In recent years, dental implants have become increasingly popular for the rehabilitation of partially and totally edentulous patients [1]. This treatment modality has proven effective in restoring masticatory function [2,3] and, consequently, improving quality of life [4]. However, dental implants are not exempt from complications. One of the most common biological complications is peri-implant mucositis [5], a reversible inflammatory condition affecting the soft tissue surrounding the functioning implant [5,6]. Another more severe complication is peri-implantitis [7], which unlike mucositis, involves unresolving inflammation of the peri-implant tissues along with the progressive peri-implant bone loss. Clinical signs of peri-implantitis include bleeding on probing (BOP), suppuration, and radiographic bone loss (RBL) [8]. If left untreated, peri-implantitis can compromise the success of implant treatment, and may ultimately lead to implant loss [9].

Apart from that, age along with the higher incidence of systemic diseases, are considered important factors influencing osseointegration and the success of dental implant therapy [10]. Among these conditions, osteoporosis [11], a disorder of bone metabolism primarily characterized by decreased bone density and general deterioration of bone tissue [12], is closely associated with aging and reduced estrogen production [13,14]. According to recent estimates, osteoporosis affects about 19.7% (95% CI = 18 to 21.4%) of adults worldwide, with prevalence exceeding 20% in women and increasing steadily in aging populations, especially in low- and middle-income countries [15]. Moreover, the burden of osteoporosis is projected to rise sharply: modeling studies forecast that by 2030 to 2034 there could be over 260 million individuals with osteoporosis globally [16]. The reduction in bone density not only increases the risk of fractures through high cortical porosity and trabecular deterioration but may also compromise the osseointegration of dental implants and peri-implant bone stability [17,18].

Although some studies suggest a higher implant failure rates in osteoporotic patients [19-21], other studies report no significant association [22,23]. Given these uncertainties and the growing clinical importance of implant therapy in older adults affected by this disease, the present systematic review aimed to assess the prevalence of peri-implant diseases in adult patients with osteoporosis.

Protocol and registration

This systematic review was conducted in accordance with the PRISMA guidelines recommendations for its preparation and reporting [24]. The protocol of this systematic review was registered a priori in the PROSPERO database under number CRD42023399275, with no subsequent modifications. The protocol can be accessed at:

https://www.crd.york.ac.uk/PROSPERO/view/CRD42023399275

Focus question

The focus question was designed according to the Population, Exposure, Comparison and Outcome (PECO) framework [25] (Table 1): What is the prevalence of peri-implant diseases in adult patients affected by osteoporosis?

Eligibility criteria

Observational studies reporting on the prevalence or incidence of peri-implantitis or peri-implant mucositis among adult patients affected by osteoporosis.

Outcome measures

Primary outcome measures - prevalence of peri-implantitis or peri-implant mucositis:

Secondary outcome measures - implant survival:

Information sources

The electronic databases considered were: MEDLINE (PubMed), EMBASE, Scopus, and Web of Science (WoS). In addition, a complementary manual search was performed on the reference lists of the full-text reviewed studies and in the WoS Indexed Q1 periodontics and implant dentistry journals: “Journal of Clinical Periodontology”, “Clinical Oral Implants Research”, “Journal of Periodontology”, “International Journal of Periodontics & Restorative Dentistry”, “Clinical Implant Dentistry” and “Related Research, and Journal of Periodontal and Implant Science”.

Search strategies for studies identification

Comprehensive search strategies were executed in the MEDLINE (PubMed), EMBASE, Scopus, and Web of Science. The first search was conducted on August 1, 2023, and the last search was performed on April 30, 2025. Potentially eligible studies were considered regardless of their publication year. No language restrictions were applied. The search used a combination of free-text and indexed terms including: “Age-related osteoporosis”, “Osteoporosis”, “Peri-implantitis”, “Postmenopausal bone loss”, and/or “Senile osteoporosis”. The resulting search algorithms were adapted and applied for each of the database (Appendix 1).

