins To obtain a comprehensive history Impalnt failure

MRONJ

Precautions

To finish invasive treatment before initiation of antiresorptive or antianglogenic drugs

Non-surgical periodontal therapy Peri-implant maintenance therapy Impaired osseointegration

Dental Implants and Diabetic Patients

Diabetes mellitus

To record baseline probing measurement and baseline level of supporting bone

Precautions

Peri-implant diseases

To provide oral hygiene instruction Prophylactic antibiotics

TMJ problems Rheumatologic disorders

Dental Implant and Immune Systemrelated Diseases

Refer to precautions for “Renal Diseases”

Increasing bone resorption

Precautions

Severe periodontal condition Immunosuppressive conditions

To evaluate TMJ Function

Rapid and severe bone loss

Antiresorptive therapy

MRONJ

Anticoagulant therapy

Haemormage

Refer to precautions for the previous “MRONJ”

Precautions

To obtain a comprehensive history

Dental Implant and Drug-induced Disorders

To reduce invasive procedures

Precautions

To test some markers if necessary Osteoporosis Conticosteroids therapy

Precautions

Refer to precautions for “Osteoporosis”

Adrenal insufficiency

To optimize the dose and frequency of radiotherapy Head and neck cancer

Poor osseointegration caused by high-dose radiation Precautions

Imparing soft tissues due to high-dose radiation

Dental Implant and Oral Diseases

Sjögren’s syndrome

Periodontal diseases

Hyper basic oxygen therapy To apply osteogenic growth factors if possible

Diminished quality and quantity of saliva

Refer to precautions for “Rental Diseases” Precautions

Saliva tests

Increased bone resorption Upregulated preinflammatory responses Oral lichen planus

Bone disturbances

Refer to precautions for “Rental Diseases” Precautions

Evaluation of lesion state

Undesirable peri-implant healing

Other Conditions Affecting Dental implant Treatment

Eiderfy patient Psychiatric disorders Genetic diseases

Undesirable peri-implant bone condition

Precautions

Pay attention to preoperative, perioperative, and postoperative conditions

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References 1. Belir A, Bora N, Yusuf E, Ozgür B, Buket A, Serhat YI. Immediate implant placement without bone grafting: a retrospective study of 110 cases with 5 years of follow-up. Implant Dent. 2013;22:360–5. 2. Meijndert CM, Raghoebar GM, Meijndert L, Stellingsma K, Vissink A, Meijer HJ.  Single implants in the aesthetic region preceded by local ridge augmentation; a 10-year randomized controlled trial. Clin Oral Implants Res. 2017;28:388–95. 3. Pjetursson BE, Thoma D, Jung R, Zwahlen M, Zembic A.  A systematic review of the survival and complication rates of implant-supported fixed dental prostheses (FDPs) after a mean observation period of at least 5 years. Clin Oral Implants Res. 2012;23:22–8. 4. Wang H, Dwyer-Lindgren L, Lofgren KT, Rajaratnam JK, Marcus JR, Levin-Rector A, et al. Age-specific and sex-specific mortality in 187 countries, 1970-2010: a systematic analysis for the global burden of disease study 2010. Lancet. 2012;380:2071–94. 5. Ofori-Asenso R, Zomer E, Curtis AJ, Zoungas S, Gambhir M. Measures of population ageing in Australia from 1950 to 2050. J Popul Ageing. 2018;11:367–85. 6. Diz P, Scully C, Sanz M.  Dental implants in the medically compromised patient. J Dent. 2013;41:195–206. 7. Bahrami G, Vaeth M, Kirkevang LL, Wenzel A, Isidor F.  The impact of smoking on marginal bone loss in a 10-year prospective longitudinal study. Community Dent Oral Epidemiol. 2017;45:59–65. 8. Nobre MA, Malã P. Prevalence of periodontitis, dental caries, and peri-implant pathology and their relation with systemic status and smoking habits: results of an open-cohort study with 22009 patients in a private rehabilitation center. J Dent. 2017;67:36–42. 9. Veitzkeenan A. Marginal bone loss and dental implant failure may be increased in smokers. Evid Based Dent. 2016;17:6–7. 10. Chrcanovic BR, Albrektsson T, Wennerberg A.  Smoking and dental implants: a systematic review and meta-analysis. J Dent. 2015;43:487–98. 11. Catherine G, Isabelle C, Andrea M. Effect of smoking on gingival crevicular fluid cytokine profile during experimental gingivitis. J Clin Periodontol. 2003;30:996–1002. 12. Birgitta SD, Jin LJ, Wickholm S. Granulocyte elastase, matrix metalloproteinase-8 and prostaglandin E2 in gingival crevicular fluid in matched clinical sites in smokers and non-smokers with persistent periodontitis. J Clin Periodontol. 2002;29:384–91. 13. Weiping Z, Meixian F, Fengyu S, L Jack W.  Effects of cigarette smoke condensate and nicotine on human gingival fibroblast-mediated collagen degradation. J Periodontol. 2011;82:1071–9. 14. Dieter B, Rudolf F, Robert H, Georg W, Georg M, Bernhard P. Long-term implant success at the academy for oral implantology: 8-year follow-up and risk factor analysis. J Periodontal Implant Sci. 2014;44:102–8. 15. Tran DT, Gay IC, Diaz-Rodriguez J, Parthasarathy K, Weltman R, Friedman L. Survival of dental implants placed in grafted and nongrafted bone: a retrospective study in a university setting. Int J Oral Maxillofac Implants. 2016;31:310–7. 16. Dalago HR, Schuldt FG, Rodrigues MA, Renvert S, Bianchini MA.  Risk indicators for Peri-­implantitis. A cross-sectional study with 916 implants. Clin Oral Implants Res. 2017;28:144–50. 17. Gómez-de Diego R, Mang-del RMR, Romero-Pérez MJ, Cutando-Soriano A, López-Valverde-­ Centeno A.  Indications and contraindications of dental implants in medically compromised patients: update. Med Oral Patol Oral Cir Bucal. 2014;19:e483–9. 18. Donos N, Calciolari E. Dental implants in patients affected by systemic diseases. Br Dent J. 2014;217:425–30. 19. Mulinari-Santos G, de Souza Batista FR, Kirchweger F, Tangl S, Gruber R, Okamoto R. Losartan reverses impaired osseointegration in spontaneously hypertensive rats. Clin Oral Implants Res. 2018;29:1126–34.

