Vertical Augmentation with Piezoelectric Sandwich Technique

Soto et al 3 5 2 No change seen Complete Resolution Partial Remission Efforts were made by telephone to contact 35 patients who had not been seen recently. 10 of the 35 who could not return for evaluation were reached and asked to rate their degree of improvement since their last treatment visit. Responses were recorded. 21 Topical Palliative Two individuals reached by telephone reported only partial remission. One patient used a topical only and the other used a topical in conjunction with a palliative treatment which included Biotene toothpaste. 2 shows Lidex® (fluocinonide gel) as the most noted at follow-up appointments. One patient commonly prescribed topical agent in our clinic, had not used any treatment since her last recall followed by Temovate® (clobetasol). There were visit, while a second patient showed no change five instances in which Lidex® was changed to a but was asymptomatic. This second patient was more potent corticosteroid such as Temovate®. followed from November 15, 2003 until May 1, However, in one particular case, a patient asked 2008. He never experienced ulcerations and for the change because she disliked the flavor he showed no discomfort although lesions con- of the topical Lidex®. In another case, a change tinued to be present. A third patient was not was made from Dexamethasone Elixir® to Temo- compliant with the prescribed treatment as she vate®. Palliative treatments (Chart 3) were never reported using the topical medicament one to used as the primary means of treatment. Many two times weekly instead of daily; she reported times a specially prepared 0.2% chlorhexidine in no discomfort and no erosions. The fourth patient water mouthrinse was prescribed along with bland attended only two appointments and at her toothpaste such as Biotene. On occasion, other request, was referred to her dentist for follow up. alcohol-free mouthrinses were recommended. Partial remission was most often seen in this In 4 patients, no change in OLP status was study mainly after use of a topical agent which The Journal of Implant & Advanced Clinical Dentistry 49

Soto et al was often accompanied by palliative treatment. could have played a role since occasional lichenoid Partial remission was also seen after other types drug reactions have been reported among indi- of treatments such as diet modification, prescrip- viduals using a number of different medications.3 tion drug changes, laser treatment, intra-lesional injections, and systemic corticosteroids as seen Our data affirms that reticular OLP is the in Graph 1. On the other hand, complete reso- most common single type of OLP, although lution was also seen most often with the use of it often is present in conjunction with vari- a topical agent. Patients in this group also may ous other types. Most OLP lesions observed have received more than one type of treatment were ulcerative or atrophic compared to white such as topical, palliative and/or local injection. lesions (reticular, plaque like, papular). Only 28 patients exclusively displayed white lesions. Among the 10 patients that gave their sta- However, it should be noted that the Stomatol- tus over the telephone (Graph 3) 5 stated that ogy Center is a referral center and it is probable they did not return because they had completely that patients with severe discomfort or severe healed, 3 said they noticed no change in their lesions are most likely to be scheduled. Conse- lesions, and 2 reported partial remission. It is quently, the disease types described here do not not known why the remaining 19 patients did not necessarily represent a true picture of the oral return for follow up after diagnosis of OLP and we manifestations of patients with lichen planus. have no information for this group. The patients that reported partial remission and complete res- The patient records reviewed in this paper olution over the telephone were also treated by document outcome findings for up to 4½ years topical agents in conjunction with other, mostly after the original histologically confirmed diag- palliative treatments. The patients that reported nosis of OLP. Overall, only 5% of patients were complete resolution over the telephone had ero- confirmed to have complete remission at the time sive LP (n=2), ulcerative LP (n=1), and mixed of data collection while 10% had remission fol- LP (n=2). Those that reported partial remis- lowed by recurrent lesions. No information was sion had reticular LP (n=1) and mixed LP (n=1). available on 19% of study participants. In con- trast, a previous record review conducted in the In a 1988 report on long term treatment out- Stomatology Center (Stomatology Center, Baylor comes among 611 OLP patients, Thorn et al19 College of Dentistry Unreported data 1989) eval- described a small percentage of patients who uated treatment outcomes in 282 patients with apparently experienced spontaneous remission OLP who were followed for less than 1 year. A of OLP, however for the most part, we did not much higher percentage (49%) of those patients observe this in our patients. There was one patient achieved complete remission of erosive lesions at who returned to our clinic after 4 years and was some point in their therapy while under intensive free of lesions. He stated he hadn’t returned previ- care. In this intensive care approach, treatment ously because he had healed within a month after was modified as necessary and compliance was sparingly using a topical medicament and after stressed during frequent recall appointments and stopping the use of Vioxx®. Vioxx® discontinuation therapy was usually continued until success was 50 Vol. 1, No. 3 May 2009

Soto et al 54 1 Topical Palliative Diet Modification Five individuals reached by telephone reported complete remission. All five patients used some type of topical, 4 used a palliative treatment in conjunction with the topical and one patient also used a cinnamon free diet thereby eliminating a contact OLP. 69 58 39 39 16 4 4 Ulcers Reticular Plaque Atrophic Papular Mixed Not Specified Four records out of 100 did not clearly specify what type of LP was present. The term Erosive was occasionally used as a generalization of atrophic and/or ulcerative LP. achieved or patients declined to return. Com- in the current study. Current study data also parison of data from the two reviews suggest that suggests that patients who do not comply with patients with chronic persistent mucosal diseases long-term (6 month to 1 year) maintenance care such as OLP may lose motivation to perform sin- experience less satisfactory therapeutic outcomes. gle or multiple daily treatment procedures over time and that they tire of keeping frequent recall The data also indicates that the majority of appointments. They tend to discontinue therapy patients with OLP do not achieve complete remis- once a satisfactory level of comfort has been sion. Because we don’t know the exact cause of achieved. It should be noted, however, that recall OLP, it is imperative that we help reduce the symp- visit fees were markedly increased during the toms of this disease to help improve the quality of years between the two reviews and it is probable life of these patients. Therefore, the patient must that financial concerns may have negatively influ- be educated on the treatment and advised on how enced recall compliance among patients included to regularly carry out their treatment regimen. The resolution or remission of OLP heavily depends on The Journal of Implant & Advanced Clinical Dentistry 51

