Dental Implant Contraindications

Let me preface my remarks by saying that this is not legal advice. I recently attended the International Associaation of OMFS meeting in Vienna and there was a symposia on management of the osteonecrosis patient on bisphosphonates. Fortunatly, almost all reported cases are due to the use of IV bisphosphonates (the exact number escapes me but I remember it being less than 50 worldwide on Fosamax and over 1500 reported on the IV drugs). The general consensus of that meeting (again NOT legal advise) was the routine dentoalveolar surgery including implant placement in patients on Fosamax was OK, but contraindicated in those on the IV meds. Obviously those on IV meds have significant medical problems including metastatic disease, lymphoma, ect. As an oral sureon, I don't really have much choice about extracting some teeth on patients on Fosamax, but I do have a "talk" first about risks/benefits.To put it in perspective, Fosamax has been used for years in millions of doses and ther are precious few reports of negative side effects. I think you have to discuss the situation in detail with the patient when you are doing elective surgery.

I agree with Larry S. Fosamax has not been shown to be much of a problem, but the I.V. bisphosphanates are. There is a good review of this subject in the Dec. issue of JADA.

I just inserted an abutment today on a patient who had the implant placed in June. The patient has lupus and is also on Fosamax. There was excellent tissue response and solid integration. This was done with a one-stage protocol. There is significantly less risk with Fosamax than with IV bisphosphonates. However, when performing elective procedures we do have to fully inform our patients of potential problems. Placing the complications in proper perspective.

I wouldn't. What is the difference b/n this case and premedicating for heart murmur ? Very low incident but still there. There is a good article by R. Marx in JOMS 2005.

Given the high #'s of pts. on fosomax (oral bisphonates), the high # of implants placed generally,the low # of pts on fosomax w/ concurrent reports of osteonecrosis, & finally ,the relatively low # of failures in postmenopausal women (most likley to be taking fosomax), I do not believe that its use is a contraindication. Certainly, i think of it as a possible risk factor (like smoking, etc.) and I think there must be a study going on someplace to give us further data, In the meantime, I do discuss w/ my patients. This drug has 1/2 life of 10 years, so we may be getting more news!

To respond to Matt L.: the AHA has significantly reduced the number of conditions for which prophylaxis is required simply because the evidence for it's efficacy was not there. Along the same lines, the evidence for substantial problems with Fosamax is not (currently) there. Another analogy is that there is a very real risk of anaphylaxis with oral antibiotics, yet we still utilize them. It's a risk/reward evauation we all make daily.

I had a consultation today regarding an extraction and the immediate placement of an implant with a patient on fosomax, The tooth must be extracted. I informed her of the risks and the reports we've all been reading as of late. I have placed implants for the last 22 years including patients on fosomax. I have never seen a complication in the fosomax patients I've treated. That does not mean I am blind to the risks. While we must be prudent I do not feel that we should be afraid to offer informed patients surgical care because of this apprantly rare occurance if that's what they really need and they are not in the higher risk IV treatment group.She decided to proceed with the above treatment.

I've contacted Dr. Marx and he recommends discussing the remote possibility of problems with patients but still places implants in patients taking Fosamax. I've been doing the same but letting the fixtures integrate longer before restoring.

when i was doing my residency i had examined a patient who was on biphosphonate. she had very big lesions around all 4 lower implants that she had placed a few years ago. i think that there is initial osseointegation but at some point the patient presents with a big lesion around the implant. That was a single case. I have also seen one more case like this in my practice.

Please read our article out of the University of Miami, published regarding Bisphosphonates in the November Issue of JOMS 2005. I would be happy to e-mail the article to anyone if you'd like it. Vishtasb Broumand, DMD, MD Oral & Maxillofacial Surgery Head and Neck Tumor and Reconstructive Surgery Assistant Professor of Clinical Surgery Division of Oral & Maxillofacial Surgery University of Miami School of Medicine/ Jackson Memorial Hospital 9380 S.W. 150th Street, Suite 170 Miami, FL 33157 Cell: (305) 502-4117 Office: (305) 256-5270 Fax: (305) 256-5280 E-mail: vbrouma1@newssun.med.miami.edu

A complete discussion of risks and benifits withthe patient is essential. I have had patients elect coronectomy and root canals and have had patients elect extractions. I picked up a case of osteonecrosis prior to its publication in the literature and the patient subsequently died from what I felt was the draining effect of prolonged antibioitcs. There is no effective treatment. While the risks of occurance are extreemely low, the consequences are devastating. The decision is therefore in this office always on the conservativbe side. F Bonine

One of the toughest lower 1st molar extractions I've done was on a pt taking bisphosphonates long before we knew anything about the drug. It seemed as if the bone was denser than the root, which crumbled repeatedly. Patient stayed on the meds and I preped the site 5-6 months later for the implant. I looked down into the 4.5 x 10 mm drilled site and saw (in a post extraction case!) absolutely no cancellous bone and no bleeding. Type I - very unusual! That gave me a heads up to a potential problem. Secondarily, the talk of "spontaneous" osteonecrosis is probably due to decreased vascular perfusion and increased bacterial susceptibility. BTW, the 1st implant failed and the 2nd is still there.

