Q U I N T E S S E N C E I N T E R N AT I O N A L
IMPLANTOLOGY
Alvaro Pons-Fuster
Dental implants in patients with oral lichen planus: A narrative review Alvaro Pons-Fuster, DDS1/Pia López Jornet, DDS, MD, PhD2 Objective: To evaluate the success and survival rates of dental implants in patients with oral lichen planus (OLP). Method and Materials: A narrative review literature search was conducted in the PubMed/Medline, Scopus, and Cochrane databases for articles published between 1990 and April 2013, using key search words “dental implants” and “oral lichen planus”. Results: This review did not identify any publications
that were randomized controlled trials. A total of 60 OLP patients and 199 dental implants were analyzed. Three cases of OLP-related oral squamous cell carcinoma were reported. Conclusion: The extent and severity of underlying disease should be determined before dental implant placement. (Quintessence Int 2014;45:599–603; doi: 10.3290/j.qi.a31963)
Key words: dental implants, oral lichen planus, oral squamous cell carcinoma
Tooth loss is accompanied by functional, esthetic, and speech problems, occlusal disorders, and psychologic difficulties, therefore dental restoration with implants is an option that offers numerous benefits.1-3 For this reason, oral rehabilitation with dental implants has become a common procedure. Although few studies have dealt with the topic of oral lichen planus (OLP) and dental implants, it has been suggested that there may be a risk of implant failure in patients with OLP, due to the epithelium’s limited capacity to adhere to the implant’s titanium surface; this can affect the mucosa-titanium interface, endangering the functioning of the implant soft tissue barrier, which will give bacteria access to the periimplant tissues.2-4 Moreover, it could be argued that dental implants would stabilize removable dentures 1
PhD Student, Department of Oral Medicine, University of Murcia, Murcia, Spain.
2
Head, Department of Oral Medicine, University of Murcia, Murcia, Spain.
Correspondence: Dr López-Jornet, Hospital Morales Meseguer, Clínica Odontológica Universitaria, 2 planta, Marques de los Velez Avenue s/n, Murcia 30008, Spain. Email: [email protected]
VOLUME 45 • NUMBER 7 • JULY / AUGUST 2014
that could result in an isomorphic effect (Köbner’s phenomenon), and thus be beneficial for the patients. The question arises, in patients treated with dental implants, to what extent does a history of OLP increase the risk for implant failure? OLP is a relatively common mucosal disease of unknown etiology, although its autoimmune features are easily recognizable.5-7 It is more frequent among women aged 50 to 55 years. The characteristic features of OLP are its chronicity, symmetric appearance, and the involvement of multiple sites. The gums are the third most common OLP site, followed by the oral mucosa and the tongue. OLP appears in various forms: atrophic, reticular, papular, plaque-like, bullous, or erosive. Its histopathologic criteria are the presence of a well-defined band of inflammatory infiltrate composed mainly of lymphocytes, hydropic degeneration of the basal layer, and the absence of dysplasia.5 The possible risks for dental implant insertion in patients with OLP remain unclear, and to date there is insufficient scientific evidence to establish adequate
599
Q U I N T E S S E N C E I N T E R N AT I O N A L Pons-Fuster / López Jornet
a
Fig 1a Example of patient with oral lichen planus lesions associated with the peri-implant tissues. Fig 1b Oral lichen planus affecting the buccal mucosa.
b
management strategies for some of the clinical situations that might arise.4-10 In spite of the wide use of dental implants, few cases of patients with OLP and implants have been documented. The aim of this study was to perform a narrative literature review of those cases.
METHOD AND MATERIALS Search strategy A literature search was performed in the PubMed/Medline, Scopus, and Cochrane databases for articles published between 1990 and April 2013 on dental implants in patients with OLP using the key terms “oral lichen planus” and “dental implants”. Two independent reviewers screened titles and abstracts of the search results (APF, PLJ). As inclusion criteria, any articles on patients diagnosed with OLP with osseointegrated dental implants were included. Clinical studies, cohort studies, case reports, and case series published in either English or Spanish were reviewed. Articles describing extraoral lesions or not involving dental implants were excluded. The following data were extracted: the population studied, the intervention made, and the results.