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20. Wu X, Al-Abedalla K, Eimar H, Arekunnath Madathil S, Abi-Nader S, Daniel NG, et  al. Antihypertensive medications and the survival rate of osseointegrated dental implants: a cohort study. Clin Implant Dent Relat Res. 2016;18:1171–82. 21. Chadban SJ, Atkins RC. Glomerulonephritis. Lancet. 2005;365:1797–806. 22. Dhondup T, Qian Q. Electrolyte and acid-base disorders in chronic kidney disease and end-­ stage kidney failure. Blood Purif. 2017;43:179–88. 23. Yuan Q, Xiong QC, Gupta M, Lopez-Pintor RM, Chen XL, Seriwatanachai D, et al. Dental implant treatment for renal failure patients on dialysis: a clinical guideline. Int J Oral Sci. 2017;9:125–32. 24. Eder A, Watzek G.  Treatment of a patient with severe osteoporosis and chronic polyarthritis with fixed implant-supported prosthesis: a case report. Int J Oral Maxillofac Implants. 1999;14:587–90. 25. Barker D, Nohl FSA, Postlethwaite KR, Smith DG. Case report of multiple implant failure in a patient with ankylosing spondylitis. Eur J Prosthodont Restor Dent. 2008;16:20–3. 26. Glösel B, Kuchler U, Watzek G, Gruber R. Review of dental implant rat research models simulating osteoporosis or diabetes. Int J Oral Maxillofac Implants. 2010;25:516–24. 27. Rosen CJ, Bouxsein ML. Mechanisms of disease: is osteoporosis the obesity of bone? Nat Clin Pract Rheumatol. 2006;2:35–43. 28. Devlin MJ, Rosen CJ. The bone-fat interface: basic and clinical implications of marrow adiposity. Lancet Diabetes Endocrinol. 2015;3:141–7. 29. Alqutaibi AY, Radi AE.  No clear evidence regarding the effect of osteoporosis on dental implant failure. J Evid Based Dent Pract. 2016;16:124–6. 30. Wagner F, Schuder K, Hof M, Heuberer S, Seemann R, Dvorak G. Does osteoporosis influence the marginal peri-implant bone level in female patients? A cross-sectional study in a matched collective. Clin Implant Dent Relat Res. 2017;19:616–23. 31. Chow L, Chow TW, Chai J, Mattheos N. Bone stability around implants in elderly patients with reduced bone mineral density-a prospective study on mandibular overdentures. Clin Oral Implants Res. 2017;28:966–73. 32. Gabriella D, Christoph A, Simone H, Huber CD, Georg W, Reinhard G. Peri-implantitis and late implant failures in postmenopausal women: a cross-sectional study. J Clin Periodontol. 2011;38:950–5. 33. Ilser T. One-year clinical outcome of dental implants placed in patients with type 2 diabetes mellitus: a case series. Implant Dent. 2010;19:323–9. 34. Rachel A, Yoav G, Yael A, Liran L. Smoking, diabetes mellitus, periodontitis, and supportive periodontal treatment as factors associated with dental implant survival: a long-term retrospective evaluation of patients followed for up to 10 years. Implant Dent. 2010;19:57–64. 35. Oates TW, Dowell S, Robinson M, Mcmahan CA. Glycemic control and implant stabilization in type 2 diabetes mellitus. J Dent Res. 2009;88:367–71. 36. Santana RB, Lei X, Hermik Babakhanlou C, Salomon A, Graves DT, Trackman PC. A role for advanced glycation end products in diminished bone healing in type 1 diabetes. Diabetes. 2003;52:1502–10. 37. Weiss RE, Gorn AH, Nimni ME. Abnormalities in the biosynthesis of cartilage and bone proteoglycans in experimental diabetes. Diabetes. 1981;30:670–7. 38. Feng W, Ying-Liang S, De-Hua L, Cui-Xia L, Yao W, Ning Z, et  al. Type 2 diabetes mellitus impairs bone healing of dental implants in GK rats. Diabetes Res Clin Pract. 2010;88:e7–9. 39. Krennmair G, Seemann R, Piehslinger E. Dental implants in patients with rheumatoid arthritis: clinical outcome and peri-implant findings. J Clin Periodontol. 2010;37:928–36. 40. Giannoudis P, Tzioupis C, Almalki T, Buckley R. Fracture healing in osteoporotic fractures: is it really different? A basic science perspective. Injury. 2007;38(Suppl 1):90–9. 41. Glassock RJ, Alvarado A, Prosek J, Hebert C, Parikh S, Satoskar A, et al. Staphylococcus-­ related glomerulonephritis and poststreptococcal glomerulonephritis: why defining “post” is important in understanding and treating infection-related glomerulonephritis. Am J Kidney Dis. 2015;65:826–32.

