Med Oral Patol Oral Cir Bucal. 2014 Sep 1;19 (5):e478-82.
Implants in disabled patients
Journal section: Medically compromised patients in Dentistry
Publication Types: Review
doi:10.4317/medoral.19564
http://dx.doi.org/doi:10.4317/medoral.19564
Implants in disabled patients: A review and update
María-Jesús Romero-Pérez 1, María del Rocio Mang-de la Rosa 1, Julián López-Jimenez 2, Javier FernándezFeijoo 3, Antonio Cutando-Soriano 4
1
DDS, Collaborator of the department of Dentistry in Special Patient. University of Granada
Private activity. Barcelona
3
Profesor Associated of Dentistry in Patient Special. Group of Investigation OMEQUI. University of Santiago of Compostela
4
PhD,MD,DDS. Department of Dentistry in SpecialPatient. University of Granada
2
Correspondence:
Departamento de Estomatología
Facultad de Odontología de la Universidad de Granada
Campus Universitario de Cartuja
s/n, E-18071 Granada, Spain
acutando@ugr.es
Romero-Pérez MJ, Mang-de la Rosa M, López-Jimenez J, FernándezFeijoo J, Cutando-Soriano A. Implants in disabled patients: A review and
update. Med Oral Patol Oral Cir Bucal. 2014 Sep 1;19 (5):e478-82.
http://www.medicinaoral.com/medoralfree01/v19i5/medoralv19i5p478.pdf
Received: 20/09/2013
Accepted: 29/09/2013
Article Number: 19564
http://www.medicinaoral.com/
© Medicina Oral S. L. C.I.F. B 96689336 - pISSN 1698-4447 - eISSN: 1698-6946
eMail: medicina@medicinaoral.com
Indexed in:
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Index Medicus, MEDLINE, PubMed
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Indice Médico Español
Abstract
The range of indications for dental implants has broadened enormously owing to their predictability and the improvement of patient satisfaction in terms of stability, comfort, aesthetics and functionality.
The aim of this article is to review those indications in patients with mental or physical disabilities as the difficulty
to cope with oral hygiene often leads to teeth extraction, adding edentulousness to the impairments already present.
Following that goal, available literature in Pubmed database, Scopus, Web of Knowledge and The Cochrane
Library database about dental implants placement in these patients has been reviewed, assessing the variables of
each study: number of patients, sex, average age, oral hygiene, parafunctional habits, impairment, bone quality,
protocol of implant surgery, necessity of deep intravenous sedation or general anesthesia, follow-up period and
number of failures. The comparison with studies involving other patient populations without mental or physical
impediments did not show statistically significant differences in terms of the failure rate recorded.
Although there is not much literature available, the results of this review seem to suggest that osseointegrated oral
implants could be a therapeutic option in patients who suffer from any physical or psychological impairment. The
success of an oral rehabilitation depends mainly on an adequate selection of the patients.
Key words: Implants, disabled, sedation.
Introduction
nathic system’s comfort and functionality (2). Patients
who suffer from mental or physical disabilities used to
be excluded because some local and general conditions
that they present contraindicated, apparently, the use
of implants as part of their dental treatment. However,
Implantology has demonstrated itself to be a useful
procedure in dentistry which has allowed the oral rehabilitation of totally and partially edentulous patients for
more than 30 years (1), improving this way the stomatoge478
Med Oral Patol Oral Cir Bucal. 2014 Sep 1;19 (5):e478-82.
Implants in disabled patients
these patients are in great need of an oral fixed rehabilitation owing to the fact that the neurologic impairment,
neuromuscular disorders, genetic syndromes or orocraniofacial anomalies involve more frequency of dental
agenesis (3) and the difficulty of ensuring adequate oral
hygiene (4). Moreover, if they wear removable prostheses, their manipulation and hygiene may pose some difficulties (5). When conventional fixed prostheses cannot
be placed, an implant-supported rehabilitation may be
the only solution.
With regard to the local conditions, daily bruxism has
been found to be common in children with brain damage (6,7), which is a risk factor and a relative contraindication to implant placement (8,9), as well as a poor
oral hygiene for soft tissue, especially relevant when
O’Leary plaque index is over 20%, being this last condition a general absolute contraindication for implant
rehabilitations despite the controversy generated by the
results found in other studies.
Regarding general conditions, most of these patients
must be treated under anxiolytic premedication, deep
intravenous sedation or general anesthesia, depending on the degree of cooperation and the difficulty
and duration of the treatment provided, as we usually
find a total lack of cooperation from these patients
(10).
Discussion
It has not been possible to perform a meta-analysis nor to
provide recommendations based on conclusive scientific
evidence, given the lack of long-term randomized studies
and relatively small sample sizes. The articles selected are
explained below, assessing their most important variables.
