Clinical Oral Investigations

, Volume 17, Issue 1, pp 167–175 | Cite as

Osteopathology induced by bisphosphonates and dental implants: clinical observations

  • Christine Jacobsen
  • Philipp Metzler
  • Matthias Rössle
  • Joachim Obwegeser
  • Wolfgang Zemann
  • Klaus-Wilhelm Grätz
Original Article



Although there are many reports about risk factors for the development of BP-associated osteonecrosis of the jaws, the role of dental implants as a local risk factor is still discussed, especially in patients with oral BP treatment. Until now, a few case reports and surveys display a possible minor risk in patients with oral BP therapy, whereas the avoidance of implant placement is generally accepted in patients with intravenous BP therapy.

Patient and methods

In this study, the cases of 14 patients with osteonecrosis of the jaws in association with BP therapy and dental implant placement were analyzed carefully with a detailed literature review.


Of 14 patients, nine had underlying malignant disease and five patients had osteoporosis. In ten patients, implants were placed either in the posterior mandible or maxilla; the mean interval between implant insertion and disease onset was 20.9 months. Pain (n12) and signs of infection (n10) were the most common symptoms. Histologically, signs of infection were found in nine of 11 analyzed patients with presence of Actinomyces in six patients. Two patients turned out to have infiltration of underlying malignant disease.


Posteriorly placed implants seem to be of higher risk of development of osteonecrosis of the jaws. Not only the implant placement but also the inserted implant itself seems to be a continuous risk factor.

Clinical relevance

The herein elaborated risk factors help dentists plan dental rehabilitation with implants in this high-risk group of patients and indicate careful and regular dental recall.


Bisphosphonate-associated osteonecrosis of the jaws (BRONJ) Dental implants Risk factors Posterior jaw Infection 


