A case of peri-implantitis and osteoradionecrosis arising around dental implants placed before radiation therapy
© Teramoto et al. 2016
Received: 1 August 2015
Accepted: 21 March 2016
Published: 5 April 2016
A little is known about the effect of radiotherapy on the dental implants that have previously been osseointegrated and charged. Here, we reported a case of osteoradionecrosis which arose around dental implants placed before radiation therapy.
Osteoradionecrosis (ORN) of the mandible is a severe complication that follows ionizing radiation therapy in patients undergoing treatment for head and neck cancer. The radiation dose, tumor location, dental trauma, premorbid state of dentition, and concomitant chemoradiotherapy are thought to be contributing factors for ORN [1–3]. Most patients with head and neck cancer are aged 50 years or more and include those who have dental prosthetic implants . Dental implant surgery and/or the peri-implant tissue condition might represent a possible etiology for ORN. Many researchers have studied and reported the effects of irradiation on dental implant therapy. Most of them have discussed the effect of previous irradiation on the success or failure of the dental implant rehabilitation [5–7]. In these cases, the dental implant was installed in the irradiated bone. In contrast, little is known about the effects of radiotherapy on dental implants that have previously been osseointegrated and charged [8, 9]. Here, we reported a case of ORN that arose around dental implants placed before radiation therapy.
In this paper, we reported a case of ORN arising around dental implants placed before radiotherapy. This is the third such case report to be published. Granström et al. reported three cases of ORN developing around dental implants previously placed for skin-penetrating prosthesis . Slama et al. reported a case of mandibular ORN in post-implant radiation . In these cases, the presence of dental implants in the radiation field was thought to play a possible role in the development of ORN. In our case, although the patients had dental implants in both sides of the mandible, ORN occurred only in the left side, which was included in the field of radiotherapy applied for the treatment of oropharyngeal cancer arising in the left side. This fact suggested a possible causal relationship between the presence of dental implants and the development of ORN.
The presence of a dental implant may affect the development of ORN by two mechanisms. Firstly, the presence of the implant may cause a change in the radiation dose distribution around the dental implant [4, 10, 11]. Radiation scatter and electronic disequilibrium from implant materials are thought to cause both soft and hard tissue complications in the oral cavity. Friedrich et al.  reported on titanium dental implants in the field of ORN. Ozen et al.  examined the dose enhancement from scattered radiation at bone-dental implant interfaces. They reported that there is a 21 % maximum increase in the dose to alveolar mandibular bone in close proximity to the titanium. The increase in dose enhancement fell off rapidly and become insignificant at 2 mm from the interface. They suggested that it is not clear whether a local overdose of the order of 15 to 21 % will cause a significant increase in the incidence of bone necrosis around osteointegrated titanium implants. Beyzadeoglu et al.  also reported that irradiation, with different radiation beams and different irradiation angles, did not sufficiently affect the total dose to lead to ORN of the mandible. From the results of these studies, it could be said that the bone-implant interface is exposed to possible dose enhancement from scattering by the dental implants if the dental implants are included in the radiation field.
Secondarily, infection associated with dental implant may become a possible cause of ORN. In radiotherapy including the oral cavity, gingivitis is frequently observed adjacent to fixed metal dental restorations because they cause significant dose enhancement around them . It is easy to speculate that the same occurs around dental implant prostheses (peri-implant mucositis). The presence of mucositis (gingivitis) causes poor oral hygiene and leads to a vicious spiral of poor oral hygiene and increased bacterial infection. Radiation therapy may also interfere with normal wound healing mechanisms. Changes in vasculature, effects on fibroblasts, and varying levels of regulatory growth factors result in the potential for altered wound healing. Radiation also induces alterations of the immune response (immunosuppression). Ionizing radiation directly affects the immune system. These conditions reduce the peri-implant tissue resistance to oral bacteria, thus increasing the risk of peri-implantitis. Slama et al.  reported the existence of peri-implantitis prior to the development of ORN. In our case, the peri-implantitis progressed to ORN. It is well known that the defense function of peri-implant tissue is weaker than that surrounding natural teeth. It is likely that the peri-implant mucositis caused by radiotherapy can easily progress to infected peri-implantitis and subsequently more severe infection of the jaw bone.
Dental implants have become increasingly popular, and a considerable number of people have undergone dental restorations using dental implants. Therefore, there will be an increasing probability of patients with dental implants receiving irradiation around their implants. Further studies are required to analyze whether dental implants located in the radiation field cause adverse effects in the long term.
Written informed consent was obtained from the patient for the publication of this report and any accompanying images.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
- O'Dell K, Sinha U. Osteoradionecrosis. Oral Maxillofac Surg Clin North Am. 2011;23(3):455–64.View ArticlePubMedGoogle Scholar
- Madrid C, Abarca M, Bouferrache K. Osteoradionecrosis: an update. Oral Oncol. 2010;46(6):471–4.View ArticlePubMedGoogle Scholar
- Jacobson AS, Buchbinder D, Hu K, Urken ML. Paradigm shifts in the management of osteoradionecrosis of the mandible. Oral Oncol. 2010;46(11):795–801.View ArticlePubMedGoogle Scholar
- Ozen J, Dirican B, Oysul K, Beyzadeoglu M, Ucok O, Beydemir B. Dosimetric evaluation of the effect of dental implants in head and neck radiotherapy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;99(6):743–7.View ArticlePubMedGoogle Scholar
- Jacobsson M, Tjellström A, Albrektsson T, Turesson I. Integration of titanium implants in irradiated bone. Histologic and clinical study. Ann Otol Rhinol Laryngol. 1988;97(4 Pt 1):337–40.View ArticlePubMedGoogle Scholar
- Granström G. Osseointegration in irradiated cancer patients: an analysis with respect to implant failures. J Oral Maxillofac Surg. 2005;63:579–85.View ArticlePubMedGoogle Scholar
- Visch LL, van Waas MA, Schmitz PI, Levendag PC. A clinical evaluation of implants in irradiated oral cancer patients. JDR. 2002;81(12):856–9.View ArticlePubMedGoogle Scholar
- Granström G, Tjellström A, Albektsson T. Postimplantation irradiation for head and neck cancer treatment. Int J Oral Maxillofac Implants. 1993;8:495–501.PubMedGoogle Scholar
- Ben Slama L, Hasni W, De Labrouhe C, Bado F, Bertrand JC. Osteoradionecrose sur implants dentaires [Osteoradionecrosis and dental implants]. Rev Stomatol Chir Maxillofac. 2008;109(6):387–91.View ArticlePubMedGoogle Scholar
- Friedrich RE, Todorovic M, Krull A. Simulation of scattering effects of irradiation on surroundings using the example of titanium dental implants: a Monte Carlo approach. Anticancer Res. 2010;30(5):1727–30.PubMedGoogle Scholar
- Beyzadeoglu M, Dirican B, Oysul K, Ozen J, Ucok O. Evaluation of scatter dose of dental titanium implants exposed to photon beams of different energies and irradiation angles in head and neck radiotherapy. Dentomaxillofac Radiol. 2006;35(1):14–7.View ArticlePubMedGoogle Scholar
- Chin DW, Treister N, Friedland B, Cormack RA, Tishler RB, Makrigiorgos GM, Court LE. Effect of dental restorations and prostheses on radiotherapy dose distribution: a Monte Carlo study. J Appl Clin Med Phys. 2009;10(1):2853.View ArticlePubMedGoogle Scholar