Could Your Prescription Pills Affect the Outcome of Dental Implant Surgery? It’s a problem highlighted by a recent study of dentists in Spain.
They found that people who were taking antidepressants – specifically selective serotonin reuptake inhibitors (SSRIs) – at the time of their surgery and at least a year before had a more than 4.5-fold increased risk of their implants failing.
The 170 patients in the study were taking some of the most commonly prescribed SSRIs in the UK, including citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine and sertraline.
Dental implants are replacement tooth roots in which a metal screw is inserted directly into the jawbone and forms a base for an artificial tooth to be placed on top.
They are not usually provided by the NHS and can cost thousands if done privately.
They found that people who were taking antidepressants – specifically selective serotonin reuptake inhibitors (SSRIs) – at the time of their surgery and at least a year before had a more than 4.5-fold increased risk of their implants failing
The 170 patients in the study were taking some of the most commonly prescribed SSRIs in the UK, including citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine and sertraline
A “failed” implant is defined as the implant falling out or moving, or the occurrence of bone loss, pain, or pus formation.
The researchers at the Complutense University in Madrid suggested that SSRIs might affect bone metabolism – ie its production and breakdown.
Normally, the body lays new bone directly onto the implant surface, making it secure – a process called osseointegration. However, this may not be the case with SSRIs, resulting in the implant not integrating with the bone.
The drugs can also cause teeth grinding, which can put pressure on implants, the researchers said in the British Journal of Oral and Maxillofacial Surgery. The drug can alter levels of the chemical dopamine in the brain, which is involved in muscle control.
Antipsychotics — prescribed for bipolar disorder, major depression, and schizophrenia — can also cause problems for dental implants, as they can also cause teeth grinding.
In a 2019 report in the Australian Prescriber magazine, Geraldine Moses, a consultant pharmacist to the Australian Dental Association, wrote that “Bruxism [i.e. teeth-grinding] is an underestimated adverse drug reaction particularly associated with the use of antipsychotics and SSRIs.
So how worried should people be if they are on those prescription drugs and have had or plan to have dental implants?
Professor Justin Durham, senior scientific adviser to the British Dental Association, described the results as “interesting” but said more research was needed before any definitive conclusions could be made and that clinical guidelines would not change based on the results of the study .
“The mechanism by which these antidepressants might affect the attachment of teeth and implants to the oral bone is complex and has yet to be fully explored and understood,” he says.
Antipsychotics — prescribed for bipolar disorder, major depression, and schizophrenia — can also cause problems for dental implants, as they can also cause teeth grinding
“While the study is interesting, there is only a small number of patients, and as the authors point out, there are other contributing factors that could also influence failure in this group.” For example, the study could not rule out that the depression of the patients themselves – and not the SSRIs – influenced the outcome of their implant surgery.
For example, it could be that elevated levels of the stress hormone cortisol in people with depression could help promote inflammation and gum disease.
In addition, “the diverse behavioral symptoms of depression also include low levels of motivation, which can impact people’s ability to maintain oral health, with a consequent increased risk of gum disease, combined with the stimulation of inflammation by the cortisol stress response,” says Professor Durham.
In other words, a bad mood can contribute to a lack of motivation to take care of their teeth.
Rhona Eskander, a dentist at Chelsea Dental Clinic in London, suggests that if you suffer from bruxism and take antipsychotic medication, you “may need a night watchman”.
This isn’t the first study to highlight how prescription medications can affect the outcome of a dental procedure.
Bisphosphonates — used to treat osteoporosis (a disease that makes bones more likely to break) and some cancers — can prevent the mouth from properly recovering from dental work that involves surgery like implants or gum therapy, says Alan Clarke , Dentist and Clinical Director at Paste Dental in Belfast.
Bisphosphonates, prescribed to one in 10 postmenopausal women in the UK (according to a 2019 study in Bone magazine), slow the breakdown and resorption of old bone.
The problem for dental patients is that the drug accumulates in areas of high bone turnover, such as the in the jaw, and can reduce blood flow to the bone.
If the patient’s treatment is not properly managed, the socket will not heal after a tooth is removed: the teeth may become loose and the bone may even die (a process known as necrosis), “with far more severe symptoms and more permanent.” than the planned dental procedure,” says Alan Clarke.
“For example, someone might have a toothache and decide to have the tooth removed. However, if this is not managed properly, necrosis of the jawbone can occur due to the bisphosphonate medications, and an oral surgeon may need to surgically remove a large portion of the jawbone under general anesthesia.
‘As such, the patient requires much more rigorous and radical treatment than extraction of a sore tooth or removal of a small area of residual infection – all to address the impact bisphosphonates have had on the outcomes of a normally routine dental procedure performed under local anesthesia.’
Whenever possible, patients taking bisphosphonates should have a root canal instead of having the tooth extracted, Alan Clarke adds.
He cites advice dentists received in a 2013 review of this medication-related problem published in the Journal of Oral Biology and Craniofacial Research.
Patients may also need regular X-rays to check for dead tissue. In complex cases that require surgery, a serum CTX test, which measures the rate of bone turnover, can be done to assess risk before surgery.
Alan Clarke adds that because bisphosphonates have a particularly long half-life, “they can continue to impair healing for many years after the drug is stopped, depending on how long the previous treatment lasted.”
SSRIs can also cause teeth grinding, which can put pressure on implants, the researchers said in the British Journal of Oral and Maxillofacial Surgery. The drug can alter levels of the chemical dopamine in the brain, which is involved in muscle control
“As documented in the New England Journal of Medicine in 2007, bisphosphonates were detectable in patients up to eight years after active intravenous therapy [intravenous] Bisphosphonates,” says Alan Clarke.
“So my advice is to always give your dentist a full medical history, even if you don’t think it’s relevant – it just might be.”
He adds reassuringly: “These drugs would have no effect on fillings, root canals, crowns or other restorative dentistry such as veneers [any ‘restorative’ work involves fixing the teeth you have and keeping them in place].’
Other types of medications that can cause problems are anticoagulants. “Drugs like clopidogrel are widely used to reduce the risk of heart disease and stroke in high-risk individuals,” said Nilesh Parmar, a dentist with a special interest in implant dentistry at Parmar Dental in Southend-on-Sea, Essex.
“The risk for dental patients is excessive bleeding when undergoing a procedure such as tooth extraction or dental implant placement. In most cases, we can perform the operation along with suturing the wound with hemostatic agents – sponges that we use that help blood clots to form.
“But if the dentist knows the patient is on an anticoagulant, we can contact their doctor to temporarily stop their medication so we can perform the surgery.”
He adds: “As long as the patient is aware that they may bleed longer than usual, most cases are fine.
“But I prefer to do these procedures in the morning so we can monitor the patient if necessary before sending them home.”
dr Adds Parmar, “Routine procedures like cleaning and fillings are largely unaffected.”
Immunosuppressive drugs, which help “quiet” the immune system and are used to treat autoimmune diseases such as rheumatoid arthritis and Crohn’s disease, can also interfere with treatment.
Because they reduce the body’s normal healing and defense mechanisms, ‘the surgical site [for dental implants, for instance] may not heal as effectively and could therefore be compromised,” says Richard Moore, Specialist in Oral Surgery and Clinical Lecturer at the University of Leeds. “As such, patients are susceptible to osseointegration failure and overall implant failure.”
As a simple rule of thumb, if your dentist asks you questions at the beginning of the appointment before any oral surgery, including fillings, “tell him your medical history and medications,” adds Richard Moore.
“This is incredibly important for all dental treatments, but also for the holistic care of your dentist,” he says.