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Implants in Patients with Sjogren’s Syndrome?

posted in Dental Implant Complications, advice, Hot Posts

« Mini Implants in Anterior Mandible: Expectations of Longevity? | Implants Too Close: How to Proceed? »

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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.

34 Responses to “ Implants in Patients with Sjogren’s Syndrome? ”

• Dr SDJ May 5th, 2008

  
  

  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!

• dean stelmaschuk May 6th, 2008

  
  

  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.

• Dr. Kimsey May 6th, 2008

  
  

  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.

• Brian James May 6th, 2008

  
  

  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.

• wade May 6th, 2008

  
  

  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.

• Dr. Dennis Nimchuk May 7th, 2008

  
  

  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.

• Dr. John A Murray May 7th, 2008

  
  

  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

• steve c May 7th, 2008

  
  

  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.

• Dr.Serge May 7th, 2008

  
  

  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…

• Dr. Mehdi jafari May 8th, 2008

  
  

  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.

• Dr. Mehdi jafari May 8th, 2008

  
  

  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 SDJ May 8th, 2008

  
  

  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?

• Dr. Mehdi jafari May 9th, 2008

  
  

  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.

• Dr SDJ May 9th, 2008

  
  

  Thanks for the reply! You suggest the transitional denture should be Implant supported? is it so?

• Dr SDJ May 9th, 2008

  
  

  Sorry I didn’t read that you wrote “denture not supported by implants.”.

• Dr. Dennis Nimchuk May 10th, 2008

  
  

  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. Mehdi Jafari May 11th, 2008

  
  

  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.

• JK May 14th, 2008

  
  

  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.

• Dr SDJ May 18th, 2008

  
  

  Taking a more philosopical view of the profession of implant dentistry, the Sjogren’s patient is generally a person who has been sobered by the jolt to his life. A person who is greatful for the small mercies life occasionally shows him. An implant probably won’t last a life time but he isn’t on the death bed, anyway. And is probably, many years away from death. So between today and that last day may have many years to live.

  How can I comfort him? If he can’t chew those food morsels how long can he go on that way. And should I as a doctor be bothered about loss of reputation I suffer if the implant fails or I should I be telling myself” Let him use that Implant for as long as he can atleast I will have abated his suffering for some time.”

  I, as a doctor wouldn’t be affected adversly by a blemish on my track record of strings of succesful implant restorations.

  The Sjogren’s patient eventually figures out the tough spot nature put them in and are generally wise.

  All we have to do as doctors is to put to good use, the art we learnt, and make good the Hypocratic oath.

  If my patient can afford it and is a wise person who fully understands maturely the short and long term implications of his decision, I shall never hesitate to put an implant in a Sjogren’s patient.

• Robert Lemke May 27th, 2008

  
  

  There was a study in which 10 patients w/ Sjogrens received Branemark implants. The success rate was very good. I have treated a nurse and performed an full arch extraction/implants/ and immed. load. She did very well. This is an excellent treatment for these patients. It is important to perform the surgery prior to the patient losing significant amounts of bone by serial extractions.

• Julie Rexroth July 3rd, 2008

  
  

  Robert Lemke - Can you link me to the study in which 10 patients w/ Sjogrens received Branemark implants. The success rate was very good. Thank you.

• sousadds July 17th, 2008

  
  

  I have a Sojgren’s patient under care who I placed 6 implants in the maxilla, (one which did not integrate) and 4 in the anterior mandible.

  Prior to implants her tissue was always inflamed as a result of her near total lack of saliva and the bacterial infection of her remaining teeth which had all severely decayed. She presented with a lower denture which she could not wear at all and her remaining upper dentition was severely decayed.
  I was able to manage the case by retaining 4 maxillary teeth and fabricating a fixed provisional bridge. the remaining upper teeth were extracted and the area allowed to heal for 5 months prior to fixture placement.

  The upper arch was restored with a screw retained PFG bridge and the lower with a bar supported overdenture. The case has been loaded for 2 1/2 years. She has had a very normal response to therapy and as of May 08, she has had bone loss to no more than about the second thread on any implant.

  Since the case was loaded, and following a strict 3 month recall protocol for hygiene she has done very well. Her tissue response is pretty good except,although not showing classic signs of inflamation, the tissue is always dry and looks redder than normal throughout her mouth.

  I will be following this case closely to see what the long term results of this case will be but I can tell you that as of now, this patient could not have been treated successfully in any other way.

• Karen Whitlock September 5th, 2008

  
  

  You all are doctors I presume from what I have read. I am searching for information on what I can possibly do regarding my Sjogren’s and my teeth that are exponentially decaying and crumbling. I am heartbroken. My dentist tells me I will never be able to wear regular dentures, at the same time I cannot keep a filling or even a crown at this point. The break off, fall out, and last rarely a month. The cost trying to save my teeth has been astronomical and it is a joke if you were to see how horrid they are decayed you would never believe the money I have spent. Eight crowns and 7 root canals and my teeth look like a meth addicts teeth.
  I am desperately trying to find information (and hope) that maybe implants are a solution. I can no longer effectively chew my food which in turn is destroying my gastrointestinal tract. Sadly my medical insurance seems to think teeth are cosmetic and will not cover help with this. Yet I am losing them due to a medical condition. *sigh* I am 47, and depression is full time fight because of this.