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42. Giovannacci I, Meleti M, Manfredi M, Mortellaro C, Greco LA, Bonanini M, et al. Medication-­ related osteonecrosis of the jaw around dental implants: implant surgery-triggered or implant presence-triggered osteonecrosis? J Craniofac Surg. 2016;27:697–701. 43. Guazzo R, Sbricoli L, Ricci S, Bressan E, Piattelli A, Iaculli F. Medication-related osteonecrosis of the jaw and dental implants failures: a systematic review. J Oral Implantol. 2017;43:51–7. 44. Madrid C, Sanz M. What impact do systemically administrated bisphosphonates have on oral implant therapy? A systematic review. Clin Oral Implants Res. 2009;20:87–95. 45. Mccartan B. Medical problems in dentistry. Br Dent J. 2005;198:314–5. 46. Adeboyeje G, Sylwestrzak G, Barron JJ, White J, Rosenberg A, Abarca J, et al. Major bleeding risk during anticoagulation with warfarin, dabigatran, apixaban, or rivaroxaban in patients with nonvalvular atrial fibrillation. J Manag Care Spec Pharm. 2017;23:968–78. 47. Cao Y, Weischer T. Comparison of maxillary implant-supported prosthesis in irradiated and non-irradiated patients. J Huazhong Univ Sci Technolog Med Sci. 2003;23:209–12. 48. Anke K, Schoen PJ, Raghoebar GM, Jelte B, Burlage FR, Roodenburg JLN, et al. Five-year follow-up of oral functioning and quality of life in patients with oral cancer with implant-­ retained mandibular overdentures. Head Neck. 2010;33:831–9. 49. Yerit KC, Posch M, Seemann M, Hainich S, Dortbudak O, Turhani D, et al. Implant survival in mandibles of irradiated oral cancer patients. Clin Oral Implants Res. 2006;17:337–44. 50. Levi LE, Lalla RV. Dental treatment planning for the patient with oral cancer. Dent Clin N Am. 2017;62:121–30. 51. Epstein JB, Thariat J, Bensadoun RJ, Barasch A, Murphy BA, Kolnick L, et al. Oral complications of cancer and cancer therapy: from cancer treatment to survivorship. CA Cancer J Clin. 2012;62:400–22. 52. Pompa G, Saccucci M, Di Carlo G, Brauner E, Valentini V, Di Carlo S, et al. Survival of dental implants in patients with oral cancer treated by surgery and radiotherapy: a retrospective study. BMC Oral Health. 2015;15:5. 53. Marx RE, Johnson RP.  Studies in the radiobiology of osteoradionecrosis and their clinical significance. Oral Surg Oral Med Oral Pathol. 1987;64:379–90.

3

The Role of Substance Abuse in Dental Implant Treatment Yan Huang and Ping Gong

3.1

Introduction

Dental implants have been routinely used to treat absence of tooth or edentulism since the early 1990s. The success of dental implant treatment highly depends on osseointegration, which is defined as a kind of interface between implant and bone playing an essential functional and structural role. The more this direct interface forms, the better jawbone remodeling and healing process become. Therefore, any factors that can exert influence on bone repair and bone healing may block successful osseointegration and, in turn, result in peri-implant complications or even premature implant loss. In fact, it has been questioned for quite a long time whether living habits and medical substance abuse such as alcoholism and smoking might affect implant survival and peri-implant health. The aim of this chapter is to provide an insight of physiological, biological, and pharmacological effects of smoking and alcoholism from preclinical and clinical data, two most common substance abuse, on the bone-­ to-­implant interface and osseointegration. In addition, we also describe concerned prevention and management of the disease.

