Late failure of implant after 5 years: Bisphosphonate related?

I have a case with a late failure of an implant at one site and bone disintegration at another other site. This patient has good oral health and no history of periodontitis. At these sites, there were no signs of inflammation at all and no signs of bone breakdown during the first 5 years after integration.

The patient developed a condition of muscular rheumatism 5 years after the implants were placed and was treated accordingly with cortisone for one year to successfully resolve this condition. In my country, it seems that when a patient is put on cortisone for a prolonged time they always prescribe bisphosphonates as well (to prevent osteoporosis). This patient received IV bisphosphonates.

When I removed the failing implant and treated the other implant no granular tissue was found and the strange thing with the implant that was removed is that the bone of the alveolus seemed intact and there was even bone on the implant itself. It looked like there was a fracture in the bone itself caused by too much strain on the bone itself and there was no bleeding at all after removing this implant. After treating the bone, there was some bleeding, but not as much I would expect.

Is it possible that the IV bisphosphonate played a role in this condition? I think that with normal use there will be some microfractures in the bone now and then, but be repaired by the bone cells in an individual, not on bisphosphonates. But that these medicines seemed to have blocked the repair capabilities of the bone itself? These implants were functioning normally for 5 years without any signs of periodontitis, and currently no evidence of periodontitis, so there would seem to be no other possibilities to explain the bone loss. I wonder what are your experiences with these kinds of cases and how would you handle a case like this? Are there scientific papers on these problems with bisphosphonates in cases of a late failure? I would like to hear your opinions. Are there better alternatives for bisphosphonates in these cases, since these are used in a preventive way?

13 Comments on Late failure of implant after 5 years: Bisphosphonate related?

New comments are currently closed for this post.

Doc

3/5/2018

I have always noticed that when a steroid, in this case cortisone, is added to a patient taking Bisphosphonates, the risk of BRONJ is greater. Sounds like the implant failure could be associated with the use of Bisphosphonates, but also the combo with cortisone.

Dennis Flanagan DDS MSc

3/5/2018

This could be related to bisphosphonate but Fralit implants can fail like this after 5-10 years. They were press fits stepped design.

Andrew Porter

3/5/2018

I am curious if the area healed well afterwards with no bone necrosis?

Julian O'Brien

3/5/2018

The problem with a blame game is that the implant may have been destined to fail for its own secret reasons unrelated to Rx or any as yet known factor. Tread (thread) with caution? An implant failing is not a catastrophe, rather statistics. Remove it and immediately place a larger diameter implant.

LE BAS

3/6/2018

Remember the patient had biphosphonates , so you do not place an other implant any more

DR S CHODREE

3/6/2018

There is alot of recent litreture on the very low failure rate of patients on oral biphos with implants.Osteoradionecrosis was not found to be a significant factor in failure of the implant,and some studies say there is no correlation between biphos and failing implants.

CRS

3/6/2018

It was the Bisphos due to the timing three year window, IV greater risk. Hopefully the bone will heal that is the proof. You might want to read up on drug induced osteonecrosis, osteoclasts are poisoned when the drug laced bone is ingested. Lost of dead brittle bone not turned over. This patient is no longer an appropriate candidate for dental implants, regardless of what else is posted on the mechanics of implants. Canâ€™t ignore biology folks.

LE BAS

3/6/2018

I really agree with you : no more implants

TH20

3/6/2018

Thank you for your replies. I know about the studies on bisphosphonates but the problem here is that at the time the implants were placed she was a healthy person without any bisphosphonates in her history. That part of the story was 5 years later. I think that in a patient without these drugs there will also be some microfractures because of some strain on the implants, but that normal repair will kick in and that resolve the condition and keeping the implant site OK. In this case, I think those microfractures didn't repair/ resolve, because of the working mechanism of these drugs on osteoclasts and caused the failure of the implant. I removed the implant and will follow the healing process closely. I put this patient on Doxi so I can access if bone healing is taking place with the help of the working mechanism of Doxi. I normally don't place implants in patients on bisphosphonates but in this case, the patient did get these drugs at a later stage ( 5 years after placing the implants) and since every patient nowadays with a little osteoporosis is put on bisphosphonates I wonder if we will see this problem more often. I couldn't find good papers on the late effect of bisphosphonates on implants like in this case that a normal healthy person gets implants, then get some bisphosphonates in a later stage and what are the survival rates after 5 - 10 years compared to patient nog on bisphosphonates. And the second question is: aren't there better alternatives to bisphosphonates? I understand in severe osteoporosis it is a good indication because of the complications of osteoporosis, but in mild and moderate cases does one really have to prescribe these drugs?

Dr. Robert Wolanski

3/7/2018

I agree with CRS that the standard of implant placement contraindication is accepted as 3 years. I have placed implants in a patient on Bisphosphonates for 4 years and so far so good. That case is about 6 years out and was 4 implant in the mandible with locator attachments. I do all of those surgeries with full open flaps to assure I can create a level crestal platform and the threads are all buried with 2-3 mm of bone over in both buccal and lingual dimensions . When I did the surgery the bone was a much yellower color. It was a risk however and the patient was willing to sign a waiver after lengthy discussions. I also kept the implants unloaded for 6 months and monitored her with great frequency. If it is the bisphosphonates to blame in your case and this is indeed a true phenomenon as you are concerned about we will have the answer handed to us in the ensuing years. I can only assume there are many patients who have been placed on bisphosphonates since having implants done and to date I have not heard this being an issue that other dentists and surgeons are seeing. Hope it stays that way. Rob

Julian O'Brien

3/7/2018

The issue is "informed consent". Certainly to remove the implant demands that the bone and soft tissue cover over a new defect of say 4 mm by 10mm over many weeks whereas a wider implant immediately inserted leaves no open wound and only a "tiny" gap to heal .... Plus no ingress of saliva, no danger of a dry socket and less chance of dislodgement of any blood clot. If I was the patient I would try a wider replacement rather than risk osseo necrosis around an open socket. The other matter to question is the validity of "nuking" the precious osteoblasts with any Rx. An increase risk of an adverse outcome is not a prohibition. Thread with caution!

bjs

3/10/2018

Slightly off subject but defects and jaw fractures can occur when working with bisphosphonate patients. Implant failure is just one small segment, imho. Until the CTX test from Quest Labs come back clean, wouldn't it be wiser to not do any type of surgery or implants?

bjs

3/10/2018

(the last sentence not attached to my post) It was: and to caution the patient for future possible use of bisphosphonates.