  1. 1.
    Marx RE (2003) Pamidronate (Aredia) and zoledronate (Zometa) induced avascular necrosis of the jaws: a growing epidemic. J Oral Maxillofac Surg 61:1115–1117PubMedCrossRefGoogle Scholar
  2. 2.
    Ruggiero SL, Dodson TB, Assael LA, Landesberg R, Marx RE, Mehrotra B, Task Force on Bisphosphonate-Related Osteonecrosis of the Jaws AAoOaMS (2009) American Association of Oral and Maxillofacial Surgeons position paper on bisphosphonate-related osteonecrosis of the jaw—2009 update. Aust Endod J 35:119–130. doi:10.1111/j.1747-4477.2009.00213.x PubMedCrossRefGoogle Scholar
  3. 3.
    Filleul O, Crompot E, Saussez S (2010) Bisphosphonate-induced osteonecrosis of the jaw: a review of 2,400 patient cases. J Cancer Res Clin Oncol 136:1117–1124. doi:10.1007/s00432-010-0907-7 PubMedCrossRefGoogle Scholar
  4. 4.
    Migliorati CA, Schubert MM, Peterson DE (2009) Bisphosphonate osteonecrosis (BON): unanswered questions and research possibilities. Rev Recent Clin Trials 4:99–109PubMedCrossRefGoogle Scholar
  5. 5.
    Lodi G, Sardella A, Salis A, Demarosi F, Tarozzi M, Carrassi A (2010) Tooth extraction in patients taking intravenous bisphosphonates: a preventive protocol and case series. J Oral Maxillofac Surg 68:107–110. doi:10.1016/j.joms.2009.07.068 PubMedCrossRefGoogle Scholar
  6. 6.
    Hellstein JW, Marek CL (2006) Bisphosphonate induced osteochemonecrosis of the jaws: an ounce of prevention may be worth a pound of cure. Spec Care Dentist 26:8–12PubMedCrossRefGoogle Scholar
  7. 7.
    Fehm T, Felsenberg D, Krimmel M, Solomayer E, Wallwiener D, Hadjii P (2009) Bisphosphonate-associated osteonecrosis of the jaw in breast cancer patients: recommendations for prevention and treatment. Breast 18:213–217. doi:10.1016/j.breast.2009.07.001 PubMedCrossRefGoogle Scholar
  8. 8.
    Advisory Task Force on Bisphosphonate-Related Ostenonecrosis of the Jaws AAoOaMS (2007) American Association of Oral and Maxillofacial Surgeons position paper on bisphosphonate-related osteonecrosis of the jaws. J Oral Maxillofac Surg 65:369–376. doi:10.1016/j.joms.2006.11.003 CrossRefGoogle Scholar
  9. 9.
    Dannemann C, Grätz KW, Riener MO, Zwahlen RA (2007) Jaw osteonecrosis related to bisphosphonate therapy: a severe secondary disorder. Bone 40:828–834. doi:10.1016/j.bone.2006.11.023 PubMedCrossRefGoogle Scholar
  10. 10.
    Ruggiero SL, Dodson TB, Assael LA, Landesberg R, Marx RE, Mehrotra B, Surgeons AAoOaM (2009) American Association of Oral and Maxillofacial Surgeons position paper on bisphosphonate-related osteonecrosis of the jaws—2009 update. J Oral Maxillofac Surg 67:2–12. doi:10.1016/j.joms.2009.01.009 PubMedGoogle Scholar
  11. 11.
    Fedele S, Kumar N, Davies R, Fiske J, Greening S, Porter S (2009) Dental management of patients at risk of osteochemonecrosis of the jaws: a critical review. Oral Dis 15:527–537. doi:10.1111/j.1601-0825.2009.01581.x PubMedCrossRefGoogle Scholar
  12. 12.
    Abtahi J, Tengvall P, Aspenberg P (2010) Bisphosphonate coating might improve fixation of dental implants in the maxilla: a pilot study. Int J Oral Maxillofac Surg 39:673–677. doi:10.1016/j.ijom.2010.04.002 PubMedCrossRefGoogle Scholar
  13. 13.
    Zahid T, Wang B-Y, Cohen R (2010) Influence of bisphosphonates on alveolar bone loss around osseointegrated implants. J Oral Implantol. doi:10.1563/AAID-JOI-D-09-00114
  14. 14.
    Bedogni A, Bettini G, Totola A, Saia G, Nocini PF (2010) Oral bisphosphonate-associated osteonecrosis of the jaw after implant surgery: a case report and literature review. J Oral Maxillofac Surg 68:1662–1666. doi:10.1016/j.joms.2010.02.037 PubMedCrossRefGoogle Scholar
  15. 15.
    Bell BM, Bell RE (2008) Oral bisphosphonates and dental implants: a retrospective study. J Oral Maxillofac Surg 66:1022–1024. doi:10.1016/j.joms.2007.12.040 PubMedCrossRefGoogle Scholar
