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Ask UsImplants in Patients with Sjogren’s Syndrome?
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Dr. G. asks:
I have a 62 year old female patient with Sjogren’s syndrome, an autoimmune disease where the flow of tears and saliva are greatly reduced due to inflammation of the lacrimal and salivary glands. Has anyone had the experience placing implants into people with Sjogren’s syndrome ( mostly women are affected)? If so what are the pitfalls to look out for? What kinds of implant restorations would be contraindicated in a patient presenting with this condition?
Editor’s Note:
Sjögren’s syndrome is a chronic disorder that causes insufficient moisture production in certain glands of the body. Sjögren’s syndrome occurs when a person’s normally protective immune system attacks and destroys moisture-producing glands, including salivary (saliva-producing) glands and lacrimal (tear-producing) glands.
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18 Responses to “ Implants in Patients with Sjogren’s Syndrome? ”
Well in such a case- ask not “the pit falls of implants in Sjogren’s sicca syndome patient”-but ask ye “what are the pit falls of a complete denture in a patient with no saliva”!
My guess ( not based on experience or research) would point to a weak collagen bundle lay out , remember such patients often have associated joint disorders.The connective tissues seem to be adversly affected. So checking out serum Calcium and other Bone calcification parameters under care of an experienced MD is obvious basic necessity. Discuss thouroughly the patients medical condition and it’s acuteness as well it’s reversibilty ( one of my patient has had reversal ) as well as the nature of the patient’s bone matrix and calcification quality.
Any negative report should not stop you from implantation but only to help you warn the patient of possible failures.
To improve probablity of osseo integration, you may place many implants of which, a couple of implants, may not integate.
But my wild guess is that Implant supported complete denture would be a better option than a denture in a dry mouth.
Removable prosthesis is out of question for the patient. Tooth supported or implant supported prosthesis may be planned, of course, both with guarded prognosis. Life ain’t fair espcially for Sjogren’s patient’s. You win some you loose some.
You have a Hobson’s choice my friend. Between the devil and the deep sea! try and keep the patients spirits high and make her see the positive side of implant therapy. Best wishes!
Haven’t place implants in Sjogrens patients but conventional restorative is tough… they accumalate plaque very quickly and though root caries isn’t an issue with implants I would imagine maintenance of peri-implant soft tissue health would be equally fraught with problems.
I currently have a pt. that I have placed a couple in without problems and will be placing a couple more this month. I think it is the best treatment for her. No caries issue.
I have placed two implants in a Sjogrens patient, on two separate occasions, healing was not problematic. As mentioned, I would agree removable pros will be a challenge, due to the lack of tissue lubrication. Obviously, implant restorations are very suitable for patients with high caries, so they can work well in these patients.
I have a patient with Sjogrens who has an “all on 5″ configuration in the mandible with a Procera implant bridge incorporating acrylic teeth. She in now entering her third year and all in well so far. Removeable was out of the question as it would have been far to bulky and she can only tolerate something smaller.
There is nothing in the way of literature support one way or another on a protocol for using implants in the Sjogrens patient that I have come across. I myself have placed and restored implants in three patients diagnosed with Sjogrens and have not had any problem whatsoever. Two cases were non removable and one case was a two implant assisted retention of a maxillary partial denture. The removable case is approximately five years old and is working well.
When I carried out my implant masters (around 10 years ago) my prof placed a hundred implants in Sjogrens pts. Success rate was 85%. I have placed many since success rate aout 90%, so a little down on “the norm”, but benefits well outweigh the risks
I have had a Sjogrens patient under periodontal maintenance care for the past 24 years. She is now 83 years old and in otherwise good health. For the first 6 to 8 years she had her natural teeth and we battled recurrent caries with frequent recall, fluorides in office and at home, crown lengthening and new restorations. Ultimately both the upper and lower dentitions failed and all teeth were extracted. Of course dentures were intolerable so 8 upper and 6 lower “Brannemark” implants were placed successfully. Porcelin fused to gold alloy superstructures were made to sit onto individual implant supported copings. These appliances are removable and there is minimal or no tissue contact. This has been an extremely successful treatment for which the patient has been totally grateful over a period of about 16 years.