RESULTS The present review did not identify any RCT (randomized controlled trial) publications. The clinical studies found were isolated cases or case series. The search located few articles; 60 patients with both OLP and osseointegrated dental implants, with a total of 199 implants. There were four single case reports, three case series, and three controlled studies (one prospective and two retrospective). Twenty-two patients had an erosive form of OLP, 18 had a reticular type, and for two patients the type of OLP was not specified. There were no data on the duration of OLP (Table 1). Mucositis was detected in 17.8% and 66.6% of the patients in two studies, and peri-implantitis in 25% and 27.7% (Table 1). The presence of desquamative gingivitis (DG) was associated with a higher rate of peri-implant mucositis for those implants of the OLP group. The implant manufacturer was unclear in most studies. Nobel implants (Nobel Biocare) of various systems were used at least in three studies, eight included ITI implants (Straumann), two HATI implants (Mathys Dental), one Camlog (Camlog Biotechnologies), one ZL Microdent, and one Astra Tech implant. Three cases of OLP-related oral squamous cell carcinoma (OSCC) were reported (Table 2).
Data extraction strategy The following data were sought: implant type, number of subjects, number of implants, number of subjects with early failures, number of early failing implants, years of follow-up, number of subjects followed up, number of implants followed up, number of subjects with late failures, number of late failing implants, and incidence of peri-implantitis/mucositis (Fig 1).
600
DISCUSSION Studies of dental implant treatments in patients with OLP are rare and most describe isolated cases. There is a clear need for well-conducted prospective studies of OLP and implants that would allow researchers to construct a classification system as a basis for establishing
VOLUME 45 • NUMBER 7 • JULY / AUGUST 2014
Q U I N T E S S E N C E I N T E R N AT I O N A L Pons-Fuster / López Jornet
Table 1
Literature search results: published studies of patients with oral lichen planus and dental implants
OLP type
OLP diagnosis, before/ after implant placement
Mucositis/ periimplantitis
Implantsupported prosthesis
Female
Erosive
Unavailable
Unavailable
Overdenture
Branemark system
72–78
Females
Erosive
Before
Unavailable
Overdenture
ITI
4
74
Female
Unavailable
Before
Unavailable
Fixed
ITI
3
10
63, 68, 79
Females
1 erosive, 2 reticular
1 before, 2 after
Unavailable
Fixed
HATI, Camlog, ZL Microdent
Czerninski18
1
3
52
Female
Unavailable
Before
Unavailable
Fixed
Unavailable
Gallego et al19
1
2
81
Female
Reticular
Before
Unavailable
Overdenture
Unavailable
Hernández et al13
18
56
53.7
14 females, 4 males
Erosive
Before
66.6/27.7
Fixed
TiUnite, Nobel Direct
Czerninski et al14
14
54
59.5
11 females, 3 males
11 erosive, 3 reticular
67% before, 13% after
Unavailable
Unavailable
Unavailable
López Jornet 16 et al15
56
64.5
10 females, 6 males
11 reticular, 5 erosive
Before
17.8/25.0
3 overdentures, 13 fixed
Unavailable
Portela Tejedor16
8
53, 59, 59
1 male, 2 females
Reticular and erosive
Before, after
Unavailable
Fixed (third case awaiting rehabilitation)
Nobel, Steri-Oss, Astra Tech
OLP patients
Number of implants
Patient age
OLP patient sex
Esposito et al3
1
2
69
Esposito et al10
2
4
Oczakir et al11
1
Reichart12
Study
3
Table 2
Oral squamous cell carcinoma (OSCC) in patients with OLP and dental implants
Study
OLP patients
Czerninski et al18
1
Number of implants 3
Patient age 52
OLP Patient sex Female
Smoking Yes
Alcohol consumption
OLP history
Mandibular
3 years after implant placement
Fixed
Mandibular
15 years after implant placement
Overdenture
Mandibular
2 years after OLP diagnosis and 1 year before implant placement
Overdenture
2
72
Male
Yes
None
Gallego et al19
2
81
Female
No
None
2 years before OSCC
VOLUME 45 • NUMBER 7 • JULY / AUGUST 2014
Implant prosthesis
Unavailable
20 years before OSCC
strategies for dealing with the clinical situations that may arise in such cases. For this reason, the outcomes of this review must be treated with caution because of the small number of studies located, the short followup times, and the quality of the evidence. Esposito et al3 described a single case of an OLP patient treated with dental implants. Esposito et al10 described two further clinical cases of OLP rehabilitated
Time of OSCC appearance
8 years before OSCC
Abu El-Naaj 1 et al20
1
Place
Implant type
with implant-supported overdentures with positive outcomes in terms of function and patient satisfaction. Oczakir et al11 described a case series of 24 patients with a variety of systemic diseases and congenital defects; one patient presented OLP and received four mandibular implants to support a complete fixed prosthesis. No complications were observed during the 6-year follow-up.