The complications may appear years later following the surgical procedure. Spontaneous cases of OJN have been reported in the complete absence of dental treatment. At this time all patients on oral or IV bisphosphonates have the potential for grave complications.

I agree with the lack of current information to substantiate contraindication of dentoalveolar surgery including implants in Fosamax patients. Nearly all of the osteonecrosis complications are with IV bisphosphonates as stated with previous postings. Please see my article with my colleagues in Nov 2005 JADA.

Have patient, 76 year old African American come in for pain on #2, and #31. Was undergoing tx for multiple myeloma and recieving zometa as well. Did not know at the time the effects of bisphosphonates, especially IV. The bone was hard as a rock, but I thought it was due to the fact that he was African American. Saw him 6 months later, upper extraction site was healed on the panex but 31 site had little to no bone in the socket. Also the tissue had failed to cover over completely. Mild purulence noted. Spoke with the oncologist today, he said he would get back to me regarding future tx. Pt has multiple areas of decay on #'s 21-27. I will be interested to see what his recommendations are for future treatment. Seems to me he should have had all his teeth out prior to treatment for his cancer.

I am planning to have an implant in my missing lower left molar tooth. I know the positive sides but there aren't much comments on the negative sides. Could you please let me know about the after effects? Many thanks, Meri

I have been reading all on biphosphonates. On the last 3 years, I have routinely prescribed SodiumAlendronate 70 mg once a week + Calcium Carbonate 1200 mg with D Vitamin 400 UI daily to ALL my patients that underwent a major bone graft (ICBG for atrophic maxilla, ICBG as block, large sinus lifts). I start 15 days after surgery, and finish it 1 month after the prosthesis is placed. Usually then I discontinue the Sodium Alendronate, and keep a lower dose of the CaCarb+ D Vit. I have not done lab research, but the clinical evidence is amazing! Very little bone graft resorption. Very good bone density. I place implants (SLA Straumann SP or TE) 4-5 months after graft, and load them at 6-8 weeks. I am working on a retrospective report, 15 consecutive cases of total edentulous maxilla, 118 implants, 2 lost. My clinical impression is strong that it makes a difference. However, due to all this comments, on my last patient I prescribed only CaCarb+D Vit. Remember that I prescribed only for a maximum of 10 consecutive months, and then discontinued it. Comments?

Fosamax, Actonel, Boniva, Zometa, and Aredia are all in a class of drugs called bisphosphonates and are commonly marketed as medications to help and prevent or treat bone loss in osteoporosis. Unfortunately with women taking these drugs at an earlier age and for much longer time spans, they are at an increased risk of developing osteonecrosis of the jaw (ONJ). There have been over 2,400 patients since 2001 that have reported bone death and jaw bone decay or osteonecrosis of the jaw. In addition, more than 120 patients have suffered from such severe pain and debilitation that they have become bedridden or in need of devices like crutches, walkers and wheelchairs.

Am postmenopausal osteopenic 58 y.o. on Fosamax 2 yrs. this Aug. Recent bone scan shows increased density hip, decrease in femur. Very recent panex: very little change from '91. 22-plus y.o. fixed bridge spans anchoring back lower molar and eye tooth, where it's come loose. Must either replace bridge or retain anchor teeth and fill in teeth 19, 20 & 21 with implants. Seek advisability of implants. Basically healthy. On thyroid meds. Functional heart murmur/mild MVP. Prone to bruxism. Take cal/mag citrate w/extra D and occasional silica, which supposedly transmutates to calcium. Calcium carbonate kidney stone '92. Lithium carbonate intake '69-'81.

Have there been any reported cases of ONJ when patients who took fosamax wore a partial on the lower jaw? I am choosing not to get implants to replace three lower teeth that were extracted years ago, but I'm wondering if a removable partial would be okay.

Has any one had experience with a patient having greatly increased pain during recuperation from periodontic reconstructive osseous surgery.

I am considering upper jaw split surgery for palatal expansion followed by extensive orthodontics and removal of pieces of lower jaw, all to correct a bad bite and improve my apprearance. I'm 50 and have been on 70 mg Fosamax for 1 year. My oral surgeon has expressed reservations about this course of action. Please advise.

I am considering upper jaw split surgery for palatal expansion followed by extensive orthodontics and removal of pieces of lower jaw, all to correct a bad bite and improve my apprearance. I'm 50 and have been on 70 mg Fosamax for 1 year. My oral surgeon has expressed reservations about this course of action. Please advise.

Have been on Fosamax and Actonel for a total of 9 years. Had a dental implant on tooth 3 last August. In February the tissue on the implant dissapeared, and after a CT scan, found major bone loss. I think as time goes on, long term use will present more and more negative results.

