Dental Implant Treatment In Medically Compromised Patients Quan Yuan

Khi xã hội già hóa toàn cầu đang đến, ngày càng có nhiều người sống với các bệnh hoặc tình trạng đa dạng như rối loạn hệ thống, rối loạn hệ thống thận và các vấn đề tâm thần. Liên tục, khi những bệnh nhân này gặp phải tình trạng mất răng, chúng ta nên lưu ý rằng những bệnh nhân này thường có các tình trạng bất lợi như rối loạn chảy máu, rối loạn chuyển hóa xương và hoặc dùng thuốc ức chế miễn dịch. Hơn nữa, đã có cơ sở rõ ràng rằng tình trạng mất răng do viêm nha chu và hỏng implant do viêm quanh implant đã được báo cáo phần lớn ở những bệnh nhân hút thuốc và bệnh nhân tiểu đường. Bên cạnh đó, quan tâm đặc biệt cũng cần được lưu ý khi chúng tôi xử lý những bệnh nhân bị ung thư đầu cổ. Mặc dù phục hình hỗ trợ cấy ghép implant được coi là phục hình thoải mái nhất và bệnh nhân thường hài lòng với chức năng, nha sĩ phải chú ý hơn khi điều trị cho bệnh nhân bị tổn thương về mặt y tế vì họ có thể không có điều kiện tốt để tích hợp xương và chữa lành mô mềm xung quanh cấy ghép. Do đó, tôi muốn biên tập một cuốn sách tham khảo cho các học viên để tìm các gợi ý về cách đưa ra quyết định khi bệnh nhân bị tổn hại về mặt y tế đến điều trị bằng cấy ghép và cải thiện kết quả của quy trình điều trị ở những bệnh nhân này. Đó là nỗ lực của chúng tôi để làm sáng tỏ một nền tảng kỹ lưỡng về các bệnh có thể có ảnh hưởng đến kết quả của cấy ghép răng miệng được đặt ở những bệnh nhân này. Cụ thể hơn, chúng tôi muốn giải thích chi tiết trong từng chương về tỷ lệ thành công chung của cấy ghép răng miệng ở những bệnh nhân bị tổn thương về mặt y tế, những thay đổi liên quan có thể có trong môi trường miệng của họ, cân nhắc điều trị của họ (bao gồm cả thủ thuật phẫu thuật và chỉnh nha), cũng như cân nhắc dược lý và duy trì vệ sinh răng miệng. Như Khổng Tử đã từng nói: Một người nên học hỏi và không ngừng. Tôi hy vọng cuốn sách này sẽ giúp độc giả đưa ra quyết định về việc thực hành hàng ngày và cải thiện kết quả điều trị, dẫn đến cải thiện chăm sóc và sự hài lòng của bệnh nhân. Tôi muốn cảm ơn Qiwen Li, Junru Wen, Shuang Jiang, Weimin Lin, Xiaohan Zhang và Caojie Liu đã giúp đỡ họ trong quá trình viết cuốn sách này. Cũng xin cảm ơn Yunshu Wu đã giúp đỡ cô ấy trong quá trình chuẩn bị bản thảo. Cuối cùng, tôi xin gửi lời cảm ơn sâu sắc nhất đến tất cả các tác giả đã chia sẻ kiến ​​thức và kinh nghiệm của họ trong cuốn sách này.

Dental Implant Treatment in Medically Compromised Patients

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Quan Yuan

Editor

Dental Implant Treatment

in Medically Compromised Patients

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© 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, recita- tion, broadcasting, reproduction on microfilms or in any other physical way, and transmission or infor- mation storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed.

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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 res-torations 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 suc-cess rate of oral implants in the medically compromised patients, their possible related changes in oral environment, their treatment consideration (including surgi-cal 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

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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

Contents

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Editors and Contributors

About the Editor

Quan  Yuan is a professor of oral implantology, and 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 interna-tional 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 tures in international conferences He also serves as vice editor or editorial board member for eight scien-tific 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

lec-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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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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© 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

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,

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

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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 individu-als [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 complica-tions and failures of dental implants are challenging practitioners Implant failures can be classified into early failures and late failures Complications include biologi-cal 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 osteo-porosis 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, complica-tions 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

short implants, bone augmentation procedures are required less frequently in rior 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.

poste-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 evi-dence 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 move-ment 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 sur-rounding 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

Over the past decades, new parameters have been put forward to assess the cess 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, sur-vival, and failure Among the four conditions, survival conditions contain two dif-ferent 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 condi-tions, 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:

suc-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 paral-lel 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 suc-cess 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 men-tioned 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, occur-rence 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 enlighten-ment 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

success criteria should be comprehensive Some dentists may ignore the patient’s satisfaction level because of their vast professional knowledge; however, it is obvi-ously 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 evalua-tion is from a professional perspective, and may not be in accordance with the sub-jective 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 suc-cess 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 den-tal 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 place-ment [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

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 implant-supported prosthesis from different perspective rather than only focusing on the mobility of the fixture Therefore, we should re-regard the high survival rate cau-tiously Gallucci et al proposed success criteria based on implant, peri-implant tis-sues, prosthodontic, and subjective parameters And a 95.5% survival rate was reported whereas an 86.7% success rate was recalculated when their proposed suc-cess criteria were adopted [27].

