(see Table 2.3) (42).
The American Dental Association also put together a panel of experts on BON to make recommendations for treatment of patients taking or have taken oral bisphosphonates. A significant study, with over 700,000 cases, was completed and published in the 2008 Journal of Oral Maxillary Surgeons, titled “Bisphosphonate Use and the Risk of Adverse Jaw Outcomes.” It concluded that patients taking or who have taken oral bisphosphonates “can be a candidate for implant therapy”, but need to be evaluated on an individual basis (43). Patients taking or who have taken intravenous bisphosphonates can be contraindicated for implant placement. It is recommended that patients complete any oral surgery (i.e., tooth extraction), implant placement, periapical surgery, or periodontal surgery prior to starting bisphosphonate therapy, if possible.
Prior to starting any surgical treatment, a comprehensive exam including a very thorough medication history is essential. The patient also needs to be informed of any risks verbally and through written instruction, including risk of BON, and should sign a witness informed consent form.
Table 2.3 Risk assessment for osteonecrosis.
| CTx Level (pg/mL) | Risk Level |
|---|---|
| 300–600 (normal)150–299101–149<100 | NoneNone to MinimalModerateHigh |
Xerostomia
The elderly population is increasing, living longer, and over 90% of adults 65 years or older are taking one or more medications that can cause xerostomia (dry mouth). Xerostomia is not limited to the elderly. A high percentage of younger people take antidepressants or other medications that have the side effect of dry mouth. Xerostomia can be caused by medications and is often increased by smoking or drinking alcohol.
Radiation therapy can also cause a reduction in saliva due to damaging the salivary glands from radiation treatments for head and neck cancer. Saliva production is necessary to help bathe the teeth, it prevents decay and makes it easier to talk, swallow, taste, and digest food. The systemic diseases associated with xerostomia are Sjogren’s syndrome (SS), sarcoidosis, and amyloidosis, all of which are inflammatory diseases.
Implant therapy has been shown to have a high implant survival rate for patient with SS with low marginal bone loss or biological complications (44, 45). As hygienists, we can help these patients with good home care recommendations specifically designed for dry mouth. Multiple products are being developed specifically for xerostomia.
Hygienists, we can help dry mouth patients with xerostomia by recommending products that provide much‐needed moisturizing relief. Neutral pH products with xylitol are ideal to prevent higher than the other patients’ risk for decay and periodontal/peri‐implant disease. Oral biofilm for dry mouth patient can lead to a higher gingival inflammation index and implant treatment has shown to be a good treatment choice for this population. Implants have the least amount of host response, as long as they remain healthy. They do not decay and have the highest success rate of any type of restorative procedure we provide in dentistry.
Oral biofilm drives periodontal inflammation starting with gingivitis/mucositis and progressing to periodontitis/implantitis. The 2017 AAP/EFP World Workshop to develop new classifications and conditions stated; “there is definitely evidence that if a patient does not control the plaque/oral biofilm and does not present for regular implant maintenance, poor biofilm control is a risk factor for peri‐implantitis” (19). Once infection is in the oral cavity it is a direct link to the bloodstream and can affect the overall health of your patient. The process can be reversed if caught early, before infection has caused a loss of bone. If it is not caught in a timely manner it can also progress into oral‐systemic diseases that can affect the heart, the lungs, and pregnancy.
Medical history/risk assessment forms
Periodontal medicine and implant therapy add a new dimension to how we look at medical history questions and develop our treatment and maintenance protocols. Dental professionals need to pay close attention to the medical history form with respect to what drugs, vitamins, and/or over‐the‐counter medications the patient is taking on a regular basis. Also, identify any risk factors that could interfere with successful implant therapy.
It is important to carefully read, review, and walk through the patient’s medical history with the patient at every implant maintenance or restorative appointment. It is also important to record if the patient is in the care of a physician at the present time and for what medical condition. This could have an impact on the overall health of the implant, maintenance requirements, and/or the proposed treatment plan. If the patient has uncontrolled diabetes, for example, it increases the risk of peri‐implantitis and ultimately may result in implant failure.
How often have you asked a patient, “Are there any changes in your medical history?” and received the “no changes” comment, then, in the process of the patient’s maintenance appointment, the patient mentions he or she has just had a stent or a pacemaker placed? The written medical history is important, but you must ask specific questions, go down the list, listen, and be observant. Previous periodontitis and poor wound healing following dental surgical treatments are identifiable for dental professionals and can help identify oral systemic risk factors.
Summary
Dentistry is changing with the dawn of periodontal medicine. Over 90% of adults over 55 and more than 70% of adults aged 35–44 are affected by periodontal disease (46). Peri‐implant mucositis can occur around 43% of implants and peri‐implantitis 22%, on an average of 5–10 years after implant placement (47). Patient selection, more important than ever to ensure implant success, involves a thorough medical history as well as comprehensive oral health and risk assessment. Well‐informed and well‐read physicians are now recognizing the benefits to interdisciplinary care with dentists. Many physicians and surgeons are now requiring written confirmation from dental professionals that the patient’s oral health is stable and free of any infections prior to cardiac or joint replacement surgeries. Physicians are recommending their patients’ good oral health and regular in‐office dental prophylaxis appointments for overall health. Implant dentistry is truly interdisciplinary, requiring close collaboration between the dentist, hygienist, and the patient’s physician for successful peri‐implant therapy.
References
1 1. Feldman RS, Kapur KK, Alman JE, et al. Aging and mastication changes in performance and in the swallowing threshold with natural dentition. J Am Geriatric Soc. 1980; 28: 97–103.
2 2. Aquilino SA, Shugars DA, Bader ID, et al. Ten‐year survival rates of teeth adjacent to treated and untreated posterior bounded edentulous spaces. J Prosthet Dent. 2001; 85: 455–460.
3 3. Humphries GM, Healey T, Howell RA, et al. The psychological impact of implant‐retained mandibular prostheses: a cross‐sectional study. Int J Oral Maxillofac Implants. 1995; 10: 437–444.
4 4. Beck JD, Elter JR, Heiss G, Couper D, Mauriello SM, Offenbacher S Relationship of periodontal disease to carotid artery intima‐media wall thickness: the atherosclerosis risk in communities (ARIC) study. Arterioscler Thromb Vasc Biol. 2001; 21: 1816–1822.
5 5. Desvarieux M, Demmer RT, Rundek T, et al. Relationship between periodontal disease, tooth
