SYSTEMIC HEALTH AND PHARMACOTHERAPY INTERPLAY IN MARGINAL BONE LOSS AROUND DENTAL IMPLANTS: A NARRATIVE REVIEW OF DIABETES, METABOLIC BONE DISEASE, SSRIS, PROTON PUMP INHIBITORS, AND LONG-TERM BISPHOSPHONATE THERAPY

Background: Long-term marginal bone loss (MBL) around osseointegrated dental implants is influenced not only by local biomechanical and biofilm-related factors but also by the systemic and pharmacological status of the host. Selective serotonin reuptake inhibitors (SSRIs), proton pump inhibitors (PPIs), poorly controlled diabetes mellitus, and long-term bisphosphonate therapy have each been implicated as modifiers of bone turnover, yet the strength, consistency, and clinical magnitude of these associations remain incompletely defined.
Objective: This narrative review synthesises the current evidence describing how these systemic conditions and medication classes alter bone remodelling and long-term peri-implant marginal bone stability, and evaluates the extent to which existing evidence is sufficient to guide clinical decision-making.
Methods: A narrative literature review was conducted using PubMed/MEDLINE, Scopus, and the Cochrane Library, supplemented by hand-searching of reference lists of relevant systematic reviews and meta-analyses published up to September 2026. Retrospective cohort studies, prospective cohort studies, systematic reviews, and meta-analyses addressing SSRIs, PPIs, diabetes mellitus, and bisphosphonates in relation to dental implant marginal bone loss or bone metabolism were included.
Results: SSRI and PPI use are each associated with modestly but consistently greater crestal and marginal bone loss around implants in retrospective cohorts, plausibly mediated through gut-derived serotonergic signalling and direct osteoclast/osteoblast inhibition, respectively. Poorly controlled diabetes mellitus (HbA1c > 8%) is associated with greater probing depth, bleeding on probing, and marginal bone loss compared with well-controlled diabetes or non-diabetic patients, whereas well-controlled diabetes shows outcomes comparable to systemically healthy patients. Long-term bisphosphonate therapy suppresses osteoclastic bone turnover and is associated with increased implant failure risk and greater marginal bone loss in meta-analyses, although the mechanistic link between jawbone turnover suppression and osteonecrosis remains contested. Across all four exposures, the underlying evidence base is dominated by retrospective, heterogeneous, and often underpowered cohorts.
Conclusion: Available evidence supports biologically plausible and clinically relevant associations between these systemic conditions/medications and long-term marginal bone loss, but causal inference is limited by study design. Prospective, adequately powered, multicentre human trials with standardised radiographic protocols and medication-exposure quantification are required to clarify the magnitude of risk and to inform evidence-based peri-implant maintenance protocols.