|Year : 2015 | Volume
| Issue : 2 | Page : 47-50
Dental implant in diabetic patients: Statement of facts
Rajashree D Jadhav, Ajay V Sabane, Paresh V Gandhi, Amit Thareja
Department of Prosthodontics, Bharati Vidyapeeth Deemed University, Dental College and Hospital, Pune, Maharashtra, India
|Date of Submission||21-Oct-2012|
|Date of Acceptance||21-Aug-2014|
|Date of Web Publication||11-Aug-2015|
Dr. Rajashree D Jadhav
Department of Prosthodontics, Bharati Vidyapeeth Deemed University, Dental College and Hospital, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Dental implants have become ideal treatment modality in patients with missing teeth. As implants are directly anchored into bones, they provide stability, a more natural appearance, and minimize the risk of bone resorption and atrophy. Diabetes mellitus is classified as a risk factor for implant treatment, and severe or poorly controlled diabetes mellitus has been suggested to be a contraindication for treatment with dental implants. Diabetic patients experience delayed wound healing, which affects the osseointegration process. Diabetes mellitus may impair bone healing after dental implant placement. As a result of that, failure rate of dental implant in diabetic patients is much higher than that in non-diabetic patients. Some studies show that individuals with well-controlled diabetes have implant survival rates similar to those of controls without diabetes. This article presents various aspects of diabetes and its effects on osseointegration and implant success.
Keywords: Dental implant, diabetes, glycemic control, osseointegration
|How to cite this article:|
Jadhav RD, Sabane AV, Gandhi PV, Thareja A. Dental implant in diabetic patients: Statement of facts. Indian J Oral Sci 2015;6:47-50
|How to cite this URL:|
Jadhav RD, Sabane AV, Gandhi PV, Thareja A. Dental implant in diabetic patients: Statement of facts. Indian J Oral Sci [serial online] 2015 [cited 2019 Dec 6];6:47-50. Available from: http://www.indjos.com/text.asp?2015/6/2/47/162628
| Introduction|| |
Dentists and scientists have for a long time been researching materials and techniques for providing predictable, efficient, and effective methods of restoring a depleted dentition. Dental implants have become ideal treatment modality in patients with missing teeth. Implant treatment is an attractive substitute to fixed/removable prosthetic appliances. In spite of the impressive success rates of osseointegrated dental implants, failures occur. Implant failures may occur early (primary) after implant placement or after the implant is loaded (secondary). There is no single etiological factor for implant failure. Failures occur due to poor surgical technique, host factors that impair healing, poor bone quality, peri-implant infections, poor prosthesis design, and traumatic loading conditions.  The impact of diabetes on dental implants has not yet been cleared up. Despite the higher risk of failure in diabetic patients, maintaining adequate blood glucose levels along with other measures improves the implant survival rates in these patients.
Diabetes and its systemic and oral implications
Diabetes mellitus is a group of metabolic disorders characterized by an increase in plasma glucose levels. This hyperglycemia is the result of a defect in insulin secretion, insulin action, or both. Diabetes is the most prevalent endocrine disease affecting 5 to 10% of the population. Type 1 DM (Previously defined as insulin-dependent DM) is caused by the autoimmune destruction of β-cell, which leads to partial or complete insulin deficiency. Clinical findings of Type 1 diabetes are polyuria and thirst, weakness and fatigue, polyphagia and weight loss, recurrent blurred vision, vulvovaginitis or pruritus, peripheral neuropathy, and nocturnal enuresis. Laboratory findings are glucosuria, ketonuria, and high fasting glucose level >140 ml/dl. Type 2 DM (previously defined as non-insulin-dependent DM) develops in response to genetic and environmental factors and is characterized by variable degrees of insulin resistance in peripheral tissues, impaired insulin secretion, and increased glucose production.  Clinical findings of type 2 diabetes such as polyuria, weakness, fatigue, recurrent blurred vision, vulvovaginitis, and peripheral neuropathy; along with the laboratory findings are same as type 1. Diabetes is associated with many systemic complications like microvascular and macrovascular diseases, increased susceptibility to infection, and altered wound healing. This increases the risk of postsurgical complications after any surgery, including dental implant surgery. Diabetes is a major risk factor for periodontal disease. Diabetes negatively impacts bone metabolism, with decreased osteoblast differentiation and proliferation, decreased collagen production, and osteoblast apoptosis having been demonstrated in hyperglycemic environments.  In the oral environment, it has been associated with xerostomia, increased levels of salivary glucose, swelling of the parotid gland, and an increased incidence of caries.  As life expectancy continues to rise in populations worldwide, particularly in the developmental world, dentists are more and more likely to treat patients who have developed diabetes mellitus. 