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Q U I N T E S S E N C E I N T E R N AT I O N A L Pons-Fuster / López Jornet
Reichart12 described the rehabilitation of three OLP patients with satisfactory outcomes; one patient was monitored for 13 years. In an excellent and well-designed controlled prospective study, Hernández et al13 studied 18 patients with OLP who received a total of 56 implants. During the follow-up period after implant insertion, recurring erosion and ulcerous manifestations were treated with topical corticosteroids, with a 100% success rate. Mucositis was detected in 66.6% of the patients, and periimplantitis in 27.7%. Czerninski et al14 carried out a controlled retrospective study of 14 OLP patients, who received 54 implants. The authors compared OLP signs and symptoms between patients with and without dental implants over a period of 12 to 24 months, finding no statistically significant differences in OLP manifestations. The implant success rate was 100%, perhaps explained by the fact that the study design excluded early implant failures from analysis. The results suggest that OLP is not a contraindication for dental implant placement and that the implant survival rate is the same as for OLP-free edentulous patients. The close contact between the oral epithelium and implant poses the question of whether titanium can activate OLP. However, the biocompatibility of titanium supports the supposition that there is only a minimal risk of lichenoid reaction to implant materials; indeed, these authors observed only a single case. López Jornet et al,15 in a study of 16 patients with OLP and osseointegrated dental implants, found mucositis and peri-implantitis in 17.86% and 25% of OLP patients respectively, while a control group showed 18% and 16% respectively. Therefore OLP did not appear to be a risk factor for peri-implantitis. Portela Tejedor16 reported three cases of OLP and implants: two were rehabilitated with fixed prostheses, the third was awaiting rehabilitation. Gingival manifestations are most commonly seen in the erosive, ulcerative, and atrophic forms of OLP. Symptomatic ulcerative or erosive gingival involvement has the potential to compromise effective plaque control.6,7 Hernandez et al13 reported that the presence
602
of DG was associated with a higher rate of peri-implant mucositis for those implants of the OLP group (P = .004). Implant survival and success in the OLP group was 100%, vs 96.8% in the DG group, where only two implants were lost after prosthetic loading. Periimplant mucositis was detected in 44.6% of the implants and 66.6% of the patients with OLP. The main objective of OLP symptom treatment is the reduction and hopefully elimination of the pain associated with lesions.6 Various treatments have been proposed: topical corticosteroids including betamethasone, clobetasol, dexamethasone, and triamcinolone; and topical calcineurin inhibitors such as ciclosporin or retinoids, pimecrolimus, or tacrolimus. Some patients do not respond to topical treatment and so require systemic treatment with corticosteroids. Prolonged therapy is one of the factors that can increase the risk of osteoporosis, which could impair implant success rates. Given the wide variety of implant systems in use, it might be supposed that these factors could determine OLP prognosis. However, this is not the case, and some authors report improvements in the evolution of erosive OLP after rehabilitation with implant-supported overdentures, perhaps due to a resolution of previous trauma arising from poor prosthetic fit.8,9 Peri-implant mucositis and peri-implantitis appear to be slightly more frequent in patients with OLP than in control patients without OLP. However, the presence of implants does not seem to aggravate OLP. On the basis of the published literature, there is no reason to consider OLP a cause of implant failure, the key causes being parafunction, poor oral hygiene, and poor bone quality.1,2,8 It is recommended that implant placement should be performed when OLP signs and symptoms are in remission. Rigorous oral hygiene practices, care of gingival lesions, and frequent check-ups are the main recommendations for OLP patients rehabilitated with dental implants.8 Nevertheless, none of the studies reviewed recognize OLP as a cause of implant loss. Monitoring OLP is essential because of its potential malignancy. The etiology of OSCC is multifactorial and includes factors related to toxic habits (smoking, alcohol consumption), infectious agents such as human