Besides implant survival rate, another focus for us dental implantology ners 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

practitio-is suggested by different literature [41, 42] Esthetic complication can be fested 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 pos-sible risks [44, 45] The last category is technical complications which include abut-ment 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 complica-tions 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

mani-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

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 den-tistry have been achieved over time, the success rate is not satisfactory when evalu-ating 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 plications 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 effec-tive solutions that make implant treatment an even more reliable and predictable option for more and more people

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4 Luan WM, Baelum V, Chen X, Fejerskov O.  Tooth mortality and prosthetic treatment terns in urban and rural Chinese aged 20–80 years Community Dent Oral Epidemiol 1989;17:221–6.

5 Mack F, Schwahn C, Feine JS, Mundt T, Bernhardt O, John U, Kocher PT. The impact of tooth loss on general health related to quality of life among elderly Pomeranians: results from the study of health in Pomerania (SHIP-O) Int J Prosthodont 2005;18:414–9.

6 Emami E, de Souza RF, Kabawat M, Feine JS. The impact of edentulism on oral and general health Int J Dent 2013;2013:498305.

7 Kwok V, Caton JG, Polson AM, Hunter PG. Application of evidence-based dentistry: from research to clinical periodontal practice Periodontol 2012;59:61–74.

8 Eaton KA. The platform for better oral health in Europe—report of a new initiative Community Dent Health 2012;29:131.

9 Jablonowski L, Matthes R, Duske K, Kocher T.  Perspectives in dental implantology In: Metelmann HR, von Woedtke T, Weltmann KD, editors Comprehensive clinical plasma medi- cine Cham: Springer; 2018 p. 319–30.

10 Cairo F, Landi L, Gatti C, Rasperini G, Aimetti M. Tooth loss and dental implant outcomes— where is dentistry going? A survey by SIdP, the Italian Society of Periodontology and Implantology Oral Dis 2018;24:1379–81.

11 Jan C, Stefanie R, Stefanie DM, Filiep R, Ronald B, Danny C. An analysis of the decision- making process for single implant treatment in general practice J Clin Periodontol 2012;39:166–72.

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 pared to maxillary sinus augmentation procedure for the rehabilitation of edentulous poste- rior 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 dence: 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 plication rates of all-ceramic and metal-ceramic reconstructions after an observation period of

com-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: ity 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.

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 cess 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 tal 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 theses 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: rent 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 random- ized 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 ment planning, esthetic evaluation In: Toistunov L, editor Horizontal alveolar ridge augmen- tation 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 tions 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 poste- rior maxilla Clin Oral Investig 2017;21:2603–11.

49 Buser D, Broggini N, Wieland M, Schenk RK, Denzer AJ, Cochran DL. Enhanced bone sition 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 spective 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.

© Springer Nature Switzerland AG 2020

Q Yuan (ed.), Dental Implant Treatment in Medically Compromised Patients,

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: yuanquan@scu.edu.cn

2

Medically Compromised Patients:

A Biological and Social Challenge

Lin Xiang, Ya-qian Chen, and Quan Yuan

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, espe-cially in today’s society

Implant treatment procedures include preoperative planning, surgery ing, restoration treatment, and post-maintenance These three stages jointly guar-antee 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

perform-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 micro-movements during osseointegration resulting in fibrous encapsulation Therefore, the quantity and degree of corticalization and density of mineralization of cancel-lous 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 ment deterioration, such as air pollution and water contamination, and increasing life pressure for people living in big cities People with these conditions are mount-ing 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 cur-rently 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

environ-in faster growenviron-ing of older population than younger environ-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 cations of dental implant treatment [6] However, plenty of work has been reported

contraindi-to illustrate that the risk of implant failure and complications could increase in tain medically compromised populations and there are some precautions that we must bear in mind Accordingly, authors strive to elucidate these issues in the fol-lowing chapters, aiming to provide a practical and comprehensive guideline for clinical practitioners

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]

Researches have shown that the metabolites of nicotine will upregulate the sion of advanced glycation end products in gingival tissues resulting in increased production of inflammatory cytokines such as interleukin (IL)-6, matrix metallopro-teinase (MMP)-1, IL-1 beta, and tumor necrosis factor-alpha (TNF-α) by gingival fibroblasts [10–12] These inflammatory cytokines contribute to periodontal colla-gen 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 discuss-ing 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

expres-to regard that smokers (especially heavy smokers) tend expres-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 possibil-ity, 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, alcohol-ism may lead to liver diseases, nutrient absorption disorders, and bleeding disor-ders, 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 there-fore be taken care as a main priority in implant dentistry Details of implant treat-ment for alcohol consumption population will be discussed in Chap 3

