Patient with Paget’s Disease: Can I Place Implants?

Pagets in my opinion is a contraindication. Patients have bleeding tendencies and are prone to postoperative osteonecrosis. So don't place! Removable option of fixed or minimal treatment maintaining what the patient has-obviously treating acute and chronic infection. Even taking a tooth out can cause necrosis so vigourous pre op chx .2% and post op chx.2% and also systemic abs required. Also remember alot of these patients are taking biphosphonates. There are varying degrees to the disease so perhaps consultation with the patients physician is advisable.

Dear Dr. PA; as you know there are two different situations with the same name of paget's disease.There are PD of breast and PD of bone. I guess you are referring to the latter.If I'm right,then people suffering from this maladie are under treatment by Bisphosphonates which is a relative contraindication for dental implant insertion per se.If you are determined to place the implants any way, then you have to follow the guidelines issued by American Association of Oral and Maxillofacial Surgeons.(www.aaoms.com)

Don't do it. Don't ask how I know.

So sorry for the mistake I have made.The right link is; (www.aaoms.org/bronj_update)

In what was called the PRISM Study (conducted by a team from Edinburg led by Professor Ralston a large scale clinical trial involving over 1300 patients in 42 patients across the UK spread over 5 years from 2001 to 2006) an attempt was made to determine the best way of managing Paget's disease. The study compares the effects of "intensive" treatment for Paget's disease with drugs that suppress bone turnover, with "symptomatic" treatment which focuses only on the control of symptoms. The PRISM study is jointly funded by the Arthritis Research Campaign and the National Association for Relief of Paget's disease Thankfully, the study by Prof Ralston's team concluded that ONJ (Osteonecrosis of the jaws) seems to be very rare in Paget’s disease. In the PRISM study, no cases of ONJ were reported. Also ONJ was not observed in any patients being treated in clinical trials with the most commonly used Bisphosphonate Zoledronic acid (Aclasta). In view of this it is quite unlikely that any problems would arise in the course of routine bisphosphonate treatment for Paget’s disease. However, just as in any other patient who has been on Bisphosphonate therapy, precautions, assessments of bone density and duration of therapy, route of administration etc, would be the concerns prior to sequencing Implant therapy. Robert Marx & Arun Garg have well-laid out protocols for conventional Implant therapy for patients on bisphosphonates and they may be kept in mind. Cheers Jeevan Aiyappa

Errata : Sorry about the error in the 3rd line of my post... read 42 'centres' instead of 42 'patients' Cheers Jeevan Aiyappa

Sir, I searched both Pubmed and Ovid-web for the article that you have just mentioned to be written by Robert Marx and Arun Garg, recommending the placement of implants in patients under treatment by BPs.Unfortunately, I couldn't find anything like that.Will you please be more specific about that article so that we can find it more easily.Thank you very much.

thinking about dental implant in Paget disease has 2 main points:- 1-disease it self 2-bisphosphonate therapy Regarding the disease we have to see:- a-stage of disease (active or remission)x-ray,lab analysis b-site affected (if jaw bone affected or not) Patient in remissive stage, good lab result(serum alkaline phosphotase)implant can be considered with proceeding with care in handling the tissue & surgical technique if the bone is soft quality type(under prepration of osteotomy site) Regarding bisphosphnate:- duration of therapy ,root of adminstation&CTX test is important before making the decsion of implant,however it is found that high risk of osteoncrosis is associated with I.V root,malignancy and glucocorticoid intake.so reporting BRONJ in paget disease was not reported,even recomendation of short duration of oral bisphosphonate therapy in paget disease patient before implant placment.

Dear professor, thank you for your wise analysis of the situation, but, I think that there is a missing point here.It is not the disease itself that may lead to osteonecrosis but the medications that the patients are taking.These patients are under treatment by Bisphosphonates AND Steroids, and this a combination with a high risk of developing BRONJ.

Dear Dr.Jafari the original Q was asking for paget disease & implant? I didn't mention that the disease lead to osteonecrosis,the problem with disase is the bone quality & staging of disease,if the patient has recived bisphosphnate,most of them have it in oral form until the remissive stage of disease.we have treated patient with such conditions,during surgery the bone quality was D4.under prepration during osteotomy,primary stability was good.the implant is functioning now for four years without complications. Paget disease was a contra indication for dental implant,but carefull analysis of the case lead to the right descsion.