VOLUME 45 • NUMBER 7 • JULY / AUGUST 2014
Q U I N T E S S E N C E I N T E R N AT I O N A L Pons-Fuster / López Jornet
papillomavirus, and potentially malignant lesions, which include OLP lesions.17-22 The incidence of malignant tumors situated close to dental implants is low, and the possibility of some association between implants and lesion malignancy remains an open question. Czerninski et al18 published a case of a female patient with OLP (a smoker), who developed OSCC around dental implants, and OLP lesions were observed. Gallego et al19 reported the appearance of OSCC in the mandible, adjacent to an implant in the symphyseal region. Abu El-Naaj et al20 described the case of a patient (a smoker) with a history of OLP, presenting an exophytic lesion around implants in the symphyseal region. Moergel et al21 studied patients with OSCC situated close to dental implants, and affirmed the need to monitor factors that might promote carcinogenesis in patients who smoke, drink alcohol, or have a previous history of carcinoma and potentially malignant lesions. Borstein et al,22 in a systematic review, found that the level of evidence indicating absolute and relative contraindications for oral implant therapy due to systemic conditions and treatments is low. Many conditions have been listed as potential risk factors, (diabetes type 1 and 2, or primary and secondary osteoporosis) but studies comparing patients with and without the condition in a controlled setting are rare. In general, the available literature is restricted to case reports and case series. Diz et al,9 in a recent review, found that there are very few absolute medical contraindications to dental implant treatment, although a number of conditions may increase the risk of treatment failure or complications. The degree of systemic disease control may be far more important than the nature of the disorder itself, and individualized medical control should be established prior to implant therapy, since in many of these patients the quality of life and functional benefits from dental implants may outweigh any risks. When it comes to clinical decision-making, dental implant treatment options should be assessed in terms of advantages and disadvantages and the cost/benefit ratio.8,9 Although dental implants are becoming the most widely used prosthetic rehabilitation, very little
VOLUME 45 • NUMBER 7 • JULY / AUGUST 2014
clinically relevant information exists on patients with OLP, which highlights the need for adequately designed, randomized, and controlled studies.
REFERENCES 1. Liddelow G, Klineberg I. Patient-related risk factors for implant therapy. A critique of pertinent literature. Aust Dent J 2011;56:417–426. 2. Alsaadi G, Quyrinen M, Komarek A, van Steenberghe D. Impact of local and systemic factors on the incidence of late oral implant loss. Clin Oral Implants Res 2008;19:670–676. 3. Esposito M, Thomsen P, Ericson LE, Sennerby L, Lekholm U. Histopathologic observations on late oral implant failures. Clin Implant Dent Relat Res 2000;2:18–32. 4. Candel-Marti ME, Ata-Ali J, Peñarrocha-Oltra D, Peñarrocha-Diago M, Bagán JV. Dental implants in patients with oral mucosal alterations: An update. Med Oral Patol Oral Cir Bucal 2011;16:e787–e793. 5. Lodi G, Scully C, Carrozzo M, Griffiths M, Sugermale PB, Thongprasom K. Current controversies in oral lichen planus: report of an international consensus meeting. Part 2. Clinical management and malignant transformation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100:164–178. 6. Guiglia R, Di Liberto C, Pizzo G, et al. A combined treatment regime for desquamative gingivitis in patients with oral lichen planus. J Oral Pathol Med 2007;36:110–116. 7. Scully C, Carrozzo M. Oral mucosal disease: lichen planus. Br J Oral Maxillofac Surg 2008;46:15–21. 8. Petruzzi M, De Benedittis M, Cortelazzi R, et al. Implant rehabilitation in patients with oral lichen planus: an overview. Clin Oral Investig 2012;16:1347–1352. 