Soto et al the instructions given to the patient and carried out part, those who were compliant and returned by them. The patient should be advised that OLP for follow-ups reached partial remission. It was can recur and/or may persist for many years.20 also seen that when treating OLP, a palliative treatment in conjunction with a topical corticos- CONCLUSION teroid may help alleviate pain and improve the quality of life for the patient. The study finds This study gives some evidence that topical evidence that reticular LP is the single most corticosteroid therapy is usually successful in common type of OLP, however it is often seen achieving satisfactory treatment results, how- along with other LP types. Our numbers were ever no single treatment should be expected to also small for complete remission and no com- be successful in all OLP patients. OLP patients plete remission was seen without treatment. should return for follow ups when lesions are painful and the clinician should modify therapy Correspondence: as necessary. When applying therapy, it is unre- Dr. Celeste Abraham alistic to believe complete long-term remission Baylor College of Dentistry, Texas will be achieved. The patient should be taught A&M Health Science Center that any completely or partially successful treat- 3302 Gaston Ave. Dallas TX 75246 ment modality may be followed by recurrences Telephone: 214-828-8467 and that they should seek treatment for manage- FAX: 214-874-4563 ment of recurrent lesions. It is also seen that e-mail: [email protected] patients are often not fully compliant and com- pliance may depend on the degree of patient discomfort being experienced. For the most Disclosure 8. Anonymous. Oral Features of Mucocutaneous 15. Jainkittivong A, Kuvatanasuchati J, Pipattanagovit The authors report no conflicts of interest disorders. J Periodontol. 2003 Oct;74(10): P, Sinheng W. Candida in oral lichen planus with anything mentioned in this paper. 1545-56. patients undergoing topical steroid therapy. Oral References: Surg Oral Med Oral Pathol Oral Radiol Endod. 1. Kirtak N, Inalöz HS, Ozgöztasi , Erba ci Z. The 9. Al-Hashimi I, Schifter M, Lockhart PB, et al. 2007 Jul;104(1): 61-6. Epub 2007 Jan 29. Oral lichen planus and oral lichenoid lesions: prevalence of hepatitis C virus infection in patients diagnostic and therapeutic considerations. Oral 16. J. Philip Sapp, Lewis R. Eversole, George P. with lichen planus in Gaziantep region of Turkey. Surg Oral Med Oral Pathol Oral Radiol Endod. Wysocki, Contermporary Oral and Maxillofacial Eur J Epidemiol. 2000;16(12): 1159-61. 2007 Mar;103 Suppl:S25.e1-12. Epub 2007 Pathology (St. Louis, Missouri: Mosby, 1997), 2. Carrozzo M. Oral diseases associated with Jan 29. 258-259. hepatitis C virus infection. Part 2: lichen planus and other diseases. Oral Dis. 2008 Apr;14(3): 10. J. Philip Sapp, Lewis R. Eversole, George P. 17. Eisen D. The evaluation of cutaneous, genital, 217-28. Epub 2008 Jan 22. Wysocki, Contermporary Oral and Maxillofacial scalp, nail, esophageal, and ocular involvement 3. Wright JM. Oral manifestations of drug reactions. Pathology (St. Louis, Missouri: Mosby, 1997), in patients with oral lichen planus. Oral Surg Dent Clin North Am 1984 Jul;28(3): 529-43. 258-259. Oral Med Oral Pathol Oral Radiol Endod. 1999 4. Eversole LR, Ringer M. The role of dental Oct;88(4): 431-6. restorative metals in the pathogenesis of oral 11.Scully C, Carrozzo M. Oral mucosal disease: lichen planus. Oral Surg Oral Med Oral Pathol. Lichen planus. Br J Oral Maxillofac Surg. 2008 18. S. Gandolfo, L. Richiardi, M. Carrozo, R. 1984 Apr;57(4): 383-7. Jan;46(1): 15-21. Epub 2007 Sep 5. Broccoletti, M. Carbone, M. Pagano, C. Vestita, 5. Axéll T, Rundquist L. Oral lichen planus a S. Rossso, F. Merleti, Risk of squamous cell demographic study. Community Dent Oral 12. Lozada-Nur F, Miranda C, Maliksi R. Double- carcinoma in 402 patients with oral lichen Epidemiol. 1987 Feb;15(1): 52-6 blind clinical trial of 0.05% clobetasol propionate planus: a follow-up in an Italian population ral 6.Andreason JO. Oral lichen planus: a clinical (corrected from proprionate) ointment in Oncology (2004) 40: 77-83. Oral Oncol. 2004 evaluation of 115 cases. Oral Surg 1968;25: orabase and 0.05% fluocinonide ointment in Oct;40(9): 964. 31-41. orabase in the treatment of patients with oral 7. Toscano NJ, Holtzclaw DJ, Shumaker ND, vesiculoerosive diseases. Oral Surg Oral Med 19. Thorn JJ, Holmstrup P, Rindum J, Pindborg JJ. Stokes SM, Meehan SC, Rees TD. Sugical Oral Pathol. 1994 Jun;77(6): 598-604. Course of various clinical forms of oral lichen Considerations and Management of Patients with planus. A prospective follow-up study of 611 Mucocutaneous Diseases.In Press. Compend 13. Thongprasom K, Luengvisut P, Wongwatanakij patients. J Oral Pathol. 1988 May;17(5): 213-8. Cont Ed Dent. 2009 A, Boonjatturus C. Clinical evaluation in treatment of oral lichen planus with topical 20. Vincent SD, Fotos PG, Baker KA, Williams TP. fluocinolone acetonide: a 2-year follow-up. J Oral Oral lichen planus: the clinical, historical, and Pathol Med. 2003 Jul;32(6): 315-22. therapeutic features of 100 cases. Oral Surg Oral Med Oral Pathol. 1990 Aug;70(2): 165-71. 14. T. Lehner and C. Lyne, Adrenal function during topical oral corticosteroid treatment, Br Med J 4 (1969), pp.138-141. View Record in Scopus , Cited By in Scopus (11). 52 Vol. 1, No. 3 May 2009

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Suzuki et al

Classi cation of Single Tooth Suzuki et al Edentulous Ridges with Augmentation Recommendations for Dental Implant Treatment Masana Suzuki1,2 2 Abstract Background: The goal of implant therapy is to Results: The morphology of soft tissues of eden- achieve both functional and cosmetic improve- tulous ridges is closely related with cosmetic ments. Dental implantation into defective alveo- conditions. If alveolar ridges are horizontally or lar ridges should be performed with more caution perpendicularly below level lines, soft tissue aug- than treatment using a fixed partial denture or mentation will be necessary. If implantation into bridge. To prepare dental implants with biologi- alveolar ridges with more than 2 mm of bone on cal stability and optimal function, it is necessary the buccal is considered as the standard, bone not only to establish appropriate conditions for augmentation is necessary in edentulous front prostheses but also to consider how they blend in teeth. Hard tissue augmentation is performed with surrounding periodontal tissues. There have when bone defects are large from the level line. been several studies on the classification of par- tially edentulous alveolar ridges, but most of them Conclusions: In this study, we propose reported simple ridge-defect patterns alone. Such new classification for single-tooth edentu- classifications may not provide enough informa- lous ridges clinically, which include treat- tion for making dental implant treatment plans. ment procedures of ridge augmentation for dental implant treatment in such regions. Methods: To prepare a classification includ- ing treatment methods of single-tooth eden- tulous ridges, we evaluated the shape of alveolar ridges according to a combination of the horizontal and perpendicular conditions. KEY WORDS: Dental implant, edentulous, alveolar ridge augmentation, classification 1. Suzuki Dental Clinic, private practice, Tokyo, Japan 2. Department of Periodontology, Nihon University School of Dentistry at Matsudo, Matsudo, Chiba, 271-8587, Japan. The Journal of Implant & Advanced Clinical Dentistry 55

Suzuki et al INTRODUCTION alveolar ridges with implant treatment. Seib- ert classified partially edentulous ridges into 3 Recently, dental implant treatment has become groups: horizontal, perpendicular and mixed clinically indispensable and this method is defects.1 Allen et al divided partially edentu- applied to patients with various complicated lous ridges, in addition to Seibert’s classifica- dental conditions. Unfortunately, however, there tion, into mild (< 3 mm), moderate (3-6 mm) and are patients in whom functional and cosmetic severe (> 6 mm) groups, based on the sever- failures result. Such failures are generally con- ity of defects for the reconstruction of partially sidered to be caused by technical insufficiency edentulous ridges using soft tissues.2 While and a lack of experience. Perhaps these cases there are several reports for the classification of would not have been attempted had there edentulous ridges, treatment methods accord- been an appropriate classification system that ing to the classification are not indicated.3-5 combines description of partially edentulous Figure1: Horizontal and perpendicular conditions of single-tooth edentulous ridge. 56 Vol. 1, No. 3 May 2009