I have several questions for you about your statement online on osseonews.blogs. What information do you have on the crippling of patients who have taken Fosamax? As I am experiencing side effects now, I am desperate for some help. Also, I have osteonecrosis of the lower jaw and I am scheduled for bone graft surgery Wednesday. I took Fosamax for four years so I have reservations about which is more dangerous, the surgery or the osteonecrosis. Thanks! Theresa

I am 53-yr old patient taking Fosamax 35 mg for 2+ years after experiencing excessive tooth breakage. If Fosamax inhibits action of osteoclasts, it should at least slow tooth breakage, but did not. I read of anecdotal evidence that bone fractures that do occur in patients taking Fosamax are slower to heal - simply put, the bone has lost the ability to regenerate through osteoblasts. Over-mineralization and brittleness were also noted early on. Personally, I have stopped Fosamax and believe it will go the way of estrogen therapy - prescribed only in extreme cases.

I'm scheduled to have 7 implants done in Sept, have been on Fosamax for five years, stopped drug in May. I am frightened to death of going through with the procedure now, help! I am on no other meds except thyroid and healthy.

I am in my mid-fifties, and been on bisphosphonates for nearly a year for ostopenia. After getting a lower back molar extracted and bone graft done last week, heard yesterday that I am at increased risk for developing ONJ - should I stop the implant procedure, or stop the Didrocal - am really worried, and waiting to tell my periodontist on Monday when he removes the dressing about this - I did tell them about Didrocal some time ago. I hope he knows of this increased risk!!

We are facing a situation wherein we were supposed to have 2 implants. All-of-a sudden the refered denist is suggesting a bridge instead. The change occured when we mentioned we are on Fosamax. Any comments?

Green: Please read Larry S comments at the top of the blogs...

I think the fear of bisphosphonates is greatly misunderstood by general practioners as welll a specialist. It appears that IV Meds are the greatest risk and use of Fosamax should not change your mind from performing an implant.Nor should in my opinion you advise its discontinuation unless you speak with the MD A greater under standing of the risk benefit ratio needs to occur. Hopefully we will understand this process more.

Would recommend that you review Robert Marx's new book on Bone Induced Osteonecrosis, from Quintessence, Quintpub.com. or attend one of his seminars on the topic. Seems to have some reasonable guidelines on risk assessment and management of patients on bisphosphonates. His recommendations are based on his management of 119 patients with IV induced and 30+ patients with oral induced osteonecrosis. If he is right and it is accumualtive dose dependent, we may start to see more and more cases of osteonecrosis from oral bisphosphonates, especially as patients get out over 5-10 years of continuous use of the oral agents. Per Marx, the risk on oral agents seems to be pretty low in the first 3 years on oral agents in otherwise healthy patients. There does seem to be some ability of osteoclast function to recover in patients on oral agents with cessation of the oral agents according to Marx. But it may take 6 months to a year. This is not the case with IV bisphosphonates. Will the same thing happen to the osteoclastic function of patients on oral agents, it.e., will they lose their ability to recover after the patient cross some threshold of accumulated drug in the bone? Time will tell. Still alot that we don't know. Informed consent is an important part of treatment.

Marx's book gives a great review of the problems with these drugs as well as the lack of proper monitoring of the osteoporotic patient. I took his course on the topic and it was well worth it. An ounce of prevention is well worth it. He is also correct in assuming this problem will get worse before it gets better.

I am told I must have either a crown (preceeded by removal of some gum tissue) or an implant of lower rear molar which has root canal done. Have been on Fosamax for 2 1/2 years for osteopenia (just tested normal for my age). I am told crown may or may not last. In my frightened state of mind after reading all this I am thinking I should avoid both implant and extraction. Right?

It was suggested to me that i need an implant, but am 67 years old and not well off. Friends have had them and have had trouble. What makes a good canidate and what does not. I need to know specifics. In old age we lose density and heal slower. It seems like its a risky business for seniors, but need to know some specifics. Its alot of money to spend at this stage of my life. YOur comments would be welcome. thanks

L Edwards, Candidates for implant therapy are wide ranging. Of course money is a factor to consider in anything and we leave that decision up to you. Age is not a contraindications if you're asking that. I have placed implants in a 92 year old who found value in maintaining her oral health. As with any surgical procedure, my suggestion is to discuss your concerns with your doctor. They will be better equiped to look at your specific health and evaluate if you are a candidate. I know this is a generic reply so I'll add some things that would complicate implant surgery and potentially make it riskier...This is not a complete list but hopefully will help answer your questions: Uncontrolled Diabetic Heavy Smoker with poor oral hygiene recent radiation therapy IV Bisphophonate use Immunocompromised Patients (Brittle patients) Any Uncontrolled disease like hypertension VERY Severe Bone Loss of the jaw - I don't do hip grafts There ARE other contraindications not listed that I'm sure will be added by my colleagues. I hope this helps and good luck.

Have taken Fosamax and Boniva for at least 10 years. Had lower left molar pulled Dec. 2008 and implant done May 27 2009. Am experiencing gnawing ache in jaw/cheek area after 3 weeks since surgery. Could this be warning of onj? Thanks.