|Year : 2012 | Volume
| Issue : 2 | Page : 83-87
Influence of diabetes on dental implants: A retrospective study
PSG Prakash, Dhyanand J Victor
SRM Dental College, Bharathy Salai, Ramapuram, Chennai, Tamil Nadu, India
|Date of Web Publication||10-Oct-2012|
Reader, SRM Dental College and Hospital, Bharathy Salai, Ramapuram, Chennai - 600089, Tamil Nadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: The aim of the study reports on the influence of diabetes on surgically placed dental implants.
Materials and Methods: This study reports on the results of placing implants in 34 patients with diabetes who were treated with 127 swiss plus zimmer implants.
Results: Upon uncovering, 114 of the 127 implants were found to have osseointegrated, a success rate of 94.3 percent. Of the thirteen failed implants, four occurred in each of two patients (both non-smokers), two occurred in one patient (also a non-smoker), and one occurred in each of three patients. Of the latter, one was a smoker.
Conclusion: The results of this retrospective study indicate that a high success rate is achievable when dental implants are placed in diabetic patients whose disease are under control.
Keywords: Dental implants, diabetes, implant prosthesis, osseointegration
|How to cite this article:|
Prakash P, Victor DJ. Influence of diabetes on dental implants: A retrospective study. J Dent Implant 2012;2:83-7
| Introduction|| |
Diabetes mellitus is one of the world's major chronic health problems. In Europe and Asia alone, this metabolic disorder affects an estimated 15.7 million individuals, i.e., 5.9% of the population.  Among men and women over 65 years of age, where the rates of edentulism are the highest, an estimated 19.7% of all individuals suffer from some or the other form of the disease.
A complex syndrome with more than one cause, diabetes is responsible for numerous complications affecting the whole body. 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.  Adult diabetics also experience a 2.8-3.4 times higher risk of developing periodontitis than nondiabetics.  Although there has been some conflicting evidence, diabetic patients appear to be more prone to infection. ,, Healing after surgery in the diabetic patient appears to occur more slowly, exposing the tissues to complications such as tissue necrosis.  Furthermore, animal studies indicate that streptozotocin-induced diabetes interferes with the process of osseointegration. ,
Because of such considerations, diabetes is sometimes considered a contradiction for the use of dental implants. The 1988 National Institutes of Heath Consensus Development Conference Statement on Dental Implants stopped short of explicitly stating this, but included "debilitating or uncontrolled disease" and "conditions, diseases, or treatment that severely compromise healing" among its list of contraindications for dental implants. 
Tempering concerns about the increased risk of implant failure in the diabetic patient, however, has been the growing awareness of the benefits provided by modern dental implants. First developed in the 1960s and commercially introduced 20 years later, implants represent a significantly better solution for tooth loss replacement than traditional dental appliances. Because these are anchored directly into bone, they provide complete stability, in contrast to traditional tooth-replacement alternatives such as dentures. These also minimize bone resorption and atrophy, which can cause facial collapse and the resultant appearance of premature aging. Five-year survival rates of more than 95% in studies on implants supporting mandibular overdentures have become common, , and research has demonstrated improved masticatory function and overall satisfaction in implant patients. ,
Since 1982, the worldwide market for dental implants has grown to approximately $450 million. A 1998 trend survey in the trade journal Dental Products Report stated that more than 50% of oral surgeons and periodontists reported placing more implants in 1997 than in the prior year.
At the same time, as techniques for managing diabetes have evolved, evidence has accumulated that diabetic patients who effectively control their disease incur a lower risk of various health complications than their uncontrolled cohorts. Well-controlled diabetics, for example, have been demonstrated to respond well to periodontal therapy and have fewer systemic complications than poorly controlled diabetics.  Before exogenous insulin was widely available, the caries incidence in diabetics was high, but since insulin therapy has become commonplace, most studies have failed to demonstrate increased incidences of caries in treated patients.  Similarly, rates of infection appear to be worse in uncontrolled diabetics. 
Awareness of such distinctions has resulted in a greater degree of openness to the notion that diabetic patients may be good candidates for dental implants. A few studies have directly addressed this question in recent years and yielded promising preliminary data. Kapur et al. in 1998 compared 37 diabetic patients who received conventional removable mandibular overdentures versus 52 who were fitted with implant-supported ones and concluded that implants can be successfully used in diabetic patients with even low-to-moderate levels of metabolic control.  A 1994 study found a 92.7% It is 97 percentage success which has been denoted in that symbol) implant success rate for type II diabetic patients under acceptable glucose control. 
