Objectives: The review aimed to explore the pharmacophysiological modes of action of both oral and intravenous bisphosphonates and the potential for adverse events in patients receiving dental implant treatment. It aimed to gather evidence on the use of alternative drugs to bisphosphonates, as well as current recommendations and guidelines for dental implant therapy in patients receiving bisphosphonates. It was hoped to devise a clinical protocol for the management of bisphosphonate-treated patients.
Methods: A Medline search was conducted to identify articles from the medical and dental literature between 1950 and 31 December 2014 according to well-defined inclusion and exclusion criteria. Searches were made of the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials and Embase for English-language studies published between 2000 and 31 December 2014. All cited references in the identified papers were cross-checked to ensure that no articles were missed. Given the rarity of studies with a sufficiently large prospective sample to determine the rate of failure (often over 10,000 patients are needed to achieve statistical significance), the heterogeneous studies yielded in this search (in terms of both design and outcome measures) were only suitable for descriptive analysis, rather than a meta-analysis.
Results: The initial search of Medline and Embase yielded a total of 37 articles on bisphosphonates and dental implants. On further investigation, only 27 met the study inclusion criteria. There were eight retrospective studies and two case series evaluating the success rate of dental implants in patients with a history of bisphosphonate use, and another 17 articles consisting of case series and case reports. They described incidences of bisphosphonate-related osteonecrosis of the jaw in dental implant patients. In addition, two relevant articles from the Cochrane Library addressed interventions for treating osteonecrosis of the jaw bone associated with bisphosphonates. A second search of Medline and Embase for “bisphosphonates” (MeSH term) in conjunction with “oral soft tissues”, “oral hard tissues”, “avascular necrosis”, “jaw bone” and “modes/mechanisms of action” yielded a total of 51 English-language studies in humans. Late implant failures are reported in patients treated with oral bisphosphonates for more than 3 years, especially if they have existing integrated implants. Early failures are reported in patients treated with bisphosphonates before or at the time of implant placement. Most organisations agree that a safe approach is the best policy for dealing with patients on oral bisphosphonatess, by assessing the risks on an individual basis and obtaining appropriate consent. This requires close communication with the prescribing physician before surgical intervention. Several alternative drugs are available and their risks profiles also need to be determined in this context.
Conclusion: Although many of the studies identified here have shortcomings, there does appear to be some risk associated with both implant placement and maintenance of osseointegrated implants in patients who take oral bisphosphonates.

Objectives: This study aimed to evaluate clinically and histologically the healing of deep intrabony defects after reconstructive surgery using a natural bovine xenograft (BDX) combined with a native collagen membrane (CM). Methods: Eight patients with severe chronic periodontitis and at least one tooth scheduled for extraction because of periodontal or prosthetic issues were included. Following local anaesthesia, full-thickness flaps were raised, and intrabony defects were exposed. Granulation tissue was removed from the defects and the roots were thoroughly scaled and root-planed by hand and ultrasonic instruments. A notch was placed in the root surface at the level of the calculus or the most apical point of the debrided root surface (if no calculus was present). Defects were filled with BDX (Cerabone[tm]) and covered with CM (Collprotect[tm]). Probing pocket depth (PD), clinical attachment level (CAL) and vertical probing bone level (PBL) were recoreded before and 9 months after reconstructive surgery. At 9 months, the teeth and surrounding soft and hard tissues were removed, fixed in buffered formalin and processed for histological analysis. Ground sections of 100µm thickness were cut and stained with toluidine blue and fuchsin and analysed under a light microscope. Results: All eight treated teeth presented deep (7.57 ± 1.16mm) one-wall intrabony defects. After 9 months, a reduction in PD (1.45 ± 1.35mm) and a gain in CAL (1.68 ± 0.62mm) was noted for all teeth. No adverse events related to the graft material or CM were observed in any biopsy tissue. Histology revealed the formation of cementum with inserting collagen fibers in the entire notch area in two cases, and new cementum at the apical extent of the notch in one case. Long junctional epithelium and biofilm formation were observed to varying extents in all cases; furthermore, graft particles were still present and encapsulated in connective tissue. There was some minute formation of bone in three biopsies, and three teeth showed signs of root resorption. Conclusion: In teeth with a poor prognosis, reconstructive surgery of intrabony defects using BDX and CM resulted in minimal or no periodontal regeneration.