Anders Ekfelt (11) carried out a prospective study in patients with neurological disabilities between 2000 and
2003. 35 implants were placed in 14 patients through
a standard protocol in two phases. Those patients had
one or more of these diseases: Down syndrome, fragile
x syndrome, autism, schizophrenia, Rett syndrome, as
well as all the medications to treat them and their side
effects which are also part of implants’ indication or
contraindication. No bruxism was observed in 2 people, 9 were categorized as having little bruxism and 3 of
them had sometimes strong bruxism. Bone quality was
also recorded according to Lekholm and Zarb as B2 (3
patients), B3 (4 patients) and C3 (7 patients). Implants
were placed under general anesthesia in 11 patients, and
with local anesthesia in 3 patients. Each implant received
a prognostic score from 1 to 4 (1=uncertain;4=very
good). The higher prognostic score required good bone
quality (7 implants were not placed in bone with good
quality), good initial stability (1 did not have it), no exposed threads (9 did not have it) and placement done according to the standard protocol. All patients and their
caregivers were given an individual prophylactic program and their oral hygiene was checked up every three
months when possible. The observational period after
placing the prostheses was between 6 and 28 months,
working out the cumulative survival rate through life
table analysis. A total of 5 implants failed, 2 of them
with a prognostic score of 3 and 4 in one patient with
Down syndrome, which results into a 80.5% survival
rate. The failures in this patient can be associated with
inmunosuppression (12,13).
Such a high rate of survival seems contradictory owing
to the frequency of parafunctions such as bruxism, inadequate bone quality or exposed threads, as well as the
fact that the two implants that failed are those with the
highest prognostic score. However, as the author points,
this can be associated with the tendency towards infection from this patient, which caused rapid bone loss in
one implant and a sequestration in the other one. The
survival rate does not distance from the one found in
general population and consequently, implants can be a
suitable option in these patients.
López Jiménez and col (14) made a study between 1992
and 2001 in which 67 implants were placed in 18 patients from 12 to 71 years old who had the following diagnosis: cerebral palsy, head injuries, pyknodysostosis,
Down syndrome, Rieger syndrome and senile dementia.
The surgical procedure required general anesthesia in
9 patients, deep intravenous sedation in 6 patients and
Material and Methods
This review is based on the research of articles about
the placement of implants in patients who present some
physical or neurological disability in Medline database
(Pub-Med), Scopus, Web of Knowledge and Cochrane
between 1992 y 2012 using the key words “dental implants” “disabled patients” and “handicapped people”
in different combinations. Some other relevant articles
were found in the references of the first ones.
Results
There has been considered inclusion criterion for this
revision any disease involving disability, either physical or mental; and systemic diseases which do not include that sort of disability have been excluded. After
a deep analysis of studies carried out in patients with
different types of disability, only six of them fulfilled
the inclusion criterion. Between the most common
disorders were: Down syndrome, fragile x syndrome,
autism, schizophrenia, Rett syndrome, cerebral palsy,
head injuries, pyknodysostosis, Rieger syndrome, senile dementia etc.
The articles finally selected were published in the following dental journals: International Journal of Oral
maxillofacial implants, Journal of Oral Implantology,
Special Care Dentistry, International Journal of Prosthodontics, Brazilian Dental Journal, Dental Update and
Oral medicine, among the most representative ones.
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Implants in disabled patients
anxiolytic premedication in 3 patients. Between 5 and 8
months were waited for loading the implants in the maxilla and 3-4 months in the mandible. They had been loaded an average of 66.5 months (between 3 and 113 months)
when they were evaluated. The lack of clinical symptoms
and mobility were considered successful criteria as well
as the absence of radiotransparencies when radiological
follow-up was possible. 4 implants failed during the osseointegration period in 3 patients (all with genetic syndromes: two patients with Down syndrome and one with
Rieger’s syndrome). 3 of the 4 implants were placed in
the only two males with Down syndrome of the sample,
in the incisive region of the maxilla, which can be associated with the higher frequency of periodontal disease in
these patients (15). All of them could receive a successful
rehabilitation with fixed prostheses.
This is a study with a long follow-up period and a sufficient sample size including different types of impairment which allows us to compare it with non-disabled
samples, though we also have to consider the bias produced by the heterogeneity of the sample. Bone quality
or parafunctions are not specified, which may be relevant, but as opposed to other studies, the location of
unsuccessful implants is mentioned. As a result of this
study, it seems that implantological treatment is possible in these patients, as no major differences are found
when compared to patients without discapacity.
The inclusion of patients with Down syndrome seems
to be the most frequent one in the studies reviewed
despite the fact that implatological treatment has been
long questioned owing to the high rate of some disorders such as osteoporosis, macroglossia, occlusion
problems (16), parafunctions, periodontal disease (15),
poor oral hygiene and cooperation, inmunosuppression
(12,13) etc. However, the frequency of microdontia in
permanent dentition (17,18), hypoplasia, hypodontia
(19), altered crown morphology (20) and the increased
life expectancy of these patients obliges to assess a new
method of treatment which has already been studied by
some authors. Those cases are explained below.
