Thematic Abstract Review

THEMATIC
ABSTRACT REVIEW
Section Editor

Clark Stanford, DDS, PhD

The University of Iowa, Iowa City, Iowa

Emad W. Estafanous, BDS, MSD

Thomas W. Oates, DMD, PhD

The University of Iowa

Iowa City, Iowa, USA

University of Texas Health Science Center

San Antonio, Texas, USA

Martin Osswald, BDS, MDent

Guy Huynh-Ba, DDS, MS

University of Alberta
Edmonton, Canada

University of Texas Health Science Center

San Antonio, Texas, USA

Jan-Eirik Ellingsen, DDS, PhD

David Chvartszaid, DDS, MSc (Prostho),

MSc (Perio), FRCDC(C)

University of Oslo
Oslo, Norway

University of Toronto
Toronto, Canada

Dental Implants Are Contraindicated in

uffice it to say and without the need to reference,

dental osseointegrated implants have become an
integral treatment modality in almost all disciplines of
dentistry. Implant therapy offers predictable treatment
outcomes with high prognostic deliverables in terms
of success and survival. The wide application of implant therapies and successes they enjoy almost begs
the question whether prognostication is a determinant
of outcome. Aside from obvious anatomical deficiencies (and this, too, is debatable), are there any absolute
contraindications in terms of medical conditions or
therapies that would negate the delivery of oral implant
treatment to our patients?
A search of published literature over the past year
sought to identify publications to assist in addressing
this question. Old favorites including therapeutic radiation therapy and immunosuppressive conditions alongside newer entrants such as bisphosphonate therapy,
among others, were targeted in the search, in an attempt to establish current evidence and thinking surrounding this topic. Many publications and studies are
based on exclusion criteria for preexisting conditions
that are/were traditionally thought of as contraindicated or at least relatively so, which skews reporting of
outcomes. Gmez-de Diego et al (2014) addressed this

by publishing a review of data that purposely included

diagnosed disease to identify contraindications to dental therapy. They found that neither controlled systemic
diseases nor smoking offered any total or partial contraindications for implant therapy. Bisphosphonate therapy
presents a relative contraindication but not an exclusion
factor, and on recommendation of the authors, requires
longer follow-up to monitor for chemically induced osteonecrosis. Radiation therapy at doses over 50 Gy with
concomitant intravenous bisphosphonates, hormonal
therapies, immunosuppressive or corticosteroids was
concluded to be contraindicated.
With further consideration to radiation therapy as a
factor, Schiegnitz et al (2014) conducted a meta-analysis
of implant survival in irradiated versus nonirradiated
patients. Their meta-analysis of the literature did not
identify statistically significant differences for implant
survival between the two patient groups for literature
published from 2007 to 2013. This was in contrast the
results for their literature search of papers published
from 1990 to 2006. The authors attributed this finding to
improvements in surgical hardware, improved surgical
procedures, and planning modalities, especially since
the earlier group (1990 to 2006) included patient studies
from as early as 1979 until 2004. The authors cautioned

1024 Volume 29, Number 5, 2014

2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

Thematic Abstract Review

negative prognostics for bone grafting and radiation

therapy in terms of implant survival but did not go as far
as contraindicating this scenario.
Katyayan et al (2013) considered the associated high
incidence of diabetes superimposed on the high demand for dental implant therapy in general, and whether
the severity of the disease sequalae and complications
posed any contraindication to implant therapy in this patient group. While not contraindicating diabetes, the authors did allude to the need for well-monitored glycemic
control and extended prospective studies to establish a
truer picture of prognostics related to diabetes. Similarly,
a systematic review by Chrcanovic et al (2014) cautioned
the extrapolation of no statistical significance of implant
failure between diabetic and nondiabetic patients, requiring better controlled studies with larger sample
sizes, particularly in the diabetic group, and separate
outcome data reporting for the two groups. The search
for abstracts including immunodeficiency as a factor was
extended to human immunodeficiency virus positive
status and systemic lupus erythematosus with regard to
prognostics in implant therapy. Interestingly, this did not
reveal any recent studies related to these conditions.
Further exploration of recent literature to identify
contraindications to dental implant therapy revealed
a publication by lvarez-Camino et al (2013) that investigated the contraindications of inserting implants
into sites with chronic periapical infection in immediate
placement scenarios. The authors concluded that there
is limited scientific evidence to support placement of
implants in the presence of apical pathology. They concluded that a type B recommendation following analysis

