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Perioperative use of non-steroidal anti-inflammatory drugs might impair dental implant osseointegration

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Winnett et al 2016

Background

Cluster Failures ; • Multiple implant failures can cluster in single

individuals ( Weyant & Burt 1993 )

Why..?• Surgical trauma ?

• Inadequate interdental space?

• Premature prosthetic loading?

• Titanium allergy?

• Poor quality control of the manufacturer ?

So far, clinical science can’t identify individual risk for dental implant osseointegration failure

- Cochrane et al 2009

Good and persuasive evidence is currently lacking

-Salvi & Brägger 2009

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..May be simply the unlikely result of a combination of several things going wrong in an single patient, or they may reflect an as yet unknown alternative single etiology

-Jemt & Häger 2006

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In the University of Toronto PG prosth clinic, they found 2 consecutive failures without any significant local or systemic risk factor..

..Persistent bleeding + Rapid bone loss

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Common peri-operative use of

Celebrex ( celecoxib)

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During 1979 -> 2010 .. ( appx 30 years )

.. only 14 of 1705 patients had celecoxib before !

9 of 14

.. severe idiopathic bone loss subsequent to the implant surgery

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9 of 14

.. severe idiopathic bone loss subsequent to the implant surgery

Clecoxib;• Belongs NSAIDs ( non-steroidal anti-inflammatory drugs)

• Selective inhibitor of COX-2

• Suppressing prostaglandins synthesis -

• associated with inflammation and pain

• Severe GI adverse effects ..

• Thrombotic cardivascular events ..

• heart attack, stroke, and even death found..

• Recently, in 2011,

• COX-2 pathway is suspected to play an important role in tissue homeostasis

-Riccioti & FitzGerald 2011

• Animal study - effect of NSAIDs .. unreliable for predicting outcomes in human

-Chen & Dragoo 2013

• NSAIDs also interfere with clot formation..

-Davies 2003

Methodology

• 1979-2010; 1705 patients received 5829 implants

• 10% osseointegration failure of one or more implants ( 168/1705 ) - patient level

• 5% failures - implant level ( 292/5829 )

• Adverse biological event;

• Mesial or distal annual bone loss > 0.2mm

• or Peri-implant PD > 5mm

• or PD 5mm AND BoP (+)

• Early failure ;

• prior to the restoration and loading

• “Suspected” early failures

• within 1 year of restoration and loading

• AND clinical signs of steady progression of failing implants

• Late failure;

• more than 1 year after restoration and loading

• Cluster failures defined ;

• Surgical removal of 50% or more of the implants,

• when 3 or more implants were placed at the same time in one surgical session

Surgical protocol;

• Branemark standard two-stage protocol

• Submerged surgery with 4-6 mo healing time

• No immediate placement / loading

• Only NobelBiocare implants until 2006, later Straumann

Results

- 15 Supervising faculties - 1 ~ 7.6% failures - Simple cases

- Perio or Prosth resident - Complex cases

- OS resident

Among 168 patients who had failures,

104 patients consented AND had sufficient records

42% had failure of osseointegration

(197 /468 implants)

Discussion

There is a limitation of Retrospective study,

But, it will be difficult to run the clinical study, knowing that there is possible harmful effect on osseointegration.

• NSAIDs as a potential cause of altered bone healing?

• Dentistry..

• Perio - sees as a favorable medication

• Ortho - sees as problematic element

• Perio - Jeffcoat, Williams group 1989 -1995

• Beagle dog study found significant reduction of periodontal disease -

• Similar result on human study

• Ortho

• NSAID use causes impairment of the tooth movement process

- Walker and Buring 2001

• Possibly by inhibiting osteoclast activity

Opposite evidence..

- Use of ibuprofen on bone healing around dental implants : randomized clinical trial

- Found no differences in peri-implant bone levels after 6 mo

- Alissa 2009

Dose?

Time - course of NSAID therapy ?

..

.. wide variety of different factors..

Process of osseointegration of implant

= Bone fracture healing ?

Bone metabolism is altered by the NSAID-medicated inhibition of prostaglandin synthesis

- Geusens 2013

Conclusion

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..May be simply the unlikely result of a combination of several things going wrong in an single patient, or they may reflect an as yet unknown alternative single etiology

-Jemt & Häger 2006

Use of NSAIDs is biologically evident that it is affecting the course of bone healing.

It is not clear that whether or not it is making changes on clinically significant point..

Still, evidence is weak to confirm the causality.

However, use of caution of NSAIDs might be needed.

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..May be simply the unlikely result of a combination of several things going wrong in an single patient, or they may reflect an as yet unknown alternative single etiology

-Jemt & Häger 2006

Thank����������� ������������������  you!