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 cardiovascu-lar 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 obstruct-ing 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, diac disorders, and disturbance of bone metabolism [21–23] All these three prob-lems may increase the risk of dental implant therapy The preoperative,

car-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 unman-ageable hemorrhage, peri-implantitis, and slow wound healing Treatment sugges-tions 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

The literature reporting cases of dental implants and bone diseases such as rosis, osteogenesis imperfecta, and polyarthritis have been published in the last decade [24–26]

osteopo-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 contraindica-tion 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 bolic 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 metabo-lism, 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 inflam-matory response around dental implants was greater in the diabetic rats than that

meta-in the controlled rats, which turned out to give rise to an meta-increased bone resorption

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 anti-septic mouth rinse, etc to avoid incidental periodontal and peri-implant infections.

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 exam-ple 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 pos-sible 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 treat-ment are similar to those of “organ diseases.” This will be well elucidated with additional measures for dental implant practitioners

In this chapter, we pay close attention to patients who take drugs such as phonates, anticoagulants, and corticosteroids

bisphos-Bisphosphonates are often used in osteoporosis patients and are known to press the osteoclast function The use of these anti-resorptive drugs, such as bisphos-phonates, is accompanied by an increased risk of medication-related osteonecrosis

sup-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 pro-longed, 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

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 pro-cedures 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 contro-versial in cancer patients [47, 48] It was found out that high-dose radiation (cumu-lative 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 vascular-ity reduction, and bone substance and soft tissues (such as periosteum and connec-tive 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, tita-nium allergy, and genetic diseases in this book What is more, due attention is also paid to those elder citizens under dental implant treatment

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 condi-tions or disorders exert on implants We should be aware of the failure risk, compli-cation 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 hap-pen Only in this way we can decrease the failure risk of dental implants in compro-mised 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 tions is listed as follow

precau-To wam the patients of the risk Tobacco consumption

Alcoholism

Soft tissue inflammation Crestal bone loss PrecautionsPrecautions Periodontiss

Peri-implant mangial bone loss

To sign an informed consent form

To encourage giving up smoking

To reduce the harmful use of alcohol

To prioritize prevention of peri-implantitis General condition eveluation Functional capacity evaluation Cardiovascular risk assessment

Cardiovascular disease Periodontal disease

Influence of blood supply Precautions

Precautions Renal disease

Thyroid disorders

Hepatitis Unmanageable hemorrhage Slowing down wound healing

Marginal bone loss Peri-implantitis Risk associated with pharmacological interventions Periodontitis

Impalnt failure

Diabetes mellitus

Rheumatologic disorders Immunosuppressive conditions

Antiresorptive therapy

Anticoagulant therapy Conticosteroids therapy

Head and neck cancer

Sjögren’s syndrome

Oral lichen planus

Eiderfy patient Psychiatric disorders Genetic diseases

Severe periodontal condition Rapid and severe bone loss

TMJ problems Increasing bone resorption Refer to precautions for “Renal Diseases”

Refer to precautions for the previous “MRONJ”

To obtain a comprehensive history

To reduce invasive procedures

To test some markers if necessary Refer to precautions for “Osteoporosis”

Poor osseointegration caused by high-dose radiation Imparing soft tissues due to high-dose radiation Diminished quality and quantity of saliva Periodontal diseases Increased bone resorption Upregulated preinflammatory responses Bone disturbances Undesirable peri-implant healing

Undesirable peri-implant bone condition Pay attention to preoperative, perioperative,and postoperative conditions

Refer to precautions for “Rental Diseases”

Refer to precautions for “Rental Diseases”

Evaluation of lesion state Saliva tests

To optimize the dose and frequency of radiotherapy Hyper basic oxygen therapy

To apply osteogenic growth factors if possible

To evaluate TMJ Function

Impaired osseointegration Peri-implant diseases

Untreated hypothyroidism Hypothyroidism related osteoporosis Thyroid hormones influences

Loss of poriodontal bone Gingival enlargement Disturbance of bone metabolism

Analgesics and anti-inflammatory drugs

To check numerical value of the thyroid hormone

To confirm a state of the control in the thyroid function

To perform the confirmation of the oral medicine

To maintain close contact with the family doctor

To avoid acidic anti-inflammatory analgesics

To avoid nosocomial infections

To obtain a comprehensive history

To obtain a comprehensive history

To finish invasive treatment before initiation of antiresorptive or antianglogenic drugs Non-surgical periodontal therapy Peri-implant maintenance therapy

To record baseline probing measurement and baseline level of supporting bone

To provide oral hygiene instruction Prophylactic antibiotics

To pay attention to hormone and bisphosphonates usage

To choose optimum implant Perioperative anti-microbial prophylaxis

A safe dosage of local anesthesia

To avoid bone augmentotions if possible Minimally invasive procedures

To provide through postoperative instructoins

Cordiovascular risk assessment General condition evaluation Blood tests Residual bone evaluation Planning for the implant surgery Antibiotic prophylaxis