9. Diz P, Scully C, Sanz M. Dental implants in the medically compromised patient. J Dent 2013;41:195–206. 10. Esposito SJ, Camisa C, Morgan M. Implant retained overdentures for two patients with severe lichen planus: a clinical report. J Prosthet Dent 2003;89:6–10. 11. Oczakir C, Balmer S, Mericske-Stern R. Implant prosthodontic treatment for special care patients: a case series study. Int J Prosthodont 2005;18:383–389. 12. Reichart PA. Oral lichen planus and dental implants. Report of 3 cases. Int J Oral Maxillofac Surg 2006;35:2;37–40. 13. Hernández G, Lopez-Pintor RM, Arriba L, Torres J, de Vicente JC. Implant treatment in patients with oral lichen planus: a prospective-controlled study. Clin Oral Implants Res 2012;23:726–732. 14. Czerninski R, Eliezer M, Wilensky A, Soskolne A. Oral lichen planus and dental implants: a retrospective study. Clin Implant Dent Relat Res 2013;15:234–242. 15. López Jornet, Camacho Alonso F, Sanchez Siles M. Dental implants in patients with oral lichen planus: a cross-sectional study. Clin Implant Dent Relat Res 2014;16:107–115. 16. Portela Tejedor P. Dental implants in patients with oral lichen planus. Literature review in related to three clinical cases. Rev Cons Odontol Estomatol 2012;17:113–123. 17. Bermejo-Fenoll A, Sanchez-Siles M, López-Jornet P, Camacho-Alonso F, Salazar-Sanchez N. Premalignant nature of oral lichen planus. A retrospective study of 550 oral lichen planus patients from south-eastern Spain. Oral Oncol 2009;45:e54–e56. 18. Czerninski R, Kaplan I, Almoznino G, Maly A, Regev E. Oral squamous cell carcinoma around dental implants. Quintessence Int 2006;37:707–711. 19. Gallego L, Junquera L, Baladrón J, Villarreal P. Oral squamous cell carcinoma associated with symphyseal dental implants: an unusual case report. J Am Dent Assoc 2008;139:1061–1065. 20. Abu El-Naaj I, Trost O, Tagger-Green N, et al. Peri-implantitis or squamous cell carcinoma? Rev Stomatol Chir Maxillofac 2007;108:458–460. 21. Moergel M, Karbach J, Kunkel M, Wagner W. Oral squamous cell carcinoma in the vicinity of dental implants. Clin Oral Investig 2014;18:277–284. 22. Bornstein MM, Cionca N, Mombelli A. Systemic conditions and treatments as risks for implant therapy. Int J Oral Maxillofac Implants 2009;24:12–27.
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IMPLANTOLOGY
Alvaro Pons-Fuster
Dental implants in patients with oral lichen planus: A narrative review Alvaro Pons-Fuster, DDS1/Pia López Jornet, DDS, MD, PhD2 Objective: To evaluate the success and survival rates of dental implants in patients with oral lichen planus (OLP). Method and Materials: A narrative review literature search was conducted in the PubMed/Medline, Scopus, and Cochrane databases for articles published between 1990 and April 2013, using key search words “dental implants” and “oral lichen planus”. Results: This review did not identify any publications
that were randomized controlled trials. A total of 60 OLP patients and 199 dental implants were analyzed. Three cases of OLP-related oral squamous cell carcinoma were reported. Conclusion: The extent and severity of underlying disease should be determined before dental implant placement. (Quintessence Int 2014;45:599–603; doi: 10.3290/j.qi.a31963)
Key words: dental implants, oral lichen planus, oral squamous cell carcinoma
Tooth loss is accompanied by functional, esthetic, and speech problems, occlusal disorders, and psychologic difficulties, therefore dental restoration with implants is an option that offers numerous benefits.1-3 For this reason, oral rehabilitation with dental implants has become a common procedure. Although few studies have dealt with the topic of oral lichen planus (OLP) and dental implants, it has been suggested that there may be a risk of implant failure in patients with OLP, due to the epithelium’s limited capacity to adhere to the implant’s titanium surface; this can affect the mucosa-titanium interface, endangering the functioning of the implant soft tissue barrier, which will give bacteria access to the periimplant tissues.2-4 Moreover, it could be argued that dental implants would stabilize removable dentures 1
PhD Student, Department of Oral Medicine, University of Murcia, Murcia, Spain.
2
Head, Department of Oral Medicine, University of Murcia, Murcia, Spain.
