Effect of Agents Affecting Bone Homeostasis on Short- and Long-Term Implant Failure

Consensus Statement 1: In patients receiving low-dose BP therapy (e.g. for osteoporosis therapy), the rate of early implant failure after implant placement is not increased compared to patients without BP therapy. Nevertheless, the history of BP administration (cumulative dose) is not sufficiently investigated. This statement is based on 12 cohort studies. (22 implant failures out of 1202 implants).

Consensus Statement 2: The influence of low-dose BP therapy on long-term implant survival has not been sufficiently documented to allow conclusions. This statement is based on expert opinions.

Consensus Statement 3: The influence of low-dose denosumab therapy on failure after implant placement and failure of existing implant has not been sufficiently reported to allow conclusions.

Consensus Statement 4: In patients receiving low- or high-dose ARD, prognosis and complications of augmentation procedures are not sufficiently reported to allow conclusions.

Consensus Statement 5: In patients receiving high-dose ARD, the early and late implant failure rate is not sufficiently documented to allow conclusions. This statement is based on a case series (no early failures, 49 implants in 27 patients).

Consensus Statement 6: In patients receiving low-or high-dose ARD, implant-related sequestration (IRS)/MRONJ is reported. The incidence of IRS/MRONJ after implant insertion or around an existing implant is unknown. This statement is based on retrospective case series. (168 patients from 20 case series).

Consensus Statement 7: Implant supported-rehabilitation after resective treatment and healing of MRONJ is not sufficiently reported to allow conclusion.

Consensus Statement 8: The influence of other drugs affecting bone metabolism (e.g. methotrexate (MTX), corticosteroid (CS), anti-angiogenic agents, or romosozumab) on failure after implant placement or failure of existing implants has not been sufficiently addressed to allow conclusions.

Consensus Statement 9: The potential effect of temporary withholding of ARD (drug holiday) on implant failure or MRONJ development after implant insertion has not been sufficiently documented to allow conclusions.

1) What has to be considered by the dentist before ARD Therapy?

A dentist should be involved when ARD therapy is planned. Present and potential intraoral infections should be resolved to prevent MRONJ. Existing dental implants without peri-implant pathology should not be removed. Pressure sores should be avoided to reduce the risk of MRONJ.

2) Is it safe to perform dental implant therapy during or after ARD therapy?

Proceed with caution in specialized comprehensive centers. In patients treated with low-dose ARDs, dental implant therapy is relatively safe. However, cumulative dose and administration time should be considered. Straightforward Direct implant placement in native bone and alternatives to bone augmentation procedures should be preferred.

3) In patients treated with high-dose ARD or after resection of MRONJ lesion, straightforward implant placement in the native bone can be considered only under rigorous risk evaluation.

• Strength of indication (no alternative to implant therapy, including no treatment)
• Specialized comprehensive center • Patients' motivation • Periodontal maintenance
• Patient awareness of specific risks (implant-related sequestration, MRONJ)
• Cooperation with ARD prescribing physicians (e.g. oncologists)
• Careful evaluation of co-morbidities, additional risk factors, and other medications.

4) How can the risk for complications around existing or newly inserted implants in patients receiving ARD be reduced?

In patients receiving ARD, periodontal supportive therapy is highly recommended to avoid peri-implantitis related MRONJ/IRS.

5) Is a “drug holiday” recommended for implant placement in patients receiving ARD?

Withholding ARD (drug holiday) for implant placement is not recommended. Based on the general effects and pharmacokinetics of ARDs, surgery should be scheduled according to the specific therapeutic windows of the last administration.

6) Are there other relevant medications with a possible impact on implant success?

Clinicians should be aware of medications affecting bone metabolism, including methotrexate (MTX), corticosteroid (CS), antiangiogenic agents, or romosozumab, which might impair wound healing leading to complications.

1) What can I do to avoid complications if I take medication that affects my bones?

Regularly check with your dentist even if you have no teeth, and tell them about your bone-modifying medication. Resolving oral infections is crucial for you because infections may lead to severe bone healing problems and even the death of bone tissue. Therefore careful daily oral hygiene and regular professional maintenance are strongly recommended. It is also essential to look out for and seek to prevent pressure sores under dentures.

2) Does anti-resorptive treatment affect my existing implants?

Regular dental care during anti-resorptive drug treatment is essential to spot existing or potential infections around your implants. The goal is to avoid problems around implants that could lead to necrosis of the jaw bone (dead bone). Equally, if your existing implants are healthy, they pose no risk of necrosis, and there is no reason to remove them.

3) Is it too risky to have implants if I am taking anti-resorptive drugs for osteoporosis?

Treatment for osteoporosis usually involves a low dose of antiresorptive drugs, and we know this carries only a low risk for bone necrosis. In this situation, dental implant therapy is possible. However, we should consider how long you have been taking the medication because we also know that the risk of problems with bone healing and necrosis increases when the drugs are taken over the years.

4) Is it too risky to have implants if I am taking anti-resorptive drugs as part of cancer therapy?

In cancer treatment where you receive a high drug dose, for example, in cases of bone metastases or multiple myeloma, there is an increased risk of bone necrosis. In this situation, dental implant therapy can only be performed after a thorough risk evaluation by a specialized multidisciplinary team. If you proceed with the implants, you need an ongoing regular dental follow-up to reduce the risk of bone necrosis.