Regular advice for patients Antibiotic treatment

Refer to “Cardiovascular Diseases”

except for “Additional oxygen supply”

Preoperative Period

Preoperative Period Perioperative Period

Perioperative Period Postoperative Period

Postoperative Period

Dental Implant and Substance Abuse

Dental Implant and Organ Diseases

Dental Implant and Bone Diseases

Dental Implants and Diabetic Patients

Dental Implant and Immune related Diseases

System-Dental Implant and Drug-induced Disorders

Dental Implant and Oral Diseases

Other Conditions Affecting Dental implant Treatment

Dental Implant Treatment

in the Medically

Compromised Patients

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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 vival 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 ginal 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.

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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 taglandin 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.

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 tis 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 lating 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 posity 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 retrospec- tive 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.

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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.

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 sis 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 ing 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.

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© 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

Y Huang

OMFS-IMPATH, Department Imagining and Pathology, K.U. Leuven, Leuven, Belgium

Department of Oral Implantology, West China Hospital of Stomatology, Sichuan University,

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 sur-vival 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

3.2 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 smok-ing as a living habit does not only influence the health of oral cavity, but also nega-tively 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:

an adverse effect on fibroblast function, interfered with chemotaxis and sis in neutrophils, and negatively influenced immunoglobulin production by lym-phocytes [5] As a consequence, smokers may have a slower healing than nonsmokers and greater risk of infection following implant surgery

phagocyto-It is also proved that bacterial plaque grows more quickly on epithelial cells in ers [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

smok-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, pared with nonsmokers, the peri-implant microbial populations in smokers were reduced, while the number of microorganisms was increased Periodontal and sys-

com-temic pathogens in smokers, such as Capnocytophaga, Treponema,

Propionibacterium , Pseudomonas, Lactobacillus, and Leptotrichia, are more dant, while in nonsmokers, the pathogen population from Streptococcus,

abun-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 constriction on peripheral vasculature [11] In addition, it has also been reported an

vaso-increased platelet aggregation, which could give rise to thromboembolic problems [12] With the alteration in the presentation of antigens to monocytes, the chemo-taxis 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, cytes, and monocytes, as well as increased hematocrit, hemoglobin, and mean cor-puscular volume This could potentially raise the risk of ischemic heart disease by causing higher blood cell counts, higher concentration of hematocrit, and alterations

lympho-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 inflam-mation 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 < 0.0001 and 0.0004 in men and women,

respec-tively) [15] A systematic review has further pointed out that, based on the evidence related to the biological plausibility, it was highly possible to observe a causal asso-ciation between smoking and tooth loss in young adults [16]

More serious is that smoking habit has a correlation with systematic diseases There is one review about smoking-related systemic diseases and oral diseases, sug-gesting a linking between smoking habit and lung cancer, cardiovascular diseases, and even other systemic diseases [14]

In view of the complexity in evaluating all kinds of local oral and systemic chronic diseases, it is generally hard to exactly identify specific external factors, internal factors, non-man-made causes, host’s immunological defenses, and suscep-tibility And the situation can go even ambiguous, when multiple factors existed (e.g., lifestyle and history of periodontitis), or after a long exposure time, or when it

is hard to confirm the subclinical stage of diseases

Regardless, a recent prospective cohort study with a total of 22,009 included adult patients highlighted a potential association between a systemic compro-mised status and smoking habits with the chronic oral diseases [17] As reported

in the study, the prevalence rate of periodontitis was 17.6% for those with promised systemic status When the exposure to systemic conditions was pre-vented, there was an estimated reduction of 12.2% of periodontitis and 4.3% of dental caries cases, while the prevention of exposure to smoking alone would result in a potential reduction of 37% of periodontitis and 7% of dental caries, respectively

com-These results are also in accordance with researches analyzing the influence of smoking on the periodontal and peri-implant diseases [18, 19], which further stresses the adverse effects of smoking, especially in periodontal status

Based on the above confirmative evidence, therefore, it is worth considering

an effective preventive protocol promoting healthy lifestyle behaviors not only

in order to improve intraoral health, but also to reduce the incidence of temic diseases

sys-3.2.1.2 Relations Between Smoking and Peri-implant Pathology

Enormous existing literature have indicated tobacco use as a major risk factor for oral diseases such as periodontal problem On the other hand, the cessation

of tobacco use is also found in association with the potential for reversal of precancer, enhanced outcomes following periodontal treatment, and better peri-odontal status compared to patients who continue to smoke [20] Furthermore,

a national consensus workshop, which was in order to examine the scientific evidence and develop consensus oral health messages for the Australian public, has pointed out that smoking is a causative factor for the periodontal disease It

is thus believed that smoking could result in more disease and injury than any other single risk factors [1]