Selection of studies

Two calibrated investigators (J.C. and K.P.), independently performed the study selection by removing duplicates, followed by screening the title and abstracts, and finally, the full-text reviewing. A third author (E.A.C.) resolved any discrepancies regarding study inclusion or exclusion. The duplicate elimination and selection processes were conducted using the Rayyan^® web application (Qatar Computing Research Institute; HBKU, Doha, Qatar [www.rayyan.ai]) [27]. If studies written in languages different from English, Spanish, French or German, were considered eligible, a translator was consulted.

Inclusion criteria

Human observational studies (i.e., cross-sectional, case-control, or cohort designs) that evaluated adult patients (≥ 18 years) diagnosed with osteoporosis or osteopenia and rehabilitated with dental implants were considered for inclusion.

Eligible studies had to include at least five patients per study group and report the prevalence of peri-implant diseases, specifically peri-implantitis (defined as progressive bone loss after functional loading and/or PD with radiographic confirmation) or peri-implant mucositis (defined as BOP in the absence of bone loss), at either the patient or implant level.

There were no restrictions on gender, ethnicity, or age for adult patients (≥ 18 years).

Exclusion criteria

Data extraction

Data extraction was independently performed by two researchers (J.C. and K.P.), using a standardized form adapted from the Cochrane Consumers and Communication Review Groups model [28]. A third author (E.A.C.) reviewed the extracted data for accuracy, and resolved discrepancies if any. When key information was missing, corresponding study authors were contacted for clarification via e-mail or, when available, through their ResearchGate profiles (www.researchgate.net).

Data were extracted as reported in the original publications. Due to variation among reporting formats (some studies reported prevalence at the patient level, others at the implant level, and some included additional clinical parameters), no attempt was made to transform or recalculate outcomes to preserve the accuracy of each study’s findings and avoid introducing assumptions that might bias the results.

Data items

A pre-designed Microsoft Excel version 2021 (Microsoft corp., Washington, U.S.A.) table was used to collect the following data from studies: (1) Study, (2) Year of publication, (3) Study design, (4) Country, (5) Age, (6) Gender, (7) Number of patients, (8) Number of implants, (9) Definition of peri-implant disease, (10) Mucositis (%), (11) Peri-implantitis (%), (12) Clinical parameters, (13) Implant location (%), (14) Antiresorptive treatment, (15) Evaluation interval, (16) Results, (17) Conclusions.

Risk of bias assessment

The risk of bias (RoB) was assessed independently and in duplicate by two investigators (J.C. and K.P.) using the Newcastle-Ottawa scale for observational studies [29]. This scale evaluates three factors: study group selection (up to 4 stars), comparability of study groups (up to 2 stars), and the exposure or outcome of interest for case-control or cohort studies, respectively (up to 3 stars). Studies scoring five or more stars were considered to have low risk of bias. A third author (E.A.C.) resolved any discrepancies in assessment.

Data synthesis

A meta-analysis was not performed due to the substantial heterogeneity among the included studies. The variability encompassed differences in osteoporosis diagnosis (densitometry vs. clinical assessment), definitions of peri-implantitis (ranging from ≥ 2 mm to ≥ 6 mm bone loss, PD cut-offs, and suppuration criteria), and unit of analysis (patient-level vs. implant-level). Moreover, several studies did not report outcomes in a comparable format. These discrepancies precluded the calculation of I² and the generation of pooled estimates. Inter-rater agreement was assessed by means of Cohen’s kappa coefficient (κ).

Selection of studies

The search yielded 321 records from electronic databases published between January 2008 and December 2023, with no additional records from manual searching. The manual search did not identify any additional eligible records. After removing 125 duplicates, 196 records remained for title and abstract screening. From these, 183 were excluded for not meeting the eligibility criteria. Three were excluded due to non-compliance with inclusion criteria. Therefore, 10 studies [22,30-38] were included in the systematic review (Figure 1). The inter-reviewer agreement for full-text analysis was 92.5% (κ = 0.85).

