Title A Drug Holiday from Oral Bisphosphonates Does Not Improve Implant Retention Rates
Clinical Question In a patient taking oral bisphosphonates, does taking a drug holiday for implant placement improve implant retention?
Clinical Bottom Line For patients who are undergoing oral bisphosphonate treatment, the retention of implants is not affected by the drug therapy. This statement is supported by systematic review articles in which the implant retention is not hindered in patients undergoing bisphosphonate therapy.
Best Evidence  
PubMed ID Author / Year Patient Group Study type
(level of evidence)
18022461Marx/2007Patients on oral bisphosphonates (BP) and patients who had taken a drug holiday from their BPProspective study
Key resultsMarx found a serum marker (CTX) that is indicative of a patient’s risk of osteonecrosis of the jaw if they are on oral bisphosphonates: <100pg/mL high risk, 100-150pg/mL moderate risk, >150pg/mL minimal risk. “The CTX values were noted to increase between 25.9 pg/mL to 26.4 pg/mL for each month of a drug holiday indicating a recovery of bone remodeling and a guideline as to when oral surgical procedures can be accomplished with the least risk. In addition, drug holidays associated with CTX values rising above the 150 pg/mL threshold were observed to correlate to either spontaneous bone healing or a complete healing response after an office-based debridement procedure.” This article is saying that if a patient is on a drug holiday before getting implants, their CTX value is higher and therefore the implant stability should be improved in these patients over other patients on oral bisphosphonates.
19663954Madrid/2009Patients on oral and IV bisphosphonatesSystematic review of non-randomized trials
Key resultsThe intake of oral bisphosphonates did not influence short-term (1-4 years) implant survival rates. Implant survival rates for the patients taking bisphosphonates ranged from 95-100%.
18201600Grant/2008Patients on oral bisphosphonates who had had implants placed Retrospective cohort study
Key resultsFor 115 female patients who took bisphosphonates at the time of implant placement, 466/468 implants were in function at the time for the study. For 343 patients who had not taken bisphosphonates, 1,426/1,450 implants integrated successfully; therefore the survival/retention rate is similar for both groups.
Evidence Search Oral bisphosphonates CTX testing, oral bisphosphonates implant stability
Comments on
The Evidence
Validity: The Marx article showed the relationship between C-terminal telopeptide (CTX) values and the incidence of implant retention and no osteonecrosis of the jaw. Marx studied “detailed data” from 30 oral bisphosphonate (OB) cases and compared them with 116 cases of intravenous bisphosphonate (IV) use. In the Madrid article, the authors looked at one prospective and three retrospective studies, with a total of 217 patients studied. In the four included articles, the number of patients on bisphosphonates was fairly small, the duration that the patients were on the bisphosphonates was as short as 24 months, and the follow-up time for implant outcomes was an average of 34 months. In the Grant article the authors looked at 468 placed implants in patients taking OBs and patients not on OBs and compared their implant surgical outcomes. There is a possibility of recall bias because the patients filled out a questionnaire on their bisphosphonate use. Also, 26 of the 115 patients in the bisphosphonate group started taking BPs after they got their implant and those patients shouldn't have been included in the study. Perspective: The Marx article seems like a great foundation for studying implants. However, the other two articles were written after Marx’s research had been conducted, and it was discovered that there was no significant difference between a patient’s healing while they are on OBs versus taking a drug holiday. Further studies should be conducted to continue to test Marx’s theory of CTX values and implant surgical success.
Applicability The current evidence is applicable to dentists and surgeons who place implants. Because a large portion of the elderly population, especially women, are taking oral bisphosphonates (OB) for their bone health, this research is of particular important to dental practitioners placing implants. There does not seem to be a ‘gold standard’ of evaluating patients taking OBs who want implants and there is no difference in clinical outcome in these patients when looking at the presented studies.
Specialty (General Dentistry) (Oral Surgery) (Periodontics) (Prosthodontics)
Keywords Oral bisphosphonates, implant stability, drug holiday
ID# 3227
Date of submission 04/19/2017
E-mail cooktg@livemail.uthscsa.edu
Author Taylor Cook
Co-author(s) e-mail
Faculty mentor Norma Olvera, DDS, MS
Faculty mentor e-mail olveran@uthscsa.edu
Basic Science Rationale
(Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?)
None available
Comments and Evidence-Based Updates on the CAT
None available