Y. Huang OMFS-IMPATH, Department Imagining and Pathology, K.U. Leuven, Leuven, Belgium Department of Oral Implantology, West China Hospital of Stomatology, Sichuan University, Chengdu, China P. Gong (*) Department of Oral Implantology, West China Hospital of Stomatology, Sichuan University, Chengdu, China © Springer Nature Switzerland AG 2020 Q. Yuan (ed.), Dental Implant Treatment in Medically Compromised Patients, https://doi.org/10.1007/978-3-030-28557-9_3

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Tobacco Smoking

3.2.1 Background 3.2.1.1 Relations Between Smoking and Oral Health It is generally known that smoking habit has a number of negative influences on oral cavity, which include direct influences (e.g., staining of teeth or filling materials, impaired ability to smell and taste), and indirect influences in the development of oral diseases (e.g., periodontitis, smoker’s melanosis, hairy tongue, oral mucosa disease, oral cancer, and implant survival rate). It should be recognized that smoking as a living habit does not only influence the health of oral cavity, but also negatively relate to the state of general health [1]. The mechanism of this negative impact of smoking may be mediated through two typical routes, namely local and systemic biologic routes: Local Route The peri-implant tissue, such as peri-implant bone and gingival tissues, is the local place influenced by tobacco smoking, resulting in a limited blood supply, nutrition on site, and thus difficult bone healing [2]. It is reported that local absorption of nicotine by the oral mucosa led to a significant vasoconstriction during the first repair processing of the implant bed [3]. Nicotine can also change the microenvironment around the implant and affect the microbial composition [4]. Moreover, local blood irrigation is reduced and platelet aggregation strengthened. Smoking also had an adverse effect on fibroblast function, interfered with chemotaxis and phagocytosis in neutrophils, and negatively influenced immunoglobulin production by lymphocytes [5]. As a consequence, smokers may have a slower healing than nonsmokers and greater risk of infection following implant surgery. It is also proved that bacterial plaque grows more quickly on epithelial cells in smokers [6, 7], which means the loss of implant could progress in a short term. Researches have implicated that the microorganisms in the loss of teeth are the same as the six major periodontal pathogens with aggressive action in the peri-implant sulcus: Actinobacillus actinomycetemcomitans, Eikenella corrodens, Fusobacterium nucleatum, Porphyromonas gingivalis, Prevotella intermedia, and Tannerella forsythensis [8, 9]. A recent research using the 16S rRNA gene sequencing method found that, compared with nonsmokers, the peri-implant microbial populations in smokers were reduced, while the number of microorganisms was increased. Periodontal and systemic pathogens in smokers, such as Capnocytophaga, Treponema, Propionibacterium, Pseudomonas, Lactobacillus, and Leptotrichia, are more abundant, while in nonsmokers, the pathogen population from Streptococcus, Selenomonas, and Porphyromonas are larger, and Lactobacillus, Propionibacterium, and Rothia are only detected in smokers [10]. Systemic Route Due to nicotine-enhanced release, arginine vasopressin produces a series of vasoconstriction on peripheral vasculature [11]. In addition, it has also been reported an

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increased platelet aggregation, which could give rise to thromboembolic problems [12]. With the alteration in the presentation of antigens to monocytes, the chemotaxis of peripheral blood could deteriorate as well, and further lead to the production of compromised systemic polymorphonuclear leukocyte function, which is often seen in diabetes and Down’s syndrome [5]. Not only this, smoking causes increased blood leukocytes, neutrophils, lymphocytes, and monocytes, as well as increased hematocrit, hemoglobin, and mean corpuscular volume. This could potentially raise the risk of ischemic heart disease by causing higher blood cell counts, higher concentration of hematocrit, and alterations in the lipid profile [13]. An Australian workshop held in 2007 examined the scientific evidence and developed consensus oral health messages [14]. So far, smoking is believed to be not only a potential causative or inducing factor for oral cancer or chronic inflammation around teeth, but also a risk factor for other oral mucosal lesions. According to a Japanese research in 2007, cigarette smoking status was positively related to tooth loss among young adults (P 10 METs. In details, 1–4 METs represent that patient can answer “Yes” for DASI Q1 and Q2 as well as walk 100  m on level ground at 3–5 km/h; and 4–10 or greater METs represent that patient can climb two flights of stairs or walk up a hill as well as answer “Yes” for DASI Q8 and Q12 [30]. According to the New York Heart Association (NYHA) Functional Classification, subjects with ≥7 METs are defined as normal or Class I (no limitation); with 5–6 METs are classified as Class II (slight limitation); with 2–4 METs belong to Class III (marked limitation); and with one MET are described as Class IV (unable to carry on any physical activity without discomfort) [34]. It is proved that high functional capacity is positively related to excellent prognosis in the stable ischemic heart disease patients with other risk factors [35]. However, the association of preoperative functional capacity with postoperative cardiac events or death is relatively weak for noncardiac surgery [36]. Furthermore, motor, perceptual, and cognitive impairments after stroke markedly impact daily life, which also influence implant surgery [37, 38]. Among the stroke patients, there are several prominent orofacial dysfunctions compared with a healthy population,