Suzuki et al Hill No Augmentation No Augmentation Soft Tissue or Level No Augmentation or Hard Tissue or Valley Soft & Hard Tissues or Hard Tissues Soft Tissue Soft Tissue Soft Tissue Soft & Hard Tissues or or Soft & Hard Tissues Soft & Hard Tissues Soft Tissue Soft & Hard Tissues or Soft & Hard Tissues With the development of dental implants, the ing to the combination of horizontal and perpen- classification of alveolar ridges without soft tissues dicular conditions. The line between the existing has been reported.6,7 From the same viewpoint bilateral teeth adjacent to an edentulous site as Seibert, Wang and Al-Shammari proposed a was defined as the “level line” and single-tooth clearer classification of alveolar ridges as the hori- edentulous ridges were classified accord- zontal, vertical and combination (HVC) classifica- ing to horizontal and perpendicular conditions. tion, and indicated surgical methods appropriate for the classes.8 In this classification, implants Classification methods and fixed partial dentures are individually divided, In the horizontal condition, the line between the indicating the usefulness for the determination of labial necks of the existing bilateral teeth adja- treatment strategies. However, there have been cent to an edentulous site was defined as the no classifications that show methods for the mea- level line, as shown in figure 1a. Alveolar ridges surement of defects. It is considered necessary were defined as “Convex type” when they were to change the evaluation methods depending on positioned on the labial side from the level line single and multiple-tooth defects. In this study, and “Concave type” when they were positioned we propose a new method for the classification on the lingual side from the level line. In the of single tooth edentulous ridges and evaluate vertical condition, the line between the lowest treatment methods based on this classification. points of the gingival scallop by clinical obser- vation of the existing bilateral teeth adjacent to MATERIAL AND METHODS an edentulous site was defined as the level line, as shown in figure 1b. Alveolar ridges were Level line defined as “Hill type” when their lowest points To prepare a classification including treatment were positioned on the coronal side from the methods of single-tooth edentulous ridges, we level line and “Valley type” when they were posi- evaluated the shape of alveolar ridges accord- The Journal of Implant & Advanced Clinical Dentistry 57

Suzuki et al Concave-H Concave-L tioned on the apical side from the level line. We summarized the several methods for treatment of Figure 2: After the implant placement (teeth numbers edentulous ridges according to the combination 7 and 9). These edentulous ridges were classi ed into of the horizontal and perpendicular conditions. Concave-H and Concave-L. RESULTS 58 Vol. 1, No. 3 May 2009 To indicate appropriate surgical methods according to the horizontal and perpendicular conditions, we summarized the results in Table 1. For example, edentulous ridges are class Convex-H if they are Convex and Hill types and class Concave-H or Concave-L if they are Concave and Hill or Concave and Level types (figure 2). If edentulous ridges are classified into the level types by both horizontal and per- pendicular conditions, they are class Level-L. Treatment methods are determined according to classification. Table 1 sug- gests treatment methods according to the horizontal and perpendicular conditions. In other words, there are several methods for the implant treatment of edentulous ridges. No ridge augmentation In alveolar ridges with a sufficient width and height, which are generally included in class Convex-H, implant treatment is possible without ridge augmentation. However, since bone con- ditions cannot be evaluated by observing soft tissues, ridge augmentation may be required in class Convex-H ridges, and if marked bone defects are detected, hard tissue ridge augmen- tation is performed. Naturally, there is a differ- ence in the level of defects estimated from the level line between front tooth and molar regions. Therefore, even if the maxillary canine tooth region is class Convex-H, it is important to suf- ficiently evaluate the necessity of augmentation.

Suzuki et al Figure 3: (above) Connective tissue graft using pouch technique. Figure 4: (right) After the nal restoration. Notice the healthy band of keratinized attached gingiva around the implants. Soft tissue augmentation tion techniques are not described in this paper, For cosmetic implant treatment, soft tissue aug- treatment is performed by the combination of mentation may be performed in many patients. roll, pouch, inlay, and onlay graft methods.1,2,9-11 This is because the morphology of soft tis- An example of a connective tissue graft using sues of edentulous ridges is closely related the pouch technique for augmentation of with cosmetic conditions and varies with mor- an implant site is shown in figures 3 and 4. phologically small changes. However, soft tis- sue augmentation is not recommended for all Hard tissue augmentation patients, as shown in Table 1. When implanta- For hard tissue augmentation, the criteria for tion can be performed into the predetermined application, methods and prognoses have not site, the management of soft tissues in classes been established.12-19 If implantation into alve- Convex-H and L is generally possible by simple olar ridges with more than 2 mm of bone on surgical techniques. However, if alveolar ridges the buccal side is considered as the standard, are horizontally or perpendicularly below the as reported by Glunder et al, bone augmenta- level lines, soft tissue augmentation will likely tion is necessary in almost all patients with be necessary. Although soft tissue augmenta- edentulous front teeth.20 However, in implan- The Journal of Implant & Advanced Clinical Dentistry 59

Suzuki et al tation into single-tooth edentulous ridges, if an the basis of our classification, which is related implant can be inserted into bone, the implant to the concept that the appearance can be will be stably maintained, even when part of the maintained without bone augmentation by the tissue on the buccal side of the implant is soft thickness of soft tissues, as long as an implant tissue. Hard tissue augmentation is performed is inserted into bone. When implant treatment when bone defects are large from the level line. is performed according to the classification of this study, in class Concave-H, for example, Hard and soft tissue augmentation the bone on the labial side has been absorbed, Generally, hard and soft tissue augmenta- and the residual alveolar ridge is often narrow. tion is necessary if bone defects extend However, if the width of the edentulous ridge is horizontally and perpendicularly beyond sufficient for implantation, soft tissue augmenta- the level line, as described above. In many tion alone is generally performed without bone cases requiring hard tissue augmentation, augmentation (figures 2, 3 and 4). Implanta- soft tissue augmentation is also necessary. tion is performed on the lingual side as much as possible, so that thick gingiva is obtained on DISCUSSION the labial side. In single-tooth defects, if gin- giva is thick on the labial side, gingival reces- In dental implant treatment for edentulous sion does not readily occur, resulting in implant ridges, to obtain the same morphology as nat- treatment with cosmetic improvement.21,22 ural teeth in multiple-teeth defects, many fac- tors have to be taken into consideration. This When establishment of the level line as makes the treatment complicated and measure- the basis of our classification is difficult due ment of the level of defects is not easy. There- to teeth malalignment and marked gingival fore, the classification of edentulous ridges and recession caused by periodontal disease, the their treatment methods cannot be readily sum- level line must be modified based on the sur- marized as a table. However, in single-tooth rounding conditions. This classification does implantation, morphological analysis of defective not indicate defects on the lingual side. How- alveolar ridges related to the existing bilateral ever, if there are large defects on the lin- teeth adjacent to a defective tooth is relatively gual side, analysis is performed as same as easy. In other words, the positions of the bone the labial side. Therefore, the classification crests of the existing, bilaterally adjacent teeth proposed in this study is considered to be and the interdental papilla, and the widths and important for single-tooth implant treatment. heights of the edentulous gingiva and alveo- lar bone can be sufficiently analyzed and diag- Single-tooth implantation is widely per- nosed. In single-tooth edentulous ridges, the formed, but failures are sometimes observed. interdental papilla and its surrounding soft tis- Such failures are not necessarily observed sues are stably maintained by not only the bone in patients with problematic conditions. In around the implant, but also the soft tissues of the classification of single-tooth edentulous the existing bilaterally adjacent teeth. This is ridges described in this study, the level line can be easily evaluated, indicating that this 60 Vol. 1, No. 3 May 2009