The situation between smoking habits and chronical oral diseases is also not optimistic, especially after dental implant therapy A research has warned of the prevalence rate of peri-implant pathology as high as 13.9%, while the prevention of exposure to smoking alone would result in a large drop of 39% of peri-implant pathology cases [17] In a systematic review and meta-analysis, Moraschini et al found that, from the published papers between 1993 and 2013, the loss of peri- implant bone tissue and the failure rate of implants in smokers were significantly higher than those of nonsmokers [4]

Therefore, smoking is believed to be one of the main predisposing factors for impaired bone healing and implant failure, especially in the early onset or aggrava-tion of periodontitis and peri-implantitis [21] Smokers have been found with an increased plaque accumulation, a higher incidence of gingivitis and periodontitis, a higher rate of tooth loss, and a growing resorption of the alveolar ridge [22] The use

of tobacco could produce a 15.8% risk of implant failure, according to an tion of 165 implants in 66 patients over 5  years [22] Moreover, De Bruyn and Collaert revealed that smoking could cause a significant reduction in the ability of peri-implant tissues to adapt over time, though it was not the only important factor [23] Although implant failure rates decreased with increasing implant length, fail-ure rates for each implant length were consistently higher in smokers than in non-smokers [3]

observa-As a result, periodontitis is linked to smoking as well as to increased loss of dental implants and development of peri-implantitis [24, 25] The mean bone loss in smokers was 1.36 mm compared with 1.25 mm in nonsmokers, with a statistically significant difference [26] In medically compromised patients, tobacco addiction and head and neck radiotherapy were two significant factors correlated to a higher loss of dental implants [27]

Given that the consumption of tobacco is a complex living habit, and their amount and frequency could vary widely, it might be difficult to determine an indi-vidual’s chance of developing an implant failure for smokers, despite the fact that the relative risk is more than ten times higher in smokers than in nonsmokers Nevertheless, 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 In addition, giving up smoking should be encouraged for long- term implant success

3.2.1.3 Different Types of Smokers and Drinkers

Numerous studies have demonstrated that cigarette smokers had more missing teeth and greater rates of tooth loss than nonsmokers, most of which focused on middle- aged and elderly populations [28–30] According to a previous study, older smokers who were over 50 years old were more likely to lose all their natural teeth, com-pared with those who had never smoked [31] In addition, current smokers tend to have fewer teeth or functional units, but more decayed root or crown surfaces It is also suggested that the severity levels of periodontal disease were more significant among current smokers by periodontal indicators So far, evidence is limited and mainly involved the links between smoking habit and tooth loss during young adult-hood A Japanese research has examined the association between cigarette smoking and tooth loss experience among young adults aged 20–39 years [15] Not only the smoking rates varied largely in men (53.3%) and women (15.5%), but also tooth loss occurred more frequently among current smokers (40.6%) than former (23.1%) and nonsmokers (27.9%)

In regard to the frequency and severity of smoking, for lighter smokers or ate smokers, tobacco use showed an approximately 10% relative risk of implant loss, whereas the heavy smokers who had more than 20 cigarettes/day were at a threefold increased risk [22] It is probably because of the confirmed effect of smok-ing on implant success that many studies concerning implant success rates exclude heavy smokers from their potential participants [4 14]

moder-When it comes to the sexual differences in smoking behavior, findings suggest that the smoking group had lower level of consciousness in oral health than the nonsmok-ing group in women [32] Besides, young female smokers between 20 and 29 years old had a higher risk of many untreated decayed teeth Therefore, there is a potential

harm in transmitting S mutans to the children when these young females become

mothers in the future As a result, in order to achieve the oral health status, it is tial to have high enough consciousness of their oral health and adequate oral care.Although a direct etiological proof between smoking and dental caries is still lacking, the abovementioned findings point to the supposed fact that smoking has some influence on high caries incidence [14] It has also been found that current smoking was associated with the prevalence of decayed teeth [15]

essen-Concerning the combined effect of alcohol and tobacco consumption on peri- implantitis, a prospective clinical study with a 3-year follow-up indicated that daily alcohol consumption and tobacco use could negatively influence the short- and long-term implant treatment outcomes, inducing peri-implant bone loss and com-promising restorative treatment with implant-supported prostheses [26] Multivariate analysis showed that peri-implant marginal bone loss was significantly related to a daily consumption of more than 10 g of alcohol, tobacco use, and increased plaque levels and gingival inflammation

In all WHO-investigated regions, females are less often current drinkers pared to males When women drink, they generally drink less than men Worldwide, the prevalence of women’s drinking went down in most regions of the world, except

com-in the Southeast Asia and Western Pacific Regions, while the absolute amounts of currently drinking women have increased in the world Total alcohol per capita con-sumption in 2010 worldwide was on average 19.4 L for males and 7.0 L of pure

alcohol for females Furthermore, women have less of the gastric enzyme alcohol dehydrogenase, which could help to metabolize ethanol As a result, more alcohol

is left in the stomach and a proportionally larger number enters the bloodstream Because of their higher alcohol levels, women are at greater risk level of developing some of the health-related consequences of heavy alcohol intake [33]