Correspondence: Dr López-Jornet, Hospital Morales Meseguer, Clínica Odontológica Universitaria, 2 planta, Marques de los Velez Avenue s/n, Murcia 30008, Spain. Email: [email protected]
VOLUME 45 • NUMBER 7 • JULY / AUGUST 2014
that could result in an isomorphic effect (Köbner’s phenomenon), and thus be beneficial for the patients. The question arises, in patients treated with dental implants, to what extent does a history of OLP increase the risk for implant failure? OLP is a relatively common mucosal disease of unknown etiology, although its autoimmune features are easily recognizable.5-7 It is more frequent among women aged 50 to 55 years. The characteristic features of OLP are its chronicity, symmetric appearance, and the involvement of multiple sites. The gums are the third most common OLP site, followed by the oral mucosa and the tongue. OLP appears in various forms: atrophic, reticular, papular, plaque-like, bullous, or erosive. Its histopathologic criteria are the presence of a well-defined band of inflammatory infiltrate composed mainly of lymphocytes, hydropic degeneration of the basal layer, and the absence of dysplasia.5 The possible risks for dental implant insertion in patients with OLP remain unclear, and to date there is insufficient scientific evidence to establish adequate
599
Q U I N T E S S E N C E I N T E R N AT I O N A L Pons-Fuster / López Jornet
a
Fig 1a Example of patient with oral lichen planus lesions associated with the peri-implant tissues. Fig 1b Oral lichen planus affecting the buccal mucosa.
b
management strategies for some of the clinical situations that might arise.4-10 In spite of the wide use of dental implants, few cases of patients with OLP and implants have been documented. The aim of this study was to perform a narrative literature review of those cases.
METHOD AND MATERIALS Search strategy A literature search was performed in the PubMed/Medline, Scopus, and Cochrane databases for articles published between 1990 and April 2013 on dental implants in patients with OLP using the key terms “oral lichen planus” and “dental implants”. Two independent reviewers screened titles and abstracts of the search results (APF, PLJ). As inclusion criteria, any articles on patients diagnosed with OLP with osseointegrated dental implants were included. Clinical studies, cohort studies, case reports, and case series published in either English or Spanish were reviewed. Articles describing extraoral lesions or not involving dental implants were excluded. The following data were extracted: the population studied, the intervention made, and the results.
RESULTS The present review did not identify any RCT (randomized controlled trial) publications. The clinical studies found were isolated cases or case series. The search located few articles; 60 patients with both OLP and osseointegrated dental implants, with a total of 199 implants. There were four single case reports, three case series, and three controlled studies (one prospective and two retrospective). Twenty-two patients had an erosive form of OLP, 18 had a reticular type, and for two patients the type of OLP was not specified. There were no data on the duration of OLP (Table 1). Mucositis was detected in 17.8% and 66.6% of the patients in two studies, and peri-implantitis in 25% and 27.7% (Table 1). The presence of desquamative gingivitis (DG) was associated with a higher rate of peri-implant mucositis for those implants of the OLP group. The implant manufacturer was unclear in most studies. Nobel implants (Nobel Biocare) of various systems were used at least in three studies, eight included ITI implants (Straumann), two HATI implants (Mathys Dental), one Camlog (Camlog Biotechnologies), one ZL Microdent, and one Astra Tech implant. Three cases of OLP-related oral squamous cell carcinoma (OSCC) were reported (Table 2).
Data extraction strategy The following data were sought: implant type, number of subjects, number of implants, number of subjects with early failures, number of early failing implants, years of follow-up, number of subjects followed up, number of implants followed up, number of subjects with late failures, number of late failing implants, and incidence of peri-implantitis/mucositis (Fig 1).
