Title	Dental Implant Placement Is Contraindicated in Patients Receiving Intravenous Bisphosphonate Treatment
Clinical Question	In comparison to healthy patients, how is dental implant placement affected in patients who have been previously treated or are currently being treated with systemic bisphosphonates to combat aggressive cancers?
Clinical Bottom Line	For cancer patients who are currently undergoing intravenous bisphosphonate therapy, dental implant placement is contraindicated because of the high risk of developing bisphosphonate-related osteoneocrosis of the jaw. However, this subject is not nearly addressed nor studied as much as the relationship between osteonecrosis and oral bisphosphonates. Therefore, it is prudent to collect as much information as possible through a comprehensive medical history and review of systems to determine whether a patient previously treated with intravenous bisphosphonates can successfully accept a dental implant.
Best Evidence
PubMed ID Author / Year Patient Group Study type (level of evidence) 19663954 Madrid/2009 Patients on oral or intravenous bisphosphonates; 217 patients in 4 included studies Systematic review of non-randomized trials Key results Most expert panels and guidelines recommend limiting unnecessary dental surgery in patients undergoing systemic nitrogen-containing bisphosphonate therapy to treat cancer. Implant placement is contraindicated in cancer patients receiving intravenous bisphosphonate therapy to decrease the risk of bisphosphonate-related osteonecrosis of the jaw. 27475681 de-Freitas/2016 Patients who received dental implants before, during, or after bisphosphonate treatment; 1339 patients included in 15 studies Systematic review of non-randomized trials Key results Patients undergoing intravenous bisphosphonate therapy are at greater risk for implant loss due to its complete bioavailability and the direct association with bisphosphonate-related osteonecrosis of the jaw. Intravenous bisphosphonates taken in combination with oral bisphosphonates were shown to cause osteonecrosis in 100% of the patients. However, when each route of bisphosphonate administration was evaluated separately in regard to how it affects dental implant success, the results are inconsistent. The only study that included patients solely on intravenous bisphosphonates (for osteoporosis) showed results of having no osteonecrosis of the jaw and no loss of implants.
Evidence Search	(systemic[All Fields] AND ("diphosphonates"[MeSH Terms] OR "diphosphonates"[All Fields] OR "bisphosphonates"[All Fields]) AND ("dental implants"[MeSH Terms] OR ("dental"[All Fields] AND "implants"[All Fields]) OR "dental implants"[All Fields])) AND (Meta-Analysis[ptyp] OR Randomized Controlled Trial[ptyp] OR systematic[sb])
Comments on The Evidence	Validity: There are limitations to both of these systematic reviews due to the lack of randomized controlled trials addressing implant success before, during, or after the treatment with intravenous bisphosphonate therapy. Both reviews stated that case series and reports offer weak to moderate evidence; therefore any conclusions made may not be very strong. Perspective: It must be noted that guidelines presented in these reviews contraindicate dental implants in patients currently receiving intravenous bisphosphonates. There is little to no available information regarding dental implant placement before or after intravenous bisphosphonate treatment.
Applicability	It is important to know the relationship between the dental implants and intravenous bisphosphonates considering the growing popularity of dental implants used to treat partial or complete endentulism and the widespread use of intravenous bisphosphonates to treat osteoporosis, multiple myeloma, and bone metastasis of breast, prostate, and lung cancer. It is likely for clinicians to come across patients seeking to replace missing teeth who also have a history of bisphosphonate use.
Specialty	(General Dentistry) (Oral Surgery) (Prosthodontics)
Keywords	Intravenous bisphosphonates, systemic bisphosphonates, bisphosphonate, dental implants
ID#	3238
Date of submission	04/21/2017
E-mail	rodriguezmj@livemail.uthscsa.edu
Author	Madeline Rodriguez
Co-author(s)
Co-author(s) e-mail
Faculty mentor	H. Stanley McGuff, DDS
Faculty mentor e-mail	mcguff@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 (FOR PRACTICING DENTISTS', FACULTY, RESIDENTS and/or STUDENTS COMMENTS ON PUBLISHED CATs) None available