It’s complicated – the challenges of using full arch dental implant rehabilitation

implant rehabilitation Izabela Turek discusses the challenges that arise when treating patients with complex medical histories using full arch dental implant rehabilitation.

Full arch dental implant rehabilitation is an ever-increasing need in our continuously growing, ageing society.

Even through the COVID-19 pandemic, people in need of this treatment have realised the importance of restoring their function and aesthetics – although they are unable to go out and socialise, they are still speaking to loved ones through virtual calls and are excited at the thought of eating out in restaurants again.

You can directly link restoring patients’ comfort, function and aesthetics as a result of their new, full arch dental implants to improving their overall health status. Also, their quality of life. This is something we measure in our clinic using an oral health impact form (OHIP-14) (Figure 1).

Full arch dental implant rehabilitation, for those in need of treatment and who are able to afford it, can therefore be a life-changing solution. But what happens when the patient’s medical status is complex or complicated?

Systemic health

People now widely accept that the medical status of the patient has a great influence on the success rate of dental implants. Compromised health conditions, and a related lack of adequate host healing, are among the most important conditions that account for implant failure.

At Evodental, we are challenged by the conflicting demands of our terminal dentition or edentulous patients and the need for responsible decision making in accordance with their medical history, since implant  rehabilitation remains an elective treatment.

It is therefore mandatory to identify, and potentially exclude, patients with systemic contraindications to ensure successful therapy without jeopardising the patient’s health.

Absolute contraindications to dental implant rehabilitation have been extensively discussed and include:

  • Recent myocardial infarction and cerebrovascular accident
  • Valvular prosthesis surgery
  • Immunosuppression
  • Bleeding issues
  • Active treatment of malignancy
  • Drug abuse
  • Psychiatric illness
  • Pregnancy
  • Intravenous bisphosphonate use.

Any of these conditions require cautious monitoring by the physician as well as the dental provider.

There are also relative contraindications, which include:

  • Adolescence
  • Ageing
  • Osteoporosis
  • Smoking
  • Diabetes
  • Positive interleukin-1 genotype (periodontal disease)
  • Human immunodeficiency virus positivity
  • Cardiovascular disease and hypothyroidism.

Although there are very few absolute medical contraindications to dental implant treatment, a number of conditions may increase the risk of treatment failure or complications.

The degree of systemic disease control may be far more important than the nature of the disorder itself: individualised medical control should then begin prior to implant therapy since, in many of these patients, the quality of life and functional benefits from dental implants may outweigh any risks.

Figure 2: Radiographic documentation: pre-op stage; surgery first stage; fit of the final prosthesis; 24-month follow up; fit of provisional bridge

Treatment decisions

As with any clinical decision in dentistry, the range of treatment options, and their relative advantages and disadvantages, should be carefully assessed in relation to the patient’s needs and wishes.

In patients with systemic conditions, it is important to carefully consider the cost-benefit analysis; taking into account the patient’s quality of life and life expectancy. It is then very important to undertake the implant surgical procedures with strict asepsis, minimal trauma, and avoiding stress and excessive haemorrhage.

Figure 3: Soft tissue upon fit of the final prosthesis

The clinician should also consider antibiotic prophylaxis and topical antiseptics (chlorhexidine) to reduce the risk of infections (following communication with the relevant physician, of course).

It is equally important in these patients to ensure proper maintenance with optimal standards of oral hygiene, without smoking, and with avoidance of any additional risk factors such as unhygienic prosthetic design

In principle, only patients with an ASA (American Society of Anaesthesiologists) grade I or II should qualify for an elective surgical procedure such as full arch dental implant rehabilitation. The patient’s surgical risks should be considered against the potential benefits offered by the dental implants.

Figure 4: Stage 1 surgery – placement of four dental implants using delay protocol; Stage 2 – healing of the soft tissue before implant exposure, extraction and additional placement

Last year, Evodental conducted an internal audit that displayed interesting results with regards to treated patients: 34 % were ASA I, 62% were ASA II and only 4% were ASA III.

It poses the question – is it worth the difficulty of seeing a patient with a severe systemic disease, or diseases, or should a clinician simply say no?

Assessing the patient

LW – a 60-year-old woman who was a non-smoker and non-drinker. She had a BMI of 20 (considered healthy). She arrived at our Liverpool clinic after a referral from a family member who we successfully treated, previously.

The motivation behind LW coming to see us was her inability to effectively masticate and enjoy food due to her failing dentition. The trigger that led to LW’s condition was a diagnosis of malnutrition after completing treatment for gastric adenocarcinoma. Not only that, but, two years prior, the patient underwent subtotal gastrectomy followed by chemotherapy. The treatment was successful, but the dieticians stressed the importance of a good diet.