of evidence be made, which is based on the Strength of

Recommendation Taxonomy (SORT) criteria to support a
procedure. A type B recommendation refers to patientoriented evidence of limited quality and does not infer a
contraindication to performing the procedure.
Finally, in the search of definitive contraindications
for this abstract review, current literature for psychologic
factors was also considered. A pilot study by Enkling et al
(2013) identified which dental phobias (as a psychologic
disease) may contraindicate implant treatment. The conclusion of the study was that dental phobia, following
adequate psychologic pretreatment therapy, was not an
absolute contraindication to dental implant treatment.
Both nonfearful and phobic patients experienced 100%
implant success during follow-up within the limitations
of the study. The authors cautioned that the phobic
group displayed increased risk for avoidance of further
treatment and that strict recall and maintenance schedules be established around this group of patients.
Within the limits of this abstract review of current literature, few absolute contraindications for implant therapy in the presence of any single medical condition or
other concurrent therapeutic treatment could be identified. Judicious clinical decision making in the absence of
thorough long-term and well-designed studies requires
individual consideration of any factors viewed as possibly being contraindicatory, especially in cases of multiple comorbidities. Generally, implant therapy remains
indicated as a treatment modality enjoying high success
rates across a spectrum of presenting medical cofactors.

Gmez-de Diego R, Mang-de la Rosa M, RomeroPrez MJ, Cutando-Soriano A, Lpez-Valverde-Centeno A. Indications and contraindications of dental
implants in medically compromised patients: Update. Med Oral Patol Oral Cir Bucal 2014 Mar 8.
[Epub ahead of print].

dental implants. Patients suffering from osteoporosis undergoing bisphosphonates therapy show an increased risk
of developing bone necrosis after an oral surgery, especially
if the drugs are administered intravenously or they are associated with certain concomitant medication.

The aim of this study was to review the current scientific

literature in order to analyze the indications and contraindications of dental implants in medically compromised
patients. Reference research was carried out on PubMed
using the key words implant* AND (oral OR dental) AND
(systemic disease OR medically compromised) in articles
published between 1993 and 2013. The inclusion criteria
were the following: clinical studies in which at least 10 patients were treated, consensus articles, reviewed articles,
and meta-analysis performed in humans treated with dental implants, and which included the disease diagnosis.
A total of 64 articles were found, from which 16 met the
inclusion criteria. Cardiac systemic diseases, diabetic endocrine pathologies, or controlled metabolic disorders do
not seem to be a total or partial contraindication to the
placement of dental implants. Tobacco addiction and head
and neck radiotherapy are correlated to a higher loss of

Martin Osswald, BDS, MDent (Pros)

Correspondence to: anlopezvalverde@gmail.com

Schiegnitz E, Al-Nawas B, Kmmerer PW, Grtz KA.

Oral rehabilitation with dental implants in irradiated
patients: A meta-analysis on implant survival. Clin
Oral Invest 2014;18:687698.
The aim of this comprehensive literature review was to provide recommendations and guidelines for dental implant
therapy in patients with a history of radiation in the head
and neck region. For the first time, a meta-analysis comparing the implant survival in irradiated and nonirradiated
patients was performed. An extensive electronic search in
the electronic databases of the National Library of Medicine was conducted for articles published between January
1990 and January 2013 to identify literature presenting survival data on the topic of dental implants in patients receiving radiotherapy for head and neck cancer. The review and
The International Journal of Oral & Maxillofacial Implants 1025

