# On the Association between Dental Implants, Osteoporosis and Bone Modulating Therapy
## 4 Discussion  
In the present study, the rate of EIF in three different groups were assessed: (1) non osteoporotic patients, (2) osteoporotic patients with BMT and (3) osteoporotic patients with no treatment. No statistically significant differences were found between the three groups. Bone augmentation was the only significant risk factor for EIF regardless of the study population. EIF in osteoporotic patients is a contentious issue. Several contradicting studies exist. [PERSON] et al. [17] claimed that EIF in osteoporotic patients is higher than non-osteoporotic ones. [PERSON] et al. [25], emphasizing the impact of oral bisphosphonates on implant failure, found a survival rate of 86% vs. 95% in bisphosphonate users [25]. [PERSON] et al., found that EIF odds for osteoporotic women with BMT is 2.69 (95% confidence interval, 1.49-4.86) [26]. Other studies are consistent with the present reported results. [PERSON] et al., found no increase in the EIF odds ratio in osteoporotic patients with BMT [27]. [PERSON] and [PERSON] et al., in their systemic review found that dental implant placement in osteoporotic patients with BMT is safe and has no impact on dental implant survival in the short-term [28]. In the present study, no case of ONJ was reported up to one year post-implant-supported prosthesis delivery, demonstrating the safety of placing implants in osteoporotic patients even when using BMT. Many patients receiving medications associated with ONJ have other comorbidities or conditions, which are likely to increase or may contribute to higher failure rates and the incidence of ONJ, for example, diabetes mellitus and smoking. In a recent review and meta-analysis on the impact of smoking on implant failure, they found a significant increase in the relative risk (RR) of implant failure in patients that smoked \(>\)20 cigarettes per day compared with non-smokers; RR = 4 at patient level and RR = 2.45 at implant level [29]. In the present study, we excluded heavy smokers, and among smokers no correlation was found between smokers and EIF with similar rates of smokers among non-failure and failure both at the patient and implant level. [PERSON] et al., found in a systematic review that the number of implant failures does not differ between diabetic and non-diabetic subjects [30]. In the present study, at patient level, no correlation was found between DM and EIF with similar rates of DM among osseointegrated (15.4%) and EIF groups (12%).\(\chi^{2}\) = 0.800, \(p\) = 0.371. Similarly, at the implant level (15.1%) vs. (12.3) \(\chi^{2}\) = 0.662, \(p\) = 0.416 respectively. A recent review [31] demonstrated that infection seems to have a major role in the pathogenesis of ONJ. Although there is no conclusive evidence for the infection hypothesis yet, available data have shown a robust association between local infection and ONJ development [31]. \"As evidence that systemic inflammation can promote ONJ, rheumatoid arthritis patients suffer more from ONJ with more serious and intense clinical and radiological appearance of ONJ\". As an additional support for the infection hypothesis, removal of infected ligature form mice induced periodontitis and ONJ demonstrating reduced inflammation and cessation of ONJ progression. \begin{table}
\begin{tabular}{c c} \hline
**Duration of Medication Intake (Years)** & **Number of Patients** \\ \hline
0 & 26 \\ \hline
1 & 6 \\ \hline
2 & 8 \\ \hline
3 & 9 \\ \hline
4 & 5 \\ \hline
5 & 11 \\ \hline More than 5 & 7 \\ \hline \end{tabular}
\end{table} 
Table 6: Duration of medication intake of osteoporotic patients. Consequently, implant placement was always performed in clean conditions in healed sites. Implants were not inserted in fresh extraction sites. This may explain the reason for zero ONJ cases following implant placement in the present study. To the best of our knowledge, this is the first study comparing EIF in osteoporoptic patients treated with BMT to osteoporoptic patients without BMT and to non-osteoporotic patients.