Osteogenesis Imperfecta and Implant Treatment?
I have a 67 year old patient who wants implant supported replacement of failed upper anterior bridgework. He is fit and well, but for having Ostegenesis Imperfecta Type 1 and is on Alendronic Acid. Published research is (perhaps unsurprisingly) sparse and largely anecdotal. It would appear that success rate may lower, but my question is, is Ostegenesis Imperfecta (OI) considered to be a comorbidity when considering Alendronate? Is he at greater risk of the dreaded MRONJ? If the worst that is likely to happen is implant failure, I would not be leaving him significantly worse off, but a rotted maxilla is another matter! Thoughts?
Note: Osteogenesis Imperfecta (OI) is a genetic bone disorder characterized by fragile bones that break easily. It is also known as “brittle bone disease.” The term literally means “bone that is imperfectly made from the beginning of life.” A person is born with this disorder and is affected throughout his or her life time. Learn more
8 Comments on Osteogenesis Imperfecta and Implant Treatment?
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Dr. Gerald Rudick
2/18/2019
Alendronic Acid 70mg Tablets - Patient Information Leaflet (PIL) - (eMC)
https://www.medicines.org.uk/emc/product/5697/pil
Alendronic acid belongs to a group of non-hormonal medicines known as bisphosphonates, which prevent bone loss from the body. Alendronic acid is used to treat a condition called osteoporosis (brittle bones). This condition is common in women after the menopause.
Biphosphonates are one of the the primary reasons that Osteonecrosis of the jaw develops....... so placing implants in a patient on this type of medication would not be a wise idea. Do run this question by Florida Oral Surgeon Dr. Robert Marx, he has written papers on this subject and can give you the best information.
Bone Graft Teacher
2/19/2019
You need to have the patients md run a blood test known as c-terminal telopeptide. Values below 200 show a patient at risk for BRONJ. If the value is low the patient can be put on a drug holiday with md approval. You can expect an increase of 25pg/ml per month. The patient must stay off the drug during healing.
Dr. Gerald Rudick
2/19/2019
Attention Bone Graft Teacher …… remember the old expression...." If you play with fire, you risk getting burnt!"....this is a very delicate situation, and probably safest to stick with old technology for tooth replacement = no implants.
Adriciu
2/19/2019
Alendronic acid (Fosamax) is a risk factor when doing surgery on the maxillary bones. It is important to know for how long was the patient on Fosamax? Less then 5 (in my books 4) years the risk for BRONJ is quite low. Over 5 years the risks are increased, even if they are lower than for injectable bisphophonates. Also is important to ask if the patient took some other bisphosphonates prior to the treatment with Fosamax (you may be surprised). If patient has a history of less than 5 years, I would proceed, with some precautions: one implant at a time, surgery as atraumatic as possible (for sure don't overtorque the implant, you really don't want some pressure necrosis of the bone, as the osseoclastic activity is diminished), patient on chlorhexidine prior (1 day) to the surgery, and a couple of weeks after the surgery. Also discuss (and document) at length the possible complications with the patient - patients have a tendency to forget all your good will when things go south. Good luck!
D-r Yaromirov
2/20/2019
Do not do it! You will put a hedgehog in your pants! And it's going to be there for a long time. Next thing that's going to happen is called osteomyelitis.
Richard Simons
2/25/2019
Thank you for the responses; I think we are all aware that there is a theoretical risk regarding MRONJ and Alendronate, and my understanding is that in the absence of comorbidities straight forward implant treatment is deemed reasonable by most authorities; I for one have treated quite a number over the years without complication, and in this particular case I would be removing (non infected) retained roots and placing implants using a delayed loading protocol at the same time so there would be one transmucosal 'insult', that would be necessary anyway- my actual question was whether Osteogenesis Imperfecta itself increased the risk of MRONJ or other serious complications (beyond possible failure) ?
Dr. Moe
2/25/2019
Hi Richard,
Here is a link to things you are wondering about, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5794128
Not sure if OI itself is a contra-indication for dental implants. I would also look into what Orthopedists do if they have to do a Knee or Hip replacement on OI patient. The other question is How long has the patient been on Bisphosphonates? The longer a patient is on therapy, the higher the chance of MRONJ. Can patient take a holiday, i.e. Stop 3 months before and then wait for 6 months of osseointegration?
I did an exo on an 86 years old Pt on Prolia, which has a much higher rate of MRONJ. I worked very closely with the Pt's PCP and she is doing great. Did atraumatic exo with Periotomes, sutured her close. Stopped Prolia shot which she was due for, kept her off for 4 months, checked the site every month to see healing and took x-ray to see bone filling in. Finally, when all bone healing was noted, sent her back to her PCP MD.
Also, I would inform the patient in clear terms about MRONJ and then needing HBO therapy for Osteomyelitis, if it were to happen. Last time I took a course on MRONJ, it was suggested by an MD who is incharge of HBO therapy at a local hospital that the Pt might have to go for 15-20 HBO "dives" as they call it. They can be expensive, approx. $1500/each dive.
Like others have suggested, I would do extraction first and see how the Pt heals. Hope this helps.
Just my $0.02
oralsurgeryjj
3/12/2019
This is too late comment, but I have to tell you this:
Please go and see MRONJ patient post op photo and panorex.
I have treated more than 100 MRONJ cases and what made me more miserable is intraoral figure of post OP, fully secondary healed patient. Patient simply have to live with their partially bulbous denture as bone reconstruction plan is way too risky for them. The patients had self-proved that the osteogenic activity of them is way lower than average.
MRONJ of maxillary anterior bone is quite rare, since there is good vascularization. But once MRONJ bombards the anterior area, you can expect disfigurement of upper lip along with nasal ridge collapse........ not to mention of oronasal fistula..
It is reported that there is less than 5 percent of MRONJ incidence rate for who is taking 'dronates.' But that is only for extaction case, I cannot even imagine placing implants without having drug holiday.
First consult to the physician who is prescribing bisphosphonates , Ask if there's any problem on bone regeneration to the doc, not our D.D.S doc. That can resolve some liability issues on your worst case scenario. Also ask if he can have some drug holiday and replace his drugs. Take drug holiday as AAOMS's guideline. I prefer to count 1 year's 'dronates' drug taking period as 1 month of drug holiday.
That is your starting point. There are lot of case report of implant treatment to osteogenesis imperfecta, you may check that on google after checking good healing of socket.
