2. Systemic disorders and compromised conditions

#### 2.1. Elderly population

Aging has an effect on biological activity via altering the inflammatory, regenerative, and remodeling phases of healing process. First, it makes inflammatory phase prolonged by promoting the release of inflammatory mediators. Second, it decreases new tissue formation in the regenerative phase by reducing angiogenesis and the number of mesenchymal stem cells, which are the progenitors of new bone formation. Last, it causes an imbalance in bone remodeling by changing cell activity, level of matrix metalloproteases, apoptosis, and collagen turnover [3]. Therefore, it may not be wrong to consider that aging causes a delay on osseointegration of dental implants.

In the literature, there are eligible studies that have been conducted for long-term time periods and the survival rate (SR) of dental implants is about 90% (Table 1). Furthermore, in a recent meta-analysis, SR has been reported to be 91.2% for up to 10 years [4]. On the other hand, considering the peri-implant pathology and bone level changes, studies have unsatisfactory results. According to the aforementioned meta-analysis [4], there is only one prospective clinical study that reports peri-implant marginal bone loss (MBL) after 10 years as 1.5 mm [5]. Additionally, another reviewer states that peri-implant mucositis and peri-implantitis are observed more commonly in totally edentulous patients, which are mainly ≥65 years old [3].

#### 2.2. Tobacco smoking

Tobacco consumption is one of the main considerable patient-related systemic conditions for the patients who require DI. Though smoking is not a contraindication for DI therapy, there have been a lot of studies that report negative effects on DI outcomes.

According to the clinical studies (Table 2), there is a tendency to consider that implant failure is correlated with smoking habits. Most of the studies confirm the association between smoking and increased failure rate of implants in both short- and long-term periods. Besides, tobacco smoking has been proved to increase the failure rate of DI from 2.5- to 3-fold [9, 12]. However, there is only one study that has showed a higher survival rate of DI in smoker patients [13].

People who consume 10–20 cigarettes daily are often counted as heavy smokers in clinical studies. And despite a small number of studies that reveal the effect of the number of cigarettes on failure, it has been demonstrated that consuming the 6–15 cig/day doubled the risk of implant failure [9].


dental implant therapy are usually associated with systemic comorbidities. For both patients' and clinicians' benefit, systemic comorbidities of the patient should be well-diagnosed before DI therapy. Besides, treatment plan and patient selection should be carried out with reference to the clinical evidence. Patients should be ensured to inform thoroughly about the risks and

Aging has an effect on biological activity via altering the inflammatory, regenerative, and remodeling phases of healing process. First, it makes inflammatory phase prolonged by promoting the release of inflammatory mediators. Second, it decreases new tissue formation in the regenerative phase by reducing angiogenesis and the number of mesenchymal stem cells, which are the progenitors of new bone formation. Last, it causes an imbalance in bone remodeling by changing cell activity, level of matrix metalloproteases, apoptosis, and collagen turnover [3]. Therefore, it may not be wrong to consider that aging causes a delay on osseoin-

In the literature, there are eligible studies that have been conducted for long-term time periods and the survival rate (SR) of dental implants is about 90% (Table 1). Furthermore, in a recent meta-analysis, SR has been reported to be 91.2% for up to 10 years [4]. On the other hand, considering the peri-implant pathology and bone level changes, studies have unsatisfactory results. According to the aforementioned meta-analysis [4], there is only one prospective clinical study that reports peri-implant marginal bone loss (MBL) after 10 years as 1.5 mm [5]. Additionally, another reviewer states that peri-implant mucositis and peri-implantitis are observed more commonly in totally edentulous patients, which are mainly ≥65 years old [3].

Tobacco consumption is one of the main considerable patient-related systemic conditions for the patients who require DI. Though smoking is not a contraindication for DI therapy, there

According to the clinical studies (Table 2), there is a tendency to consider that implant failure is correlated with smoking habits. Most of the studies confirm the association between smoking and increased failure rate of implants in both short- and long-term periods. Besides, tobacco smoking has been proved to increase the failure rate of DI from 2.5- to 3-fold [9, 12]. However, there is only one study that has showed a higher survival rate of DI in smoker patients [13].

People who consume 10–20 cigarettes daily are often counted as heavy smokers in clinical studies. And despite a small number of studies that reveal the effect of the number of cigarettes on failure, it has been demonstrated that consuming the 6–15 cig/day doubled the risk of

have been a lot of studies that report negative effects on DI outcomes.

2. Systemic disorders and compromised conditions

precautions.

2.1. Elderly population

60 Clinical Trials in Vulnerable Populations

tegration of dental implants.

2.2. Tobacco smoking

implant failure [9].


MCP, medically compromised patients; DI, dental implant; SR, survival rate; MBL, marginal bone loss; BoP, bleeding on probing; RR, risk ratio; ND, no data available; OD, overdenture.

Regarding the MBL, smoking seems to have a destroying effect by increasing the annual rate of MBL by 0.164 mm/year [14], and MBL is about 1.4 mm after 3 years with a statistically significant difference from people who do not smoke tobacco [15, 16].

As a result, tobacco smoking alone is not contraindicated for DI, and DI survival is about 90% for a long time period. On the other hand, smokers are under a higher risk of implant failure compared to the nonsmokers. Thus, clinicians should take into account other concomitant systemic factors which could increase the risk of failures.

#### 2.3. Alcohol consumption

There is no evidence to suggest that alcoholism is a contraindication for DIs. SR of DI is similar to healthy population with a reasonable alcohol consumption. Nevertheless, alcoholism is claimed to increase the risk of complications for DI because it may cause many systemic disorders like liver disease, bleeding disorders and osteoporosis (OP), and it may impair immune response and some nutritional elements like folate and B vitamins, and it is often associated with tobacco smoking [28].

It is reported that consumption of >10 g of alcohol increases the MBL and decreases DI survival in humans [15]. Despite there are few studies available (Table 3) concerning the DI outcomes in patients who consumed high level of alcohol, further clinical studies with well-defined subjects are required for clarifying the relation.

#### 2.4. Cardiovascular diseases

Cardiovascular disease (CVD) compromises the blood flow which may restrict oxygen or nutrients in the osseous tissue, thus is hypothesized to have higher risk of osseointegration failure [29–31]. Clinical studies and reviews demonstrate no evidence of contraindication related to DI success in patients with CVD (Table 4), and this disease is registered as a relative complication due to the risk of infective endocarditis. Antibiotic prophylaxis is necessary prior to the surgery [31] according to the guidelines of the American Heart Association's last publish [32, 33].

Author, year, study design

Ekfeldt et al., 2001,

8 years

 54 total (half part is smoker,

ND

31 DI loss in 7

6% of implants

Except from instability associated

with bad bone quality, implant losses mostly occur in patients with

heavy smoking habits or bruxism.

It is more prominent in postloading period (22 implants had

lost after loading in 7 patients of

heavy smokers) There is a correlation smoking and increased failure rate

(RR = 1.56)

 between

had infection during healing in

smokers

heavy smokers

(at least half of

their implants)

and 9 of them defined as

heavy smokers who

consumed ≥10 cig/day)

Retrospective

study [17] (half of subjects lost

at least half of their implants)

Moy et al., 2005,

2–20 years 173 smoker

ND

79.77% for

–

smokers

Retrospective

Galindo-Moreno

Prospective

Alsaadi et al., 2007,

Up to the

ND (2004 total)

6946 total (343

92.95% for heavy

–

Smoking of >20 cig/day is shown

significantly

failure when compared to no

smoking groups Implants placed in smokers are 2.6

times more likely to fail than

implants placed in

Tobacco use alone cannot be

considered

related to early implant failures

 as a factor for risk

nonsmokers

 higher early implant

smokers

heavy smoker

who consumed

>20 cig/day) 83 in smokers

 88% for smokers –

abutment

connection

Retrospective

Holahan et al., 2008,

5 years

 24 smoker

Retrospective

Sverzut et al., 2008,

<1 year

 76 smoker (out of 650 total)

 197 in smokers

97.19% for

–

> smokers, 96.68%

for

nonsmokers

(1628 total)

Retrospective

Alsaadi et al., 2008,

2 years

 22 (>20 cig/day)

93 implants in

93.94%

–

Smoking does not seem

Dental Implants in the Medically Compromised Patient Population

http://dx.doi.org/10.5772/intechopen.70182

predominant

implant loss

 player for late

patients who

consumed >20

cig/day

95 in smokers

 94.44%

–

Tendency for more early implant

failures is noticed in smokers

Retrospective

Alsaadi et al., 2008,

<1 year

 90 smoker

Prospective

Lee et al., 2011,

5 years

 ND (95 total)

ND (249 total) 246 in smokers

–

 ND

ND

Implant failures are correlated with

smoking

Smoking is not affected the DI

survival

63

Retrospective

Cakarer et al., 2014,

5 years

 ND

Retrospective

 [24]

 [23]

 [22]

 [21]

 [20]

 chart review [19]

 [18]

 [15]

 et al., 2005,

3 years

 63 smoker

ND (514 total)

–

MBL is 1.36 mm

MBL is tobacco smoking

significantly

 related to

> in smokers

 [6]

 controlled

 Follow-up

 No. of patients

No. of implants

 SR of implant

Peri-implant

Conclusion

pathology


Regarding the MBL, smoking seems to have a destroying effect by increasing the annual rate of MBL by 0.164 mm/year [14], and MBL is about 1.4 mm after 3 years with a statistically

MCP, medically compromised patients; DI, dental implant; SR, survival rate; MBL, marginal bone loss; BoP, bleeding on

As a result, tobacco smoking alone is not contraindicated for DI, and DI survival is about 90% for a long time period. On the other hand, smokers are under a higher risk of implant failure compared to the nonsmokers. Thus, clinicians should take into account other concomitant

There is no evidence to suggest that alcoholism is a contraindication for DIs. SR of DI is similar to healthy population with a reasonable alcohol consumption. Nevertheless, alcoholism is claimed to increase the risk of complications for DI because it may cause many systemic disorders like liver disease, bleeding disorders and osteoporosis (OP), and it may impair immune response and some nutritional elements like folate and B vitamins, and it is often

It is reported that consumption of >10 g of alcohol increases the MBL and decreases DI survival in humans [15]. Despite there are few studies available (Table 3) concerning the DI outcomes in patients who consumed high level of alcohol, further clinical studies with well-defined

Cardiovascular disease (CVD) compromises the blood flow which may restrict oxygen or nutrients in the osseous tissue, thus is hypothesized to have higher risk of osseointegration failure [29–31]. Clinical studies and reviews demonstrate no evidence of contraindication related to DI success in patients with CVD (Table 4), and this disease is registered as a relative complication due to the risk of infective endocarditis. Antibiotic prophylaxis is necessary prior to the surgery [31] according to the guidelines of the American Heart Association's last

significant difference from people who do not smoke tobacco [15, 16].