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such as decreased lip force, salivary flow rate, and chewing performance [39]. We recommend to carefully assess these parameters and communicate with patients clearly about which could be improved. Cardiovascular Risk Assessment According to the Guideline by ESC/ESA, before noncardiac surgery the cardiovascular risk is recommended to be assessed using revised cardiac risk index and the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) model [40, 41]. Both the index and model are available in the following websites so dentists could easily employ these tools in the clinic (revised cardiac risk index: http://www.mdcalc.com/revised-cardiac-risk-index-orpre-operativerisk/; NSQIP: http://www.surgicalriskcalculator.com/miorcardiacarrest). Electrocardiography (ECG) is commonly used as a routine method for cardiac risk classification [42]. However, it is not versatile for myocardial ischemia patients, especially for those with infraction [30]. Therefore, echocardiography is recommended to assess their cardiac function and structure. It is known that preoperative left ventricular dysfunction, moderate-to-severe mitral regurgitation, and aortic valve abnormality are related to major cardiac events [43]. Additionally, carotid artery and cerebral imaging are needed in patients with a history of transient ischemic attack and/or stroke within 6 months [30]. Blood Tests Blood tests should be performed to properly evaluate the patient. On the basis of the previously mentioned tools, all patients should be measured for serum creatinine levels preoperatively. The value directly affects patients’ risk grade (normal level: ≤130 μmol/L or ≤1.5 mg/dL). In the high-risk patients, cardiac troponins T and I (cTnT and cTnI) as well as plasma B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) may be assessed to reflect prognosis and potential cardiac events [44–46]. A complete blood count will determine the presence and severity of anemia because it can increase the risk for myocardial ischemia in patients with coronary heart disease [30]. Most CVD patients are under antiplatelet and some under anticoagulant therapy, and their blood tests should be conducted 72 h prior to surgery [47]. Patients with less than 50 × 109/L platelets (normal range: 150–350 × 109/L) represent a high risk of bleeding, and more than 450 × 109/L, called thrombocytosis, are more likely of forming clot [48]. International normalized ratio (INR) is used to measure the clotting tendency of blood, particularly for those patients treated with vitamin K antagonists, like warfarin. Based on the ESC/ESA guideline, INR ≤1.5 can prove that the surgery was performed safely. A systematic review shows that there is no significantly higher risk of postoperative bleeding for the patients (INR 2–4) without discontinuation of anticoagulants than controls. However, this conclusion is just suitable for simple dental implant surgery not for bone grafts and extensive flaps [49]. Additionally, for those patients with non-vitamin K antagonist oral anticoagulants (NOACs), because of their short median half-time (7–13 h), the overall recommendation is to stop them for 2–3 times the mentioned half-time before surgery, except in those patients at high thromboembolic risk. Of note, any discontinuations of present medicine should be prescribed by cardiologists not by dentists.

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Evaluation of the Residual Bone To the best of our knowledge, there is no evidence of bone deficiency and/or defect in CVD patients. However, as the CVD patients are mostly elders, the residual bone volume and density could be compromised. Complicated flap design and alveolar bone augmentation surgery are not recommended because only the simple dental procedure with restricted wound size is graded as low risk of bleeding [50]. Eliminating Oral Infections Patients with valvular heart disease are at greater risk for infective endocarditis [51]. Also, chronic dental infection is associated with acute myocardial infarction [52]. Therefore, it is essential to perform needed dental therapy to eliminate caries, pulpitis, and even apical lesions as well as diminish the periodontal inflammation before implant treatment. However, antibiotics and nonsteroidal anti-inflammatory drugs (NSAIDs) should be used in caution when managing oral/periodontal infections and inflammations, especially in the patients taking warfarin. Metronidazole, tetracycline, and macrolide derivatives are most significantly evident to enhance anticoagulant activity. Also, NSAIDs are showed to increase gastrointestinal bleeding 4–5-fold [53]. On the other hand, the success of dental implants is closely linked to oral hygiene. Periodontal treatment is necessary before implant surgery to prevent future peri-­implant diseases. Meanwhile, CVD patients have shown a higher risk to suffer from periimplantitis after dental implant placements than healthy population, indicating that conscientious periodontal maintenance should be conducted in these patients [54]. Antibiotic Prophylaxis CVD patients are generally at high risk for infective endocarditis due to their impacted endothelial function and impaired blood vessels, especially in valve heart disease patients. AHA recommends that prophylactic antibiotics are used before invasive dental procedures for patients with high risks of infection [55]. We all know that patients with CVD usually take many medications, and unfortunately many of them have potential interactions with antibiotics which are often employed in dental practice [56]. It is reported by many researchers that macrolide antibiotics have severe, even lethal, side effects, when it interacts with digoxin, calcium blockers, and class III antiarrhythmics [56]. Similarly, tetracycline can induce digoxin toxicity. Moreover, it has reduced effects in patients under bile acid sequestrants. Because macrolide antibiotics and azole antifungal agents can elevate serum statin levels, they should be avoided in patients taking statins to prevent myopathy and hepatotoxicity [57]. For the patients taking warfarin, the consideration will be more complicated. The evidence remains relatively controversial. Some researchers suggest a careful prescription of antibiotics in these patients, especially those who inhibit the hepatic metabolism of warfarin, including co-trimoxazole, metronidazole, macrolides, and fluoroquinolones [58]. Also, rifampin can enhance the hepatic metabolism of warfarin [59]. However, other researchers believe that those considerations should not be put into the single-dose prophylactic regimens [57]. For CVD patients with impaired kidney function, nephrotoxic drugs should be avoided.