This article reports on results obtained by the authors after placing 127 implants in 34 diabetic patients.
| Materials and Methods|| |
The study population [Table 1] included 17 male and 17 female, with an age range of 34-79 years. The average age was 62.1 years (standard deviation equaled 11.4). Two of the subjects, both male, were smokers. The diabetic status for the most part was determined from patient health histories or personal interviews. All patients were questioned about how their disease was being treated, and all were urged to strive for optimal metabolic control at the time of implant placement. In addition, a 10-day course of wide-spectrum antibiotics was begun for all subjects on the day of surgery.
Between April 2007 and May 2008, the study subjects were treated with a total of 127 implants, an average of 3.7 per person. [Table 2] shows the anatomic distribution. Virtually, all the fixtures placed were ZIMMER IMPLANT System [Figure 1]. Implant lengths were in the range 7.0-16.0 mm [Figure 2]. Approximately 97 implants were 10- to 16-mm long [Figure 3]. [Table 3] details the distribution of implants by length.
|Figure 1: SwissPlus implants (formerly called OctaPlus), 4.8 mmD, 10 mmL, and 4.1 mmD, 12 mmL, used in this case|
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|Figure 3: Remove Implant/Fixture Mount assembly from vial using fingers, drill mandrel, or screwdriver handle|
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Of the 127 total implants, 91 were placed in fresh extraction sites, while the remaining 36 were placed in osteotomies created by standard drilling techniques [Figure 4], [Figure 5], [Figure 6], [Figure 7].
|Figure 4: Round bur is used to establish initial implant location prior to using 2.3 mmD Pilot Drill|
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|Figure 5: Initiate insertion by holding Fixture Mount with fingers, drill mandrel, and screwdriver handle (for maxilla)|
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|Figure 6: With 1 mm of machined neck subcrestal and the Cover Screw covering the implantæs shoulder, about 3.5 mm is projected above the bone crest|
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|Figure 7: A 4.8 mmD, 10 mmL SwissPlus implant suspended on 6.0 mmD emergence profile Fixture Mount. Note the tapered end of implant with a cutting groove|
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Four of the 127 implants were loaded immediately after placement, all in the same patient. This individual simultaneously was fitted with 11 other implants that were not immediately loaded. Bone grafting was utilized at 31 of the 127 sites.
Thirty of the original 34 patients were followed-up through uncovering and final restoration of 77 implants. The healing period between the first- and second-stage surgeries ranged from 0 to 15.5 months, with 5.9 months being the average healing period per implant.
| Results|| |
Upon uncovering, 114 of the 127 implants were found to have osseointegrated, a success rate of 94.3%. Of the 13 failed implants, four occurred in two patients each (both non-smokers), two in one patient (also a non-smoker), and one in three patients each. Of the latter, one was a smoker.
Of the four implants that were loaded immediately,  three failed. In the same patient, a second implant that was not immediately loaded also failed.
Six of the 13 surgical failures were located in the posterior mandible, four in the posterior maxilla, two in the anterior maxilla, and one in the anterior mandible. [Table 4] summarizes the location, diameter, length, and healing period of all the failed implants.
Of the 31 grafted sites, one (3.2%) failed. Autogenous bone, Bio-oss, and a membrane were also employed at this site.
Of the 77 implants that were followed-up through final restoration, one failure was identified, a failure rate of only 6%. This implant, which was initially placed in a grafted site in the left maxilla and restored five months later, had a diameter 3.75 mm and a length 10 mm. The cause of the failure appeared to be occlusal overload caused by bruxism.
[Table 5] summarizes the results achieved by the patients at each stage.
| Discussion|| |
Although the findings of this study indicate that excellent results can be obtained when Zimmer Implant System is placed in diabetic patients, certain precautionary measures can increase the likelihood of a successful outcome.
- Adequate screening is essential. A comprehensive health history should be obtained from every candidate for implant therapy, with attention given to fundamental systemic problems. If the patient has a history of diabetes, additional information should be gathered about his/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.