Table 1. Studies that indicate dental implant outcomes in the elderly population.

No. of patients No. of

4765 patients above middle ages

probing; RR, risk ratio; ND, no data available; OD, overdenture.

implants

>1082 SR is 90% for long-term period

SR of implant Peri-implant

pathology

0.1 mm in the 1st, 1.7 mm in the 5th, and 1.5 mm in the 10th year followups (out of 3 in available 8 studies) Conclusion

Implant therapy is a successful treatment in the medically compromised patient

systemic factors which could increase the risk of failures.

2.3. Alcohol consumption

Author, year, study

62 Clinical Trials in Vulnerable Populations

Followup

1–20 years

design

Mean/total of values/subjects and considerations

associated with tobacco smoking [28].

2.4. Cardiovascular diseases

publish [32, 33].

subjects are required for clarifying the relation.


Table 2. Studies that indicate dental implant outcomes in patients with smoking habits.

surgery [35].

Author, year, study design

Galindo-Moreno et al., 2005, Prospective [15]

Gander et al., 2014,

Retrospective [26]

Scully et al., 2007, Review [27]

Diz et al., 2013, Review [28]

Followup

20 months No. of patients No. of

ND ND ND Similar to

ND ND ND Similar to

Table 3. Studies that indicate dental implant outcomes in patients with alcohol abuse.

3 years 23 alcohol users ND

33 (29 patients with SCC, 24 underwent mandibular reconstruction)

implants

SR of implant

136 total 92.7% (at 1st year), 87.5% (after 20th month)

> healthy population

> healthy population

Periimplant pathology

Dental Implants in the Medically Compromised Patient Population

– MBL: 1.66 mm

Conclusion

http://dx.doi.org/10.5772/intechopen.70182

of alcohol

– In head and neck oncology patients alcohol (

– May not be a risk for DI

– May be at increased risk of complications for DI

associated with higher implant failure rate

MBL is significantly related to a daily consumption of >10 g

p = 0.001) is

65

2.5. Diabetes

are needed in this respect.

DI surgery is suggested as a legitimate procedure for the patients at high risk for IE (such as aortic or mitral valve replacement or cyanotic congenital malformation) which under prophylactic antibiotic regime of 2 g amoxicillin orally at 1 hour preoperatively [34]. There is also evidence suggesting that this regimen significantly reduces failures of DIs though it is still unknown whether postoperative antibiotics are more beneficial, and which antibiotic is the most effective [33]. Reviewers stated the importance of concomitant bleeding or cardiac ischemia which could develop during DI insertion, therefore, procuring medical advice is recommended prior to the implant surgery [28]. As a matter of fact, recent myocardial infarction, stroke, and cardiovascular surgery are well-known contraindications for performing DI

MBL, marginal bone loss; ND, no data available; SR, survival rate; SCC, squamous cell carcinoma; DI, dental implant.

According to the current literature, CVD does not hinder the osseointegration of DI [36, 37] and is not associated with higher risk of implant failure (Table 4). SR is about 89% up to 20 years (Table 4). However, the number of the studies that reports peri-implant health condition is insufficient. Unlike the other studies available, one study revealed that CVD has risk factors for peri-implant bone loss with the mean value of 1.38 mm after 3 years [16]. Further studies

As being the most prevalent endocrine disease, diabetes mellitus is a metabolic disorder that is generally diagnosed by the characteristic symptoms of polydipsia, polyuria, and polyphagia in correlation with exceeded blood glucose levels more than 200 mg/dL. It causes hyperglycemia due to a defect of insulin secretion [39], that insulin has an effect on the regeneration of bone matrix. In a diabetic patient, hyperglycemia reduces clot quality, number of osteoclasts, and

collagen production, which are the keys of bone regeneration [30].

ratio; ND, no data available.


MBL, marginal bone loss; ND, no data available; SR, survival rate; SCC, squamous cell carcinoma; DI, dental implant.

Table 3. Studies that indicate dental implant outcomes in patients with alcohol abuse.

DI surgery is suggested as a legitimate procedure for the patients at high risk for IE (such as aortic or mitral valve replacement or cyanotic congenital malformation) which under prophylactic antibiotic regime of 2 g amoxicillin orally at 1 hour preoperatively [34]. There is also evidence suggesting that this regimen significantly reduces failures of DIs though it is still unknown whether postoperative antibiotics are more beneficial, and which antibiotic is the most effective [33]. Reviewers stated the importance of concomitant bleeding or cardiac ischemia which could develop during DI insertion, therefore, procuring medical advice is recommended prior to the implant surgery [28]. As a matter of fact, recent myocardial infarction, stroke, and cardiovascular surgery are well-known contraindications for performing DI surgery [35].

According to the current literature, CVD does not hinder the osseointegration of DI [36, 37] and is not associated with higher risk of implant failure (Table 4). SR is about 89% up to 20 years (Table 4). However, the number of the studies that reports peri-implant health condition is insufficient. Unlike the other studies available, one study revealed that CVD has risk factors for peri-implant bone loss with the mean value of 1.38 mm after 3 years [16]. Further studies are needed in this respect.

#### 2.5. Diabetes

Author, year, study design

Busenlechner

Retrospective

Tran et al., 2016, chart review [12] Krennmair et al., 2016,

3 years

 9 smoker (out of 44 total)

 ND

–

1.45\* mm in

Smoking is risk factors for MBL

(OR: 8.9)

smokers

Prospective

Neves et al., 2016,

7.3 years

476 smoker

ND

85.1% (patient

36.6% pathology

Smoking is not associated with

higher risk of implant failure and

peri-implant

pocket depth with BoP or MBL)

Smoking has an influence on both

mesial and distal bone loss (<sup>p</sup> =

0.037)

Smokers have a significantly DI survival rate than nonsmokers

 higher

 pathology (>4 mm

rate (patient

based)

based)

of mean

Retrospective

Pedro et al., 2017, Analytical,

2–4 years

 ND (18 total)

ND (57 total)

–

ND

observational,

study [25] Niedermaier

Retrospective

Clementini

Systematic review and meta-

analysis [14] Mean/total of

Statistically

ratio; ND, no data available.

Table 2. Studies that indicate dental implant outcomes in patients with smoking habits.

 significant difference with healthy groups.DI,

 dental implant; SR, survival rate; MBL, marginal bone loss; BoP, bleeding on probing; OR, odds ratio; RR, risk

values/subjects

 1–20 years 3520 patients with smoking habits (13 out of 17 available

1057 implants in

SR is about 90%

Apprx. 1.4 mm

Smoking has a negative impact on

the success and survival of dental

implants

MBL after 3 years

for smokers

smokers (6 out

of 17 available

studies)

studies)

 et al., 2014,

>1 year

 478 smoker and 1207

ND

ND

Smoking

Smoking has a harmful effect on

peri-implant

the level of evidence for oral implant therapy in patients with

systemic conditions is very low

 bone loss. However,

increases the annual rate of

MBL by 0.164

mm/year

nonsmoker

 cohort [13]

 et al., 2017,

7 years

 141 smoker (out of 380 total) ND (2081 total)

 98.6% for

–

> smokers, 96.1%

for nonsmokers

 longitudinal

 [2]

 cohort [16]

Retrospective

10 years

 215 smoker

(2729 total)

–

 –

 [9]

 et al., 2014,

8 years

 1726 smoker

ND (13147 total) 76.5% for

smokers (overall

–

Smoking increases the failure rate

64 Clinical Trials in Vulnerable Populations

by 3-fold 6–15 cig/day doubles the

risk of implant failure

Smoking increases the failure rate

by 2.6-fold

SR is 97%)

 Follow-up

 No. of patients

No. of implants

 SR of implant 97.5% (6 failed

out of 246

implant)

Peri-implant

Conclusion

pathology

As being the most prevalent endocrine disease, diabetes mellitus is a metabolic disorder that is generally diagnosed by the characteristic symptoms of polydipsia, polyuria, and polyphagia in correlation with exceeded blood glucose levels more than 200 mg/dL. It causes hyperglycemia due to a defect of insulin secretion [39], that insulin has an effect on the regeneration of bone matrix. In a diabetic patient, hyperglycemia reduces clot quality, number of osteoclasts, and collagen production, which are the keys of bone regeneration [30].


Table 4. Studies that indicate dental implant outcomes in patients with cardiovascular diseases.