600
DISCUSSION Studies of dental implant treatments in patients with OLP are rare and most describe isolated cases. There is a clear need for well-conducted prospective studies of OLP and implants that would allow researchers to construct a classification system as a basis for establishing
VOLUME 45 • NUMBER 7 • JULY / AUGUST 2014
Q U I N T E S S E N C E I N T E R N AT I O N A L Pons-Fuster / López Jornet
Table 1
Literature search results: published studies of patients with oral lichen planus and dental implants
OLP type
OLP diagnosis, before/ after implant placement
Mucositis/ periimplantitis
Implantsupported prosthesis
Female
Erosive
Unavailable
Unavailable
Overdenture
Branemark system
72–78
Females
Erosive
Before
Unavailable
Overdenture
ITI
4
74
Female
Unavailable
Before
Unavailable
Fixed
ITI
3
10
63, 68, 79
Females
1 erosive, 2 reticular
1 before, 2 after
Unavailable
Fixed
HATI, Camlog, ZL Microdent
Czerninski18
1
3
52
Female
Unavailable
Before
Unavailable
Fixed
Unavailable
Gallego et al19
1
2
81
Female
Reticular
Before
Unavailable
Overdenture
Unavailable
Hernández et al13
18
56
53.7
14 females, 4 males
Erosive
Before
66.6/27.7
Fixed
TiUnite, Nobel Direct
Czerninski et al14
14
54
59.5
11 females, 3 males
11 erosive, 3 reticular
67% before, 13% after
Unavailable
Unavailable
Unavailable
López Jornet 16 et al15
56
64.5
10 females, 6 males
11 reticular, 5 erosive
Before
17.8/25.0
3 overdentures, 13 fixed
Unavailable
Portela Tejedor16
8
53, 59, 59
1 male, 2 females
Reticular and erosive
Before, after
Unavailable
Fixed (third case awaiting rehabilitation)
Nobel, Steri-Oss, Astra Tech
OLP patients
Number of implants
Patient age
OLP patient sex
Esposito et al3
1
2
69
Esposito et al10
2
4
Oczakir et al11
1
Reichart12
Study
3
Table 2
Oral squamous cell carcinoma (OSCC) in patients with OLP and dental implants
Study
OLP patients
Czerninski et al18
1
Number of implants 3
Patient age 52
OLP Patient sex Female
Smoking Yes
Alcohol consumption
OLP history
Mandibular
3 years after implant placement
Fixed
Mandibular
15 years after implant placement
Overdenture
Mandibular
2 years after OLP diagnosis and 1 year before implant placement
Overdenture
2
72
Male
Yes
None
Gallego et al19
2
81
Female
No
None
2 years before OSCC
VOLUME 45 • NUMBER 7 • JULY / AUGUST 2014
Implant prosthesis
Unavailable
20 years before OSCC
strategies for dealing with the clinical situations that may arise in such cases. For this reason, the outcomes of this review must be treated with caution because of the small number of studies located, the short followup times, and the quality of the evidence. Esposito et al3 described a single case of an OLP patient treated with dental implants. Esposito et al10 described two further clinical cases of OLP rehabilitated
Time of OSCC appearance
8 years before OSCC
Abu El-Naaj 1 et al20
1
Place
Implant type
with implant-supported overdentures with positive outcomes in terms of function and patient satisfaction. Oczakir et al11 described a case series of 24 patients with a variety of systemic diseases and congenital defects; one patient presented OLP and received four mandibular implants to support a complete fixed prosthesis. No complications were observed during the 6-year follow-up.
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Q U I N T E S S E N C E I N T E R N AT I O N A L Pons-Fuster / López Jornet
Reichart12 described the rehabilitation of three OLP patients with satisfactory outcomes; one patient was monitored for 13 years. In an excellent and well-designed controlled prospective study, Hernández et al13 studied 18 patients with OLP who received a total of 56 implants. During the follow-up period after implant insertion, recurring erosion and ulcerous manifestations were treated with topical corticosteroids, with a 100% success rate. Mucositis was detected in 66.6% of the patients, and periimplantitis in 27.7%. Czerninski et al14 carried out a controlled retrospective study of 14 OLP patients, who received 54 implants. The authors compared OLP signs and symptoms between patients with and without dental implants over a period of 12 to 24 months, finding no statistically significant differences in OLP manifestations. The implant success rate was 100%, perhaps explained by the fact that the study design excluded early implant failures from analysis. The results suggest that OLP is not a contraindication for dental implant placement and that the implant survival rate is the same as for OLP-free edentulous patients. The close contact between the oral epithelium and implant poses the question of whether titanium can activate OLP. However, the biocompatibility of titanium supports the supposition that there is only a minimal risk of lichenoid reaction to implant materials; indeed, these authors observed only a single case. López Jornet et al,15 in a study of 16 patients with OLP and osseointegrated dental implants, found mucositis and peri-implantitis in 17.86% and 25% of OLP patients respectively, while a control group showed 18% and 16% respectively. Therefore OLP did not appear to be a risk factor for peri-implantitis. Portela Tejedor16 reported three cases of OLP and implants: two were rehabilitated with fixed prostheses, the third was awaiting rehabilitation. Gingival manifestations are most commonly seen in the erosive, ulcerative, and atrophic forms of OLP. Symptomatic ulcerative or erosive gingival involvement has the potential to compromise effective plaque control.6,7 Hernandez et al13 reported that the presence