If the case wasn’t already complex enough, we discovered that LW suffered from mixed connective tissue disease (MCTD) too; a specific subset of the broader category of rheumatic ‘overlap syndromes’, where a patient has features of more than one classic inflammatory rheumatic disease. In LW’s case, it was:

  • Rheumatoid arthritis
  • Systemic lupus erythematosus
  • Sjörgren’s syndrome

Medication

She also received target treatment for non-Hodgkin lymphoma (NHL) and osteoporosis. This complex medical history truly highlights the extent of LW’s immunosuppression. A further issue with regards to the patient healing properly was the list of medication she was taking:

  • Methotrexate
  • Truxima (biological therapy)
  • Aludronic acid (bisphosphonate)
  • Vitamin D3 supplements
  • Folic acid
  • Pro-Cal (powered protein supplement in malnutrition.

Upon examination, during the patient’s full clinical assessment (FCA), we discovered:

  • Failing dentition in the lower jaw
  • Five teeth had been heavily restored and decayed
  • Soft tissue was healthy
  • She had a thick tissue biotype.

The dentition in the upper jaw only required minor restorative work, however. We then took a CBCT, as part of the FCA. This confirmed adequate bone volume and density for the placement of four to six dental implants. Also, that the patient was suitable for full lower jaw dental implant rehabilitation, using our Evoadvanced solution.

Treatment

We felt that an interdisciplinary approach, in close cooperation with the responsible specialists, was mandatory before taking on this case.

The rationale and description of LW’s proposed dental treatment was explained in a letter and sent to the patient’s rheumatologist and her doctor.

The response was quick and featured a thorough report that included results and details on:

  • A recent blood test
  • A full blood count
  • Parathyroid hormone levels
  • Liver function
  • Vitamin D3
  • Calcium levels
  • ESR (erythrocyte sedimentation rate)
  • CPR (C-reactive protein)
  • A urine test (concerning protein excretion including Bence-Jonce test)
  • An ultrasound scan of the liver.

The results were as expected, confirming that the patient’s management was good.

It stated: ‘LW is planning to have dental implants at the end of August. I have advised that, providing she is having this under a local anaesthetic, it is safe to proceed.’

However, before providing a finalised treatment plan, unanswered questions still stood:

Does the patient need our treatment to improve quality of her life?

Yes.

Can the risks of the treatment outweighs the benefits?

Possibly yes, considering correspondence with consultants.

Can the treatment deteriorate patient dental status further?

Not really: the patient already has terminal dentition.

We then discussed the potential postoperative risks with LW, namely:

  • Prolonged healing
  • Increased risks of infections
  • An increased possibility of early implant failure
  • Increased risks of late implant failure
  • Long term complications, such as peri-implant mucositis and peri-implantitis

We obtained informed consent from LW. We decided to stage the treatment plan using a delayed load protocol (which is outside of our pathway approach).

This was to avoid direct loading of the implant during healing, as well as to confirm good postoperative healing; which is one of the foremost steps towards successful rehabilitation.

Further to this, osseointegration originates from the same mechanisms as bone fracture healing. Thus, directly linking it to an adequate immune response. We expected a compromise for LW.

We executed the treatment plan without complications:

  1. First stage surgery: implant placement in edentulous sites, without full jaw clearance, using a delayed load protocol in the correct vertical height for full arch prosthetics, with no sedation under local anaesthetic. Healing period of four months with regular reviews at three, six and twelve weeks.
  2. Second stage surgery: implant exposure and confirmation of successful osseointegration. Followed by extraction of the remaining teeth, and additional immediate implant placement in the post extraction socket with an immediate load protocol. Temporary full arch prosthesis fitted.
  3. Fit of the final prosthesis: Evoadvanced bridge after four months of healing and, again, confirmation of the successful healing of additional implant in LL3 position.
  4. Maintenance appointments: scheduled every six months.
Figure 5: Intraoral before and after photos

Conclusion

Two years later, and we are delighted that there are no complications to report. Particularly considering the complexity of this case. LW’s general medical history remains unchanged and is being managed with the same medication.

Our literature search in preparation to treat medically compromised patients confirmed that a number of animal and human studies have been performed in order to investigate the possible influence of common systemic diseases on implant survival/success.

However, the level of available data and information derived from well-recognised, evidence-based criteria was weak overall.

We obtained this data and information from case series or case report studies. Only a limited number of published randomised controlled trials exist. None of which were narrowed to full arch rehabilitation using immediate load protocol.

At Evodental, we are fortunate to have access to quality in-house data as we have treated patients using full arch dental implant rehabilitation for nearly 15 years.

Every day, we treat and maintain patients who are ASA II and ASA III, and whose medical statuses fluctuate from one visit to another.

Our weekly multidisciplinary meetings allow us to discuss cases as a team, with both the clinical and technical teams coming together, and tailor individual treatment plans when required.

There is no data-based conclusion on whether placing dental implants in patients with complex medical histories is the correct thing to do or not.

Clinicians planning to carry out implant-based therapy in patients with coexistent systemic diseases, who are taking immunosuppressants, should never aggravate the general morbidity of patients and must not interfere in life-saving therapies or jeopardise their health.

In general, a careful risk assessment prior to treatment, based on the patients’ medical record and current medical status, is fundamental. 

Figure 6: LW before and after photos

For references please contact: [email protected] 

This article first appeared in Implant Dentistry Today magazine. You can read the latest issue here. 

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