A decreased bone density is observed around the titanium implants in animal subjects, and implant survival is slightly reduced in poor metabolic control [28] with an average rate of 89% (Table 5). Yet no clinical evidence exists to establish an association of glycemic control with implant failure because of the insufficient identification and reporting of glycemic control in

Dental Implants in the Medically Compromised Patient Population

http://dx.doi.org/10.5772/intechopen.70182

Though diabetes is not a contraindication for DI therapy, evaluating the HbA1c level of the patient and chlorhexidine mouth wash and antibiotic prophylaxis are recommended in order

There is no evidence to suggest that bleeding disorders (BDs) are contraindication for placement of DIs [28] or a contraindication for implant survival/success [31]. Since the risk of thromboembolism of interrupting or changing the antiplatelet therapy is higher than the risk of hemorrhage caused by dental implant surgery, invasive dental procedures including dental

Considering the oral anticoagulant therapy (OAT), DI is not contraindicated in patients under an OAT [28, 31]. Minor DI surgery (that does not involve autogenous bone grafts, extensive flaps, or osteotomy preparations extending outside the bony envelope) is asserted

local hemostatic agents are suggested enough for these patients [43, 44]. On the other hand, it should be noted that some medications that are commonly used in dental practice (like metronidazole, erythromycin, and clarithromycin) may increase the anticoagulant effect of

There are some additional precautions for the patients with inherited BDs such as taking medical advice previously, the replacement of deficient coagulation factor to reach a minimum level of 50% before surgery, slow injection of local anesthesia with vasoconstrictor, the use of antifibrinolytic agents (oral tranexamic acid and/or 5% tranexamic mouthwash) up to 7 days postsurgically, and the use of topical antiseptics (chlorhexidine or povidone iodine) in order to reduce the risk of local infection. Sinus lifting and bone graft procedures are recommended to be avoided, and consulting for the use of nonsteroidal anti-inflammatory drugs is advised as

Studies that analyze the bleeding risk and DI success after invasive DI surgeries are lacking (Tables 6 and 7). Studies are also required for evaluating whether anticoagulants have an effect

Thyroid hormones of triiodothyronine (T3) and thyroxine (T4) have been demonstrated to have influence on cortical bone healing than cancellous bone around titanium implants [47]. Thus, thyroid hormones-related disorders could be regarded as the considerable issues for

–4, and

67

to be safe regarding the risk of hemorrhage in patients who have an INR value of 2

to reduce the relative risk of infection associated with diabetes [28, 30].

implant surgery are suggested to perform normally [42].

they may increase the risk of a dangerous hemorrhage [31].

on DI therapy negatively or which is the optimum drug or regimen.

most of the published studies [40].

2.6. Bleeding disorders

warfarin [31].

2.7. Thyroid disorders

evaluating the success of dental implants.

A decreased bone density is observed around the titanium implants in animal subjects, and implant survival is slightly reduced in poor metabolic control [28] with an average rate of 89% (Table 5). Yet no clinical evidence exists to establish an association of glycemic control with implant failure because of the insufficient identification and reporting of glycemic control in most of the published studies [40].

Though diabetes is not a contraindication for DI therapy, evaluating the HbA1c level of the patient and chlorhexidine mouth wash and antibiotic prophylaxis are recommended in order to reduce the relative risk of infection associated with diabetes [28, 30].

#### 2.6. Bleeding disorders

There is no evidence to suggest that bleeding disorders (BDs) are contraindication for placement of DIs [28] or a contraindication for implant survival/success [31]. Since the risk of thromboembolism of interrupting or changing the antiplatelet therapy is higher than the risk of hemorrhage caused by dental implant surgery, invasive dental procedures including dental implant surgery are suggested to perform normally [42].

Considering the oral anticoagulant therapy (OAT), DI is not contraindicated in patients under an OAT [28, 31]. Minor DI surgery (that does not involve autogenous bone grafts, extensive flaps, or osteotomy preparations extending outside the bony envelope) is asserted to be safe regarding the risk of hemorrhage in patients who have an INR value of 2–4, and local hemostatic agents are suggested enough for these patients [43, 44]. On the other hand, it should be noted that some medications that are commonly used in dental practice (like metronidazole, erythromycin, and clarithromycin) may increase the anticoagulant effect of warfarin [31].

There are some additional precautions for the patients with inherited BDs such as taking medical advice previously, the replacement of deficient coagulation factor to reach a minimum level of 50% before surgery, slow injection of local anesthesia with vasoconstrictor, the use of antifibrinolytic agents (oral tranexamic acid and/or 5% tranexamic mouthwash) up to 7 days postsurgically, and the use of topical antiseptics (chlorhexidine or povidone iodine) in order to reduce the risk of local infection. Sinus lifting and bone graft procedures are recommended to be avoided, and consulting for the use of nonsteroidal anti-inflammatory drugs is advised as they may increase the risk of a dangerous hemorrhage [31].

Studies that analyze the bleeding risk and DI success after invasive DI surgeries are lacking (Tables 6 and 7). Studies are also required for evaluating whether anticoagulants have an effect on DI therapy negatively or which is the optimum drug or regimen.

#### 2.7. Thyroid disorders

Author, year, study

Follow-up

 No. of patients

 No. of

SR of implant

Peri-implant

Conclusion

pathology

implants

ND (4680 total) 85% for

design

Moy et al., 2005,

2–20 years 1140 total (202 with

hypertension,

with CVD, 75 with

pulmonary

 disease)

 106

hypertension,

–

There is no correlation

coronary artery disease, pulmonary

increased failure rate of DI

 between

hypertension,

 disease and

66 Clinical Trials in Vulnerable Populations

85% for CVD

Retrospective

Alsaadi et al., 2007,

Up to the

ND (2004 total)

 ND (6946 total) ND

–

Cardiac disease is not associated with increased

incidence of the early failures

abutment

connection

Retrospective

Alsaadi et al., 2008,

2 years

 19 subjects with CVD 76 in subjects

with CVD

ND

89.2% (patient

32% (patient based)

 Cardiac disease is not associated with higher risk

of implant failure and

(>4 mm pocket depth with BoP or MBL)

Implant

treatment for diabetic patients with or without

coexisting CVD, with a good risk/benefit

(nonsignificant

 differences

 between the groups)

 ratio

rehabilitations

 represent a valid

peri-implant

 pathology

based)

90.79%

–

Cardiac problem does not seem a

player for late implant loss

predominant

Retrospective

Neves et al., 2016,

7.3 years

222 subjects with

> of mean

CVD

Retrospective

Nobre et al., 2016,

5 years

70 total (CVD

352

CVD: 86.7%;

MBL at 1st and 5th

non-CVD:

year is 0.95–1.52 mm in

CVD; 0.78–1.54 mm in

non-CVD group

93.8%

after

subjects: 38 patients; non-CVD subjects: 32

patients)

loading

Retrospective

Krennmair

Prospective

Pedro et al., 2017,

2–4 years

 ND (18 total)

 ND (57 total) –

Analytical,

observational,

longitudinal

Niedermaier

2017, cohort [13] Mean/total

subjects

Statistically

available; SR, survival rate.

Table 4. Studies that indicate dental implant outcomes in patients with

 significant

 difference with healthy

groups.CVD,

cardiovascular

 disease; RD, rheumatic

cardiovascular

 diseases.

 disorders; OR, odds ratio; MBL, marginal bone loss; ND, no data

 of values/

2–20 years 1533 patients with

428 (in 2 out of

Approx. 89%

0.95 mm at 1st year 1.38 mm at 3rd year

1.52 mm at 5th year

SR

8 available

studies)

CVD (in 6 out of 8

available studies)

Retrospective

 et al.,

7 years

 95 subjects with CVD

ND (2081 total) 97.8%

–

DI survival in patients with

problems does not differ from the healthy

control subjects CVD may not pose a risk for dental implants

cardiovascular

(380 total)

 [25]

 cohort [16]

 et al., 2016,

3 years

 19 subjects with CVD

ND

–

1.38 mm in CVD\*

ND

Heart diseases are not a

bone loss

contraindication

 for DI

CVD is risk factors for bone loss. (OR: 5.1)

> (out of 44 total)

 [38]

 [2]

 [21]

 [18]

 cohort [6]

Thyroid hormones of triiodothyronine (T3) and thyroxine (T4) have been demonstrated to have influence on cortical bone healing than cancellous bone around titanium implants [47]. Thus, thyroid hormones-related disorders could be regarded as the considerable issues for evaluating the success of dental implants.


DI, dental implant; BoP, bleeding on probing; MBL, marginal bone loss; ND, no data available; SR, survival rate; RR, risk ratio; PD, pocket depth.

Concerning the peri-implant pathology, thyroid disorders are reported to have the lowest potential risk compared to the other systemic disorders, in a recent clinical study [2] (Table 8). Due to the limited number of clinical studies that report DI outcomes in patients with thyroid disorders, it is hard to deduce a suggestion. Therefore, there is a certain need for further

Table 7. Studies that indicate dental implant outcome in patients with bleeding disorders or under an anticoagulant

Concerning the dental implantology, hepatitis is one other disease which has not been studied widely yet. These infectious diseases impair immune system, increase oxidative stresses induced by the viral proteins, and cause virus-associated organ damage including liver fibro-

studies about the thyroid disorders.

sis, steatosis, or hepatocellular carcinoma [48].

2.8. Hepatitis

Author, year, study design

Clemm, 2016, Clinical comparative study [45]

Author, year, study

Markovic et al., 2016, Randomized study [46]

design

therapy.

Objective of the study No of

Postoperative bleeding risk of patients continuing their anticoagulation therapy (antiaggregant, vit-K inhibitors, vitamin-K inhibitor withdrawal bridged with heparin, direct oral anticoagulants) and undergoing implant surgery and advanced bone grafting procedures

Follow-up No. of

patients

OAT, oral anticoagulation therapy; ISQ, implant stability quotient; SR, survival rate.