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AHA 2007 recommendations suggest that patients should take amoxicillin orally or ampicillin intramuscularly (IM) or intravenously (IV). For patients allergic to amoxicillin, cephalexin and clindamycin can be used. For patients allergic to penicillin and ampicillin or unable to take oral medications, cefazolin and ceftriaxone administered IM or IV can also be considered [60]. It is highly recommended to consult cardiologists before prescribing antibiotics to CVD patients, particularly those under anticoagulant therapy. Planning for the Implant Surgery According to the guidelines by the America College of Cardiology/American Heart Association (ACC/AHA), the stability and timing of coronary heart disease are linked with the incidence of the major adverse cardiac event after noncardiac surgery and affect the perioperative morbidity and mortality [61]. Moreover, a recent myocardial infarction, which was defined as occurring within 6 months before noncardiac surgery, was shown to be an independent risk factor for perioperative stroke [62]. Therefore, implant surgery is suggested to be postponed at least 6 months in these patients depending on their general conditions. Furthermore, for the patients with systolic pressure 2, a postoperative measurement of BNP and high-sensitivity troponin is recommended for early diagnosis of potential complication [30]. Timing and method of complications management are much more vital than the incidence of complications [76].

4.1.3.4 Restoration Timing for Restoration The success of the dental implant depends on osseointegration. Currently, there is no relevant clinical research that indicates that CVD can affect implant healing. However, considering the compromised general condition of these patients, we suggest an extension of the healing time or usage of a temporary crown with lower occlusal force before the final restoration. Evaluation of Osseointegration It is very important to quantify implant stability at various time points and to project a long-term prognosis based on measured implant stability in CVD patients due to the possible alteration in general conditions.

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Retention of the Restorations CVD patients have poor oral health and are more likely to get oral infections and periodontitis. Gingival enlargement due to calcium channel blockers is one of the most common oral symptoms in patients with hypertension [27]. Of note, except cough, ACE inhibitor has other side effects called angioedema and perioral swelling because of the same mechanism, which may be confused with odontogenic infection [67, 68]. Considering these possible risk factors, we highly recommend screw retention for ease of maintenance. Screw retention is designed so that it is easy and safe to remove the crown, which is convenient for the maintenance of the implant.

4.1.4 Prosthesis Maintenance 4.1.4.1 Risk Factors of Dental Implant Failure A 31-year follow-up study including 6384 patients shows that after adjusting with age, gender, and location of the implant, no systemic disease/disorder was associated with implant failure [77]. Smoking is a significant risk factor that can increase early dental implant failure. Therefore, smoking should be avoided by CVD patients with dental implants. In addition to smoking, a history of periodontitis is also a risk factor on early implant failure [78]. Due to the close relationship between CVD and periodontitis, the oral cavity of CVD patients should be examined carefully and frequently for prompt diagnosis and treatment of possible dental implant diseases and other oral problems. 4.1.4.2 The Prevention and Therapy of Peri-implant Mucositis and Peri-implantitis The prevalence of peri-implantitis was 27.3% in CVD patients. Moreover, patients with a history of CVD are 7.7 times more likely to suffer from peri-implantitis after adjustments [54]. To prevent peri-implant diseases in CVD patients, it is necessary to include the patients in a regular periodontal maintenance program and to recommend proper oral hygiene on a regular basis. In addition, it has been observed that comorbidities of CVD, such as diabetes and chronic kidney disease, also play important roles in periodontal disease. Therefore, the proper control of these systemic diseases can help prevent periodontal problems and peri-implant diseases [79]. A recent systematic review found that nonsurgical periodontal treatment was sufficient to improve the periodontal condition of CVD patients and had beneficial effects on systemic inflammation which contributed to the development of CVD [80]. However, when nonsurgical treatment fails, other available therapies should be adopted such as regenerative approaches.