Depending on the alcohol consumption, implant failures favored in patients sified as heavy drinkers (i.e., more than 5 units/day) in comparison with light drink-ers (i.e., less than 5 units/day) and those who denied alcohol consumption [34]

clas-3.2.2 Prevention and Treatment

3.2.2.1 Prevention

After analyzing the abovementioned relationship between smoking and oral health, the prevention of peri-implantitis has become a prerequisite that any oral health professionals need to accept The first consideration and strong focus of the treat-ment of peri-implantitis is how to maintain the peri-implant health and prevent potential peri-implantitis at the early stage

First of all, lifestyle factors should be taken into consideration It is necessary to analyze and identify persons with a need of preventive dental services In addition,

a comprehensive oral health education should be given with a focus on the possible risks of smoking The recommendation on smoking is definitely: Quit smoking to improve oral and general health

Tobacco use has been identified as a major risk factor for oral disorders It is therefore possible to expect a reversal of precancer and healthier periodontal status after the smoking cessation Consequently, to help smokers to quit has become a part of both the responsibility of oral health professionals and the general practice

of dentistry

As suggested, in order to apply the tobacco prevention and cessation, it is better

to include behavioral support, and if accompanied by pharmacotherapy is more likely to be successful To ensure that the whole plan becomes part of standard care, continuing education courses and updates are even required to all oral health team (including dental practitioners, specialists, hygienists, and oral health promotion staff) on a regular basis

Here an example of oral care gradient is shown, proposed by the 2nd European Workshop on Tobacco Prevention and Cessation for Oral Health Professionals, which would be taken as a recommended and effective prevention way [20]:

1 Basic care: brief interventions for all patients in the dental practice to identify tobacco users, assess readiness to quit, and request permission to readdress at a subsequent visit

2 Intermediate care: interventions consisting of (brief) motivational interviewing sessions to build on readiness to quit, to enlist resources to support change, and

to include cessation medications

3 Advanced care: intensive interventions to develop a detailed quit plan including the use of suitable pharmacotherapy

Other recommendations were developed by the 11th European Workshop on Periodontology to optimize the prevention of periodontal and peri-implant diseases, based on critical scientific evidence: (1) plaque control at the individual and popula-tion level (oral hygiene); (2) control of risk factors, e.g., smoking; and (3) delivery

of preventive professional interventions There is also an approach, named the Ask, Advise, Refer (AAR), defined as the minimum standard to be used in dental settings for all subjects consuming tobacco [35]

To improve the accuracy of these prevention approaches, further research on the development of clinical prediction rules for periodontal risk stratification is recom-mended naturally It is also suggested to have systematic evaluations and optimiza-tion of different combinations of individual risk indicators Not only these but also the public, dental policymakers, and dental educators should pay more attention to the cost-effectiveness of the whole prevention approach

3.2.2.2 Treatment

In case there is already an extensive inflammatory lesion residing in peri-implant soft tissues and/or accompanied by loss of peri-implant marginal bone [36], an effective and evidence-based treatment of peri-implantitis needs to be considered as well Mild-to-moderate mucositis and peri-implantitis are generally treated effec-tively by conservative methods When it comes to severe advanced peri-implantitis, surgical therapies are believed to be more effective than traditionally conservative approaches [37]

Anti-infective treatment is considered as one of the successful therapies in ing disease progression, substantiated by long-term observation on surgical treat-ment of peri-implantitis In general four treatment modalities to supplement mechanical debridement can be identified: apically repositioned flap, chemical sur-face decontamination, implantoplasty, and bone augmentation, though there is no reliable evidence to suggest which methods are the most effective [38] Yet results from a randomized controlled clinical trial based on 3-year follow-up revealed that surgical treatment of peri-implantitis was effective and that outcomes of therapy were affected by implant surface characteristics [39] The application of systemic antibiotics showed a positive treatment outcome at implants with modified surface characteristics The analysis based on a long-term (i.e., 3-year) observation, how-ever, implied that this benefit cannot last for long The absence of bleeding/suppura-tion on probing during follow-up after treatment of peri-implantitis has a high predictive value for no further bone loss Similar observation was also reported in a long-term study on the treatment of periodontitis [40]

arrest-Therefore, given the multifactorial etiology, treatment options, and study results,

we would like to address again the importance of individualized plans in surgical treatment of peri-implantitis Surgery can be performed in order to eliminate defects, to re-establish hygienic abilities, and to limit or even stop peri-implantitis progression Regenerative approaches, e.g., bone replacement materials in combi-nation with a resorbable membrane, are still promising It is also better to take into account that treatment outcomes depend on implant surface characteristics and potential benefit of systemic antibiotics is short term and limited to implants with modified surfaces