2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

Thematic Abstract Review

meta-analysis were performed according to the Preferred

Reporting Items for Systematic Review and Meta-Analyses
statement. For meta-analysis, only studies with a mean
follow-up of at least 5 years were included. After screening
529 abstracts from the electronic database, the authors included 31 studies in qualitative and 8 in quantitative synthesis. The mean implant survival rate of all examined studies
was 83% (range, 34% to 100%). Meta-analysis of the current
literature (2007 to 2013) revealed no statistically significant
difference in implant survival between nonirradiated native
bone and irradiated native bone (odds ratio [OR], 1.44; confidence interval [CI], 0.67 to 3.1). In contrast, meta-analysis
of the literature from 1990 to 2006 showed a significant difference in implant survival between nonirradiated and irradiated patients ([OR], 2.12; [CI], 1.69 to 2.65) with a higher
implant survival in the nonirradiated bone. Meta-analysis of
the implant survival regarding bone origin indicated a statistically significantly higher implant survival in the irradiated
native bone compared to the irradiated grafted bone ([OR],
1.82; [CI], 1.14 to 2.90). Within the limits of this metaanalytic approach to the literature, this study describes for
the first time a comparable implant survival in nonirradiated
and irradiated native bone in the current literature. Grafted
bone combined with radiotherapy was identified as a negative prognostic factor on implant survival. The evolution of
implant hardware and improvement of treatment strategies
during the last years have affirmed dental implantsupported concepts as a valuable treatment option for patients with
a history of radiation in the head and neck region.
Correspondence to: eik.schiegnitz@unimedizin-mainz.de

Katyayan PA, Katyayan M, Shah RJ. Rehabilitative

considerations for dental implants in the diabetic patient. J Indian Prosthodont Soc 2013;13:175183.
Diabetes is a serious illness that affects many people, and
there are many new cases diagnosed every year in all populations around the world. Dental implants are one of the
restorative methods to replace missing teeth. As implants
are directly anchored into bones, they provide stability and
a more natural appearance, and minimize the risk of bone
resorption. Thus, today, there is a high demand for dental
implants, and it is inevitable to meet diabetics who request
implant treatment. However, diabetes mellitus patients may
pose contraindications to dental implants because of microvascular complications leading to slower healing process
after surgery. Studies have shown that the dental implantation failure rate in diabetic patients is much higher than that
in nondiabetic patients. This article reviews the effect of
diabetes on the osseointegration of implants and the soft
tissue healing. It presents the factors used in assessing
the severity of diabetes and its complications, as well as
considerations for rehabilitation planning in these patients.
In addition, the role of antibiotic prophylaxis has been reviewed since its effect on wound healing in diabetics is controversial. Integration of these factors by the dentist can
dictate whether as well as what type of implant-supported
prosthesis should be given to the diabetic patient.
Correspondence to: preeti80_a@yahoo.com; drkatyayan@ymail.
com

Chrcanovic BR, Albrektsson T, Wennerberg A. Diabetes and oral implant failure: A systematic review.
J Dent Res 2014;93:859867.
The aim of this systematic review and meta-analysis was to
investigate whether there are any effects of diabetes mellitus on implant failure rates, postoperative infections, and
marginal bone loss. An electronic search without time or
language restrictions was undertaken in March 2014. The
present review followed the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Eligibility criteria included clinical human studies. The
search strategy resulted in 14 publications. The I2 statistic
was used to express the percentage of total variation across
studies due to heterogeneity. The inverse variance method
was used for the random effects model when heterogeneity
was detected or for the fixed effects model when heterogeneity was not detected. The estimates of an intervention
for dichotomous outcomes were expressed in risk ratio and
in mean difference in millimeters for continuous outcomes,
both with a 95% confidence interval. There was a statistically significant difference (P = .001; mean difference = 0.20,
95% confidence interval = 0.08, 0.31) between diabetic
and nondiabetic patients concerning marginal bone loss,
favoring nondiabetic patients. A meta-analysis was not possible for postoperative infections. The difference between
the patients (diabetic vs nondiabetic) did not significantly
affect implant failure rates (P = .65), with a risk ratio of
1.07 (95% confidence interval = 0.80, 1.44). Studies are
lacking that include both patient types, with larger sample
sizes, and that report the outcome data separately for each
group. The results of the present meta-analysis should be
interpreted with caution because of the presence of uncontrolled confounding factors in the included studies.
Correspondence to: bruno.chrcanovic@mah.se; brunochrcanovic@
hotmail.com

