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Dental Implants in Patients with Cardiovascular Disorders

Introduction

Cardiovascular diseases (CVD) are a group of diseases that include atherosclerosis, congestive heart failure, coronary artery disease, hypertension, and vascular stenosis. It has been proposed that restricted supply of oxygen and nutrients to tissues may negatively affect osseointegration in patients with CVD (Elsubeihi and Zarb, 2002). To our knowledge from indexed literature, only a limited number of studies have assessed the influence of CVD on osseointegration of dental implants (Khadivi et al., 1999). It has been reported that the risk of stroke is 80% higher for nonsmoking patients with up to 24 teeth as compared to individuals who had 25 or more teeth (Joshipura et al., 2003). Likewise, results from another study reported an association to exist between periodontitis and increased risk of ischemic stroke compared with patients without periodontitis, gingivitis, or tooth loss (Wu et al., 2000).

The correlation between periodontitis and CVD has several possible pathophysiologic links. An increased systemic burden of bacteria, endotoxin, and other bacterial products could induce an abundant production of proinflammatory cytokines, cause inflammatory cell proliferation into large arteries, and increase the production of clotting factors (such as fibrinogen) through the liver, which may contribute to atherogenesis and thromboembolic events (Carroll and Sebor, 1980; Mask, 2000). Moreover, periodontopathogenic microbes may induce platelet aggregation that may be thrombogenic when entering the systemic circulation as in periodontitis (Herzberg and Weyer, 1996; 1998). Furthermore, bacterial toxins (lipopolysaccharides) may also damage the endothelial cells by attacking the arterial lining (Reidy and Bowyer, 1977). These results indicate that there is a relationship between periodontitis and CVD.

Since a previous history of periodontitis is a significant risk factor for peri‐implant diseases (Romanos et al., 2015), it is hypothesized the outcome of dental implant therapy is compromised in patients with CVD compared with systemically healthy controls.

Objective

The aim of this chapter is to review indexed literature to determine whether dental implants can osseointegrate and remain functionally stable in adult patients with CVD.

Materials and Methods

Focused Question

The addressed focused question was, “Can dental implants osseointegrate and remain functionally stable in adult patients with CVD?”

Eligibility Criteria

The following eligibility criteria were entailed: (a) Clinical studies and (b) placement and survival of dental implants in adult patients with CVD. Literature reviews, letters to the editor, commentaries, and articles published in languages other than English were excluded.

Literature Search

PubMed/Medline (National Library of Medicine, Bethesda, Maryland), EMBASE, ISI‐Web of Knowledge, SCOPUS, and Google‐Scholar databases were searched up to and including June 2016 using the following key words in different combinations: “dental implant,” “cardiovascular diseases,” “osseointegration,” “heart attack,” “ischemic heart disease,” “coronary heart disease,” “angina pectoris,” “atherosclerosis,” “stroke,” “survival,” and “success.” Titles and abstracts of studies that fulfilled the eligibility criteria were screened and checked for agreement. Full texts of studies judged by title and abstract to be relevant were read and assessed in accordance with the eligibility criteria (as stated above). In addition, hand searching of the reference lists of potentially relevant original and review studies was also performed and checked for agreement via discussion.

Results

Results from a retrospective analysis of patients with certain types of CVD showed no statistically significant difference in the implant failure rates among patients with and without CVD (Khadivi et al., 1999). This study concluded that patients with controlled CVD are not at an increased risk of failure of osseointegration (Khadivi et al., 1999).

In another retrospective study, influence of CVD on implant failure, up to one week after the second stage of surgery was evaluated (van Steenberghe et al., 2002). The results showed that there was no statistically significant association between CVD and failure of osseointegration (van Steenberghe et al., 2002). Similarly, in the study by Alsaadi and associates, CVD were not associated with an increased incidence of early implant failures (Alsaadi et al., 2007). In another retrospective analysis, the authors reported that CVD such as hypertension and ischemic heart diseases are not significantly associated with early implant loss (Alsaadi et al., 2008). Although results from a publication showed that a history CVD is associated with dental implant failure (Neves et al., 2016); it has also been reported that oral rehabilitation with dental implants among patients with or without CVD is a valid treatment (Nobre Mde et al., 2016) (Table 4.1).