3.3 Alcoholism

3.3.1 Background

Alcohol (ethanol) has been largely used in many cultures for centuries, playing as a psychoactive substance with dependence-producing properties, although it is not an essential nutrient so far as is known

The harmful use of alcohol is now recognized as one of the leading risk factors for population health worldwide, resulting in about three million deaths (5.3% of all deaths) globally [41] According to the recent WHO report, the effects of alcohol consumption on mortality are even greater than those of tuberculosis (2.3%), HIV/AIDS (1.8%), diabetes (2.8%), hypertension (1.6%), digestive diseases (4.5%), road injuries (2.5%), and violence (0.8%) What is more is that alcohol drinkers, although fewer in numbers, have increased their per capita consumption in most countries or regions of the world

Alcohol consumption is a systemic risk to the central gastrointestinal tract, culoskeletal system, immune system, liver, and cardiovascular system [42] Alcohol could also exert negative effects on osteoclast activity, reduce bone quality, and delay fracture repairs [43–46]

mus-The exact mechanism by which alcohol influences bone metabolism is not fully understood; however, it has been suggested that, following alcohol consumption, the ongoing balance between erosion and remodeling of bone tissue may change accordingly, with the decrease in bone mass and strength [47, 48] Study also showed that alcohol could impair T-cell functions and neutrophil, which may raise the probability of infection, and thus increasing the risk of periodontitis [49].Direct and indirect mechanisms of actions have also been introduced for the effects of alcohol consumption on bone, though further investigations are needed for the exact mechanisms [48]:

1 Alteration on the number and activity of the osteoblasts and osteoclasts as well

as an increase in osteocyte apoptosis

2 Modulated in part by the Wnt/DKK1 signaling pathway due to increased tive stress

3 Changes to cell differentiation are probably responsible for low bone mass and are associated with an increase of fat accumulation in the bone marrow

4 By means of a decrease of calorie intake and a change of body composition.The general effect of alcohol consumption on bone is usually linked to the dose ingested and duration of consumption The results from previous researches may be controversial if without a clear differentiation of light alcohol consumption from moderate and heavy chronic alcohol consumption There are currently several defi-nitions of chronic alcohol consumption in the literature, in which Ganry et  al defined light alcohol consumption as a consumption of 1–10 g of ethanol/day, mod-erate alcohol consumption as 11–30 g of ethanol/day, and heavy alcohol consump-tion as more than 30 g of ethanol/day [50]

A consumption of one alcohol drink/day for women and two for men, respectively,

is considered as no harm for bone tissue whereas higher consumption levels (2–4 drinks/day) cause damage to bone tissue However, one more thing to note is that the exact effects depend on consumer’s age, sex, and hormonal status as well as type of alcoholic beverage When more than four glasses/day are consumed, the effects of alcohol on bone can be deleterious [48] In respect to long-term chronic heavy alcohol consumption, bone mass as well as bone mineral density decrease [51]

3.3.2 Potential Harm to Dental Implants

Similar to smoking, alcoholism is also linked to periodontitis [52] A preclinical study confirmed that experimental rabbits, after alcoholic feeding, had significantly reduced alveolar bone density and direct bone-to-implant contact [53] Similar results were observed in a rat model [46] Dental implants were found lost in a ret-rospective clinical study for more than half of the included patients due to alcohol addiction [54]

Thanks to a dose-response meta-analysis, the evidence from previous tional studies on alcohol consumption and risk of periodontitis was summarized quantitatively The final results suggested that alcohol consumption was associated with an increased risk of periodontitis [55] Patients who have routine and excessive alcohol consumption may therefore be at the list of high-risk failure of implant treatment They may have poor wound healing and infection and even develop osteomyelitis at a surgical wound as a result of alcohol-induced deficiencies in the complement system, may be unable to accumulate enough protein and collagen, and may have suppression of T lymphocytes, as well as impairment in their mobility, adhesion, and phagocytic capabilities of the innate immune system [56]

observa-Furthermore, based on a 3-year prospective clinical study, it was found that those who daily consumed more than 10 g of alcohol had a mean peri-implant marginal bone loss of 1.66 mm, compared with a loss of 1.25 mm in patients who did not drink any amount of alcohol The results indicate that daily alcohol consumption may have a negative influence on predictable long-term implant treatment out-comes, producing peri-implant bone loss and compromising restorative treatment with implant-supported prostheses [26] Another interesting finding is that the greater peri-implant bone resorption was associated with alcohol intake compared with that induced by tobacco use It is also evident that, if a patient uses both alcohol and tobacco, an increased likelihood of tissue damage and further implant failure would be expected

3.3.3 Prevention and Treatment

3.3.3.1 Prevention

The evidence of harmful use of alcohol to the peri-implantitis is still growing; ever, this does not prevent us from considering effective strategies and action plans

how-for global and oral health According to WHO, there has been a global improvement

in alcohol policy development and implementation; nevertheless, it is still far from accomplishing effective protection of populations from alcohol-related harm [41]