lvarez-Camino J, Valmaseda-Castelln E, Gay-Escoda C. Immediate implants placed in fresh sockets associated to periapical infectious processes.
A systematic review. Med Oral Patol Oral Cir Bucal
2013;18:e780785.
The development of treated implant surfaces, added to the
increase of the esthetic requirements by patients, has led
to a change in the treatment protocols as well as the development of techniques such as one-phase implants and
immediate prosthetic loading. One of the usual contraindications of implant treatment is the presence of periapical
disease associated to the tooth to be replaced. The aim of
this paper is to review the published literature on immediate
implant placement in extraction sockets of teeth with periapical pathology, considering the level of scientific evidence,
and following the principles of medicine and evidence-based
dentistry. A search of articles published between 1982 and
2012 was conducted. The search terms immediate, dental
implant, extraction, infected, and periapical pathology were
used. The search was limited to studies in animals and humans, published in English. Sixteen articles were selected
from a total of 438, which were stratified according to their
level of scientific evidence using the SORT criteria (Strength

1026 Volume 29, Number 5, 2014

2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

Thematic Abstract Review

of Recommendation Taxonomy). Studies in both animals

and humans presented high rates of implant survival, but
human studies are limited to a small number of cases.
There is limited evidence regarding implant placement immediately to the extraction of teeth affected by chronic periapical pathology. Following analysis of the articles, and in
function of their scientific quality, a type B recommendation
is given in favor of immediate implant placement in fresh
sockets associated to periapical infectious processes.
Correspondence to: cgay@ub.edu

Enkling N, Hardt K, Katsoulis J, Ramseier CA, Colombo A, Jhren P, Mericske-Stern R. Dental phobia
is no contraindication for oral implant therapy. Quintessence Int 2013;44:363371.
Dental phobia is a psychologic disease and a possible
contraindication for implant therapy. The study aimed to
show that implant therapy in dental-phobic patients (DP, test
group) after adequate psychologic and dental pretreatment
(PDPT) is successfully possible and results in a similar implant prognosis as in nonfearful patients (NF, control group).

Fifteen DP with PDPT and 15 NF were treated with dental

implants and were reevaluated 2 to 4 years after denturemounting regarding: alteration of dental anxiety (Hierarchical Anxiety Questionnaire [HAQ], Visual Analog Scale [VAS]),
patient satisfaction and compliance, implant success, and
peri-implant health. Statistical tests of noninferiority DP versus NF were performed with Hodges-Lehmann estimators
and respective one-sided 97.5% confidence intervals of Moses, and pairwise testings with the Mann-Whitney test. The
DP test group rated its anxiety significantly lower at followup than at baseline (PHAQ < .001). However, at follow-up,
anxiety was still higher in DP than in NF (PHAQ = .046;
PVAS < .001). Implant success at follow-up was 100%.
Oral health was equally good in DP and NF patients. At
follow-up, all patients were satisfied with implant therapy,
but compliance was better for NF (100%) than for DP (73%
dental checkup; 67% dental hygienist). Implant therapy can
be successfully performed in DP patients with PDPT, as
phobia is not negatively influenced by the invasive implant
therapy. However, motivation for professional maintenance
programs remains challenging.
Correspondence to: norbert.enkling@zmk.unibe.ch

JOMI iPad App Now Available!

Read JOMI on the go with the new JOMI iPad app. Current JOMI
subscribers and Academy of Osseointegration members can
receive complimentary access to the iPad version of JOMI
issues from 2012 to present.
Visit www.quintpub.com/journals/apps for more
information and instructions on how to download the app.
Not a subscriber/AO member? Single issues as well as 6-month and 1-year subscriptions
can be purchased through iTunes.

The International Journal of Oral & Maxillofacial Implants 1027

2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

Copyright of International Journal of Oral & Maxillofacial Implants is the property of

Quintessence Publishing Company Inc. and its content may not be copied or emailed to
multiple sites or posted to a listserv without the copyright holder's express written permission.
However, users may print, download, or email articles for individual use.