Exclusion of studies

The reasons for excluding three studies after full-text assessment were: two primarily analysed osteonecrosis [39,40], and one did not present the clinical parameters of interest [41] (Appendix 2).

Overview of the studies

The included studies comprised cross-sectional [30,37,38], case-control [32,33,37], and retrospective studies without a clearly defined control group [22,34,35], conducted between 2008 and 2023. Two studies were from Latin America (Peru [22] and Brazil [37]), while the majority were from Europe, including Austria [30], Spain [35,38], and Sweden [33].

Most of the included studies examined the association between systemic diseases and peri-implantitis [22,32,33,35,37,38]. Four studies exclusively focused on the relationship between bisphosphonate therapy and peri-implant diseases [30,31,34,36], with only one specifically assessing the prevalence of peri-implantitis and implant failure in postmenopausal women with osteoporosis [30] (Table 2).

Clinical description of the studies

The 10 studies included a total of 1472 patients, 260 of whom were reported as affected by osteoporosis [22,30-37]. However, one study did not clearly specify the number of patients affected by osteoporosis [38]. The pooled mean age of patients was 57.13 years, ranging from 18 [22,35], to 84 years [35]; though, some studies did not report the mean age or age range of the included patients [34,36] (Table 2).

Two studies exclusively included female participants [30,31], while the remaining studies had a significantly higher proportion of women [32-34,36,38], with an average of 66.48% of female participants across all studies. Only one study did not report the gender ratio [35]. Among the osteoporosis-affected patients, four studies provided gender-specific data [30,31,34,36], revealing that 86% (189/221) were women.

A total of 3889 dental implants were analysed, though one study did not specify the number of implants [33]. In particular, five studies reported 318 implants in patients with osteoporosis [31,32,34,36,37]; however, the remaining studies did not specify the number of implants placed in patients with osteoporosis [22,30,33,35,38].

Implant placement distribution varied across studies, with no significant differences between the upper and lower jaw, being 51% and 49% [22], 52% and 48% [30], 43% and 57% [31], 52% and 48% [32], 55% and 45% [38], respectively. On the other hand, the distribution between anterior and posterior also varied between: 57% and 43% [30], 70% and 30% [31], 18% and 82% [38]. Some studies did not report the areas where implants were placed [33-35,37].

Most studies reported osteoporosis treatment with antiresorptive drugs, mainly bisphosphonates [22,31,32,34,36]. Three studies specified that patients received bisphosphonates prior to implant surgery [31,34,36], while some restarted treatment after the osseointegration phase [31]. However, most studies did not specify bisphosphonate therapy duration or discontinuation [22,32] or whether participants received any antiresorptive therapy for the treatment of osteoporosis [30,33,35,37,38] (Table 3).

Peri-implant mucositis

Implants affected in general

Three studies reported that 283/2003 implants were affected by peri-implant mucositis (14%) [22,37,38], while 148/468 patients presented mucositis (32%) [33,37,38]. Most studies did not report mucositis prevalence at the implant level [30-36] nor at the patient level [22,30-32,34-36].

Implants affected in patients with osteoporosis

None of the included studies specified the number of implants affected by peri-implant mucositis in patients with osteoporosis. Only one study reported that one patient affected by osteoporosis (1/5 - 20%) presented peri-implant mucositis, without specifying the number of implants involved [33].

Prevalence of peri-implant mucositis in patients with osteoporosis

Only one study recorded all three variables of interest [33], reporting a prevalence of 20% (1/5 patients).

Peri-implantitis

Implants affected in general

Six studies reported 311/3093 implants with peri-implantitis (10%) [22,30-32,37,38], while at the patient level, 256/710 individuals were affected (36%) [31-33,35,37,38]. One study found no peri-implantitis [31]. Two studies reported 15/241 implant failures due to different reasons [34,36].