4.1.5 Conclusion 4.1.5.1 Evaluation of the Systemic Condition 1. Collection of the systemically medical history, including metabolic syndromes, immune status or infection, anemia, and coagulation function. 2. Assessment of the functional capacity: (a) For stroke patients with impairments and orofacial dysfunctions, careful and clear communication with them

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preoperatively is required, and (b) for patients with METs ≤4, a postoperative measurement of BNP and high-sensitivity troponin is recommended. 3. Assessment of cardiovascular risk: (a) For the high-risk patients, preoperative measurement of cTnT, cTnI, BNP, and NT-proBNP is recommended, and (b) for patients with a revised cardiac risk index value >2, a postoperative measurement of BNP and high-sensitivity troponin is recommended. 4. Assessment of cardiac function: (a) Echocardiography is recommended, and (b) for the patients with a history of transient ischemic attack and/or stroke within 6 months, carotid artery and cerebral imagings are needed. 5. Assessment of the total amount of red blood cells (RBCs) or hemoglobin in the blood. 6. Assessment of clotting tendency of blood: INR ≤1.5 is recommended, and for simple dental implant surgery, INR 2–4 is acceptable. 7. Assessment of blood pressure: For patients with systolic pressure ≥180 mmHg and diastolic pressure ≥110 mg, delayed surgery is recommended. 8. Others: (a) At least 6 months should elapse after myocardial infarction before implant surgery and for those after stent treatment 12 months is recommended; (b) ACE inhibitors are recommended to be replaced by ARBs; and (c) for patients under antiplatelet and anticoagulants, warfarin or aspirin should not be discontinued before surgery. 9. Consultation with the cardiologist preoperatively is highly recommended.

4.1.5.2 Controlling Oral Infection and Inflammation 1. Dental therapy to eliminate caries, pulpitis, and apical lesions. 2. Periodontal treatment: (a) Periodontal treatment and oral hygiene instruction are necessary preoperatively, and (b) a regular periodontal maintenance program should be conducted conscientiously postoperatively. 3. Chemistry plaque control: Chlorhexidine 0.12% twice daily postoperatively is required for at least 1 week. 4. Antibiotics and NSAIDs: (a) Preoperative and postoperative antibiotics are recommended. Taking amoxicillin orally is suggested, and for patients who are allergic to amoxicillin, cephalexin and clindamycin can be used; (b) NSAIDs should be avoided in the following patients: old, with renal or heart failure, on diuretics, and with unstable hemodynamics. Patients under monotherapy with 100 mg aspirin are not a concern. 5. Related systemic factors: (a) Smoking should be avoided, and (b) proper control of comorbidities of CVD, e.g., diabetes and chronic kidney disease, should be reminded. 4.1.5.3 Planning for the Implant Surgery 1. Computer-guided flapless surgery is recommended. 2. Multiple placements of implants (>3) within one surgery are not recommended. 3. The arrangement of the surgery is recommended to be in the morning with short waiting time.

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4.1.5.4 During the Implant Surgery 1. Monitoring blood pressure is necessary, and continuous ECG monitoring is encouraged. 2. Rinse with chlorhexidine 0.12–0.20% mouthwash for 3 min before surgery. 3. Oxygen: (a) Supplemental oxygen needs to be prepared for all ischemic heart disease patients; (b) for those with a history of angina or myocardial infarction, an additional oxygen supply (4–6 L/min) via nasal cannula is recommended. 4. Anesthesia and sedation: (a) 4% Articaine without epinephrine is a safe choice, and (b) for anxious and fearful patients, diazepam is the currently recommended choice (0.1–0.8 mg per kg body weight in a single oral dose). However, consultation with the cardiologist preoperatively is still highly recommended because of the large variation of the dose. 5. Hemostatic measures: For patients under antiplatelet and anticoagulants, common local hemostatic measures can effectively control bleeding. Electrocautery may be an additional choice to control hemorrhage during invasive dental procedures. 6. Minimally invasive procedures for implant surgery are highly recommended, especially for those under antiplatelet and anticoagulants.

Fig. 4.1  Oral view of a CVD patient pre-surgery

Fig. 4.2  Flap elevation during implant surgery

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Fig. 4.3  A dental implant was inserted with good primary stability

Fig. 4.4  Postoperative panoramic radiograph

Fig. 4.5  Final restoration

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Fig. 4.6  Four-year panoramic radiograph follow-up after final restoration

4.1.5.5 Restoration 1. An extension of the healing time or usage of a temporary crown with lower occlusal force before the final restoration is suggested. 2. Evaluation of osseointegration before the final restoration is recommended. 3. Screw retention is encouraged for ease of maintenance.

4.1.6 Clinical Case The following is a simple clinical case of a patient with cardiovascular disease (Figs. 4.1, 4.2, 4.3, 4.4, 4.5, and 4.6).

4.2

Renal Disease

4.2.1 Background Kidney is a vital organ of the body. Kidney is crucial for fluid and electrolyte balance. Besides, kidney is in the function of endocrine regulation, waste removal, and vitamin D metabolism. Disorders to renal function caused by heterogeneous disease pathways will lead to various metabolic disorders and organic complications. However, due to a growing population of patients who suffer from diabetes and hypertension in many developed and developing countries, the number of patients with chronic kidney disease (CKD) is increasing throughout the world [81]. The global prevalence of CKD is estimated to be 8–16% [81]. For adult US residents, the estimated prevalence of CKD stages 1–4 is 11.6% [82]. For Chinese residents, the prevalence of CKD is reported to be 10.8% [83]. Many people with CKD are asymptomatic in its early stages. Nevertheless, owing to the decrease in kidney function, toxins accumulate in the patients’ blood and affect other organs [84]. Clinical symptoms of renal failure can be readily observed as various systems affected by the accumulating uremic toxins and their compounds [85]. In a controlled study, implant availability in 100 hemodialysis patients is comparable with a control group of 50 healthy patients [86]. The effect of CKD on implant

4  Organ Diseases and Dental Implant Treatment

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osseointegration has been studied in animal models. Reduced bone-implant contact was detected when compared to controls at early stages (2 weeks) and no significant difference was found at 4 weeks [87]. Although CKD patients may have decreased quantity and quality of bone tissue compared with healthy people, we should not regard dental implants as a contraindication for them. However, we should still evaluate the conditions of the patient carefully and consult the nephrologist frequently.