1 year 20 80 100% for

patients

564 patients

Table 6. Hemorrhagic risks in patients undergoing advanced implant surgery and bone grafting procedures.

SR of implant

both groups

No. of implants Conclusion related to surgical risks of DI

Dental Implants in the Medically Compromised Patient Population

the anticoagulant therapy

bleeding frequencies

anticoagulant

measures

Periimplant pathology

1. No thromboembolic complication occurred 2. The postoperative bleeding risk after

http://dx.doi.org/10.5772/intechopen.70182

69

3. The invasiveness of the surgical procedure had no statistically significant effect on

4. Patients taking vit-K inhibitors had a significantly higher risk of a postoperative bleeding compared to patients without any

5. Most of the postoperative bleedings are easily controllable via local hemostatic

Conclusion

– There is no difference between

healing of the hydrophilic and hydrophobic TiZr implant surface. OAT influences the bone healing by resulting in lower ISQ at 3rd month in comparison with baseline values, although without compromising implant stability

implant surgery and/or bone grafting procedures is very low in patients continuing

Table 5. Studies that indicate dental implant outcomes in patients with diabetes.


Table 6. Hemorrhagic risks in patients undergoing advanced implant surgery and bone grafting procedures.


OAT, oral anticoagulation therapy; ISQ, implant stability quotient; SR, survival rate.

Table 7. Studies that indicate dental implant outcome in patients with bleeding disorders or under an anticoagulant therapy.

Concerning the peri-implant pathology, thyroid disorders are reported to have the lowest potential risk compared to the other systemic disorders, in a recent clinical study [2] (Table 8). Due to the limited number of clinical studies that report DI outcomes in patients with thyroid disorders, it is hard to deduce a suggestion. Therefore, there is a certain need for further studies about the thyroid disorders.

#### 2.8. Hepatitis

Author, year, study design

68 Clinical Trials in Vulnerable Populations

Moy et al., 2005, Retrospective cohort [6]

Alsaadi et al., 2007,

Alsaadi et al., 2008,

Busenlechner et al., 2014, Retrospective [9]

Retrospective [18]

Retrospective [21]

Neves et al., 2016, Retrospective [2]

Niedermaier et al., 2017, Retrospective cohort [13]

Shi et al., 2016 Meta-analysis [41] (abstract available)

Diz et al., 2013, Review [28]

Oates et al., 2013, Review [40]

Mean/total of values/subjects

ratio; PD, pocket depth.

Follow-up No. of

8 years 185 (4.3% out

of 4316 total)

ND ND ND Slightly

Unrestricted – – Implant

2–20 years 559 diabetic

patients (in 6 out of 7 available studies)

Table 5. Studies that indicate dental implant outcomes in patients with diabetes.

620 (in 2 out of 7)

56 diabetic ND 92.9%

Up to the abutment connection

7.3 years (mean)

patients

2–20 years 48 diabetic ND 68.75% in

No. of implants SR of implant

diabetic patients

2 years 9 33 100% – Diabetes type 2 does not seem

ND 95.1% for diabetes (overall 97%)

> (patient based SR)

7 years 9 ND 91.9% – DI survival in diabetic patients

ND 252 587 ND – There is no difference between

reduced in bad metabolic control

failure rates ranging from 0 to 9.1%

Approx. 89% SR

DI, dental implant; BoP, bleeding on probing; MBL, marginal bone loss; ND, no data available; SR, survival rate; RR, risk

Periimplant pathology

ND ND ND – Controlled diabetes type 2 is not

26.8% patient based

Conclusion

– There is a correlation between

rate (RR = 2.75)

implant loss

0.928)

– Diabetes is not associated with

PD with BoP/MBL)

control subjects

– Evaluating the HbA1c level for patient selection, avoiding hypoglycemia, using chlorhexidine and antibiotic prophylaxis are recommended for diabetic patients

– Clinical evidence is lacking for the association of glycemic control with implant failure, because the identification and reporting of glycemic control are insufficient or lacking in most of

the published studies

Diabetes may interfere with the SC and SR pf implants

diabetes and increased failure

associated with increased incidence of the early failures

predominant player for late

long-term implant survival (p =

Diabetes is not associated with higher risk of implant failure and peri-implant pathology (>4 mm

does not differ from the healthy

the failure rates of the patients with uncontrolled and wellcontrolled diabetes

> Concerning the dental implantology, hepatitis is one other disease which has not been studied widely yet. These infectious diseases impair immune system, increase oxidative stresses induced by the viral proteins, and cause virus-associated organ damage including liver fibrosis, steatosis, or hepatocellular carcinoma [48].


Author, year, study design

Alsaadi et al., 2007,

Alsaadi et al., 2008,

Retrospective [18]

Retrospective [21]

Holahan et al., 2008, Retrospective chart review [19]

Busenlechner et al., 2014, Retrospective [9]

Dvorak et al., 2011, Crosssectional study [51]

Siebert et al., 2015, Comparative prospective [54]

Chow et al., 2016, Prospective [53]

Niedermaier et al., 2017, Retrospective [13]

Temmerman et al., 2017, Prospective nonrandomized controlled multicenter [52] Follow-up No. of patients No. of

(21.4% of 192 total), 57 with OPN (29.7% of total)

OP (3.5% out of 4316 total)

OP, 16 with OPN, 140 are healthy controls

half was under iv. 5 mg zoledronic acid once-yearly, others without OP)

2 years 19 subjects with OP

8 years 151 subjects with

6 years 47 subjects with

1 year 24 women (the

5 year 79 subjects with OP

1 year 20 subjects with

OP, 28 control subjects

5 years 41 with OP

Up to the abutment connection implants

SR of implant

ND 94.4% for OPsubjects (overall rate is 97%)

ND 81% for OPN, 87% for OP, 87% for the control

158 98.7% MBL 0.65 mm

7 years 7 subjects ND 94.1% – OP under the medication

98.4% is for OP group, 100.0% is for control group

63 in OPpatients, 85 in control

BOP 49.6% PI 47.4%

MBL: 0.11 0.49 mm for OP group; 0.05 0.52 mm for control group (implant based)

Peri-implant pathology

Dental Implants in the Medically Compromised Patient Population

68 86.76% – OP does not seem

ND ND – OP or OPN is not a

Peri-implantitis rates: 75% in the OPN, 76.1% in OP group, 76.5% in the control

120 100% ND The mean MBL is similar

ND ND ND – OP is found significantly

Conclusion

2.88)

http://dx.doi.org/10.5772/intechopen.70182

– OP is not associated with

associated with early implant failures (OR: 71

predominant player for late implant loss

contraindication to DI. No association between BMD T-score and DI survival is found

long-term implant survival (p = 0.661)

There is no relation between (neither OPN nor OP) bone status and peri-implantitis or implant loss

for both groups. Immediate implant osseointegration can be successful in patients who received iv. zoledronic acid

OP is not a

with MBL

DI

contraindication for DI, and reduced skeletal BMD is not associated with increased MBL. BOP is found significantly correlated

with BF seems to be a risk factor for success of

DI in patients suffering from OP/OPN is a reliable treatment compared to healthy patients. Long-term follow-up is necessary

BoP, bleeding on probing; MBL, marginal bone loss; ND, no data available; SR, survival rate; PD, pocket depth.

Table 8. Studies that indicate dental implant outcomes in patients with thyroid disorders.

Being one of the most spread and dangerous human pathogens, hepatitis C is shown to affect the oral conditions by increasing decays, gingival bleeding, and pocket depth due to the evident change in salivary flow [49].

Though hepatitis was indicated only as a possible risk factor previously [50], a present report is registered that hepatitis is the only risk factor for peri-implant pathology among the other systemic compromising factors such as cardiac diseases, thyroid disorders, diabetes, rheumatologic disorders, HIV infection, and smoking [2] (Table 9).

#### 2.9. Bone diseases

Being the most frequent bone disorder, osteoporosis (OP) affects both bone mass and density. The effect is also more prominent in cancellous bone and in women [30].

Clinical studies have demonstrated that a SR of DIs in the patients with the diagnosis of OP is about 94% (Table 10). Despite a small number of studies that report peri-implant conditions, one study has presented a high rate of peri-implantitis in patients with OP (76.1%), but this rate does not differ from the healthy population or the patients with osteopenia [51]. Regarding the peri-implant MBL, one recent study has reported a mean value of 0.11 mm at first


OR, odds ratio; BoP, bleeding on probing; MBL, marginal bone loss; ND, no data available; PD, pocket depth.

Table 9. Studies that indicate dental implant outcomes in patients with hepatitis.


Being one of the most spread and dangerous human pathogens, hepatitis C is shown to affect the oral conditions by increasing decays, gingival bleeding, and pocket depth due to the

Though hepatitis was indicated only as a possible risk factor previously [50], a present report is registered that hepatitis is the only risk factor for peri-implant pathology among the other systemic compromising factors such as cardiac diseases, thyroid disorders, diabetes, rheuma-

Being the most frequent bone disorder, osteoporosis (OP) affects both bone mass and density.

Clinical studies have demonstrated that a SR of DIs in the patients with the diagnosis of OP is about 94% (Table 10). Despite a small number of studies that report peri-implant conditions, one study has presented a high rate of peri-implantitis in patients with OP (76.1%), but this rate does not differ from the healthy population or the patients with osteopenia [51]. Regarding the peri-implant MBL, one recent study has reported a mean value of 0.11 mm at first

> Periimplant pathology

66.7% (patient based)

Conclusion

with BoP or MBL)

Hepatitis is not associated with higher risk of implant failure but it is a risk factor for periimplant pathology (OR = 3.74) (>4 mm PD

SR of implant

(patient based)

OR, odds ratio; BoP, bleeding on probing; MBL, marginal bone loss; ND, no data available; PD, pocket depth.

evident change in salivary flow [49].