- The doctor should emphasize to the patient about 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 10-day regime of broad-spectrum antibiotics should be begun on the day of surgery to reduce the risk of infection.
- The deleterious impact of smoking on osseointegration has been well documented.  Although the results of this study suggest that diabetics who smoke can experience success with dental implants, the authors believe that 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|| |
Dental implants offer significant benefits that make them of interest to a wide spectrum of patients, including the growing number of individuals with diabetes mellitus. Although uncontrolled diabetes has been shown to interfere with various aspects of the healing process, the results of this retrospective study indicate that a high success rate is achievable when dental implants are placed in diabetic patients whose disease is under control.
| References|| |
|1.||National Diabetes Data Group, National Institutes of health, Diabetes in America. 2nd ed. Bethesda, MD: National Institutes of Health; 1995. NIH Publication No. 95-1468. |
|2.||Murrah VA. Diabetes mellitus and associated oral manifestations: A review. J Oral Pathol 1985;14:271-81. |
|3.||Kiokkevoid PR. Periodontal medicine: Assessment of risk factors for disease. J Calif Dent Assoc 1999;27:135-42. |
|4.||Smith RA, Berger R, Dodson TB. Risk factors associated with dental implants in healthy and medically compromised patients. Int J Oral Maxillofac Implants 1992;7:367-72. |
|5.||Goodson WH, Hunt TK. Wound healing and the diabetic patient. Surg Gynecol Obstet 1979;149:600-8. |
|6.||Larkin JG, Frier BM, Ireland JT. Diabetes mellitus and infection. Postgrad Med J 1985;61:233-7. |
|7.||Rothwell BR, Richard EL. Diabetes mellitus: Medical and dental considerations. Spec Care Dentist 1984;4:58-65. |
|8.||Nevins ML, Karimbux NY, Weber HP, Giannobile WV, Fiorellini JP. Wound healing around endosseous implants in experimental diabetes. Int J Oral Maxillofac Implants 1998;13:620-9. |
|9.||Takeshita F, Murai K, Iyarna S, Ayukawa Y, Suetsugu T. Uncontrolled diabetes hinders bone formation around titanium implants in rat tibiae. A light and fluorescence microscopy and image processing study. J Periodontol 1998;68:314-20. |
|10.||National Institutes of Health consensus development conference statement on dental implants. J Dent Educ 1989;52:824-7. |
|11.||Donatsky O. Osseointegrated dental implants with ball attachments supporting overdentures in patients with mandibular alveolar ridge atrophy. Int J Oral Maxillofac Implants 1993;8:162-6. |
|12.||Mericske-Stern R, Zarb GA. Overdentures: An alternative implant methodology for edentulous patients. Int J Prosthodont 1993;6:153-62. |
|13.||Naert I, Quirynen M, Theuniers G, van Steenberghe D. Prosthetic aspects of osseointegrated fixtures supporting overdentures. A 4-year report. J Prosthet Dent 1991;65:671-80. |
|14.||Spiekermann H, Jansen VK, Richter EJ. A 10-year follow-up study of IMZ and TPS implants in the edentulous mandible using bar-retained overdentures. Int J Oral Maxillofac Implants 1995;10:231-43. |
|15.||Grossi S, Skrepcinski F, DeCaro T, Zambon JJ, Cummins D, Genco RJ. Response to periodontal therapy in diabetics and smokers. J Periodontol 1996;67(10-supplement):1094-102. |
|16.||Kapur KK, Garrett NR, Hamada MO, Roumanas ED, Freymiller E, Han T, et al. A randomized clinical trial comparing the efficacy of mandibular implant-supported overdentures and conventional dentures in diabetic patients. Part I: Methodology and clinical outcomes. J Prosthet Dent 1998;79:555-69. |
|17.||Shernoff AF, Colfwell JA, Bingham SF. Implants for type II diabetic patients: Intermin report. VA Implants in Diabetes Study Group. Implant Dent 1994;3:183-5. |
|18.||Balshi TJ, Wolfinger GJ. Immediate loading of Bränemark implants in edentulous mandibles: A preliminary report. Implant Dent 1997;6:83-8. |
|19.||Bain CA. Smoking and implant failure -- benefits of a smoking cessation protocol. Int J Oral Maxillofac Implants 1996;11;756-9. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]