Glycosylated hemoglobin assay
The use of dental implants in diabetic patients is controversial. In patients with diabetes, dental implant therapy has been considered a contraindication.  Although it is generally accepted, the patients with controlled diabetes have similar rates of success for dental implants as healthy individuals.  This controversy is further demonstrated as implant failure rates were found to correlate with the duration of disease but not with levels of hemoglobin ArC (Glycosylated hemoglobin). It is for sure that dental implants are usually contraindicated in poorly controlled diabetic patients. Glycosylated Hemoglobin Assay or HbA 1c should be evaluated before implant surgery. This assay allows the determination of the average glucose level over the 2-3 months preceding the test. A normal HbA 1c is less than 6%. There is strong evidence that improved glycemic control decreases the risk of long-term diabetic complications  [Table 1]. One of the most important factors in preventing systemic diabetic complications such as retinopathy, neuropathy, and nephropathy is establishing good glycemic control. Diabetic patient can manage their glycemic control through diet, exercise, and medications. Patients are now counseled and educated in proper ways to bring glucose levels as close to normal as possible. There is some evidence that better glycemic control decreases the risk for and severity of periodontal diseases.  Very few implant studies have examined the level of glycemic control in their diabetic patient populations. Hyperglycemia may negatively affect the outcome of implant therapy, and glycemic control is an essential parameter for the success of implants in individuals with diabetes.  Patients with poorer glycemic control may present an elevated risk of postoperative complications, such as infection and delayed wound healing.
|Table 1: HbA1c levels and approximate corresponding average plasma glucose levels |
Click here to view
Bone healing and diabetes
Dental implant success has been dependent on direct bone-to-implant contact. The formation of bone on and around dental implants has been achieved by the normal mechanisms of bone repair. But, bone and mineral metabolism are altered in diabetes. Diabetes decreases the rate of bone formation and alters remodeling. The mechanism of altered bone metabolism has not been fully elucidated, but it may be best explained by collagen abnormalities in response to advanced glycosylation end products (AGE). Several induced diabetic rat model investigations have indicated that there is reduction in the rate of bone formation and a reduced amount of bone-to-implant contact. This may be because of changes in the wound-healing response following implant insertion in diabetic patients. The early failure of implants could be the result of a mechanical overload of a reduced percentage of bone-to-implant contact, immature bone, or incorrectly formed bone. All of these reasons for overload are most likely related to AGE formation. The biological concepts of the diabetic effects on osseointegration may be related to the AGEs interacting with bone-forming cells, signaling proteins, and/or extracellular matrix components. Presence of AGE may produce an environment unfavorable to osseointegration. The binding of AGE may inhibit bone-forming protein from initiating bone formation. 
The animal models of Type 1 Diabetes reveal decreased bone-to-implant contact on machined surface and rough surface dental implants placed in diabetic animals compared with non-diabetic animals.  Trabecular bone volume around implant is also decreased in diabetic animals. Cortical bone remains relatively unaffected. Conversely, animal model of Type 2 diabetes have shown no difference in osseointegration or trabecular bone volume around machined surface of implant compared with non-diabetic control animals.  The existing studies in animals have evaluated histological, histomorphometric, chemical, and biomechanical parameters. Histologic analysis of the tissue healing in response to diabetic and non-diabetic animals was performed. Following placement of dense hydroxyapatite implants in rat diabetes, nearly entirely inhibited new bone formation away from the periosteum endosteum. However, at a distance, the endosteum and periosteum, only matrix calcification was reduced in diabetic rats, compared with non-diabetic control during the initial healing period. Newly formed bone around implants was immature and less organized in uncontrolled diabetic rats compared to non-diabetic controls, showing qualitative difference in newly formed bone.  Demonstrating the 14 th day after implant placement, newly formed bone surrounding implants in the diabetes induced grows less mature (woven bone) compared to that deposited around the implants in diabetic controls (lamellar bone).  On the 30 th day post-operatively, controls demonstrated higher lamellar bone deposition, whereas only a thin layer of lamellar bone surrounding the implants was evident in diabetic rats. These data indicate that diabetes may delay bone healing around implants. No statistically significant differences in bone to implant contact were reported between diabetic and non-diabetic rats 10 days after implant placement. However, 3 weeks following implant installation, diabetic rats exhibited a 50% lower bone-to-implant contact, relative to non-diabetic controls. Diabetes reduced bone formation around titanium implants and increased the number of adipocytes in the bone marrow of the diabetic rats. Bone density was found statistically significantly lower in diabetic rabbits as non-diabetic controls in areas of 200 μ and 600 μ around the implants. Thickness of bone surrounding the implant was statistically significantly lower in diabetic than in non-diabetic rats, when dense hydroxyapatite implants were inserted. However, in another study of the same experimental group where titanium implants were installed, bone thickness was lower only 84 days, but not 28 or 50 days, after implant placement, implying that type of implants used might have an effect on bone thickness.  Many experimental studies suggested that diabetes may be associated with reduced bone formation around implants and an incomplete and delayed healing response to their placement. Furthermore, newly formed bone around implant was reported immature and less organized in uncontrolled diabetic rats than in non-diabetic controls and the quality of the newly formed bone (woven bone) was demonstrated inferior to that deposited around implants in non-diabetic controls (lamellar bone).