Implants affected by peri-implantitis in patients with osteoporosis

Two studies reported 15/62 implants with peri-implantitis (24%) [31,32], while at the patient level, four studies reported 18/204 affected patients (9%) [30,31,33,35]. One study found no peri-implantitis in osteoporosis patients [31].

Prevalence of peri-implantitis in implants affected by osteoporosis

Only one study recorded all three variables of interest [32], reporting a prevalence of 94% in 15/16 implants.

Prevalence of peri-implantitis in patients affected by osteoporosis

Four studies recorded all three variables of interest [30,31,33,35], reporting a prevalence of 22% (18/83 patients).

Implants loss and survival

Two studies reported a total of 15/241 lost implants in patients with osteoporosis [34,36]. Otherwise, one study reported an odds ratio (OR) of 44.8 (95% CI = 2.4 to 834.8) for an osteoporosis associated risk of implant failure, from a total of 12 patients with osteoporosis [22]. None of the studies provided specific implant survival rates.

Clinical parameters

The heterogeneity between the clinical parameters reported in the studies was notable. Inconsistently including different combination of the parameters: BOP [31,32-38], PD [22,31-38], suppuration [32,33,35,37,38], MBL [22,31-38], mobility [31,36], thread exposure [31], osteonecrosis [34], plaque index [35,36-38], mucosal recession [35,38], and keratinized mucosa [37]. One study did not record any clinical parameters [22]. However, the studies did not compare the clinical parameters between groups of patients with osteoporosis and control group [22,30-38] (Table 3).

Risk of bias

RoB assessment of the included studies was performed using the Newcastle-Ottawa Scale (Table 4). Studies scores ranged from 4 to 7 stars, indicating moderate to high methodological quality. Studies with higher scores, such as Shabestari et al. [31] (7/9), achieved an adequate level of quality in all three domains assessed. In contrast, studies such as Dvorak et al. [30] (4/9) had limitations in the selection and outcome domain, potentially affecting their validity. Only two studies scored less than 5 stars [30,35].

This study investigated the relationship between peri-implant diseases and osteoporosis. The overall results indicate that osteoporosis is not considered a risk factor for the development of peri-implantitis in the available literature [22,30,31,33-36,38]. A study reported similar results to ours, suggesting that the impact of osteoporosis/osteopenia is more likely associated with the process of implant osseointegration rather than with the development of peri-implant diseases [42]. Furthermore, only one study included patients with osteopenia [30], which highlights limited evidence on this association.

Only four studies in our review focused on the analysis of osteoporosis and peri-implantitis [30,31,32,35], while only one study assessed peri-implant mucositis [33]. These findings are important for clinical practice; since they provide evidence on the safety and efficacy of dental implant treatments in patients with osteoporosis. The absence of a significant association between osteoporosis and peri-implantitis prevalence in most studies suggests that patients with osteoporosis are not at higher risk of implant failure associated to progressive bone loss. This aligns previous data stating that osteoporosis should not be considered a contraindication for implant placement [43]. Similarly, D’Ambrosio et al. [44] reported that osteoporosis alone is not a determining factor for the maintenance of peri-implant health and implant loss.

This implies that bisphosphonate therapies should not be considered a critical risk factor for implant failure, as long as appropriate precautions are taken. The intake of oral bisphosphonates at low doses for the treatment of osteoporosis; in general, does not compromise implant therapy. That is, patients taking bisphosphonates do not lose more implants or suffer more implant-related complications or failures compared to patients not taking bisphosphonates [45]. Só et al. [46] using wild type rats reported no different clinical or histological signs of osteonecrosis or peri-implant diseases, even in ovariectomized animal models of osteoporosis. In summary, no significant effects of antiresorptive or antiangiogenic medications on the progression of experimentally induced peri-implantitis lesions were found [46,47].