Suzuki et al method is clinically useful. Furthermore, the dif- Disclosure ficulty level of implant treatment will become The authors report no conflicts with anything mentioned in this paper. clear by evaluating this classification method. Acknowledgements In conclusion, future implant treatment will This work was supported in part by a Grant for Supporting Project for Strategic become safer by performing single-tooth Research by the Ministry of Education, Culture, Sports, Science, and Technology, implantation according to this classification. 2008-2012. References Correspondence: 1. Seibert F. Reconstruction of deformed, partially edentulous ridges, using Yorimasa Ogata, Department of Periodontology, full thickness onlay grafts. Part II. Prosthetic/periodontal interrelationships. Nihon University School of Dentistry at Compend Contin Educ Dent 1983; (4): 549-562. Matsudo, 2. Allen E, Gainza C, Farthing G, Newbold D. Improved technique for localized 2-870-1, Sakaecho-nishi, Matsudo, Chiba, ridge augmentation. A report of 21 cases. J Periodontol 1985; (56): 195-199. 271-8587, Japan. 3. Sposetti V, Young H, Collins J. A classification system of edentulous ridge Phone & Fax: +81-47-360-9362. problems in prosthodontics. Gen Dent 1985; (33): 504-507. email: [email protected] 4. Glisi B, Stanisi D. Reconstruction of initial dimensions of the lower residual ridge and classification of reduction in vertical direction. Stomatol Glas Srb 1989; (36): 261-266. 5. Denissen H, Kalk W. Classification of edentulous mandibles in preventive implantology. Ned Tijdsch Tandheelkd 1990; (97): 230-233. 6. Lekholm U, Zarb G. Patient selection and preparation. In: Brånemark P-I ed. Tissue-Integrated Prostheses: Osseointegration Clin Dent Chicago: Quintessence; 1985: 199-209. 7. Misch C, Judy K. Classification of partially edentulous arches for implant dentistry. Int J Oral Maxillofac Implantol 1987; (4): 7-13. 8. Wang H, Al-Shammari K. HVC ridge deficiency classification: a therapeutically oriented classification. Int J Periodontics Restorative Dent 2002; (22): 335- 343. 9. Abrams L. Augmentation of the deformed residual edentulous ridge for fixed prosthesis. Compend Contin Educ Dent 1980; (1): 205-213. 10. Langer B, Calagna L. The subepithelial connective tissue graft. J Prosthetic Dent 1980; (44): 363-367. 11. Seibert J. Treatment of moderate localized alveolar ridge defects. Preventive and reconstructive concepts in therapy. Dent Clin North Am 1993; (37): 265-280. 12. Buser D, Brägger U, Lang N, Nyman S. Regeneration and enlargement of jaw bone using guided tissue regeneration. Clin Oral Implants Res 1990; (1): 22-32. 13. Buser D, Dula K, Belser U, Hirt H, Berthold H. Localized ridge augmentation using guided bone regeneration. II. Surgical procedure in the mandible. I Int J Periodontics Restorative Dent 1995; (15): 10-29. 14. Hermann J, Buser D. Guided bone regeneration for dental implants. Curr Opin Periodontol 1996; (3): 168-177. 15. Isaksson S, Alberius P. Maxillary alveolar ridge augmentation with onlay bone- grafts and immediate endosseous implants. J Craniomaxillofac Surg 1992; (20): 2-7. 16. Misch C. Comparison of intraoral donor sites for onlay grafting prior to implant placement. Int J Oral Maxillofac Implants 1997; (12): 767-776. 17. Scipioni A, Bruschi G, Calesini G. The edentulous ridge expansion technique: a five-year study. Int J Periodontics Restorative Dent 1994; (14): 451-459. 18. Simion M, Baldoni M and Zaffe D. Jawbone enlargement using immediate implant placement associated with a split-crest technique and guided tissue regeneration. Int J Periodontics Restorative Dent 1992; (12): 462-473. 19. Tinti C, Parma-Benfenati S. Vertical ridge augmentation: surgical protocol and retrospective evaluation of 48 consecutively inserted implants. Int J Periodontics Restorative Dent 1998; (18): 434-443. 20. Grunder U, Gracis S, Capelli M. Influence of the 3-D bone-to-implant relationship on esthetics. Int J Periodontics Restorative Dent 2005; (25):113- 119. 21. García García A, Somoza Martin M, Gandara Vila P, Gandara Rey JM. A preliminary morphologic classification of the alveolar ridge after distraction osteogenesis. J Oral Maxillofac Surg 2004; (62): 563-566. 22. Winkler S. Implant site development and alveolar bone resorption patterns. J Oral Implantol. 2002; (28): 226-229. The Journal of Implant & Advanced Clinical Dentistry 61

Ketabi et al

Factors Driving Peri-implant Ketabi et al Crestal Bone Loss - Literature Review and Discussion: Part 2 of 4 Mohammad Ketabi, DDS, MDS1 2 3 Abstract Many factors contribute to the cumulative in English language refereed journals for the crestal bone loss seen around endosseous decade preceding May 2008 and attempted to dental implants. This can create confusion for identify the major factors associated with peri- the practicing clinician and lead to undesirable implant bone loss. Part two of this article series outcomes. In this four part review series, we examines patient and biologic width factors have searched the literature for papers published associated with peri-implant crestal bone loss. KEY WORDS: Crestal bone loss, dental implants, causative factors, biologic width 1. Dean, Professor and Chairman, Department of Periodontology, Faculty of Dentistry, Islamic Azad University (Khorasgan Branch), Arghavanieh, Isfahan, Iran 2. Professor Emeritus, Faculty of Dentistry & Center for Biomaterials, University of Toronto 3. Professor, Discipline of Periodontology and Oral Reconstructive Center, Faculty of Dentistry, University of Toronto The Journal of Implant & Advanced Clinical Dentistry 63

Ketabi et al Introduction Discussion Many factors, both biological and biomechani- A number of patient based and implant bio- cal, will have a cumulative impact on the final logic width based factors may contrib- amount of bone loss seen. It is important ute to peri-implant crestal bone loss. The for clinicians to understand all of these fac- most common of such factors include: tors in addition to their relative contributions and interactions. This is the second install- Patient Factors in Crestal Bone Loss ment of a four part series review of factors As is the case with periodontitis induced bone driving peri-implant crestal bone loss. Part loss in the natural dentition, peri-implant crestal one of this review examined surgical and ana- bone loss can be influenced by a plethora of tomical factors associated with peri-implant host factors. Some of these factors include the crestal bone loss. In the present review, patient host’s genetic profile, medical history, periodon- and biologic width factors associated with tal status, oral hygiene, and smoking history. peri-implant crestal bone loss are reviewed. Genetic Profile Materials and Methods Thus far, controlled clinical studies investigat- A literature search of papers published in ref- ing an association between genetic profile and ereed journals in the English language for the peri-implant crestal bone loss have focused on decade preceding May 2008 was performed polymorphisms of the interleukin IL-1 gene. This by computer using the National Library of Medi- same gene had earlier been linked to periodon- cine and SCOPUS Cochrane Oral Health Group tal disease susceptibility.1 Investigators have databases. Search strategy included a specific reported significantly greater (p < 0.05) early series of terms and key words. The reference marginal bone loss (i.e. during initial site heal- lists of identified publications, relevant textbooks ing) in patients with the IL-1B−511 2/2 genotype and professional workshops also were scanned. receiving moderately rough (particle-blasted) or rough (TPS-coated) surfaced dental implants.2,3 As the first selection method, relevant refer- Genetic polymorphisms of other factors such as ences were selected on the basis of their titles the calcitonin receptor genotype and bone mor- and abstracts. As the final selection method, full phogenic protein BMP-4 genotype4,5 also have texts of publications identified as possibly relevant been linked to early marginal bone loss with were reviewed for more detailed evaluation. Pub- particle-blasted dental implants. Likewise, links lications reviewed included experimental animal have been established between IL-1 genotype studies, prospective and retrospective human clini- and late bone loss associated with peri-implan- cal studies, a few case reports and relevant review titis about a variety of dental implant systems.6,7 papers. Because of the limited numbers of avail- able studies for some factors and their heterogene- Oral Hygiene, Smoking and ity, focusing on a specific pre-defined question to Alcohol Consumption be answered by a systematic review was not feasi- There is general agreement that patients with ble and therefore no meta-analysis was attempted. 64 Vol. 1, No. 3 May 2009

