Dual effects of bisphosphonates on bone metabolism and implant osseointegration: mechanisms, risks and clinical strategies

Osseointegration is the fundamental mechanism facilitating the direct bonding between implants and bone tissue, which significantly influences the success and long-term stability of the implant. Bisphosphonates, potent antiresorptive agents, are widely utilized in the treatment of osteoporosis and other bone metabolic disorders due to their capacity to inhibit osteoclast activity. However, their effects on implant osseointegration present a 'double-edged sword.' Bisphosphonates inhibit mitochondrial ADP/ATP translocase through an interaction with class II aminoacyl-tRNA synthetase, leading to osteoclast apoptosis. Conversely, they also inhibit the prenylation of small GTPases, disrupting cytoskeletal integrity and vesicular transport, ultimately resulting in osteoclast apoptosis. In osteoblasts, low concentrations of bisphosphonates promote differentiation and bone formation, while high concentrations hinder bone metabolism. Animal experiments and clinical studies have demonstrated that the local application of bisphosphonates, such as through implant coatings, significantly enhances the strength of osseointegration and reduces marginal bone resorption. Furthermore, synergistic effects can be achieved when bisphosphonates are combined with parathyroid hormone or basic fibroblast growth factor (bFGF). However, systemic prolonged use of bisphosphonates, particularly through intravenous administration, may excessively inhibit bone remodeling. This can lead to increased rates of osseointegration failure, a heightened risk of jaw necrosis, and impaired soft-tissue healing. Current challenges focus on regulating the drug concentration window, resolving jawbone-specific sensitization mechanisms, and optimizing both systemic and local drug delivery strategies. In the future, it will be essential to integrate the regulation of the bone immune microenvironment, the development of novel coating materials, and multicenter clinical studies to balance efficacy and risk, thereby promoting the establishment of individualized implant treatment strategies.