  Thank you for all your posts, it has helped me know what choices I have and the possible risks involved. I am fortunate that I am not on corticosteroid treatment and my life is managed with Plaquenil at this time. I also suffer from lupus and am having a colon resection very soon due to chronic diverticulitis. All of which I feel is exasperated by Sjogren’s.
  Please keep up the great work.

• Ken Clifford, DDS September 6th, 2008

  
  

  Mini implant stabilized removables work. Easy to clean. No more decay. Patient can eat and speak comfortably. Simple and relatively easy to fabricate. I have done only one case like this for Sjogren patient, but wouldn’t hesitate to do it again. She did lose one implant after a year, I replaced it with a larger diameter mini. Next time I will use all 2.5mm diameter in the first place. Bone resorbtion seemed more than normal, but a simple reline after one year solved the problem. Patient is thrilled with result. If she could afford it she would do the upper as well with six minis and no palate on the denture. I still don’t get the logic of major implant surgury on most cases of this type. Mini implant dentistry allows immediate loading, nice aesthetics, minimal pain, should be far less expensive for the patient, and the dentist still makes a nice income. The only thing you don’t get is a thirty year history of success, and we have to wait another 25 years for that.

• Jean September 8th, 2008

  
  

  Hi Karen,…. I felt so badly when I read your post about your poor health that I did some research. On one of the internet forums, I found a post from a lady who has Sjogren’s and had found great help holistically. I contacted her regarding her program and she kindly wrote me back the next day. Some of the info she gave me was indeed eye-opening and since her diagnosis of 10 years ago, for the past 4 or 5 she has basically been fine. If you are interested, please feel free to email me at: palacie@sbcglobal.net and I will be happy to forward to you all the information she sent me.

• Dixie January 3rd, 2009

  
  

  Sjogrens has played havoc with my teeth. I am 76, retired, and have spent tens of thousands on my teeth in the last 8 years. I now have 4 implants upper front, and 2 molar implants. I have had many, many crowns and root canals, which all fail rapidly. I have a new 8-tooth lower fixed bridge (I’m praying it last longer than the 6-tooth bridge it replaced) Next week, I am having surgery to extract both canines (These have 2yr old root canals - infected) and other grafting of tissue and bone to begin work to get implants for the canines. There are many, many tooth problems I have suffered, but I just wanted to say, I am so happy with the implants (I’m knocking on wood they last), and I wanted to let people know. I am 76 years old, and I am almost certain I would have great difficulty with the usual dentures. I am praying tha I can get by during the time I have left with implants on the top and bridges on the bottom. Also praying I can find the money to keep on getting implants as needed!

• Eleanor Travis January 18th, 2009

  
  

  I suspect that since the initial post in May, nobody will read this, but here goes anyway. Unlike most of you, I am not a dental professional; however, I have had Sjogren’s Syndrome for more than twelve years. In 2007 it progressed to Non Hodgkin’s Lymphoma (NHL). Like Karen, while I took great care of my teeth, my cavities grew exponentially and I made the decision to have my teeth removed and replaced with implants on the bottom with an attachable/removable denture. Initially, my plan was to have implants on the top as well; however, because two of the cancerous lymph nodes were in each cheek, it could be that I will need radiation at some point, so I decided against upper implants. I have had my implants for more than a year now.
  My father, 88, also has sjogren’s and developed NHL at the age of 83. His teeth were removed shortly before manifestations of sjogren’s - I don’t know if they had implants in 1965. He now only wears an upper denture. Like me he has limitations in what food he can eat - no acidic or spicy foods. Thankfully, he and I understand our limitations.
  Back to the implants. I am very pleased that I made the choice to have my teeth removed and replaced with implants and dentures. Is it perfect? No. I must rince my dentures and mouth out after eating, which requires privacy…not always available. Additionally, I find that my tongue, (I believe in an attempt to stimuate the salivary glands) continues to play with both upper and lower dentures. However, on balance, it was the right decision.
  Just as an aside, one of the physicians indicated that at some stage the sjogren’s corrects itself. I have never heard of this; everything I know about the disease indicates that it is progressive, at varying rates.

• Ali April 25th, 2009

  
  

  I am 63,have Sjogren’s Sydrome and have worn full dentures since I was 17 due to some familial tendency to rapid decay in both primary and secondary teeth. I manage them well, except that I can no longer find a dentist willing to make a new set of dentures (which I desperately need) as I am having trouble chewing due to wear down of my lower jaw, and I suspect some TMJ problems are starting. It seems that my only hope is an implant supported lower denture. So far the SS has caused dry eyes and arthritis, but the oral mucosa doesn’t seem to be affected. I also have hypothyroidism. I take Plaquenil and Armour thyroid replacement. Are mini-implants possible or would they be too likely to fail?