Ketabi et al poor oral hygiene and/or existing periodontal dis- coated press-fit cylinder implants) in 421 partially ease experience greater peri-implant crestal bone edentulous patients with similar oral hygiene sta- loss than patients with good oral hygiene and a tus on regular recall. After 1 to 7 years of implant stable periodontal status.8-10 Cigarette smoking function, smokers (quantity of cigarettes/day not is a known health risk factor. Both current and reported) showed significantly (p < 0.01) greater lifetime cigarette smoking are associated with (3.95mm vs 1.47mm) bone loss around maxil- deterioration in bone quality and impaired wound lary implants than around mandibular implants. healing.11,12 Smoking has been shown to be However, in contrast to Lindquist,16 no signifi- one of the most significant factors predisposing cant (p > 0.05) difference was found for bone to implant failure13-15 and a number of investiga- loss around mandibular implants between smok- tors have reported a significant impact of ciga- ers and non-smokers. This differential impact of rette smoking on marginal peri-implant bone loss. smoking in maxilla vs mandible may relate to the Lindquist et al16 reported ten year follow-up data fact that maxillary bone is generally more cancel- for marginal bone loss around machine-turned lous than mandibular bone. Nociti et al19 reported implants placed in mandibular sites of edentulous animal findings documenting a greater effect of patients and, using multivariate analysis, found intermittent cigarette smoke exposure on loss of cigarette smoking to have a highly important influ- bone density in cancellous versus cortical bone. ence (p < 0.001). Mean bone loss values were Similar outcomes to Haas18 were reported by nearly twice as large for smokers as for non-smok- Nitzan et al.20 Their recorded mean bone loss ers year following implant treatment and this differ- values generally appeared to be smaller, per- ence remained throughout the observation period. haps because of implant type used and/or the The mean difference between smokers and non- fact that orthopantographs were used exclu- smokers had reached 0.6 mm after 10 years. Non- sively to record bone loss, this type of radiograph smokers had less bone loss than both low ( 14 being considered inaccurate for the purpose.21 cigarettes/day) and high ( 14 cigarettes/day) smokers while smokers with low cigarette con- Only one study was found where the effect sumption had less bone loss than those with high of alcohol consumption on peri-implant mar- consumption. Among smokers, those with poor ginal bone loss was assessed.22 After 3 years of oral hygiene had significantly greater bone loss implant function, significantly (p < 0.0008) higher (p < 0.001) than those with good oral hygiene. marginal bone loss (1.66mm vs 1.29mm) was detected in patients drinking >10g (gms alcohol Implant surface roughness might modify = 0.8 x volume in mls) alcohol daily compared crestal bone loss in smokers. Watzak et al17 to those who did not consume this level of alco- reported that anodized implants used with man- hol. Other important factors were gingival index dibular complete overdentures showed less and implant surface. Individuals who use alcohol crestal bone loss than machine-turned implants to excess may have inadequate nutrition includ- after a mean functional time of 33 months. ing vitamin deficits23 which may compromise ini- tially site healing. Alcohol also is a liver toxin and Haas et al18 reported retrospective results can alter production of prothrombin and vitamin for 1366 implants (Branemark-Type® and TPS- The Journal of Implant & Advanced Clinical Dentistry 65

Ketabi et al K, both affecting coagulation,24 and therefore, implant bone loss. Implants in the periodontitis early clot formation at the bone-implant interface. group suffered a mean bone loss of 2.2mm com- pared to 1.7 mm in the non-periodontitis group. History and Type of Periodontitis Several recent review articles have addressed the An important clinical factor often not possible effect of a history of treated periodontitis addressed in published papers on the effect of on the performance of dental implants in partially previous history of periodontitis, is the quality of edentulous patients.25-29 One of these papers27 supportive periodontal maintenance treatment highlighted the limitations of evidence published (SPT) provided for patients during the period of to date including failure to account for confound- implant function being studied. In a recent review ing factors, especially smoking, and factors such of literature, Quirynen et al26 concluded that peri- as variability in definitions used, outcome crite- odontally compromised patients can be success- ria (e.g. what constitutes “excessive” bone loss) fully treated with minimally or moderately rough and quality of ongoing supportive periodontal surfaced implants provided that regular SPT is therapy. As is the case with smoking and kerati- included to keep periodontal disease at bay. Type nized tissue, implant susceptibility in patients with of periodontitis also appears to be of significance a history of periodontitis will likely be affected by with aggressive periodontitis (AP) having more implant type. In a small group of patients treated impact on outcomes with dental implants than with TPS-coated threaded implants, Karoussis et chronic periodontitis (CP). Mengel and Flores- al30 reported different outcomes for patients with de-Jacoby33 provided data on the performance or without a history of chronic periodontitis. Uti- of Branemark-Type® or acid-washed threaded lizing as success criteria, pocket probing depth implants in patients previously treated for AP or CP compared to a non-periodontitis control group, 6mm and crestal bone loss < 0.2mm annually all patients being provided with SPT. In this 3-year after year one, over a 10-year interval, 71.4% of prospective study, bone loss was greater for implants were considered successful in patients implants than for teeth in all three patient groups. with a history of periodontitis compared to 94.5% Implants and teeth in patients with a history of AP of implants in the non-periodontitis group. At showed greater bone loss than in either of the recall visits, implant complications were man- other two groups. This bone loss in AP patients aged according to a defined interceptive support- was continuous over the study period, leading ive therapy.31 Hardt et al32 determined marginal the investigators to suggest that implants in this bone loss for Branemark-Type® implants placed patient group might be at greater risk to progres- in posterior maxillary sites in patients for whom sive bone loss and complications in the long term. an age-related bone loss score (ArB-score) for remaining posterior maxillary teeth was used to Diabetes categorize patients in regard to previous his- Several medical conditions, like diabetes, Crohn’s tory of periodontitis. Over a 5-year follow-up disease and osteoporosis, and/or medications period, they found a statistically significant (p < used to treat them have been implicated in the fail- 0.05) relationship between ArB-scores and peri- ure of dental implants,34 but published evidence 66 Vol. 1, No. 3 May 2009

Ketabi et al of an effect on crestal bone loss about implants maxillary implants. Excessive alcohol consump- appears to be limited to studies on diabetes. It tion may also play a role in promoting peri-implant is well known that diabetics are at higher risk for bone loss but, further investigation is needed here. developing periodontitis and are also more prone to infection,35 making it highly likely that perfor- In patients with a history of treated periodonti- mance of dental implants will be affected as well. tis, higher levels of peri-implant marginal bone loss Accursi36 examined retrospectively the effect of can be expected than seen in control patients, at diabetes on Branemark-Type® implants in fully least where effective supportive periodontal treat- and partially edentulous patients with 1 to 17 ment was lacking or where very rough implant year follow up. Fifteen (2 Type I, 13 Type II) con- surfaces were used. Patients with a history of trolled diabetic patients had received 59 implants. treated aggressive periodontitis may be at par- Each of these 15 patients was matched by strict ticular risk to continued peri-implant crestal bone criteria to two non-diabetic control patients, the loss over time as they are with their remaining nat- latter having received in total 111 implants. Dia- ural teeth. Well-controlled diabetic patients may betic patients exhibited greater crestal bone loss suffer somewhat greater early peri-implant bone than controls during the first year of loading, but loss but, no significant differences in the long- this difference disappeared with function over term are likely to occur compared to non-diabetic time. All implant failures occurred in fully eden- control patients, assuming good homecare, regu- tulous patients and no differences in implant fail- lar SPT and a non-smoking lifestyle. Effects of ure rates were seen between diabetic and control other medical conditions and medications used patients. Poor metabolic control in diabetic sub- to treat them on marginal bone loss with den- jects does increase the risk of developing peri- tal implants have yet to be studied and reported. implantitis.10 A more extensive review of dental implant performance in both diabetic animals and Biologic Width Factors in Crestal Bone Loss humans has been published by Kotsovilis et al.37 Remodeling of crestal bone to allow estab- lishment of a “biologic width” or soft tissue Summary of Patient Factors seal in peri-implant mucosal tissues is consid- As is the case with periodontitis, genetic factors, ered the central driving force in early crestal including certain polymorphisms of IL-1, BMP-4, bone loss with all types of endosseous dental and calcitonin receptor may predispose affected implants.39,40 Factors known to affect this bone individuals to greater peri-implant bone loss so loss include the level of the micro-gap in rela- that pre-treatment genetic testing may become tion to bone crest, platform-switching achieved widely used in future for patients seeking den- either by implant body design and/or using an tal implants.38 Significantly greater peri-implant abutment smaller in diameter than the implant crestal bone loss is expected to happen in patients body and, tooth-implant or inter-implant horizon- who practice poor oral hygiene, have untreated tal distance. It has also been suggested that periodontitis, and/or smoke cigarettes. The effects repeated removal and replacement of abutments of smoking are dose-dependent and greater for may have a deleterious effect on crestal bone because of disruption of the soft tissue seal.41 The Journal of Implant & Advanced Clinical Dentistry 67