Followup

7.3 years of mean

No. of patients

12 with hepatitis

Follow-up No. of

2 years 25 Hypo-

7.3 years of mean

Up to 7 years

patients

6 Hyper-

68 133 (in

Table 8. Studies that indicate dental implant outcomes in patients with thyroid disorders.

No. of implants

111 Hypo-22 Hyper-

37 ND 86.5% (patient

one study available)

BoP, bleeding on probing; MBL, marginal bone loss; ND, no data available; SR, survival rate; PD, pocket depth.

SR of implant Peri-

93.69% Hypo-86.36% Hyper-

based SR)

implant pathology

18.9% (patient based)

Conclusion

– Hypo- or hyperthyroidism

does not seem a predominant player for late implant loss

Further studies are required

Thyroid disorders are associated with neither higher risk of implant failure nor periimplant pathology (>4 mm PD

with BoP or MBL)

2.9. Bone diseases

Author, year, study design

Neves et al., 2016, Retrospective [2]

Author, year, study design

Alsaadi et al., 2008, Retrospective [21]

70 Clinical Trials in Vulnerable Populations

Neves et al., 2016, Retrospective [2]

Mean/total of values/subjects

tologic disorders, HIV infection, and smoking [2] (Table 9).

The effect is also more prominent in cancellous bone and in women [30].

No. of implants

Table 9. Studies that indicate dental implant outcomes in patients with hepatitis.

ND 83.3%


OP, osteoporosis; OPN, osteopenia; OR, odds ratio; ND, no data available; BMD, bone mineral density; MBL, marginal bone loss; DI, dental implant; SR, survival rate.

Table 10. Studies that indicate dental implant outcomes in patients with bone diseases.

year [52], and one other has reported a mean of 0.65 mm at fifth year [53]. Additionally, bone status does not seem to be a predisposition for DI failures.

#### 2.10. Rheumatologic disorders

Rheumatologic disorders encompass a large number of diseases and syndromes such as rheumatoid arthritis, osteoarthritis, and osteoporosis, which are the most common rheumatologic diseases (RDs) [2]. Different RDs could affect DI success in different ways [28]. For instance, rheumatoid arthritis (RA) has not stated a predominant player for late implant loss in one study [21]. However, together with the connective tissue disease, RA increases bone resorption when compared to the connective tissue disease alone [55].

In conclusion, BFs do not seem to have an adverse effect on DI survival under optimum oral care conditions, and OBFs are not associated with occurrence of osteonecrosis of jaws (ONJ) (Table 12).

RD, rheumatologic disease; RA, rheumatoid arthritis; BoP, bleeding on probing; MBL, marginal bone loss; DI, dental

Squamous cell carcinoma, adenocarcinoma, and ameloblastoma are the most common malignancies that are encountered in the head and neck regions. These patients with malignancies frequently go under challenging adjuvant therapeutic procedures such as radiotherapy (RT) or chemotherapy (CT) in addition to the tumor surgery. Due to the aggressive nature of the cancer and challenging cancer therapies, it is difficult to manage the DI surgery and prosthetic procedures. Furthermore, studies that evaluate the DI success in cancer patients are limited because most of the studies had a control group of patients who are under another cancer treatment (instead of a healthy control group) or have no control subjects to compare the success of dental implants. Therefore, the results are sufficient to achieve a conclusion regarding DI success (Tables 13 and 14). According to these clinical studies, CT does not seem to be associated with the higher DI failure when compared with the surgical treatment only. RT seems to be impairing the osseointegration process. Regardless of the cancer-treatment procedure, smoking and alcohol consumption in patients diagnosed with head and neck cancer yield higher implant failures. Additionally, there are no studies about implant therapy in patients with malignant diseases that are treated with BFs [64], and no study determined peri-implant

For improving the DI success in cancer patients, implant surgery is recommended to be performed at least 21 days prior to the initiation or following after 9 months of radiotherapy under a strict surgical asepsis and antimicrobial prophylaxis. Premature loading of the

2.12. Head and neck cancer

Author, year, study design

Alsaadi et al., 2008, Retrospective [21]

Krennmair et al.,

Neves et al., 2016, Retrospective [2]

2016, Prospective [16] Followup

7.3 years (mean) No. of patients

2 years 6 patients with RD

3 years 6 patients with RD (44 total)

> 36 patients with RD

implant; SR, survival rate; ND, no data available; OR, odds ratio.

No. of implants SR of implant

ND – 1.61 mm

(patient based)

– 80.6%

Table 11. Studies that indicate dental implant outcomes in patients with rheumatologic disorders.

Periimplant pathology

in RD

25% (patient based)

Conclusion

Dental Implants in the Medically Compromised Patient Population

28 100% – RA does not seem predominant player for late implant loss

RD is risk factors for bone loss (OR: 50.1)

http://dx.doi.org/10.5772/intechopen.70182

73

RDs are associated neither with higher risk of implant failure nor peri-implant pathology (>4 mm pocket depth with BoP or MBL). However, it is associated with a higher number of implant failures

conditions of DI in such patient population.

implants should be avoided [28, 31].

Today, there are only a few number of clinical studies with limited amount of participants that evaluate the success of DIs in patients with RD. Although RD was shown as risk factor for periimplant MBL in a recent prospective study [16], no relationship was found with the implant failure risk or peri-implant pathology in another study [2]. Therefore it can be concluded that any relation of RD in DI success is unclear, and there is a certain need for further studies with sufficient number of participants (Table 11).

#### 2.11. Bisphosphonate therapy

Bisphosphonates (BFs) suppress the osteoclast function and therefore are used for the treatment of disorders causing abnormal bone resorption such as OP, malignancies (multiple myeloma, bone metastases of breast, or prostate cancer), or nonmalignant bone diseases (the most prevalent of osteoporosis and Paget disease) [30, 37].

According to the recent meta-analyses, the consumption of oral BF in patients with OP could only be assumed to be a relative contraindication for DI. Further, there is no evidence that any BFs have a negative impact upon implant survival. In this context, patients should be informed about the related risks and DI could be placed under optimum oral care conditions. On the contrary, in patients who are under BF treatment intravenously together with RT doses of above 50 Gy, DI placement was reported to be a contraindication [30, 56].


RD, rheumatologic disease; RA, rheumatoid arthritis; BoP, bleeding on probing; MBL, marginal bone loss; DI, dental implant; SR, survival rate; ND, no data available; OR, odds ratio.

Table 11. Studies that indicate dental implant outcomes in patients with rheumatologic disorders.

In conclusion, BFs do not seem to have an adverse effect on DI survival under optimum oral care conditions, and OBFs are not associated with occurrence of osteonecrosis of jaws (ONJ) (Table 12).

#### 2.12. Head and neck cancer

year [52], and one other has reported a mean of 0.65 mm at fifth year [53]. Additionally, bone

OP, osteoporosis; OPN, osteopenia; OR, odds ratio; ND, no data available; BMD, bone mineral density; MBL, marginal

implants

409 (in 4 out of 9 available studies)

SR of implant

94% SR in patients with OP Peri-implant pathology

Mean MBLs are 0.11 mm at 1st year and 0.65 mm at 5th year follow-ups

Conclusion

Bone disease does not seem to be associated with the peri-implantitis or failure of DIs

Rheumatologic disorders encompass a large number of diseases and syndromes such as rheumatoid arthritis, osteoarthritis, and osteoporosis, which are the most common rheumatologic diseases (RDs) [2]. Different RDs could affect DI success in different ways [28]. For instance, rheumatoid arthritis (RA) has not stated a predominant player for late implant loss in one study [21]. However, together with the connective tissue disease, RA increases bone

Today, there are only a few number of clinical studies with limited amount of participants that evaluate the success of DIs in patients with RD. Although RD was shown as risk factor for periimplant MBL in a recent prospective study [16], no relationship was found with the implant failure risk or peri-implant pathology in another study [2]. Therefore it can be concluded that any relation of RD in DI success is unclear, and there is a certain need for further studies with

Bisphosphonates (BFs) suppress the osteoclast function and therefore are used for the treatment of disorders causing abnormal bone resorption such as OP, malignancies (multiple myeloma, bone metastases of breast, or prostate cancer), or nonmalignant bone diseases (the

According to the recent meta-analyses, the consumption of oral BF in patients with OP could only be assumed to be a relative contraindication for DI. Further, there is no evidence that any BFs have a negative impact upon implant survival. In this context, patients should be informed about the related risks and DI could be placed under optimum oral care conditions. On the contrary, in patients who are under BF treatment intravenously together with RT doses of above 50 Gy, DI placement was reported to be a contraindica-

status does not seem to be a predisposition for DI failures.

Follow-up No. of patients No. of

available studies)

Table 10. Studies that indicate dental implant outcomes in patients with bone diseases.

1–8 years 388 (in 8 out of 9

resorption when compared to the connective tissue disease alone [55].

2.10. Rheumatologic disorders

bone loss; DI, dental implant; SR, survival rate.

Author, year, study design

72 Clinical Trials in Vulnerable Populations

Mean/total of values/subjects

sufficient number of participants (Table 11).

most prevalent of osteoporosis and Paget disease) [30, 37].

2.11. Bisphosphonate therapy

tion [30, 56].

Squamous cell carcinoma, adenocarcinoma, and ameloblastoma are the most common malignancies that are encountered in the head and neck regions. These patients with malignancies frequently go under challenging adjuvant therapeutic procedures such as radiotherapy (RT) or chemotherapy (CT) in addition to the tumor surgery. Due to the aggressive nature of the cancer and challenging cancer therapies, it is difficult to manage the DI surgery and prosthetic procedures.