• Lori, RN August 3rd, 2009

  
  

  I am a sufferer of Sjogren’s, currently 34 years old, and I wasn’t diagnosed until I last year. My dental caries, multiple root canals and restorative crowns started about 10 years ago. I thought I just had unbelievably bad fortune until I started having joint pain two years ago, now it all makes sense.

  Please to those dental practitioners out there, PUBLISH YOUR WORK! I am concerned about myself and all other Sjogren’s patients out there which will be given substandard treatment because there is little IF ANY studies published on this topic.

  For the DDS above who says implants are a strict contraindication, please do not submit to forums about this topic any longer. To assume that all/most Sjogren’s patients are on high dose corticosteroids is a beginner’s mistake. You should not make these assumptions, and I recommend you refer your Sjogren’s patients out to another DDS, or shadow a Rheumatologist awhile. The goal is NOT to be on prednisone. I believe that there should be a specialty certificate in Dentistry for autoimmune diseases; it is very difficult to get good consistent care. I personally drive 2 1/2 hours to a teaching hospital.

• Cathleen Williams August 11th, 2009

  
  

  I was diagnosed with Primary Sjogren’s at age 67, though clearly I have had the disease for years. Since my early thirties, I seem to have had nerve death in my teeth, resulting in root canal after root canal. I mention this because most of the dental information I have researched talks about caries. My caries are few for some reason, though I have dry mouth, but my root canals are many. I am wondering, if anyone knows, how the nerve death is connected with the Sjogren’s disease. I have had both primary nerve death, with and without infection and nerve death following the replacement of fillings. What causes the root nerve to die? From other posts I gather that other Sjogren’s sufferers have the same problem and I’m curious, though innured to root canals on the few remaining teeth that don’t have them. Thank you for the information on implants - it will problably come in handy in the not so distant future.

• Carolyn September 20th, 2009

  
  

  I am 56 years old..I have had Sjorgens for a little over 13 years..I lost all my teeth to this disease 2 years ago and have tried a upper plate-I have tried a lower plate but due to quick bone loss from the beginning I cannot wear a lower plate..I get sores from the upper plate this is even using vaseline..
  I constanty am swallowing and now look older than I am..Due to the severe dryness I have a hard time with foods and must drink warm to hot drinks such as tea in able to eat small portions..Unfortuantely the foods that I can eat are not always the best so I have gained weight and am in process of working on this as well..I constantly am drinking water as my tongue will stick to roof of mouth due to the dryness..
  I don’t understand why insurance does not see this as a medical condition in helping people with diseases that affect the mouth..Why not help us get the implants..In the long run the implants would save money as people could eat better and live better..
  I am now on Methotrexate to help with arthritis and pain..I see a Ophthalmologist regularly due to the sjorgens and my lids sticking to my eye balls.. Am I to be denied implants something that could help me physically and mentally?

• Patricia Resnick September 28th, 2009

  
  

  I am a 58-yr-old female with recently diagnosed secondary Sjogren’s. My teeth are rapidly just falling out of my mouth (4 in the last year), but due to lack of insurance I receive no dental care. The Sjogren’s is secondary to Psoriatic Arthritis, and both are being treated by Methotrexate and Enbrel, NOT by corticosteroids. The comment about a goal being to have patients NOT on steroids is absolutely accurate.
  I came to this forum to see what the facts are regarding Sjogren’s and tooth replacement (by implant or removable denture). I have been enlightened by the information here, and I encourage all of you to continue posting. It never occurred to me that I would not be able to use removable dentures, so this is extremely eye opening.
  Thank you all for your posts.

• Richard Hughes, DDS, FAAID, FAAIP, DABOI December 18th, 2009

  
  

  Sojens would be a relative contraindication to treatment not an absolute contraindication. So this would be on a case by case manner. We may seem abstract, but we have to practice in a detached manner inorder to make clear decisions that are not based on emotions.

• Becki March 11th, 2010

  
  

  I am 39 and was diagnosed with sjogrens 2001 after all my teeth were removed and a submanibular gland which had been playing up for many years started to excrete yellow pus - The dentist in the oral and maxillofacial unit in Adelaide answered ALOT of questions that I had for years about these strange ‘unrelated’ aches, pains and dryness (dry skin, mouth and vagina) with his diagnosis and told me that the reason all my teeth ‘fell to pieces’ in four years is Sjogrens.
  I noticed above in the comments repeatedly that Sjogrens patients cannot wear a full denture and I have in fact been wearing one since 2000. I will admit that it is uncomfortable and sometimes if I am very dry it causes ulcers and slices into my gums when eating - I have only once been offered implants and was told to start saving now and maybe you can afford them someday…. someday never seems to come!

  Good luck to you all in your endeavour to porvide the best care for the Sjogrenites out there - I don’t get a lot of understanding in my plight and my doctors usually have to sit there with a book to consult so I have no confidence most of the time it is good to see that you guys do care

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