Clinical studies indicate that diabetes is no contraindication for implant placement, on condition that it remains under metabolic control. The influence of age and duration of diabetes on the success of dental implants has been investigated. Diabetes has shown that there is no association of age with the survival rates of dental implants.  Diabetic patients experience delayed wound healing, which logically affects the osseointegration process. Fiorellini et al. (2001) demonstrated a lower success rate of only 85% in diabetic patients, while Olson et al. (2000) found that the duration of the diabetes had an effect on implant success: More failures occurred in patients who had diabetes for longer periods. Fiorellini et al. (2001) also observed that most failures in diabetic patients occurred in the first year after implant loading.  Diabetes mellitus may impair bone healing after dental implant placement. Gui-Ke Zou et al. evaluated effects of the local delivery of basic fibroblast growth factor (bFGF) from poly (lactide-co-glycolide) (PLGA) microspheres on osseointegration around titanium implants in diabetic rats. The local delivery of bFGF from PLGA microspheres into areas around titanium implants may improve osseointegration in diabetic rats. 
Precautionary measures to be taken in diabetic patients
- Comprehensive health history should be obtained from every candidate for implant therapy. If the patient has a history of diabetes, additional information should be gathered about his or her current treatment 
- If the diabetic patient's metabolic control appears to be clinically inadequate, implant therapy is best delayed until better control is achieved. High levels of glucose in plasma have a negative influence on healing and bone remodeling processes. In order to ensure osseointegration of the implants, understood as the direct bond of the bone with the surface of the implant subjected to functional loading, and to avoid delays in the healing of gum tissue, it is necessary to maintain good glycemic control before and after surgery. To measure the status of blood-glucose levels in the previous 6 to 8 weeks, we have to know the HbA1c values. A figure of less than 7% for HbA1c is considered a good level of glycemic control (the normal value for healthy individuals is 3.5 to 5.5% depending on the laboratory) 
- The doctor should stress to the patient the importance of taking all diabetic medications on the days of surgery and maintaining an acceptable level of metabolic control throughout the healing period
- A ten-day regime of broad-spectrum antibiotics should be started on the day of surgery to reduce the risk of infection. The antibiotic of choice is amoxicillin (2 gr per os 1 hour previously), as the pathogens most frequently causing postoperative complications following the placement of implants are Streptococci, Gram-positive anaerobes, and Gram-negative anaerobes. Clindamycin may also be used (600 mg per os 1 hour previously), azithromycin or clarithromycin (500 mg per os 1 hour previously), and first-generation cephalosporins (cephalexin or cefadroxil: 2 gr per os 1 hour previously) only if the patient has not had any anaphylactic allergic reaction to penicillin.  In addition to antibiotic prophylaxis, the use of 0.12% chlorhexidine mouthwash has shown a clear benefit by reducing the failure rates from 13.5% to 4.4% in type 2 diabetics, during a follow-up period of 36 months. 
- Implant failure in diabetics was significantly greater than that in non-diabetics when multiple adjoining implants were placed. The larger the number of implants placed adjacent to each other in an edentulous space in these patients, the more likely they will fail because the wound is much larger. 
- The deleterious impact of smoking on osseointegration has been well documented. The combination of smoking and diabetes may substantially increase the risks of implant failure. For that reason, diabetic patients who smoke should be urged to enter a smoking cessation program before implant surgery. 
| Conclusion|| |
Although there is a higher risk of failure in diabetic patients, experimental studies have shown that the optimization of glycemic control improves the degree of osseointegration in the implants. Stabilization of glycemic control (HbA(1c) at around 7%) and preventative measures against infection can increase the success of dental implantation in diabetic patients to a satisfactory rate of 85 to 95%. 
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