Furthermore, studies that evaluate the DI success in cancer patients are limited because most of the studies had a control group of patients who are under another cancer treatment (instead of a healthy control group) or have no control subjects to compare the success of dental implants. Therefore, the results are sufficient to achieve a conclusion regarding DI success (Tables 13 and 14). According to these clinical studies, CT does not seem to be associated with the higher DI failure when compared with the surgical treatment only. RT seems to be impairing the osseointegration process. Regardless of the cancer-treatment procedure, smoking and alcohol consumption in patients diagnosed with head and neck cancer yield higher implant failures. Additionally, there are no studies about implant therapy in patients with malignant diseases that are treated with BFs [64], and no study determined peri-implant conditions of DI in such patient population.

For improving the DI success in cancer patients, implant surgery is recommended to be performed at least 21 days prior to the initiation or following after 9 months of radiotherapy under a strict surgical asepsis and antimicrobial prophylaxis. Premature loading of the implants should be avoided [28, 31].


Author, year, study design

Mean/total of values/subjects

Author, year, study design

Kovacs, 2001, Retrospective [65]

Cao and Weischer, 2003 [66] (abstract available)

Korfage et al., 2011, Prospective [67]

Gander et al., 2014,

available.

Retrospective [26]

Followup

1–10 years

Followup

10 years (3 years of mean)

20 months No. of patients No. of implants

3472 in controls)

out of 8 available studies)

1238 2233 (in 7

No. of patients No. of

30 (received postsurgical adjuvant CT) and 17 (received only oncological surgery)

? 27 total number of nonirradiated and irradiated patients

5 years 50 (18 patients were treated with surgery only, 32 patients with RT in addition to the

surgery)

33 (29 patients with SCC, 24 underwent mandibular reconstruction)

Table 13. Studies that indicate dental implant outcomes in head and neck oncology patients.

SR of implant Peri-implant

and 100% in nonusers

SR is about 97% in patients who are under BFs therapy

BF, bisphosphonate; OBF, oral bisphosphonate; OP, osteoporosis; BRONJ, BP-related osteonecrosis of the jaws; ONJ, osteonecrosis of the jaws; MBL, marginal bone loss; DI, dental implant; SR, survival rate; ND, no data available.

Table 12. Studies that indicate dental implant outcomes in patients who underwent bisphosphonate treatment.

implants

106 in CT group, 54 in surgery group

195 (72 in surgery-, and 123 in surgery + RT)

SCC, squamous cell carcinoma; CT, chemotherapy; RT, radiotherapy; DI, dental implant; SR, survival rate; ND, no data

131 total 65% on

SR of implant

98.1% on implant basis

patient basis

98.6% for non-RT treated, 89.4% for RT-treated group

year), 87.5% (after 20th month)

136 total 92.5% (at 1st

pathology

Dental Implants in the Medically Compromised Patient Population

1.35 mm at 3rd year follow-up (in one study available)

> Periimplant pathology

Conclusion

http://dx.doi.org/10.5772/intechopen.70182

ONJ

Conclusion

– CT is not detrimental to the

in the mandible

– Implants and prostheses in irradiated patients have significantly lower survival rates than in nonirradiated

patients

– Implant loss is higher in

– Only smoking (p = 0.016) and alcohol abuse (p = 0.001) are associated with higher implant failure rates

patients with head and neck cancer who received RT posttumor surgery

survival and success of DIs

involving larger sample sizes and longer durations of follow-up are required to confirm these results

75

BFs do not seem to have an adverse effect on DI survival under an optimum oral care conditions, and OBFs are not associated with occurrence of


Author, year, study design

Jeffcoat, 2006, Longitudinal single-blind controlled [57]

Martin et al., 2010, Cohort [58]

Famili et al., 2011, Retrospective [59]

Al-Sabbagh et al.,

Retrospective [60]

Mozzati et al., 2015, Clinical chart review [61]

Siebert et al., 2015, Comparative prospective [54]

Suvarna et al., 2016,

Tallarico et al., 2016, Prospective [63]

Ata-Ali et al., 2016, Systematic review and metaanalysis [56]

1–7 years

Retrospective [62]

10 years

2015,

Followup

74 Clinical Trials in Vulnerable Populations

No. of patients

3 years 50 (the half is under OBF, the other half is not used BF)

>1 year 589 aged women

> 235 middleaged women under OBPs for OP

1 year 24 women (half under iv. BF, others without OP)

3 years 112 (58

patients on OBF therapy)

1288 patients (386 cases and 902 controls)

4562 (1090 DI in cases,

No. of implants

210 100% for OBF,

ND 26 implants loss in 16 patients

1267 98.7% (implant based) 93.2% (patient based)

and 99.2% for control group

1 year 211 women 347 98.7% – OBF therapy is not

6 years 39 51 86.4% – It is suggested that there is a

120 100% ND (MBL is

3 years 32 98 98% 1.35 0.21 No prosthesis failed during

Ranged between 66.7 and 100% in BF users, 95.5

similar)

140 92% – No significant risk of implant

SR of implant Peri-implant

pathology

Conclusion

– OBF usage is not associated

– Implant failure occurred as

success

9.22)

– The risk for developing

recommended

Immediate implant osseointegration can be successful in a patient with OP using once-yearly infusion of 5 mg iv. zoledronic acid

failure is seen in patients on OBP therapy compared with

the entire follow-up, and no major complications were recorded. OBF therapy is not significantly affecting DI success in case of accurate treatment selection, minimally invasive surgical approach and constant

healthy patients

follow-up

– There is not enough evidence that BFs have a negative impact upon implant SR Further, prospective studies

with occurrence of ONJ compared to placebo

early as 4 weeks and as late as 11 years after placement

significantly affects implant

possible association between implant failure and not using of BF in elder patients (OR:

BRONJ associated to DI surgery remains low for patients receiving oral BPs. The use of procedures that could enhance healing such as platelet concentrates is

BF, bisphosphonate; OBF, oral bisphosphonate; OP, osteoporosis; BRONJ, BP-related osteonecrosis of the jaws; ONJ, osteonecrosis of the jaws; MBL, marginal bone loss; DI, dental implant; SR, survival rate; ND, no data available.

Table 12. Studies that indicate dental implant outcomes in patients who underwent bisphosphonate treatment.


SCC, squamous cell carcinoma; CT, chemotherapy; RT, radiotherapy; DI, dental implant; SR, survival rate; ND, no data available.

Table 13. Studies that indicate dental implant outcomes in head and neck oncology patients.


2.12.1. Radiotherapy and hyperbaric oxygen therapy

or in grafted bone [68].

remains controversial.

Followup

No. of patients

– – 1689 in

irradiated jaws

HBO, hyperbaric oxygen; RR, risk ratio; RCT, randomized controlled trial; MBL, marginal bone loss.

Table 15. The effect of hyperbaric oxygen (HBO) on reducing the risk of DI failure in irradiated patients.

1 year 26 (the half is HBO treated, others is control)

No. of implants

ND 85.2% in HBO

group, 93.9% in non-HBO group

The mean SR of 15 studies ranged from 46.3 to 98.0%

Author, year, study design

Schoen et al., 2007, RCT [74]

Esposito and Worthington, 2013, Systematic review [75]

Chambrone et al., 2013, Systematic review [76]

RT reduces the cellular and vascular processes of healing, therefore it is assumed to impair the osseointegration and increase the risk of DI-related complications [31]. RT doses higher than 50 Gy are known to hinder osseointegration of DIs [30]. On the other hand, DI placement becomes contraindicated in patients who have received additional therapy of BFs intravenously or hormonal therapy, corticosteroids or immunosuppressive medication [30]. According to the data retrieved from the recent studies, it can be concluded that implant loss is clearly higher in irradiated patients (Table 14). The failures are more prominent in mandible

In the past, adjuvant hyperbaric oxygen therapy (HBO) treatment was shown to lead lower DI failure rates in cancer patients who underwent RT than those nonirradiated and irradiated patients [73]. Whereas, according to the recent clinical studies and reviews (Table 15), it seems that HBO has no positive effect on implant survival in irradiated patients. Therefore, this issue

SR of implant Peri-implant

–– – – – Despite the limited amount of

pathology

MBLs: 0.6

 0.6 mm in HBO-, 0.7 0.7 mm in non-HBO group

Dental Implants in the Medically Compromised Patient Population

http://dx.doi.org/10.5772/intechopen.70182

77

Conclusion

satisfaction

– The risk of implant failure

failure

Adjuvant hyperbaric oxygen therapy does not influence implant survival or periimplant MBL in radiated mandibular jaw bone. There is no statistically significant difference for postoperative complications and patient

clinical research available, it appears that HBO therapy in irradiated patients requiring dental implants may not offer any appreciable clinical benefits. There is a definite need for more RCTs to ascertain the effectiveness of HBO in irradiated patients requiring dental implants

increases significantly in irradiated patients (RR: 2.74) and in maxillary sites (RR: 5.96). HBO therapy does not reduce the risk of implant

#### 2.12.1. Radiotherapy and hyperbaric oxygen therapy

RT reduces the cellular and vascular processes of healing, therefore it is assumed to impair the osseointegration and increase the risk of DI-related complications [31]. RT doses higher than 50 Gy are known to hinder osseointegration of DIs [30]. On the other hand, DI placement becomes contraindicated in patients who have received additional therapy of BFs intravenously or hormonal therapy, corticosteroids or immunosuppressive medication [30]. According to the data retrieved from the recent studies, it can be concluded that implant loss is clearly higher in irradiated patients (Table 14). The failures are more prominent in mandible or in grafted bone [68].

In the past, adjuvant hyperbaric oxygen therapy (HBO) treatment was shown to lead lower DI failure rates in cancer patients who underwent RT than those nonirradiated and irradiated patients [73]. Whereas, according to the recent clinical studies and reviews (Table 15), it seems that HBO has no positive effect on implant survival in irradiated patients. Therefore, this issue remains controversial.


