Dental Implants as a Prosthetic Option in Epidermolysis Bullosa

Why Oral Manifestations of Epidermolysis Bullosa Can Pose Prosthetic Challenges?

• Epidermolysis bullosa (EB) is a unique and rare inherited skin disease or condition with a genetic origin. This condition is known to be a genetically recessive disease of the skin, particularly of the body's mucosal membranes. The patients affected by EB are usually characterized clinically by the presence of trauma-induced bullae (large blisters filled with fluid), pseudo-syndactyly (inflamed or improper wound healing characterized by skin fibrosis) of hands and feet, as well as scar formation in these affected areas.

• This disease is of particular interest and research in the field of maxillofacial surgery, dentistry, or, specifically, in the field of dental implantology. This is because EB manifests with oral symptoms that can not only be a source of constant discomfort to the patient but also pose challenges to prosthetic rehabilitation in individuals affected by EB. The most common oral manifestation that is usually noted with EB is that of blistering in the oral mucosal membranes.

• Further, in a majority of individuals affected by EB, the oral manifestations can include the appearance of milia (tiny bumps that are whitish and occur in the oral cavity or on the oral mucosal membranes). Milia range from a diameter of usually 0.04 to 0.6 inches and are considered to be benign white papules. These are found easily in EB patients, most commonly on the palate. These milia are keratin-filled cysts when observed histopathologically, and range from microstomia (small-sized mouth), ankyloglossia or tongue tie (adherence of the tongue with the oral cavity ), moderate to severe periodontal disease (serious gum infection), hypoplasia (incomplete development) of enamel, moderate to severe dental caries, and even atrophy of the maxilla or accompanied possibly with mandibular prognathism (protrusion or bulging out of lower jaw).

Why Are Implants Preferred Over Removable Dentures in Epidermolysis Bullosa Patients?

• The most common challenge for EB patients is indeed oral prosthetic rehabilitation. For these cases, the oral surgeon, even after fabricating removable dentures, may still find that the long-term success rates are quite low for EB patients. This is because removable dentures might prove difficult often for patients with EB. This would be mainly due to the fragility of the oral membranes or mucosa, as well as the internal pressure or tiny denture-related micromovements created by wearing removable dentures.

• Current dental research shows that dental implants are more efficient in the long term for oral rehabilitation of individuals suffering from EB. The advent and advance of modern-day implantology techniques and care taken by the dental implantologist can ensure that long-term success rates can possibly be improved in EB patients.

• Additionally, EB patients who wear only removable dentures may frequently complain of the clinical side effects associated with dentures, such as oral mucosal irritation, ulcerations, or jaw pain. Hence, both in terms of efficiency in chewing as well as in preventing the common complications encountered with removable dentures in EB patients, oral surgeons have, over the last decade, researched extensively the use of implant-supported restorations.

What Are the Advantages and Research-Based Evidence of Implant Prosthesis in Epidermolysis Bullosa?

An implant-supported prosthesis can minimize the trauma created on the oral mucosa while also improving the chewing efficiency and, in turn, the long-term quality of life of patients suffering from EB. Several research studies are now investigating how best to make implant-supported restorations last for a longer duration and how to counteract the common clinical complications that are encountered because of oral bleeding, swelling, pain, and fragility in EB patients.

Current dental research shows that even though many EB patients who were rehabilitated with implant-supported prostheses continued to exhibit the oral manifestations of EB, like blisters and ulcerations, the quality of chewing as well as of adjustment to implant prosthesis was significantly higher compared to the removable dentures.

Care is usually advocated by dental implantologists to patients suffering from EB to maintain the implant prosthesis after placement with great care and following strict oral hygiene instructions or home care, followed by timely dental follow-ups or checkups. To avoid attrition (wearing off) to the prosthesis or excess pressure on the jaw bone, individuals need to follow up with the dental implantologist for best results.

Also, dental research showed that before dental implantation, EB patients usually intake food in the puree or liquid form and cannot have the potential to grind even mild to moderate hard foods because of ulcerations and fragile jaw bone, bleeding, and swelling. However, post-dental implantation, these common discomforts were significantly reduced in these individuals.

When Are Prosthetic Failures Possible?

• EB patients usually tend to lose weight and suffer from weight issues because of poor bolus and liquidized food consumption, which can impact the long-term nutritional status and systemic health of these individuals.

• Research shows that patients who were fabricated with implant prostheses reported a significant improvement in their chewing or masticatory ability for all types of foods, which led the individuals to start gaining healthy weight.

• Further, the recorded cases of dental implant failure in EB patients are estimated at a very low rate of only around 1.3 percent. These one percent of failures may be linked more to the poor systemic health status of the individual and the fragility of the jaw bone in epidermolysis bullosa condition. These prosthetic failures usually may occur in the early stages of post-dental implantation and are unlikely to be of any use in the long term in severe cases of epidermolysis bullosa.

• According to dental implantology research, individuals who reported severe oral ulcerations and microstomia, oral commissures, severe blistering or oral mucosal membranes, or rupture of bullae were found to have an early dental implant failure in one percent of reported cases. However, it should be noted that dental surgeons still consider dental implants to be the best prosthesis, ideally for EB patients, to improve their long-term quality of life.

What Care and Caution Should Be Taken By an Implantologist?

Certain operator instructions need to be followed by oral surgeons or dental implantologists placing implants in the oral cavity or EB patients. These are recommended by surgical experts as follows:

• The advocation of short dental arch rehabilitation with fixed prosthesis.

• At least three-fourths of the implant surgical sites in the maxilla or upper jaw region should be ideally prepared using osteotomes as opposed to the conventional drilling procedure that can destroy the residual alveolar process in EB patients.

• Local anesthesia is only preferred in EB compared to general anesthesia due to the risk of esophageal bullae that might occur in these patients during intubation.

• The use of smaller implant drills and dental implants of smaller diameter are advocated for long-term success rates for improving primary implant stability in the jaw bone.

Conclusion

Dental implants can hence be used to improve chewing or masticatory efficiency significantly, as well as possibly decline the oral manifestations of EB in the long term. However, more investigations are needed to confirm the success rates of dental implants in these patients. Individuals affected by epidermolysis bullosa period are required to visit the oral surgeon or dentist every three to six months to ensure the long-term prosthetic success of the dental implants, which are more efficient than removable dentures to improve the quality of life.