Too Sick for Dental Implants
Featuring the MOST Important Question to Ask in Every Decision
Is this patient healthy enough for dental implant treatment? This question is similar and related to our recent post regarding implant treatment and patient age. Thankfully, it doesn’t seem quite as macabre in asking about disease as about age. Here the concern is less “will this patient die before reaping the benefits of treatment?” and more “will the patient reap the benefits of treatment at all, or will the treatment fail due to confounding medical conditions?” Ethically and emotionally, this is much more in our wheelhouse as clinicians and scientists.
[This will NOT be a discussion related to medical management of compromised patients, which is far, far too much for one post. Rather, we will focus on implant outcomes related to various disease states. For considerations of management during treatment, the best bet is a strong oral surgery referral.]
The Research
We owe a debt to Dr.’s Schimmel, Srinivasan, McKenna, and Müller for putting together a strong and thorough systematic review and meta-analysis aimed at addressing this quandary. Further thanks are in order to Wiley for making the full text available for free. [Research publishers: DO THIS. You’re smart, figure out another way to monetize.]
Their study focused solely on patients over 75 years old, and/or with the most common medical conditions according to the World Health Organization (WHO) — cardiovascular disease (CVD) (including ischemic heart disease, stroke, and hypertensive heart disease), cancer, respiratory diseases (chronic obstructive pulmonary disease (COPD), and lower respiratory infections), diabetes mellitus, cirrhosis of the liver, osteoarthritis, and conditions that involve neurocognitive impairment (unipolar depression, Alzheimer’s disease, and other dementias). They drew from an enormous array of studies of varying designs; prospective, retrospective, cohort, observational, etc. Aggregating and re-analyzing this vast network of data points is what gives the systematic review and meta-analysis such power to uncover valid and generalizable clinical truths. This is particularly true in cases like this one, where it would be impractical and unlikely that even a large single study institution could find a robust enough sample of, say, patients over the age of 75 suffering from Alzheimer’s disease and in need of dental implant treatment. The authors took special care as well to mitigate the risks of sundry biases inherent in each study design, utilizing the Cochrane collaboration’s tool and the Newcastle-Ottawa scales. They further used a funnel plot to observe the risk of publication bias. This attention to detail and intellectual honesty is a gift to us as scientists and consumers of research. It allows us to view the results and conclusions of this study without fear of being intellectually out over our skis. This article is free, and the discussion section alone is worthy of careful pondering. Please do read it in full.
So what did they find? High predictability overall; implant survival of 97.3% (95% CI: 94.3, 98.7; studies = 7) and 96.1% (95% CI: 87.3, 98.9; studies = 3), for 1 and 5 years, respectively. With respect to specific disease states; cardiovascular disease showed equal or slightly better implant survival compared to non-diseased cases. High rates of implant survival were reported in patients with Parkinson’s disease, patients receiving low dose anti-resorptive therapy (ART — often oral bisphosphonates) for osteoporosis, and patients with Type II diabetes (caveat here — poor control (HbA1c ≥ 8.0%) may have a negative effect… not exactly shocking). Increased failures and high risk for complications were reported for patients with cancer, namely those treated with radiation of the head and neck. Patients with high likelihood of bone metastases (breast cancer, prostate cancer, multiple myeloma) receiving high dose ART (often IV bisphosphonates) showed increased risk of complications, particular bone necrosis. Despite the vast data collection effort, no strong evidence could be gleaned with respect to implant survival in patients with dementia, respiratory diseases, liver cirrhosis, or osteoarthritis.
What do we do with that?
Where does this leave us as clinicians? Just there: as clinicians. We can have further confidence that advanced age does not appear to negatively affect osseointegration. We can have confidence that certain disease states do not affect our outcome, certain disease states do, and others will require an individualized risk assessment for each individual patient. As the great Dr. Scott De Rossi (Former Dean at UNC Adams School of Dentistry) has said many times: people are not HVAC units — they require doctors, not technicians.
The authors of this study touch on important aspects of implant dentistry. In fact, they ask the most important question in any decision making process, which is not “is this a good choice?” The most important question in every decision making process is: “compared to what?” In other words: “is this the best choice when compared to my other options here in the real world?” Not: “is this imperfect treatment that exists here in reality worse than some ideal treatment that exists only in my imagination?” Real options are limited for patients with head and neck cancer, or patients with hyposalivation (for whatever reason), or patients with compromised cognitive ability.
The most important question in every decision making process is: “compared to what?”
Implant treatment may have lower survival rates in patients with significant radiation history than in those without; but as the authors note, “implants may be the only means to achieve a psychosocial and functional rehabilitation” for these patients (emphasis added). Similarly, patients with hyposalivation may have irritated tissues related to full-smile implant treatment, but these patients also have extremely high caries risk, and are wholly unable to tolerate removable prosthetics. Just so with patients who have compromised cognitive abilities, they will need closer follow up with something like full-mouth implant treatment, but the maintenance and even the simple necessity to not lose removable prostheses can make fixed full-mouth implant treatment the most advantageous choice.
For these tough situations, the critical factor may not be age or disease state, as this study shows. Rather, having a team with the ability to actually deliver the best option available in the best way possible is the real differentiating factor. Medically complex or compromised patients can be poorly served by overly timid clinicians with neither the confidence nor the ability to give them the optimal treatment. Long treatment times and multiple appointments are real stressors and challenges here. The potential for mid-treatment complications is high. In all non-ideal cases, particularly those with medically compromised patients, we as clinicians must remain well informed so we can make evidence based decisions, and recognize that velocity and predictability of treatment are often the crucial factors for success. The decision, and the outcome, are mostly up to us.