Ketabi et al Level of the Micro-Gap mucosal collar. It was reported that one-piece The connection between implant body and pros- implants placed with a 3mm long polished thetic abutment is termed the “micro-gap” and is trans-mucosal collar and the collar-to-rough- generally susceptible to microbial accumulation ened surface junction initially positioned at the and micro-movements between the parts during level of bone crest suffered less crestal bone clinical function. Both of which can lead to local- loss than 2-piece implants with 1.5mm long pol- ized inflammation and associated bone loss if the ished collars and placed in either a submerged micro-gap is within a minimum distance from the or non-submerged approach with the micro-gap alveolar crest. Biologic width around the neck of positioned at the crestal level. Differences in a tooth or a dental implant constitutes a mucosal bone loss were attributed to the level of micro- seal intended to offer protection to underlying gap, establishment of biologic width apical to bone. It is formed apical to the micro-gap and all micro-gaps and a greater inflammatory reac- requires a minimum of about 1.5mm of fibrous tion seen with 2-piece implants.47 Piattelli et al48 connective tissue between bone and epithe- drew similar conclusions on the importance of lial attachment of the gingival sulcus of tooth or the position of micro-gap from a study examin- implant.39,40 With one-piece implants, the micro- ing primates and rough surfaced (TPS) implants. gap is generally placed sufficiently proud of the alveolar crest to have minimal impact on crestal Platform Switching bone loss. As such, peri-implant crestal bone “Platform-switching” is defined as the inward loss with these implants is primarily driven by horizontal repositioning of the implant-abut- dimensions of biologic width and elements pre- ment interface (micro-gap).49 This design fea- viously reviewed in part one of this series. With ture can be created in an implant body by the 2-piece implants, the micro-gap is generally ini- manufacturer or achieved by the clinician using tially positioned at the level of the alveolar crest a compatible abutment of lesser diameter and when biologic width is established in relation than the implant platform. The effect of plat- to the micro-gap, there may be greater bone loss form-switching is to create a horizontal com- because of the latter’s negative influences (i.e. ponent for the total linear distance between bacteria and micro-movements).42-44 With 2-piece micro-gap and bone crest required for biologic implants placed in dogs, whether with non-sub- width,50,51 and possibly to shift stress concen- merged or submerged technique, the most coro- tration away from the cervical bone-implant nal bone-to-implant contact was consistently interface.52 Generally the horizontal compo- located about 2mm apical to the micro-gap.45 nent created by platform-switching is around 0.5mm but, this is sufficient to result in signifi- In another study in animals, Hermann et cantly less radiographically detectable crestal al46 compared soft and hard tissue dimensions bone loss in humans.50,52,53 Not only does this around one-piece and 2-piece implants both situation reduce the risk of peri-implantitis in the placed in either submerged or non-submerged future but, also has the benefit in the aesthetic fashion. The implants had a moderately rough zone of providing better soft tissue support.54 surface and varying heights of polished trans- 68 Vol. 1, No. 3 May 2009

Ketabi et al Implant-Tooth or Inter-Implant Distance implant distance would be incomplete papilla For single tooth dental implants, provided that reformation and poor esthetics. Whether this a minimum horizontal distance of approximately lateral component can be reduced or eliminated 2mm is left between the implant and the two by platform-switching remains to be shown. approximating tooth root surfaces, after bio- logic width accommodation crestal bone loss in For one-piece moderately rough implants, the relation to the implant will be dependent upon amount of radiographically detectable bone loss height of periodontal bone support of the two will vary with the original positioning of the rough teeth.55-57 When two implants are placed side surfaced segment of the implant body with respect by side, the bone loss that occurs between to alveolar crest. Implants with their rough sur- them has a more complicated etiology. First and faced segment initially positioned below the crest, foremost, inter-implant crestal bone loss will be at 6 months showed greater vertical crestal bone affected by the horizontal distance between the loss (average 1.72 mm) than those with the coro- two implants which, in the esthetic zone, should nal level of their rough surface segment placed at be as close to 3mm as possible. Of course, it or near the crest (average 0.68 mm).61 The reason will also be affected by the level of the micro- for greater bone loss with implants with submerged gap, biologic width, and whether or not platform- rough surfaces is likely disuse atrophy in relation switching has been employed. A clear tendency to the segment of submerged polished collar.62 for increased inter-implant vertical bone loss occurs as inter-implant distance decreases Summary of Biologic Width Factors below 3mm.58,59 Histological data from ani- The positioning of both implant micro-gap and, in mal experiments using 2-piece, moderately the case of moderately rough implants, coronal- rough submerged implants showed that verti- most level of rough surface in relation to the bone cal crestal inter-implant bone loss decreased crest both will affect extent of peri-implant mar- from 1.98mm for a 2 mm inter-implant distance ginal bone loss. Because one-piece implants are to 0.23 mm for a 5 mm inter-implant distance.60 generally placed with the micro-gap well proud Tarnow et al58 also showed there to be a lat- of the crest, they generally suffer less marginal eral component to this inter-implant bone loss bone loss than 2-piece implants which are usu- around minimally rough implants in humans in ally placed with the micro-gap at the level of the addition to the more commonly discussed ver- alveolar crest. Inter-implant horizontal distance tical component. Following re-entry of 2-piece must be greater than 3mm in order to avoid exces- minimally rough implants and establishment of sive inter-implant vertical bone loss and associ- biologic width, approximately 1.4 mm of hori- ated suboptimal regeneration of inter-implant zontal marginal bone loss was seen in relation soft tissue papillae. In some situations, use of to the implant surface. This lateral contribution smaller diameter implants may assist with main- resulted in further vertical bone loss if the inter- taining the required inter-implant horizontal dis- implant distance was not > 3mm. In the esthetic tance >3mm. Features in implant body design zone, the overall effect of sub-optimal inter- or use of under-sized abutments to achieve platform-switching will reduce peri-implant and The Journal of Implant & Advanced Clinical Dentistry 69