HBO, hyperbaric oxygen; RR, risk ratio; RCT, randomized controlled trial; MBL, marginal bone loss.

Author, year,

Followup

No. of patients

No. of implants

 SR of implant

 Peri- implant

Conclusion

pathology

study design

Moy et al., 2005,

2–20

22 patients received RT

ND

68.18% in irradiated

–

There is a correlation neck radiation and increased failure rate (RR

= 2.73)

 between head and

76 Clinical Trials in Vulnerable Populations

patients

Retrospective

years

cohort [6] Alsaadi et al.,

2 years 2 patients received RT

15 in irradiated patients

 80%

–

RT is affected loss (OR: 3.32)

significantly

 the late implant

2008,

Retrospective

Carr, 2012,

2 years ND (412 total)

ND (1512 total)

 ND

ND

 Late implant failure is influenced by the

local factor of systemic factor of

"implant location" and the

"radiotherapy"

Retrospective

case series [69] Mancha, 2012,

5 years 30 RT-group, 20 control (non-RT

225 in RT group, 130 in

92.6% for irradiated

–

Irradiated patients have

implant loss than

0.063)

significantly

nonirradiated

 patients (<sup>p</sup> =

 higher

> (48.3% for ORN-

developed patients) 91.5% for irradiated,

–

Implant loss is higher in irradiated patients

(<sup>p</sup> < 0.001) but no significant difference is

shown for bone loss assessed on panoramic

radiographs

associated with the occurrence RT dose of <50 Gy units also showed

significantly

survival rate

 increased amount of implant

 of ORN

 Smoking is also not found

99.5% for nonirradiated

control group

Retrospective

Korfage et al.,

14

164 patients with oral cancer

318 in RT-group, 206 in

nonirradiated

 group

years

(also 91 of them are smoker, 65

are nonsmoker)

2014,

Retrospective

Rana et al., 2016,

5 years 46 patients with oral cancer

 162

67% (52 implant had

lost)

Retrospective

Nooh, 2013,

1–14

944 patients with oral cancer

 3775

88.9% (for 3357

–

In

preimplantation

significantly

than for the maxilla (78.9%) or for grafted

bone (87.5%) While RT dose above 55 Gy

significantly

RT, especially a dose above 50 Gy, negatively

affects DI success

 decreased implant survival

 higher for the mandible (93.3%)

 RT, SR of DI is

implants)

years

Systematic

Review [68]

Mean/total

 of

1–20

284 patients with oral cancer (in

720 implants in

Approx. 83.07% SR

in irradiated patients

irradiated patients (in 4

out of 6 available

studies)

values/subjects

ORN, Table 14. Studies that indicate dental implant outcomes in patients who underwent

osteoradionecrosis;

 RT,

radiotherapy;

 DI, dental implant; OR, odds ratio; RR, risk ratio; SR, survival rate; ND, no data available.

 radiation therapy.

years

5 out of 6 available studies), 54

irradiated patients (in 3/6)

 [72]

 [71]

 [70]

treated oral cancer group)

 [21]

Table 15. The effect of hyperbaric oxygen (HBO) on reducing the risk of DI failure in irradiated patients.

#### 2.13. Immunosuppressive conditions

Immunosuppressive disabilities encompass several disorders and conditions including RDs, autoimmune skin diseases (scleroderma, pemphigus, burning mouth syndrome etc.), organ transplantation, and immunosuppressive drug usage [2, 77, 78].

Since a good immune response is necessary for wound healing, immunocompromised conditions have been commonly assumed as a contraindication for DI placement [31]. In animal studies, it is showed that immunosuppressive drugs reduce osteoblast's proliferation and impair implant osseointegration [79, 80]. Furthermore, immunocompromised condition may present additional risks for blood borne infections [28]. Therefore, installation of DIs in patients under long-term immunosuppressive treatment should be elucidated with additional measures [81].

#### 2.13.1. Organ transplantation

Bone healing is negatively affected by immunosuppressive medications. There are reports of case series and clinical studies that show successful treatments of DIs in patients who underwent organ transplants (Table 16). Reviewers stated that DIs could be a valid treatment providing that the appropriate surgical procedures and hygienic conditions are ensured [28, 78]. Modification of the immunosuppressive medication could lead a significantly lower toxicity [78].

As a conclusion, it is apparent that DI is not contraindicated for the patients who had organ transplants. However, it is suggested that the patients' medical condition should be investigated with the relevant physician before DI surgery, and the surgery should also be conducted under prophylactic medication in order to reduce the risk of blood-borne infections [28, 31].

#### 2.13.2. HIV-positive patients

Acquired immune deficiency syndrome (AIDS) is a condition that is caused by the infection of the human immunodeficiency virus (HIV). HIV-infected individuals may have compromised oral health because of having HIV-associated gingivitis and periodontitis etc. [85] that yield an additional impairment of the general health.

Recently, HIV-infection is regarded as a chronic disease rather than a terminal disease owing to the therapeutic regimen of highly active antiretroviral therapy (HAART) that includes combinations of diverse antiretroviral medications. This regimen, however, is associated with many adverse effects including bone disorders, osteopenia, osteonecrosis, and osteoporosis [86, 87]. Hence, there is a need for identifying the predictability of dental implant therapy in patients with HIV-infection.

2.14. Psychiatric disorders

1–5 years

Author, year, study design

Gu and Yu, 2011, Case series [82]

Gu et al., 2011, Case report [83] (only abstract available)

Montebugnoli et al., 2012, Prospective [84]

Montebugnoli et al., 2015, Prospective [81]

Mean/total of values/subjects 3 months 20 (10 have organ transplant, the other 10 are in control group)

transplanted (11 hearts, two livers, and 13 control subjects)

37 patients had organtransplant

MBL, marginal bone loss; DI, dental implant; SR, survival rate; PD, pocket depth.

Table 16. Studies that indicate dental implant outcomes in patients who received organ transplant.

1 year 13 organ

Followup

No. of patients No. of

implants

32 (20 in transplanted, 12 in control group)

29 in transplanted, 28 in healthy control subjects

SR of implant

3 years 13 45 100% MBL is 1.30 mm DI treatment can be

5 years 1 11 – – A stable osseointegration

105 implants 100% 0.19 mm for 1st year

– MBL is 0.21 mm for transplanted, 0.32 mm is for control

group

– For transplanted and control subjects, MBLs are 0.17 and 0.20 mm, PDs are 0.06 and 0.11 mm

1.30 mm at 3rd year

Peri-implant pathology

Dental Implants in the Medically Compromised Patient Population

Conclusion

http://dx.doi.org/10.5772/intechopen.70182

offered to liver transplant patients who are stable under long-term immunosuppression. Stable liver function and general condition should be affirmed though overall examination and consultation

79

with moderate vertical bone loss is achieved

The bone response around submerged DI in immunocompromised organ transplant patients does not differ from that observed in control

It seems that bone and periodontal response and microbiological status around submerged DI in immunocompromised organ-transplanted patients do not differ 1 year after loading from those observed in healthy control patients

SR outcome is scarce. MBL seems acceptable More studies needed

patients

Patients with neurologic disorders or other disabilities such as cerebral palsy, mental retardation, epilepsy, Down syndrome, Rett's syndrome, Asperger syndrome, Prader-Willi syndrome, fragile X chromosome, dystrophia myotonica, autism, and schizophrenia cause many problems during implant treatment and prosthetic maintenance [93]. Epilepsy impairs the oral condition of patients due to nausea-induced vomiting, mechanical trauma caused by seizures, and antiepileptic drugs-associated oral complications such as gingival overgrowth, xerostomia, and yeast infections [94, 95]. Likewise, most widely used antidepressant drugs, selective serotonin reuptake inhibitors (SSRIs), affect not only the nervous system but also peripheral tissues

According to the clinical studies available (Table 17), clinical outcomes regarding the periimplant pathology are conflicting. There may be a tendency for peri-implant infections due to the immunocompromised condition. However, HIV infection does not seem to increase the failure in the short or long term. So DI could be regarded as an eligible treatment for improving quality of life in the HIV-positive patients.


MBL, marginal bone loss; DI, dental implant; SR, survival rate; PD, pocket depth.

Table 16. Studies that indicate dental implant outcomes in patients who received organ transplant.

#### 2.14. Psychiatric disorders

2.13. Immunosuppressive conditions

78 Clinical Trials in Vulnerable Populations

measures [81].

toxicity [78].

2.13.1. Organ transplantation

2.13.2. HIV-positive patients

with HIV-infection.

additional impairment of the general health.

ing quality of life in the HIV-positive patients.

transplantation, and immunosuppressive drug usage [2, 77, 78].

Immunosuppressive disabilities encompass several disorders and conditions including RDs, autoimmune skin diseases (scleroderma, pemphigus, burning mouth syndrome etc.), organ

Since a good immune response is necessary for wound healing, immunocompromised conditions have been commonly assumed as a contraindication for DI placement [31]. In animal studies, it is showed that immunosuppressive drugs reduce osteoblast's proliferation and impair implant osseointegration [79, 80]. Furthermore, immunocompromised condition may present additional risks for blood borne infections [28]. Therefore, installation of DIs in patients under long-term immunosuppressive treatment should be elucidated with additional

Bone healing is negatively affected by immunosuppressive medications. There are reports of case series and clinical studies that show successful treatments of DIs in patients who underwent organ transplants (Table 16). Reviewers stated that DIs could be a valid treatment providing that the appropriate surgical procedures and hygienic conditions are ensured [28, 78]. Modification of the immunosuppressive medication could lead a significantly lower

As a conclusion, it is apparent that DI is not contraindicated for the patients who had organ transplants. However, it is suggested that the patients' medical condition should be investigated with the relevant physician before DI surgery, and the surgery should also be conducted under prophylactic medication in order to reduce the risk of blood-borne infections [28, 31].