  16. 16.
    Favia G, Piattelli A, Sportelli P, Capodiferro S, Iezzi G (2011) Osteonecrosis of the posterior mandible after implant insertion: a clinical and histological case report. Clin Implant Dent Relat Res 13:58–63. doi:10.1111/j.1708-8208.2009.00181.x PubMedCrossRefGoogle Scholar
  17. 17.
    Goss A, Bartold M, Sambrook P, Hawker P (2010) The nature and frequency of bisphosphonate-associated osteonecrosis of the jaws in dental implant patients: a South Australian case series. J Oral Maxillofac Surg 68:337–343. doi:10.1016/j.joms.2009.09.037 PubMedCrossRefGoogle Scholar
  18. 18.
    Lazarovici TS, Yahalom R, Taicher S, Schwartz-Arad D, Peleg O, Yarom N (2010) Bisphosphonate-related osteonecrosis of the jaw associated with dental implants. J Oral Maxillofac Surg 68:790–796. doi:10.1016/j.joms.2009.09.017 PubMedCrossRefGoogle Scholar
  19. 19.
    Martin DC, O'Ryan FS, Indresano AT, Bogdanos P, Wang B, Hui RL, Lo JC (2010) Characteristics of implant failures in patients with a history of oral bisphosphonate therapy. J Oral Maxillofac Surg 68:508–514. doi:10.1016/j.joms.2009.09.055 PubMedCrossRefGoogle Scholar
  20. 20.
    Shin E-Y, Kwon Y-H, Herr Y, Shin S-I, Chung J-H (2010) Implant failure associated with oral bisphosphonate-related osteonecrosis of the jaw. J Periodontal Implant Sci 40:90–95. doi:10.5051/jpis.2010.40.2.90 PubMedCrossRefGoogle Scholar
  21. 21.
    Shirota T, Nakamura A, Matsui Y, Hatori M, Nakamura M, Shintani S (2009) Bisphosphonate-related osteonecrosis of the jaw around dental implants in the maxilla: report of a case. Clin Oral Implants Res 20:1402–1408. doi:10.1111/j.1600-0501.2009.01801.x PubMedCrossRefGoogle Scholar
  22. 22.
    Starck WJ, Epker BN (1995) Failure of osseointegrated dental implants after diphosphonate therapy for osteoporosis: a case report. Int J Oral Maxillofac Implants 10:74–78PubMedGoogle Scholar
  23. 23.
    Ferlito S, Liardo C, Puzzo S (2011) Bisphosponates and dental implants: a case report and a brief review of literature. Minerva Stomatol 60:75–81PubMedGoogle Scholar
  24. 24.
    Pirih FQ, Zablotsky M, Cordell K, McCauley LK (2009) Case report of implant placement in a patient with Paget's disease on bisphosphonate therapy. J Mich Dent Assoc 91:38–43PubMedGoogle Scholar
  25. 25.
    Torres J, Tamimi F, García I, Cebrian JL, López-Cabarcos E, Lopez A (2008) Management of atrophic maxilla in severe osteoporosis treated with bisphosphonates: a case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 106:668–672. doi:10.1016/j.tripleo.2008.03.008 PubMedCrossRefGoogle Scholar
  26. 26.
    Torres J, Tamimi F, Garcia I, Herrero A, Rivera B, Sobrino JA, Hernández G (2009) Dental implants in a patient with Paget disease under bisphosphonate treatment: a case report. Oral Surg Oral Med Oral Pathol Oral Rradiol Endod 107:387–392. doi:10.1016/j.tripleo.2008.11.024 CrossRefGoogle Scholar
  27. 27.
    Fugazzotto PA, Lightfoot WS, Jaffin R, Kumar A (2007) Implant placement with or without simultaneous tooth extraction in patients taking oral bisphosphonates: postoperative healing, early follow-up, and the incidence of complications in two private practices. J Periodontol 78:1664–1669. doi:10.1902/jop. 2007.060514 PubMedCrossRefGoogle Scholar
  28. 28.
    Grant B-T, Amenedo C, Freeman K, Kraut RA (2008) Outcomes of placing dental implants in patients taking oral bisphosphonates: a review of 115 cases. J Oral Maxillofac Surg 66:223–230. doi:10.1016/j.joms.2007.09.019 PubMedCrossRefGoogle Scholar
  29. 29.
    Uebelhart B, Rizzoli R (2009) Osteoporosis. Rev Med Suisse 5:124–129PubMedGoogle Scholar
  30. 30.
    Leonida A, Vescovi P, Baldoni M, Rossi G, Lauritano D (2010) Immediate loading of dental implants in mandible full-arch: pilot study in patients with osteoporosis treated with bassoonists therapy. J Oral Implantol. doi:10.1563/AAID-JOI-D-09-00132.1
