Female doctor points to an xray with a patient while an assistant stands behind them.

As dentists and dental specialists, we all strive to provide excellent care for our patients. Part of that care consists of proper diagnosis, recommendations and a conversation about the risks and benefits of the proposed treatment.

Discussing alternative treatments and risks can be difficult, but it's the patient's right to know of existing oral and systemic conditions that may predispose them to biological complications and/or failures.

Many clinicians already discuss the inherent risks associated with implant complications when patients have a history of smoking, diabetes or bisphosphonate use. With tobacco use, current evidence indicates that there is a higher risk of implant failure related to the number of smoking years, pack years, and the number of cigarettes per day.

Higher risk of failure is associated with removable prosthetics vs. fixed prosthetics and with the maxillary arch. There are mixed recommendations for the duration of cessation, more common suggestions range from 2-6 weeks prior to dental implant placement and eight weeks following placement.

In addition to smoking, you must also consider a history of periodontal disease. There is a high prevalence of peri-implant disease in patients that do not continue supportive periodontal therapy (SPT) following implant placement.

SPT should be considered a preventative measure for peri-implantitis and management of peri-implant mucositis. A systematic review of 6,283 implants included the frequency of peri-implant mucositis at 30.7% and peri-implantitis was 9.6%. This frequency estimate increased to 36.3% for smokers.

There are medications and other conditions that are much more common than smoking and poorly controlled diabetes. Recent literature in the form of a systematic review and meta-analysis suggests that two classes of medication can increase implant failure rates and that clinicians should be aware of these risks.

Proton pump inhibitors (PPI) showed an increase in failure rates by 4.3%. Many of our patients are on PPI and often consider them insignificant to mention during their medical history review if not taken daily. With an increasing number of patients with mental illness such as anxiety and depression, we see many patients taking prescriptions to help manage and treat these conditions.

In the same article, they looked closely at selective serotonin reuptake inhibitors and estimated a 7.5% associated failure rate.

Furthermore, a patient who has been informed of the potential for future complications prior to treatment may be less likely to see an adverse event as a complication, but rather as part of supportive or maintenance care. In other words, the worst type of complication may be the unexpected one — the complication that was not discussed during the treatment planning stage. The most difficult scenario to manage might be when a patient has been told that the implant treatment will “last a lifetime” or that “implants are better than teeth.”

The reality is, we cannot avoid treating patients with an increased risk associated with implant failure. In patients with significant documented risk, it is beneficial to discuss these risks and be more diligent with treatment planning to preserve teeth for a longer duration.

Hunter Dawson, D.D.S., is a contributor to Spear Digest.


  1. Atieh, M. A., Alsabeeha, N. H., Faggion, C. M. and Duncan, W. J. (2013), The Frequency of Peri-Implant Diseases: A Systematic Review and Meta-Analysis. Journal of Periodontology, 84: 1586-1598. doi:10.1902/jop.2012.120592
  2. Schimmel, Srinivasan, Mckenna, and Muller (2018), Effect of advanced age and/or systemic medical conditions on dental implant survival: A systematic review and meta-analysis. Clin Oral Impl Res. 29(Suppl. 16): 311-330
  3. Salvi, G.E., Zitzmann, N.U. (2014), The effects of anti-infective preventative measures on the occurrence of biologic implant complications and implant loss: a systematic review. Int J Oral Maxillofac Implants. 2014;29 Suppl:292-307
  4. Chappuis, Avila-Ortiz, Araujo, Monje (2018), Medication-related dental implant failure: Systematic review and meta-analysis Clin Oral Impl Res. 29(Suppl. 16):55-68.
  5. Twito and Sade (2014), The effect of cigarette smoking habits on the outcome of dental implant treatment. PeerJ 2:e546
  6. Bragger, U. Heitz-Mayfield, L.J.A (2015) ITI Treatment Guide Volume 8, Biological and Hardware Complications in Implant Dentistry


Commenter's Profile Image John P.
January 9th, 2020
Thanks for this summary. I heard about the PPI and SSRI concern, and will be interesting to figure out what the pathophysiology of this association is about! Another potential risk factor that's being discussed is the patient with a penicillin allergy who is treated with clindamycin: Do Penicillin-Allergic Patients Present a Higher Rate of Implant Failure? in Int J Oral Maxillofac Implants 2018;323:1390-1396.
Commenter's Profile Image Hunter D.
January 9th, 2020
Great point John!! Another risk that is emerging in the literature is metal allergy and sensitivity. Thank you so much for sharing and I hope you enjoyed the information