Dental implant protocol for patient on Actonel?

Any medically compromised patient should have a conventional treatment plan. There is no description of it here. One implant insertion resolves neither mastication nor cosmetic issues. Moreover, as bone density is different in the lower and upper jaws, you cannot make further decisions based on the results of one implant insertion.

Her treatment plan includes: 1. Stabilization and maintenance of periodontal health. 2. Implant replacing 16 with simultaneous summers lift. 3. Implants in position 13 and 11 with simultaneous GBR. 4. Implant in position 46 without bone augmentation She has since crowned her lower dentition including a bridge replacing 35 and 36 as per her request. I am concerned about the possibility of osteonecrosis prior to implantation. Considering her history of Actonel and protolos use would you go ahead with implantation? Would you run any tests prior to this? I would be very grateful to hear your thoughts. Many thanks Jean Paul

I take it your patient is on low dose oral risedronate for osteoporosis. If so you can regard it as a slghtly "weaker" (in terms of BMD) version of alendronic acid, and follow the same management protocol. You're going to have big aesthetic problems in the UR321 region if you are thinking in terms of implant retained bridge work.

Hi did she toke the medicine orally or IV? if it was oral intake with low dose there is no problem to do implant , consider pre +post antibiotics , chlorhexidine MW , Aseptic technique if she take it IV , it's not advisable to do implant surgery. note : why you dont give here implant in place # 19 ( 36) mandible left first molar !!1 to provide her with one side full function good luck

I think your unilateral treatment plan sounds risky from both surgical and prosthetic points of view, because it will result in the right side overloading even if the patient were without osteoporosis. I would suggest making two partial dentures with metal frame first. It will restore cosmetic and mastication function and a low smile line will mask some prosthesis disadvantages.

I cannot understand why you would call this a unilateral treatment plan. The lower left posterior quadrant is already restored, the upper left is fine and doesn't need restoring. Why would you believe it would turn out to be unbalanced?

I would regard a unilateral upper anterior implant bridge as the most difficult challenge to get right from a cosmetic point of view, Not only have you got to place cosmetically acceptable gum fitting teeth but the gingival contours of UR321 have to match those of the natural UL123. I suggest it's essential to ask your lab to mock up a partial upper denture with gum fitting UR321, try this in, and make absolutely sure your patient is happy with the appearance before going ahead with the implants. You can the duplicate the denture in clear acrylic and use this as an implant placement guide. Unless you get the implant positions just right, and the bridge exactly replicating the denture you're likely to have a very unhappy bunny on your hands.

How long has she been on the oral bisphosphonate. How often is it dosed ? Are there any contributing medical conditions ? Is she on a glucocorticoid ? Is the patient on a monoclonal antibody drug like bevacizumab ? What is the patient CTX levels ? Without knowing those indices and issues, it is difficult to comment on the question.

Thankyou for your input. I do not have the exact readings, I will ask her and post an update on this query. Thanks again

You need to get a CTX test on her and ideally the result would be >150. If the number is lower then have her take a drug holiday for 9 months and retake the test.

You should also have her take a test for cholesterol and Vit D levels as long as she is going to go to a lab. Dr. Choukroun from France has some new ideas why implants fail.

Dr. Demajo, I agree with your treatment plan. Restoring function on the right side is important in the long run, and will help reduce overload on the fixed bridge you recently made for the third quadrant. Also good for her TM joints. I will not waste your and everybody else's time by commenting on your proposed anterior implants, as it is not what you asked for nor can I judge from this image [Excellent panoramic X-ray, looks like a Planmeca, is it?] Orally administered risedronate rarely has been associated with ONJ, check the research; provided it is a clean surgery with no undue trauma to bone and no exposed bone in mouth like after major wisdom molar surgeries. As an added precaution, you may ask her to skip it for a week before the surgery, and she can start it a week after. This is what I usually do. If the medication is a weekly tablet, then basic pharmacology states that less than half of initially absorbed dose is still circulating in her blood after 7 days. Stop it two weeks before (with MD's approval) if you are still nervous. All that Protolos Strontium and dense Calcium will give you a hard Type I cortical bone at time of surgery. Try not to go high on final torque as you could be stopping important circulation, vitally important in these senior ladies with bone density issues. Now, tell her not to go jumping around in bouncy castles or mountain bike riding while she is off her regular risedronate schedule, and healing with an implant in the mouth. Else she can blame you for a broken hip! Also supplement with a wide spectrum antibiotic like Amoxicillin to be safe. Good sterile technique, proper planning and adequately bleeding osteotomy is what you need for good osseointegration. I would worry a bit more if she were on injectable bizphosphonates. Good Luck!

Many thanks for all your comments which have been very helpful from all sides. I have asked her to perform a CTX test. She has been taking protolos for 3yrs at 2mg per day and Actonel at 35mg per week. Will come back with more info on the CTX test. Regards Jean Paul

Assuming the periodontium, muscles and temporomandibular joints are stable, and the patient is able to afford implant reconstruction, consider the following: Requesting a CTX test is prudent for medico-legal reasons, since lack of one if something goes wrong would be more ammo for a case against you. The fact that she has taken the medication for three years only will make it easier to get her bone repair biology to normal levels after a drug holiday. I would be happier with a guided bone regeneration procedure in the anterior right edentulous area to create enough width to place two implants and an implant supported three unit bridge than a removable partial denture. These cases can be made to look nice it is a better service for the patient. This is what I would want in my mouth. The low smile line helps, but beware of low smile lines that go higher once the patient can show a nice smile after being restored. If you are not planning to place enough implants in the lower right posterior area to provide an occlusal stop for the supraerupted maxillary second molar, I would consider doing a three unit bridge which would allow you to correct the level of the supraerupted molar, replace the missing first molar and prevent further migration of the second molar. Good case, thanks for posting it and good luck!