Acquired immune deficiency syndrome (AIDS) is a condition that is caused by the infection of the human immunodeficiency virus (HIV). HIV-infected individuals may have compromised oral health because of having HIV-associated gingivitis and periodontitis etc. [85] that yield an

Recently, HIV-infection is regarded as a chronic disease rather than a terminal disease owing to the therapeutic regimen of highly active antiretroviral therapy (HAART) that includes combinations of diverse antiretroviral medications. This regimen, however, is associated with many adverse effects including bone disorders, osteopenia, osteonecrosis, and osteoporosis [86, 87]. Hence, there is a need for identifying the predictability of dental implant therapy in patients

According to the clinical studies available (Table 17), clinical outcomes regarding the periimplant pathology are conflicting. There may be a tendency for peri-implant infections due to the immunocompromised condition. However, HIV infection does not seem to increase the failure in the short or long term. So DI could be regarded as an eligible treatment for improvPatients with neurologic disorders or other disabilities such as cerebral palsy, mental retardation, epilepsy, Down syndrome, Rett's syndrome, Asperger syndrome, Prader-Willi syndrome, fragile X chromosome, dystrophia myotonica, autism, and schizophrenia cause many problems during implant treatment and prosthetic maintenance [93]. Epilepsy impairs the oral condition of patients due to nausea-induced vomiting, mechanical trauma caused by seizures, and antiepileptic drugs-associated oral complications such as gingival overgrowth, xerostomia, and yeast infections [94, 95]. Likewise, most widely used antidepressant drugs, selective serotonin reuptake inhibitors (SSRIs), affect not only the nervous system but also peripheral tissues


including bones because of having serotonin receptors [96]. Therefore, SSRI blocks on bone cells

ND, neurologic disabilities; SSRI, selective serotonin reuptake inhibitor; PD, probing depth; MBL, marginal bone loss; SR,

88.4% for users, 95.4% for nonusers

Since bone metabolism and oral conditions have an influence on the osseointegration of DI, neuropsychiatric disabilities and the drugs used are considerable issues for DI treatment. Clinical research related to the effect of psychiatric disorders on DI success is limited. It seems that this kind of disorders do not cause higher failures or peri-implant pathology (Table 18). On the other hand, SSRIs might increase DI failure rate as presented in a cohort study with a large number of subjects. Further studies are required to ascertain the association between

Implant survival in the elderly population, osteoporosis (OP) and HIV infection seem to be similar with the healthy population. CVDs or diabetes may present a small risk. RT seems to have the worst effect on DI success with an average SR of 83%. Some of the other compromised conditions such as alcoholism, bleeding disorders, thyroid disorders, hepatitis, RDs, organ transplantation, and HBO therapy should be investigated with additional clinical data to

have been reported to affect bone formation negatively [97].

antidepressant drugs and DI failure.

reveal objective conclusions regarding DIs.

3. Conclusion

Author, year, study design

Ekfeldt et al., 2013, Prospective [93]

Wu et al., 2014, Retrospective cohort [98]

survival rate.

Cune et al., 2009, Retrospective [95] Followup

16 years

10 years

3 –67 months No. of patients No. of

61 patients with epilepsy, additional motor and/or intellectual impairments

22 patients with different neurologic disabilities

490 total number of SSRI-users and nonusers

implants

916 (94 in users, 822 in nonusers)

Table 18. Studies that indicate dental implant outcomes in patients with psychiatric disorders.

SR of implant

134 97.6% 72% of implants were

70 85.8% Peri-mucositis: 14

(PD

3 threads)

considered having inadequate level of hygiene PD is 2 mm

implants in 10 patients

≥ 4 mm). Periimplantitis: 4 implants in 3 patients (bone loss

Peri-implant pathology Conclusion

http://dx.doi.org/10.5772/intechopen.70182

Dental Implants in the Medically Compromised Patient Population

≥

– SSRI is associated with

patients

Although adequate plaque control is not feasible in those patients, MBLs remained stable and implant loss is rare

81

DI is a valid option in patients with ND, although maintenance often requires the management of more complications compared with healthy

increased failure risk of osseointegrated implants, which might suggest a careful surgical treatment planning for SSRI users


ND, neurologic disabilities; SSRI, selective serotonin reuptake inhibitor; PD, probing depth; MBL, marginal bone loss; SR, survival rate.

Table 18. Studies that indicate dental implant outcomes in patients with psychiatric disorders.

including bones because of having serotonin receptors [96]. Therefore, SSRI blocks on bone cells have been reported to affect bone formation negatively [97].

Since bone metabolism and oral conditions have an influence on the osseointegration of DI, neuropsychiatric disabilities and the drugs used are considerable issues for DI treatment. Clinical research related to the effect of psychiatric disorders on DI success is limited. It seems that this kind of disorders do not cause higher failures or peri-implant pathology (Table 18). On the other hand, SSRIs might increase DI failure rate as presented in a cohort study with a large number of subjects. Further studies are required to ascertain the association between antidepressant drugs and DI failure.

#### 3. Conclusion

Author, year, study

Follow-up

 No. of patients

 No. of

SR of implant

Peri-implant

 pathology

 Conclusion

implants

design

Stevenson et al.,

6 months

 20 HIV+, and 9 HIV

edentulous

 adults

40 in HIV+, 18

100% for both

–

No difference in short-term clinical outcome is

found between the HIV+ and the HIV

subjects

80 Clinical Trials in Vulnerable Populations

in HIV

groups

subjects

60 (20 in each

100% for all

0.49 mm in PI-HAART

The placement of DI in HIV+ patients is a

reasonable

 treatment, regardless of CD4+ cell

groups

group, 0.47 mm in

NNRTI-HAART

mm in control

 and 0.55

count, viral load levels, and type of

therapy. Longer follow-ups

ascertain the success

 are necessary to

antiretroviral

groups)

2007,

Prospective

Oliveira et al., 2011,

1 year

 40 (11 PI-based

HAART, 14 NNRTI-

based HAART

without PI, 15

control group of who

had HIV

> Neves et al., 2016,

7.3 years

5 HIV+

ND

60% (patient

60% implant pathology rate)

(patient-based

 peri-

AIDS is not risk factor for neither higher implant

failure nor depth with BoP or MBL). However, these rates are

high when compared mean failure rates of

population

Despite higher incidence of

peri-implant

 infections

peri-implant

 pathology (>4 mm pocket

based)

Retrospective

Gherlone et al.,

1 year

 66 HIV+

190

92.1% on

MBL is 1.19 mm, peri-

implantitis

5.2% on implant basis (a,

b)

 prevalence

 is

in the first 6 months (a), DI is a suitable treatment

with a slightly worse results (a, b) regardless of

CD4+ cell count (b). HIV+ heavy smokers (>10 cig/

day)

demonstrated

peri-implantitis,

Though there is a high prevalence diseases, DI in HIV+ patients seem to provide

satisfactory

 clinical results

 of

peri-implant

 pus, and pain (b)

 increased risk of early failure,

implant basis

(a, b)

2016, Prospective

[90, 91] Gay-Escoda

2016,

case series [92]

Mean/total

 of

Up to 7.3

125 HIV+ patients

 347 (in 4 out of

Approx. 90%

0.83 mm MBL in 1st year.

SR is acceptable.

and conflicting.

seem higher as compared to the healthy

population

 Mean MBL outcomes are scarce

Peri-implant

 pathology incidences

50% of pathology rate for mean

follow-up of 7 years

nonnucleoside

 reverse

transcriptase

 inhibitor; MBL, marginal bone loss; BoP, bleeding on

peri-implant

SR

5 studies)

years

values/subjects

HAART, highly active

probing; SR, survival rate; resp, Table 17. Studies that indicate dental implant outcomes in

anti-retroviral

 therapy; PI, protease inhibitor; NNRTI,

respectively.

HIV-infected

 patients.

Retrospective

of mean

 et al.,

6.5 years

9 HIV+

57

98.3%

Success rate: 68.4%. Patient- and implant-

based rates of peri-

implant mucositis:

22.2%–10.5%,

implantitis:

44.4%–45.6%

 peri-

 [2]

of mean

)

Pilot study [89]

 [88] Implant survival in the elderly population, osteoporosis (OP) and HIV infection seem to be similar with the healthy population. CVDs or diabetes may present a small risk. RT seems to have the worst effect on DI success with an average SR of 83%. Some of the other compromised conditions such as alcoholism, bleeding disorders, thyroid disorders, hepatitis, RDs, organ transplantation, and HBO therapy should be investigated with additional clinical data to reveal objective conclusions regarding DIs.

Results with regard to peri-implantitis or peri-implant conditions are insufficient and even conflicting for majority of the compromising systemic aspects. Future studies should be designed for indicating peri-implant tissue health and maintenance in compromised patients.

comparative study. Clinical Implant Dentistry and Related Research. 2016;18(4):745-751.

Dental Implants in the Medically Compromised Patient Population

http://dx.doi.org/10.5772/intechopen.70182

83

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DOI: 10.1111/cid.12351

tripleo.2010.02.019

jpis.2014.44.3.102

Nov 22. DOI: 10.1111/jopr.12570

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DOI: 10.1111/j.1600-0501.2005.01148.x

j.ijom.2013.11.012

cid.12340

It must be taken into account that follow-up of the patients in a professional oral maintenance regimen after implant placement reduces the implant failure rate by 80% [12]. Thus, it can be stated that controlling the systemic diseases before the implant therapy and proper establishment of the medical conditions are more important than the presence of a compromise alone.