Ketabi et al most likely inter-implant vertical bone loss by Correspondence: capturing a horizontal component that can con- Douglas Deporter, DDS, PhD tribute to the overall linear length of implant sur- [email protected] face needed for biologic width accommodation. Conclusion A number of factors contribute to peri-implant crestal bone loss. Patient and biologic width factors such as medical history, genetic profile, oral hygiene status, smoking history, implant microgap, platform switching, and inter- implant distances are a few of these factors. This is part 2 of a 4 part review series. Parts 3 and 4 will appear in future issues of JIACD. Disclosure: 7. Andreiotelli M, Koutayas S, Madianos P, Strub J. 14. Hinode D, Tanabe S-I, Yokoyama M, Fujisawa K, The authors report no conflicts of interest with Relationship between interleukin-1 genotype and Yamauchi E, Miyamoto Y. Influence of smoking anything mentioned within this article. peri-implantitis: A literature review. Quintess Inter on osseointegrated implant failure: A meta- References 2008; 39: 289-298. analysis. Clin Oral Implants Res 2006; 17: 1. Kornman K, Crane A, Wang H, di Giovine F, 473-478. 8. Lindquist L, Carlsson G, Jemt, T. A 15-year follow- Newman M, Pirk F, Wilson T, Higginbottom F, Duff up study of mandibular fixed prosthesis supported 15. Strietzel F, Reichart P, Kale A, Kulkarni M, G. The interleukin-1 genotype as a severity factor by osseointegrated implants. Clin Oral Implants Wegner B, Kuchler I. Smoking interferes in adult periodontal disease. J Clin Periodontol Res 1996; 7: 329–336. with prognosis of dental implant treatment: 1997; 24: 72-77. A systemic review and meta-analysis. J Clin 2. Lin Y, Huang P, Lu X, Guan D-H, Man Y, Wei N, 9. Hänggi M, Hänggi D, Schoolfield J, Meyer J, Periodontol 2007; 34: 523-544. Wang Y-Y, Gong P. The relationship between Cochran D, Hermann J. Crestal bone changes IL-1 gene polymorphism and marginal bone loss around titanium implants. Part I: A retrospective 16. Lindquist L, Carlsson G, Jemt T. Association around dental implants. J Oral Maxillofac Surg radiographic evaluation in humans comparing two between marginal bone loss around 2007; 65: 2340-2344. non-submerged implant designs with different osseointegrated mandibular implants and 3. Shimpuku H, Nosaka Y, Kawamura T, Tachi Y, machined collar lengths. J Periodontol 2005; smoking habits: A 10-year follow-up study. J Shinohara M, Ohura K. Genetic polymorphisms 76:791-802. Dent Res 1997; 76: 1667-1674. of the interleukin-1 gene and early marginal bone loss around endosseous dental implants. Clin 10. Ferreira S, Silva G, Cortelli J, Costa J, Costa F. 17. Watzak G, Zechner W, Busenlechner D, Arnhart Oral Impl Res 2003; 14: 423-429. Prevalence and risk variables for peri-implant C, Gruber R, Watzek G. Radiological and clinical 4. Nosaka Y,Tachi Y, Shimpuku H, Kawamura T, disease in Brazilian subjects. J Clin Periodontol follow-up of machined- and anodized-surface Ohura K. Association of calcitonin receptor gene 2006; 33:929–935. implants after mean functional loading for 33 polymorphism with early marginal bone loss months. Clin Oral Implants Res 2006 ; 17:651- around endosseous implants. Int J Oral Maxillofac 11. Bernards C, Twisk J, Snel J, van Mechelen W, 657. Implants 2002; 17: 38-43. Lips P, Kemper H. Smoking and quantitative 5. Shimpuku H, Nosaka Y, Kawamura T, Tachi Y, ultrasound parameters in the calcaneus in 18. Haas, R, Haimbock, W, Mailath, G, Watzek, G. Shinohara M, Ohura K. Bone morphogenetic 36-year-old men and women. Osteoporos Int The relationship of smoking and peri-implant protein-4 gene polymorphism and early marginal 2004; 15: 735-741. tissue: A retrospective study. J Prosthet Dent bone loss around endosseous implants. Int J Oral 1996; 76: 592–596. Maxillofac Impl 2003;18: 500-504. 12. Levin L, Schwartz-Arad D. The effect of cigarette 6. Laine M, Leonhardt A, Roos-Jansaker A, Pena A, smoking on dental implants and related surgery. 19. Nociti F, Cesar N, Carvalho M, Sallum E. van Winkelhoff A, Winkel E, Renvert S. IL-IRN Implant Dent 2005; 14:357-363. Bone density around titanium implants may gene polymorphism is associated with peri- be influenced by intermittent cigarette smoke implantitis. Clin Oral Implants Res 2006; 17: 13. Bain C, Moy P. The association between the inhalation: a histometric study in rats. Int J Oral 380-385. failure of dental implants and cigarette smoking. Maxillofac Implants 2002; 17: 347-52. Int J Oral Maxillofac Implants 1993; 8: 609–615. 20. Nitzan D, Mamlider A, Levin L, Schwartz-Arad D. Impact of smoking on marginal bone loss. Int J Oral Maxillofac Implants 2005; 20: 605-609. 70 Vol. 1, No. 3 May 2009

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Current Clinical Review Review of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) Gregory D. Naylor, DDS, ABOM1 Hypertension is a disease that affects Patients with a SBP of 120-139 mmHg or approximately 50 to 60 million individuals a DBP of 80-89 mmHg are considered as in the United States and over a billion prehypertensive, and require health-promoting people worldwide. It is the most common lifestyle changes to prevent CVD. primary medical diagnosis in the United States Thiazide-type diuretics should initially be and represents approximately one third of used in the treatment for most patients with the population. As the population ages, the uncomplicated HTN, either alone or combined prevalence of hypertension (HTN) will continue with drugs from other classes. to increase unless effective preventive measures Most patients will require two or more drugs are implemented. The JNC 7 represents the to achieve the goal BP of less than 140/90 seventh iteration of hypertension guidelines. mmHg. It was designed to provide a new, clear, and The most effective therapy prescribed by the concise guideline for clinicians, and to simplify clinician will control HTN only if the patient is the classification of blood pressure (BP). All motivated. dentists and their staff need to be aware of these Refer to Table 1 for the updated classification important changes and should be proactive in of HTN. the measurement, detection, and treatment of hypertension. Medical Management Significant JNC 7 Changes Goals of therapy. The primary goal of antihypertensive therapy is the reduction of In patients older than 50 years, systolic blood cardiovascular and renal disease. Patients pressure (SBP) greater than 140 mmHg is a older than 50 years will reach the DBP goal much more important cardiovascular disease once the SBP goal is maintained; therefore, (CVD) risk factor than diastolic blood pressure the primary focus should be to attain the SBP (DBP). goal. For patients younger than 50, the primary 1. Dental Consultant, Metropolitan Life Insurance Company The Journal of Implant & Advanced Clinical Dentistry 73

Current Clinical Review focus should be the DBP goal. A BP less than products with an overall emphasis on the 140/90 mmHg is associated with a decrease in reduction of saturated and total fat. Dietary CVD complications. For patients with diabetes sodium should be reduced to no more than 6 or renal disease, the goal BP is set at less than grams of sodium chloride. Engaging in regular 130/80 mmHg. aerobic physical activity, such as a brisk walk for 30 minutes, for most days of the week Lifestyle Modifications. Adoption of is also indicated. Consumption of alcohol healthy lifestyles by all patients is critical for should be limited to no more than 24 ounces the prevention of HTN. A number of lifestyle of beer, 10 ounces of wine, or 3 ounces of modifications have been shown to lower BP. whiskey as a daily guideline. Adoption of these Weight reduction in those individuals who are lifestyle modifications will reduce BP, enhance overweight or obese can significantly lower antihypertensive drug efficacy, and decrease the BP. Also, adoption of the Dietary Approaches patient’s CVD risk. to Stop Hypertension (DASH) eating plan is very important. The DASH eating plan consists Pharmacological Treatment. The following of a diet rich in potassium and calcium found classes of drugs are used to lower BP: primarily in fruits, vegetables, and low fat dairy angiotensin converting enzyme inhibitors, Table 1: Classi cation of Blood Pressure for Adults BP SBP* DBP* Lifestyle Classifications mm of Hg mm of Hg Modification Normal < 120 and < 80 Encourage Prehypertension 120-139 or 80-89 Yes Stage 1 140-159 or 90-99 Yes Hypertension Stage 2 160 or 100 Yes Hypertension *SBP, systolic blood pressure; DBP, disatolic blood pressure Source: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 Report, JAMA 2003; 289, 2560-2572 74 Vol. 1, No. 3 May 2009