Ribiero and col (21) published a case report in which 7
maxillary implants and 5 mandible implants were placed
in a 36 year-old woman with Down syndrome. The patient had moderate mental retardation but was able to
speak and to perform simple everyday tasks without
difficulties, for this reason it was not necessary to use
auxiliary techniques such as general anesthesia or deep
intravenous sedation. She had a poor oral hygiene and
periodontal disease (moderate bone loss in the maxilla
and severe bone lost in the mandible). 6 months after the
placement of the implant, the radiographic assessment
showed peri-implant bone loss around dental implant
number 22, as well as pain. For those reasons, it was not
included into the rehabilitation. The rest of the implants
were successfully osseointegrated.
Soares and col (22) also published a case report about the
success of an implant in a patient with Down syndrome.
This patient had moderate mental retardation, pseudomacroglossia and sleep obstructive apnea syndrome. A
maxillary left central incisor was replaced with the help
of general anesthesia and was immediate loaded. The patient was followed up clinically and radiographically for
4 years without showing any sign of failure.
Additionally, Lusting and col (23) made a study in a 16
year-old patient with Down syndrome and partial anodontia, who received 4 implants in the place of 15,25,34
and 45. The patient had moderate mental retardation,
gingivitis, dental plaque, macroglossia, anterior open
bite and hypersalivation. The surgical procedure required intravenous sedation. Bone was very spongy and
for this reason a gradual loading was performed for one
year, starting 8 months after their placement. Implant
number 34 failed and this was attributed by the authors
to its narrower diameter. Osteoporosis bone was not a
risk factor, as it is not in general population (24,25).
Rogers (26) studied the response from a patient who
suffered from athetoid cerebral palsy towards the implantological treatment necessary to place a mandibular
implant overdenture. The patient was 64 years old and
her bone quality and quantity was adequate for implant
surgery. Her dental hygiene was good but she presented
involuntary movements of the mandible, tongue and lips
which led to incapability to wear the prostheses. 4 implants were placed in the canine and premolar regions
of the mandible with the help of general anesthesia to
control involuntary movements. Finally, the prostheses
was placed over two implants, leaving the other two
submucous, and obtaining very positive results because
of the improvement in speech and chewing.
The response from patients suffering from Parkinson’s
disease towards the implantological treatment has also
been studied (27), being this one pretty satisfactory. Implant supported prostheses provide stability, make easier to insert, remove and clean the prostheses and reduce
gastrointestinal problems because of the improvement
in chewing function.
The table 1 shows all the studies reviewed and the results in terms of failure.
Conclusions
More studies with bigger sample sizes and further follow-ups should be carried out, with detailed information about the systemic condition of each patient, the
presence of parafunctions, hygiene and placement of
the implants ( anterior or posterior region of the maxilla
or the mandible). This last issue is especially relevant
because bone quantity and quality are decisive factors
in the survival of implants, and very few authors mention this variable as it has been shown. The comparison
with studies involving other patient populations without
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Implants in disabled patients
Table 1. Studies reviewed and their results in terms of failure.
Authors
Anders Ekfeldt.
(11)
López Jiménez J,
RomeroDomínguez A,
Giménez-Prats
MJ. (16)
Number of
implants
Number of
patients
Age
35
14
19-55
years old
Sex
Follow-up period
Number of
failures
2000-2003
5
Pathologies
Down syndrome,
fragile x syndrome,
autism,
schizophrenia, Rett
syndrome
cerebral palsy,
head injuries,
pyknodysostosis,
Down syndrome,
Rieger syndrome
and senile
dementia
67
18
12-71
years old
7 male
and 11
female
1992-2001
4
12
1
36 years
old
Female
6 months
1
Down syndrome
1
1
22 years
old
Female
4 years
0
Down syndrome
Lustig JP, Yanko
R, Zilberman U
(27)
4
1
16 years
old
Male
2 years and a half
1
Down syndrome
Rogers JO. (30)
4
1
64 years
old
Female
2 years
0
athetoid cerebral
palsy
Ribeiro CG,
Siqueira AF, Bez
L, Cardoso AC,
Ferreira CF (25)
Soares MR, de
Paula FO,
Chaves MG,
Assis NM,
Chaves Filho
HD. (26)
mental or physical impediments did not show statistically significant differences in terms of the failure rate
recorded.
Oral health is an integral part of general health and for
this reason it must be reestablished when it is altered,
especially in those patients who have the greatest need,
providing them all the resources of modern Dentistry
so as to improve oral function and aesthetics, regardless of their physical or neurological condition. It is necessary to evaluate each case individually, following a
strict surgical protocol and frequent check-ups, as well
as informing the patient’s caregivers about the importance of maintaining good oral hygiene and the absence
of oral habits.
It must be kept in mind that edentulousness is frequent
among disabled patients and implants may be the only
choice that not only reestablishes oral health but provides an increase in patient self-esteem from an aesthetic point of view as well as in their quality of life,
reduced by other diseases.
Although more experience is needed, implant rehabilitation can be considered a suitable option in people
with disabilities as bone quality and quantity seem to be
more relevant in order to achieve positive outcomes.
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