In sjogren syndrom the flow of saliva may be near normal or completely absent…
the bone quality is not affected by the syndrom but the maintenance of the implant is much more difficult and increase when the saliva is less. Bacteria are much more so strict hygiene is important…
If i have such case i would prefer a crown restoration with the limits placed supra gingival to allow maximum possibility for cleaning if ecthetics may allow that…
Sjogren’s syndrome is a chronic, autoimmune, inflammatory connective tissue disorder, with women being the majority of the patients afflicted. It is mostly diagnosed in the fourth or fifth decade of life. It is an autoimmune exocrinopathy characterized by lymphocytic infiltration of exocrine glands in multiple sites causing salivary and lacrimal gland dysfunction that leads to secretory hypofunction and the sequela of xerostomia and keratoconjunctivitis sicca, due to the production of autoantibodies. The involvement of lacrimal and salivary glands results in the typical features of KCS and salivary dysfunction; however, about one third of the patients also present with extraglandular manifestations. Sjogren’s syndrome can be seen alone (primary), or in association with another autoimmune rheumatic disease(secondary), usually rheumatoid arthritis, but also including systemic lupus erythematosus or other autoimmune connective tissue diseases. It sometimes leads to enlargement of the parotid and submandibular salivary glands, which may be associated with reduced salivary flow and symptoms of fatigue and arthralgias as well as oral complications including dental caries located at the gingival margins, incisal edges,and cusp tips; candidal infections; and difficulties with eating, swallowing, and speaking. Both primary and secondary Sjogren patients face reduced salivary function and suffer from xerostomia. Patients with primary type of the disease have an increased risk of developing non-Hodgkin lymphoma, and for them, there is also a frequent occurrence of autoimmune thyroiditis. Primary Sjogren syndrome is in most cases associated with extraglandular manifestations such as autoimmune hepatitis, interstitial lung disease, and interstitial nephritis. Patients with the secondary disease entity may also get involved with rheumatoid arthritis or systemic lupus erythematosus.Sjogren syndrome is a strict contraindication for implant placement, not only because of xerostomia that predisposes mucosal or gingival inflammation leading to peri-implantitis and failure, but because these patients are receiving large doses of steroids to suppress the illness. This corticosteroid regimen as a very serious impact on the systemic and local defense mechanisms and the most sophisticated form of the healing process; the magnificent OSSEOINTEGRATION.
So Sorry for the error on the last sentence, hereby it is corrected:
(This corticosteroid regimen has a very serious impact on the systemic and local defense mechanisms and the most sophisticated form of the healing process; the magnificent OSSEOINTEGRATION.)
Dr Mehdi don’t you think that the patient is faced with little choices? Sjogren’s patient becomes edentulous eventually. Edentulism on one hand and potential risk of failure of implant on the other hand. If the patient is well informed then where is the problem. Steriods may cause a problem as steriod may worsen loss of calcium from bone collagen bundle forming and lower immunity. But these patients can’t even wear regular dentures. It’s a Hobson’s choice, damned if you do, damned if you don’t.
What would your take be on this situation?
With all due respect sir, I,ll go for a transitional full denture instead of prostheses supported by implants. The denture’s base can be covered by soft liners or tissue conditioners to avoid any hardness to the highly irritated oral mucosa, and its removing from the mouth and cleansing would be more feasible. After the situatation gets better and salivary flow goes back to normal or/and steroids are discontinued, implant therapy can be considered upon the situation on the ground.
Thanks for the reply! You suggest the transitional denture should be Implant supported? is it so?
Sorry I didn’t read that you wrote “denture not supported by implants.”.
Dr. Jafari, you have given a very nice and worthwhile review of the Sjogrens condition but you have stated that Sjogens is a strict contraindication for placing dental implants. While I agree that there may be some contraindication, I am inclined to state it as being a relative contraindication and not a strict one. There is not a lot of publication on this matter, but there are a some (including some positive comments posted here) which have shown that dental implants can be a very valuable and for the most part, a successful treatment for Sjogrens patients who tend to suffer quite a bit from having to endure tissue borne prosthetics.
Dr. Nimchuk,sir, If you have paid attention to my reply to Dr.SDJ, I have stated that I recommend implants for Sjogren’s syndrome patients, only after the situation is totally resolved and there is no need for steroid therapy.This statement puts sjogren’s syndrome in the list of relative contra-indications of dental implants automatically.As you see, there is no conflict of opinions.
The term “contraindication” denotes an absloute resolve that the patient should not get the treatment under consideration. There really is no such thing as relative contraindication. One can discuss precautions or warnings of diminished performance under a situation like Sjogren’s sicca. To say something is a strict contraindication, however, suggests that dental implants are never to be considered for these patients. It seems from the comments above there are some cases with early success with using dental implants in these patients. It is likely that the long-term failure rate may be higher than when used in more healthy patients but this diminished performance needs to be considered against the benefits of using these devices.
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