Current Clinical Review angiotensin receptor blockers, beta-blockers, For patients with a BP over 180/110 mmHg, calcium channel blockers, and thiazide-type dental treatment should be deferred and the diuretics. patient should be referred immediately to their physician. Dental Management Vasoconstrictor use. The use of Although HTN is the most common primary vasoconstrictors in local anesthetics for patients medical diagnosis in the United States, 30 with CVD is debatable and is finally addressed percent of the people with HTN are unaware in the JNC 7 recommendations. A review they have the condition, and of all the patients of the literature dealing with the CV effects being treated for HTN, only 34 percent have of epinephrine on dental patients with HTN their BP controlled at levels consistent with the demonstrated that the use of epinephrine in current JNC 7 guidelines. As a result, practicing local anesthetics resulted in infrequent adverse dentists encounter many patients on a daily outcomes. It has been concluded that the basis with undetected or poorly controlled HTN advantages of profound anesthesia far outweigh that may require medical evaluation. Therefore, any potential disadvantages or risks. However, the dentist and their staff should measure the it is recommended that vasoconstrictor use be BP for all new patients and for all recall patients minimized in patients with increased CVD risks. on an annual basis. Patients with known HTN Although there is no official maximum ceiling should have their BP measured at each visit in dose for local anesthetics with vasoconstrictors, which significant procedures are planned. Also, two to three carpules of lidocaine with regular BP measurements for patients with 1:100,000 epinephrine is considered safe known HTN can determine their level of control. in patients with all but the most severe CVD. It is important to note that a distinctly elevated The use of gingival retraction cord containing BP measurement is an indication of poor control epinephrine should be avoided due to the and increases the patient’s risk of experiencing availability of suitable alternatives. a cardiovascular episode while undergoing dental treatment. Urgent dental care. Elevated BP in patients seeking urgent dental care is very common. Patients with well controlled HTN or those This can be due to the patient’s chief complaint, with Stage 1 HTN are good candidates for all previously undetected HTN, inadequate dental procedures. In fact, studies indicate treatment of HTN, or poor patient compliance. that patients with BP measurements less than There are no professionally recognized criteria to 180/110 mmHg can undergo any necessary determine when it is safe to treat patients with dental treatment, both surgical and nonsurgical, an elevated BP that require urgent dental care. with very little risk of an adverse outcome. In the absence of such a guideline, a logical However, patients with a BP over 160/100 ceiling for urgent care should be a SBP over mmHg should have their BP monitored during 180 mmHg or a DBP over 110 mmHg. A BP surgical or prolonged procedures and then be referred to their physician for timely reevaluation. The Journal of Implant & Advanced Clinical Dentistry 75

Current Clinical Review at either of these levels requires an immediate Oral Complications referral. Xerostomia. Many antihypertensive medications Stress management. The dentist should cause xerostomia and the likelihood of make every effort to reduce as much as possible symptoms increases with multiple medication the stress and anxiety associated with dental use. Xerostomia increases the potential for treatment for all patients. Stress management caries; difficulty with mastication, swallowing, is very important in patients with HTN to prevent and speech; candidiasis; and burning mouth. If the release of endogenous catecholamines xerostomia is severe, relief can be provided with during a dental appointment. Long or the use of a parasympathetic stimulator such as stressful appointments should be avoided, pilocarpine, or by taking frequent sips of water, and short morning appointments should be using moisturizing gels, sucking on sugarless implemented. Anxiety can be minimized by candy, chewing sugarless gum, and minimizing using oral premedication with a short acting intake of caffeinated and alcoholic beverages. benzodiazepine at bedtime the night before the Due to the increase incidence of caries, custom scheduled appointment followed by another trays for fluoride delivery should be considered. dose one hour before the dental appointment. Nitrous oxide and oxygen inhalation sedation Gingival overgrowth. Calcium channel is an excellent method to minimize anxiety blockers may cause gingival overgrowth. This during the dental procedure. For stage 2 HTN gingival overgrowth can result in pain, gingival patients, it is advisable to monitor the BP during bleeding, and difficulty with mastication. the procedure and if the BP goes over 180/110 Excellent oral hygiene can reduce or minimize mmHg then treatment should be terminated as the overgrowth. Extensive gingival overgrowth soon as possible. may require gingivectomy, gingivoplasty or a combination of both. In these cases, the Orthostatic hypotension. A number patient’s physician should consider the use of of antihypertensive medications produce another antihypertensive medication in order to orthostatic hypertension. In order to prevent reverse the gingival changes. an episode at the end of a dental appointment, the dental chair should be returned slowly to Lichenoid drug reactions. A number of the upright position. After a few minutes of antihypertensive medications may cause what sitting in a normal position, the patient should is known as a lichenoid drug reaction, which have adjusted and can be assisted while are lesions clinically identical to lichen planus. getting out of the chair. If there is any problem The best and easiest method to deal with this with lightheadedness or dizziness, the patient complication is withdrawal of the offending drug should sit back down until the postural change and to prescribe another medication. The drug symptoms disappear. withdrawal will allow resolution of the lesions; otherwise short term symptomatic management with topical corticosteroids is indicated. 76 Vol. 1, No. 3 May 2009

Current Clinical Review Burning mouth symptoms. Angiotensin of blood pressure. Due to the increase in converting enzyme (ACE) inhibitors have been the number of patients with hypertension reported to be associated with oral burning. and the aging of the population, each dental The use of an alternative antihypertensive practitioner will encounter more complications medication and discontinuing the ACE inhibitor of antihypertensive therapy that will require alleviates the burning mouth symptoms. ACE medical consultation. Dentists and their staff inhibitors have also been implicated in loss of have an opportunity to play an important role taste symptoms. in the treatment success of the patient with hypertension by monitoring blood pressure, Drug interactions. Drug interactions between detecting hypertension, and encouraging antihypertensive medications and some of patients to develop a healthy lifestyle. the therapeutic agents used in dentistry may result in adverse effects for the patient. An Correspondence interaction with nonselective beta blockers and [email protected] epinephrine in local anesthetics can result in a reduction of cardiac output, an increase in BP, References and a reduction in heart rate. However, with 1. Chobanian A, Bakris G, Black H, Cushman W, Green L, Izzo J, et al. The Seventh careful administration of local anesthetic with frequent aspiration will prevent this interaction. Report of the Joint National Committee on Prevention, Detection, Evaluation, Also epinephrine use with patients taking non- and Treatment of High Blood Pressure: The JNC 7 Report. JAMA 2003 ;289 potassium sparing diuretics, can decrease (19): 2560-2572. potassium levels and increase the chance of a dysrhythmia. Prolonged use of nonsteroidal anti-inflammatory agents (NSAIDs) decreases the antihypertensive effect of diuretics, beta blockers, alpha blockers, ACE inhibitors, vasodilators, and central agonists. Alternative analgesics may be substituted to avoid this interaction; fortunately short term use of NSAIDs does not appear to produce a clinically significant effect. Summary The goal of successful antihypertensive therapy is the reduction of cardiovascular and renal morbidity and mortality. The JNC 7 has developed clear and concise prevention oriented guidelines and simplified the classification The Journal of Implant & Advanced Clinical Dentistry 77