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of DG was associated with a higher rate of peri-implant mucositis for those implants of the OLP group (P = .004). Implant survival and success in the OLP group was 100%, vs 96.8% in the DG group, where only two implants were lost after prosthetic loading. Periimplant mucositis was detected in 44.6% of the implants and 66.6% of the patients with OLP. The main objective of OLP symptom treatment is the reduction and hopefully elimination of the pain associated with lesions.6 Various treatments have been proposed: topical corticosteroids including betamethasone, clobetasol, dexamethasone, and triamcinolone; and topical calcineurin inhibitors such as ciclosporin or retinoids, pimecrolimus, or tacrolimus. Some patients do not respond to topical treatment and so require systemic treatment with corticosteroids. Prolonged therapy is one of the factors that can increase the risk of osteoporosis, which could impair implant success rates. Given the wide variety of implant systems in use, it might be supposed that these factors could determine OLP prognosis. However, this is not the case, and some authors report improvements in the evolution of erosive OLP after rehabilitation with implant-supported overdentures, perhaps due to a resolution of previous trauma arising from poor prosthetic fit.8,9 Peri-implant mucositis and peri-implantitis appear to be slightly more frequent in patients with OLP than in control patients without OLP. However, the presence of implants does not seem to aggravate OLP. On the basis of the published literature, there is no reason to consider OLP a cause of implant failure, the key causes being parafunction, poor oral hygiene, and poor bone quality.1,2,8 It is recommended that implant placement should be performed when OLP signs and symptoms are in remission. Rigorous oral hygiene practices, care of gingival lesions, and frequent check-ups are the main recommendations for OLP patients rehabilitated with dental implants.8 Nevertheless, none of the studies reviewed recognize OLP as a cause of implant loss. Monitoring OLP is essential because of its potential malignancy. The etiology of OSCC is multifactorial and includes factors related to toxic habits (smoking, alcohol consumption), infectious agents such as human
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papillomavirus, and potentially malignant lesions, which include OLP lesions.17-22 The incidence of malignant tumors situated close to dental implants is low, and the possibility of some association between implants and lesion malignancy remains an open question. Czerninski et al18 published a case of a female patient with OLP (a smoker), who developed OSCC around dental implants, and OLP lesions were observed. Gallego et al19 reported the appearance of OSCC in the mandible, adjacent to an implant in the symphyseal region. Abu El-Naaj et al20 described the case of a patient (a smoker) with a history of OLP, presenting an exophytic lesion around implants in the symphyseal region. Moergel et al21 studied patients with OSCC situated close to dental implants, and affirmed the need to monitor factors that might promote carcinogenesis in patients who smoke, drink alcohol, or have a previous history of carcinoma and potentially malignant lesions. Borstein et al,22 in a systematic review, found that the level of evidence indicating absolute and relative contraindications for oral implant therapy due to systemic conditions and treatments is low. Many conditions have been listed as potential risk factors, (diabetes type 1 and 2, or primary and secondary osteoporosis) but studies comparing patients with and without the condition in a controlled setting are rare. In general, the available literature is restricted to case reports and case series. Diz et al,9 in a recent review, found that there are very few absolute medical contraindications to dental implant treatment, although a number of conditions may increase the risk of treatment failure or complications. The degree of systemic disease control may be far more important than the nature of the disorder itself, and individualized medical control should be established prior to implant therapy, since in many of these patients the quality of life and functional benefits from dental implants may outweigh any risks. When it comes to clinical decision-making, dental implant treatment options should be assessed in terms of advantages and disadvantages and the cost/benefit ratio.8,9 Although dental implants are becoming the most widely used prosthetic rehabilitation, very little
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clinically relevant information exists on patients with OLP, which highlights the need for adequately designed, randomized, and controlled studies.
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