What are the contraindications for dental implants?

Contraindications for Dental Implants

Severe periodontal disease, cognitive impairment, and bisphosphonate therapy are absolute contraindications for dental implant placement due to their significant impact on implant survival and patient morbidity. 1, 2, 3

Absolute Contraindications

1. Severe Periodontal Disease

   • Compromises bone quality and quantity needed for implant stability
   • Increases risk of peri-implantitis and implant failure 3
   • Requires complete resolution before implant consideration

2. Cognitive Impairment

   • Patients with moderate to severe cognitive impairment face challenges with:
     • Informed consent process
     • Long-term maintenance of implants
     • Potential for confusion during extended treatment periods 1
   • Case example: Patients with progressive cognitive decline may initially consent to treatment but lose capacity during the lengthy implant process 1

3. Bisphosphonate Therapy

   • Particularly intravenous bisphosphonates
   • Significantly increases risk of medication-related osteonecrosis of the jaw (MRONJ)
   • Dental implants are specifically mentioned as a risk factor for MRONJ in the FDA label for bisphosphonates 2, 4

Relative Contraindications

1. Uncontrolled Diabetes Mellitus

   • Poorly controlled diabetes increases:
     • Risk of peri-implantitis
     • Higher implant failure rates
     • Delayed healing
   • Well-controlled diabetes is not a contraindication 5

2. Radiation Therapy to Head and Neck

   • Correlated with higher implant loss
   • Risk increases with radiation dose >50 Gy 4, 3
   • Consider timing: implant placement ideally >12 months post-radiation

3. Heavy Smoking

   • Associated with significantly higher implant failure rates
   • Impairs osseointegration and healing 3
   • Recommendation: smoking cessation at least 1 week before and 8 weeks after implant placement

4. Bruxism

   • Increases mechanical stress on implants
   • May lead to implant fracture or loss of osseointegration 3
   • Requires management with occlusal guards before implant placement

5. Inadequate Bone Volume

   • Insufficient bone for implant stability
   • May require bone augmentation procedures prior to implant placement 1

Special Considerations

1. Patients with Metal Implants

   • MRI safety concerns for future diagnostic needs
   • Implants may be classified as "MRI conditional" requiring specific protocols 1

2. Patients Using Mandibular Advancement Devices

   • Implants may be contraindicated in patients with severe TMD using MADs for sleep apnea 1

3. ASA IV or Higher Status

   • Severe systemic disease that is a constant threat to life
   • Risk of complications during surgical procedures outweighs benefits 3

Clinical Decision Algorithm

1. Assess for absolute contraindications:

   • Severe periodontal disease → Treat first
   • Moderate-severe cognitive impairment → Consider alternative treatments
   • IV bisphosphonate therapy → Contraindicated

2. Evaluate relative contraindications:

   • Uncontrolled diabetes → Achieve glycemic control first (HbA1c <7%)
   • Recent radiation therapy → Delay implants >12 months
   • Heavy smoking → Recommend cessation program
   • Severe bruxism → Implement management strategies first

3. Consider risk-benefit ratio:

   • Higher-risk patients require thorough informed consent
   • Document discussion of increased failure risks
   • Consider simpler alternative treatments for high-risk patients

Pitfalls to Avoid

1. Underestimating cognitive decline progression

   • Patients may lose capacity during extended treatment
   • Consider shorter treatment protocols or non-implant options 1

2. Inadequate medical history review

   • Always screen for medications that affect bone metabolism
   • Verify duration and route of bisphosphonate administration 2

3. Failing to consider future diagnostic needs

   • Dental implants may interfere with imaging studies
   • Document implant materials for future reference 1