Differences in results across studies may be due to variations between study designs, inclusion/exclusion criteria, and clinical history recording. Most of the reviewed studies focused on the relationship between a set of systemic diseases and the development of peri-implant diseases, without considering osteoporosis among them, or only considering bisphosphonate use as a variable of interest. However, only four studies included in this review specifically evaluated patients with osteoporosis as a primary variable to determine its impact on the development of peri-implant diseases [30,31,34,36].

Current evidence indicates that peri-implant disease prevalence in patients with osteoporosis is comparable to that in the general population [19,35,48]. For instance, a meta-analysis of over 29,000 implants reported similar survival rates, with only a minor increase in marginal bone loss in osteoporotic patients that did not translate into higher implant failure [12,49]. This likely reflects the multifactorial nature of peri-implant diseases, where local risk factors (such as history of periodontitis, poor oral hygiene, smoking, diabetes, and maintenance adherence) play a larger role than systemic bone density alone [35,50,51]. Osteoporosis primarily affects trabecular bone density, whereas peri-implant health is more closely linked to local bone quality and host response, which are not substantially altered in the absence of additional risk factors [30,50]. Moreover, studies consistently demonstrate that with proper surgical technique and maintenance, implant osseointegration and survival are reliable in osteoporotic patients [19,43,48,49]. Overall, osteoporosis does not appear to be an independent risk factor for peri-implant diseases, and prevalence in this population mirrors that of the general implant population, with other local and systemic factors being more influential, highlighting the importance of individualized risk assessment and standardized peri-implant disease definitions.

The Working Group 3 of the International Team for Implantology (ITI) Consensus Conferences Group 3 report [7] concluded that low-dose antiresorptive therapy does not adversely affect the rate of early implant loss. Furthermore, no studies on long-term effects or impact on peri-implant infections were included, as these topics have been poorly explored or unstudied. Thus, from a clinical perspective, these findings suggest that dental implants are a viable option for patients with osteoporosis, following appropriate protocols and closely monitoring patients. In practice, this underscores the importance of individualized treatment planning and regular follow-up, carefully balancing risks and benefits, particularly given the current lack of long-term evidence on implant outcomes in osteoporotic patients [52].

Limitations

The main limitations of the present systematic review include the variability in study designs and a lack of uniform peri-implantitis assessment criteria across the included studies. In addition, considerable heterogeneity was observed in how outcomes were reported, with some studies presenting prevalence at the patient level, others at the implant level, and some incorporating additional clinical parameters. Although attempts were made to contact study authors for clarification of missing data, not all could be resolved, and no transformations were applied in order to preserve the integrity of the original findings. This heterogeneity limited the across studies and precluded the conduct of a meta-analysis, as differences in study methodologies, osteoporosis definitions, and outcome measures made statistical pooling and heterogeneity assessment (e.g., I²) unreliable.

Consequently, findings were synthesized narratively, which restricts the strength of quantitative conclusions but allowed identification of consistent patterns and gaps in the evidence. Furthermore, the relatively small number of included studies and sample sizes may limit the generalizability of the conclusions. Future research with larger and more diverse populations, standardized definitions and methodologies, and long-term follow-up is needed. Particular attention should also be given to factors such as bone quality, implant type, duration of bisphosphonate use, and broader geographic and demographic representation to provide a more comprehensive understanding of implant outcomes in patients with osteoporosis.

In conclusion, peri-implantitis prevalence ranged from 9% at the patient level to 24% at the implant level, while peri-implant mucositis was scarcely reported, with one study noting a prevalence of 20% in osteoporotic patients. Moreover, osteoporosis was not consistently associated with higher implant loss. Given the small number of osteoporosis-specific reports and substantial heterogeneity, the current evidence suggests that implant therapy remains feasible in this population, without reporting increased prevalence of peri-implant diseases or implant loss.