It is necessary to realize that there are still many challenges in reducing the ful use of alcohol, such as low levels of political commitment to effective coordina-tion of multisectoral action, influence of powerful commercial interests, and strong drinking traditions in many countries and cultures Not only “whole of government” but also “whole of society” should work on the same platform in the fight against the harmful use of alcohol, with appropriate involvement of public health associa-tions, groups, and professionals

harm-Since peri-implantitis is thought to be the most challenging biological tion, it would cost extensive medical and health resources For the daily practicing, prevention of peri-implantitis should therefore be taken care as a main priority in implant dentistry Similar to the goal of prevention and treatment of periodontitis, the main aim of prevention and treatment of peri-implant mucositis or peri- implantitis is to achieve a healthy peri-implant mucosa and resolve the peri-implant lesions without visible signs of inflammation in clinical, such as swelling and bleed-ing on probing [57]

complica-An individual therapy program, including preventive education, self-performed oral hygiene measures around implants, and personalized follow-up therapy, is of importance for alcohol drinkers, and in view of the new research findings oral microflora might lead to the development of intraoral carcinoma [58] To prevent a potential risk of medication-related adverse events and drug interactions, dentists should be responsible to inquire the history of alcohol consumption of patients, though most of the patients may be reluctant to discuss their alcohol dependence During inquiry of a medical history, it is also possible to uncover indicators of patients who are at risk of developing alcoholism More potential problems may be indicated by historical factors, including insomnia, headache, seizures, dyspepsia, diarrhea, palpitations, sexual dysfunction, anxiety, irritability, depression, trauma, motor vehicle accidents, domestic violence, and multiple visits to a hospital emer-gency department [56]

Dental professionals also have to better encourage and instruct patients how to

do proper toothbrushing and flossing to remove dental plaque at the most extent After the implant-supported therapy, it is recommended that the clinician obtain baseline radiographic and probing measurements [59, 60] When necessary, they should also be able to prescribe artificial salivary products for patients with signs of xerostomia, because a lack of saliva is associated with increased concentrations of bacteria which is able to produce acetaldehyde later [56]

As far as we know, plaque is clearly determined as the etiological factor of peri- implant mucositis [59, 60] After reinstitution of plaque control procedures, it is possible to resolve peri-implant mucositis lesions [61, 62] Thus, it would be helpful for an early discovery and control of existing peri-implant mucositis, in order to prevent the conversion from peri-implant mucositis into peri-implantitis, which could be an even challenging treatment situation

It is also worth noting that there is an increased risk of developing peri- implantitis

in patients who have a history of severe periodontitis, poor plaque control, and no regular maintenance care after implant therapy And no chemical agent has been found superior to saline in the decontamination procedures of implant surfaces [57]

3.3.3.2 Treatment

For the treatment of peri-implantitis, a profound local anesthesia at the beginning is mandatory especially for those often-anxious patients Dental treatment should con-sist of subgingival scaling, root planning and curettage, caries control, and restor-ative treatment It is suggested that a comprehensive medical evaluation, such as a complete blood cell count, coagulation profile, liver function studies, and consulta-tion with their treating physician, is required for patients who need an extensive surgery but also have a long history of alcohol abuse [56]

As mentioned before in the treatment of peri-implantitis for smokers, numerous peri-implantitis treatment protocols with clinical efficacy have been reported, includ-ing nonsurgical, surgical, respective, regenerative, and combined approaches Nevertheless, due to the heterogeneity related to previous studies, including severity

of peri-implantitis, patients’ living habits, implant and prosthesis design, surgery experience, length of follow-up, and including/excluding of standards, it is still hard

to identify a most effective treatment protocol from previous reported protocols [63]

In respect of early peri-implantitis, besides a routine therapy, i.e., a nonsurgical method such as biofilm removal in the supra-mucosal area around implants, it is helpful to instruct patients with proper and adequate self-performed oral hygiene measures to remove and control dental plaque in the treatment of peri-implant diseases

While for the severe peri-implantitis, nonsurgical procedures may be insufficient and in order to professionally remove the biofilm from the implant surface, a surgi-cal treatment becomes more necessary All the methods performed in surgical treat-ment of peri-implantitis, whether with or without grafting materials and barrier membranes, are aimed to resolve the connective tissue lesion with different mechan-ical procedures Results reported in prospective and retrospective case series and in randomized controlled clinical trials have confirmed successful outcomes in the long term [39, 60, 64–66] Furthermore, high implant survival rates in the medium

to long term are confirmed by different systematic reviews; it is highly mended to have the therapy of peri-implantitis followed by regular or even extended (over 3 years) supportive care [63, 67, 68]

Dental implants are used in dentistry with great success especially since the last three decades Besides development and renovation of implant materials and designs, it is essential to optimize bone remodeling, repair in the early stages of osseointegration, and long-term peri-implant health status