Table 4.1 Outcome of assessing the outcome of implant therapy among patients with cardiovascular diseases.

Authors et al.

Study design

Participants

Outcome

Khadivi et al. (1999)

Retrospective

Group 1: 39 patients with CVD Group 2: 98 without CVD

There was no difference in implant survival rates among patients with and without controlled CVD.

van Steenberghe et al. (2002)

Prospective

399†

CVD was not associated with implant failure.

Alsaadi et al. (2007)

Retrospective

2004†

CVD was not associated with implant failure.

Alsaadi et al. (2008)

Retrospective

283†

CVD was not associated with implant failure.

Neves et al. (2016)

Retrospective

721†

CVD was not associated with implant failure.

Nobre Mde et al. (2016)

Retrospective

Group 1: 38 patients with CVD Group 2: 32 without CVD

CVD was not associated with implant failure.

CVD: cardiovascular diseases

†Patients had systemic diseases, including CVD. The exact number of patients with CVD remained unknown.

Discussion

The literature search revealed that there is a dearth of studies assessing the long‐term success/survival of dental implants in patients with CVD. However, the results indicate that as long as CVD is controlled (via therapeutic strategies such as medication), it is not a contraindication to dental implant therapy.

Conclusion

From the literature reviewed, it seems that dental implants can osseointegrate and remain functionally stable in patients with CVD; however, further long‐term follow‐up studies are needed in this regard.

GRADE ACCORDING TO LEVEL OF EVIDENCE: D

References

1. Alsaadi, G., Quirynen, M., Komarek, A. and van Steenberghe, D. 2007. Impact of local and systemic factors on the incidence of oral implant failures, up to abutment connection. Journal of Clinical Periodontology 34, pp. 610–617. doi:10.1111/j.1600‐051X.2007.01077.x.
2. Alsaadi, G., Quirynen, M., Michiles, K., Teughels, W., Komarek, A. and van Steenberghe, D. 2008. Impact of local and systemic factors on the incidence of failures up to abutment connection with modified surface oral implants. Journal of Clinical Periodontology 35, pp. 51–57. doi:10.1111/j.1600‐051X.2007.01165.x.
3. Carroll, G. C. and Sebor, R. J. 1980. Dental flossing and its relationship to transient bacteremia. Journal of Periodontology 51, pp. 691–692. doi:10.1902/jop.1980.51.12.691.
4. Elsubeihi, E. S. and Zarb, G. A. 2002. Implant prosthodontics in medically challenged patients: the University of Toronto experience. Journal of Canadian Dental Association 68, pp. 103–108.
5. Herzberg, M. C. and Meyer, M. W. 1996. Effects of oral flora on platelets: possible consequences in cardiovascular disease. Journal of Periodontology 67, pp. 1138–1142. doi:10.1902/jop.1996.67.10s.1138.
6. Herzberg, M. C. and Weyer, M. W. 1998. Dental plaque, platelets, and cardiovascular diseases. Annals of Periodontology 3, pp. 151–160. doi:10.1902/annals.1998.3.1.151.
7. Joshipura, K. J., Hung, H. C., Rimm, E. B., Willett, W. C. and Ascherio, A. 2003. Periodontal disease, tooth loss, and incidence of ischemic stroke. Stroke 34, pp. 47–52.
8. Khadivi, V., Anderson, J. and Zarb, G. A. 1999. Cardiovascular disease and treatment outcomes with osseointegration surgery. Journal of Prosthetic Dentistry 81, 533–536.
9. Mask, A. G., Jr. (2000). Medical management of the patient with...