  31. 31.
    Shabestari GO, Shayesteh YS, Khojasteh A, Alikhasi M, Moslemi N, Aminian A, Masaeli R, Eslami B, Treister NS (2010) Implant placement in patients with oral bisphosphonate therapy: a case series. Clin Implant Dent Relat Res 12:175–180. doi:10.1111/j.1708-8208.2009.00150.x PubMedGoogle Scholar
  32. 32.
    Kasai T, Pogrel MA, Hossaini M (2009) The prognosis for dental implants placed in patients taking oral bisphosphonates. J Calif Dent Assoc 37:39–42PubMedGoogle Scholar
  33. 33.
    Koka S, Babu NMS, Norell A (2010) Survival of dental implants in post-menopausal bisphosphonate users. J Prosthodont Res 54:108–111. doi:10.1016/j.jpor.2010.04.002 PubMedCrossRefGoogle Scholar
  34. 34.
    Bornstein MM, Cionca N, Mombelli A (2009) Systemic conditions and treatments as risks for implant therapy. Int J Oral Maxillofac Implants 24:12–27PubMedGoogle Scholar
  35. 35.
    Edwards BJ, Hellstein JW, Jacobsen PL, Kaltman S, Mariotti A, Migliorati CA, Jaw ADACoSAEPoB-AOot (2008) Updated recommendations for managing the care of patients receiving oral bisphosphonate therapy: an advisory statement from the American Dental Association Council on Scientific Affairs. J Am Dent Assoc 139:1674–1677, 1939PubMedGoogle Scholar
  36. 36.
    Flichy-Fernández A-J, Balaguer-Martínez J, Peñarrocha-Diago M, Bagán JV (2009) Bisphosphonates and dental implants: current problems. Med Oral Patol Oral Cir Bucal 14:E355–360PubMedGoogle Scholar
  37. 37.
    Hwang D, Wang H-L (2006) Medical contraindications to implant therapy: part I: absolute contraindications. Implant Dent 15:353–360. doi:10.1097/ PubMedCrossRefGoogle Scholar
  38. 38.
    Javed F, Almas K (2010) Osseointegration of dental implants in patients undergoing bisphosphonate treatment: a literature review. J Periodontol 81:479–484. doi:10.1902/jop. 2009.090587 PubMedCrossRefGoogle Scholar
  39. 39.
    Madrid C, Sanz M (2009) What impact do systemically administrated bisphosphonates have on oral implant therapy? A systematic review. Clin Oral Implants Res 20:87–95. doi:10.1111/j.1600-0501.2009.01772.x PubMedCrossRefGoogle Scholar
  40. 40.
    Mellado-Valero A, Ferrer-García JC, Calvo-Catalá J, Labaig-Rueda C (2010) Implant treatment in patients with osteoporosis. Med Oral Patol Oral Cir Bucal 15:e52–57PubMedGoogle Scholar
  41. 41.
    Montoya-Carralero J-M, Parra-Mino P, Ramírez-Fernández P, Morata-Murcia IM, MdC M-G, Calvo-Guirado J-L (2010) Dental implants in patients treated with oral bisphosphonates: a bibliographic review. Med Oral Patol Oral Cir Bucal 15:e65–69PubMedGoogle Scholar
  42. 42.
    Scully C, Madrid C, Bagan J (2006) Dental endosseous implants in patients on bisphosphonate therapy. Implant Dent 15:212–218. doi:10.1097/ PubMedCrossRefGoogle Scholar
  43. 43.
    Reid IR (2009) Osteonecrosis of the jaw: who gets it, and why? Bone 44:4–10. doi:10.1016/j.bone.2008.09.012 PubMedCrossRefGoogle Scholar
  44. 44.
    Kaplan I, Anavi K, Anavi Y, Calderon S, Schwartz-Arad D, Teicher S, Hirshberg A (2009) The clinical spectrum of Actinomyces-associated lesions of the oral mucosa and jawbones: correlations with histomorphometric analysis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 108:738–746. doi:10.1016/j.tripleo.2009.06.019 PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2012

Authors and Affiliations

  • Christine Jacobsen
    • 1
  • Philipp Metzler
    • 1
  • Matthias Rössle
    • 2
  • Joachim Obwegeser
    • 1
  • Wolfgang Zemann
    • 1
  • Klaus-Wilhelm Grätz
    • 1
  1. 1.Department of Craniomaxillofacial SurgeryUniversity Hospital of ZurichZurichSwitzerland
  2. 2.Institute of PathologyUniversity Hospital of ZurichZurichSwitzerland

Personalised recommendations