4.2.2 Dental Implant-Related Oral Manifestations 4.2.2.1 Oral Health Status It has been reported that oral hygiene decreases in advanced stages of CKD [88]. On the basis of findings from various researchers, patients with end-stage kidney disease have poorer oral health status [89, 90]. According to the research, patients on dialysis do brush their teeth once or more frequently daily; however, few use floss [90]. A study that evaluated the dental status of a group of Chinese patients on hemodialysis showed that dialysis patients had a great need for dental treatment [84]. 4.2.2.2 Periodontal Condition Studies have shown that patients on dialysis have poorer periodontal conditions than healthy patients. CKD patients have a higher plaque index and higher dental calculus formation than controls [91, 92]. Elevated salivary pH, decreased salivary magnesium, and high levels of salivary urea and phosphorus lead to precipitation of calcium–phosphorus and calcium oxalate, and hence dental calculus formation [93]. However, the conclusions of reports relating to gingival inflammation are controversial. Some authors reported that gingival inflammation was strongly associated with the formation of dental plaques in CKD patients [94]. In contrast, other researchers drew the conclusion that there was no obvious relationship [95]. Compared with the general healthy population, periodontitis and loss of periodontal bone were significantly more severe in Chinese patients undergoing hemodialysis [96]. The most frequently reported periodontal condition is gingival enlargement. Gingival enlargement is a side effect of drugs such as calcium channel blockers, which are frequently used in these patients [94, 97]. There could be hemodialysis patients who previously received a failed renal transplant, and these patients could suffer from gingival enlargement related to the use of cyclosporine [98]. Patients may have bad breath and taste because of the presence of urea in the saliva, which is converted to ammonia; this occurs in one third of hemodialysis patients [99]. 4.2.2.3 Bone-Related Manifestations Histological evidence shows that 84% of CKD patients have bone disorders (CKD-­ Work Group 2009). Bone metabolism is regulated by several factors including parathormone (PTH), fibroblast growth factor 23 (FGF23), and dihydroxycholecalciferol (1,25(OH)2D). Complications of CKD, including hyperphosphatemia, hypocalcemia, hyperparathyroidism, and vitamin D deficiency, may interrupt the balance of these factors, impacting bone structural integrity and resulting in CKD-mineral and -bone disorder [100].

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The oral facial disorders related to renal osteodystrophy include bone demineralization, decreased trabeculation, decreased thickness of cortical bone, ground-glass appearance of bone, metastatic soft-tissue calcifications, radiolucent giant-cell lesions, radiolucent fibrocystic lesions, lytic areas of bone, jaw fracture, and abnormal bone healing after extraction [101, 102]. Several cases of expansive jaw lesions have been reported in CKD patients [103].

4.2.3 Dental Implant Treatment Considerations As previously mentioned, hemodialysis patients may lose their teeth early due to dental and/or periodontal problems. These patients may go to the dentist asking for implants to replace the missing teeth. Dental implant surgery is complicated for patients with end-stage kidney disease because of the clinical manifestations and side effects of the therapy, including dialysis. Dental implant surgery could also affect the patient. Therefore, dentists need to plan carefully and have complete consideration before conducting the surgery.

4.2.3.1 Preoperative Period Evaluation of the General Condition Before implant surgery, dentists must evaluate the general condition and oral situation of the patient very carefully. Consultation with the nephrologist is necessary to collect information including the overall degree of CKD, causes, clinical features, risk factors, ongoing therapy, previous and present medical treatments, drug excretion or metabolism, and the best time for implant surgery [104]. A systemic review should be performed regarding the history of cardiovascular disease and diabetes, immune status or infection, anemia, bone involvement, and abnormal hemostasis. It is necessary to explain the treatment that we recommend for the patient to the nephrologist in a simple manner. Blood Tests Blood tests should be performed properly to evaluate the patient. The typical preoperative diagnostic testing in patients with CKD includes the measurement of Na+, K+, Ca2+, Mg2+, Cl−, blood urea, creatinine, and bicarbonate levels. A complete blood count will determine the presence and severity of anemia or thrombocytopenia. The bleeding time should be measured as coagulation should be within the normal limits, and bleeding time >10–15 min has been associated with high risks of hemorrhage [105]. If the test results are not normal, it is necessary to refer the patient to a nephrologist to manage the state of the patient. Platelet transfusion should be considered if the platelet count is