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 Table of Contents  
REVIEW ARTICLE
Year : 2018  |  Volume : 10  |  Issue : 2  |  Page : 96-100

Dental implants in type 2 diabetic patients: A review


1 Department of Oral Medicine and Radiology, Government Dental College, Aurangabad, Maharashtra, India
2 Department of Prosthodontics, CSMSS Dental College, Aurangabad, Maharashtra, India
3 Department of Oral Medicine and Radiology, Rural Dental College, Ahmednagar, Maharashtra, India

Date of Web Publication10-Sep-2018

Correspondence Address:
Vikrant Kasat
Department of Oral Medicine and Radiology, Government Dental College, Aurangabad - 431 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jorr.jorr_6_18

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  Abstract 


India has the second largest number of people living with diabetes worldwide, after China. As periodontal disease is the sixth major complication of diabetes, these patients are at increased risk for teeth loss. Dental implants have been recognized as an acceptable treatment method for the replacement of missing teeth, but diabetes mellitus is considered a relative contraindication for dental implant therapy. Due to this, these patients may be denied the benefit of dental implants. Hence, this review was done with the aim of reporting findings of various implant studies conducted in diabetic humans so as to improve the understanding of the possibilities for implant therapy in patients with diabetes.

Keywords: Dental implants, diabetes mellitus, glycosylated hemoglobin


How to cite this article:
Kasat V, Ladda R, Ali I, Farooqui AA, Kale N. Dental implants in type 2 diabetic patients: A review. J Oral Res Rev 2018;10:96-100

How to cite this URL:
Kasat V, Ladda R, Ali I, Farooqui AA, Kale N. Dental implants in type 2 diabetic patients: A review. J Oral Res Rev [serial online] 2018 [cited 2018 Dec 14];10:96-100. Available from: http://www.jorr.org/text.asp?2018/10/2/96/240927




  Introduction Top


Diabetes mellitus is a chronic disorder of carbohydrate metabolism characterized by hyperglycemia.[1] It occurs when the pancreas does not produce enough insulin (type 1) or when the body cannot effectively use the insulin that it produces (type 2).[2] Type 2 diabetes comprises 90% of diabetes cases.[3] Approximately 415 million people worldwide, or 8.8% of adults aged 20–79 years, are estimated to have diabetes.[4] The World Health Organization estimates that globally, high blood glucose is the third highest risk factor for premature mortality, after high blood pressure and tobacco use.[5] India (69.2 million) is home to the second largest number of adults living with diabetes worldwide, after China (109.6 million).[4]

Dental implants have been recognized as an acceptable treatment method for the replacement of missing teeth. A number of patient and procedure-related parameters determine the success of the implant treatment.[6] Glycemic control is viewed as a critical variable in identifying whether patients with diabetes are eligible for implant therapy.[7] If diabetes remains uncontrolled, then the high concentrations of extracellular glucose covalently bond to macromolecules in the body. Eventually, these bonds become irreversible and form advanced glycosylation end products. They inhibit normal organ function by depositing in unwanted areas, leading to complications such as nephropathies, neuropathies, and retinopathies.[3],[8] There is delayed wound healing, increased risk of infection associated with a diminished immune response including neutrophil and lymphocyte function, chemotaxis, and phagocytosis and altered bone metabolism, as well as microvascular and macrovascular abnormalities.[3],[8] The persistent hyperglycemia in diabetic individuals inhibit osteoblastic activity, decreases collagen production during callus formation, induces apoptosis in lining cells of bone, and increases osteoclastic activity due to persistent inflammatory response. The consequent result is diminished bone formation during healing, which is observed in number of experimental animal studies.[1] Löe[9] recognized the periodontal disease as the sixth major complication of diabetes.

Since diabetes mellitus remains a relative contraindication for dental implant therapy, depending upon the person's level of glycemic control, many persons with diabetes may be denied the benefits of implant therapy.[7] Hence, this review was done with the aim of reporting findings of various implant studies conducted in diabetic patients so as to improve the understanding of the possibilities for implant therapy in patients with diabetes. A search of “PubMed” and “Google Scholar” was carried out for articles dating from 1999 up to 2017 with the keywords “diabetes AND implants,” “dental implants AND diabetes,” “oral implants AND diabetes,” “oral implants AND type 2 diabetes,” dental implants AND type 2 diabetes.” It was supplemented with hand search to identify related published articles in dental journals. For review, only those articles published in English and studies conducted in humans were considered. Animal studies were excluded from review. Parameters such as publication year, number of dental implants placed, their survival rate, and follow-up period were recorded for each study.


  Dental Implants in Diabetic Patients Top


Like for any other dental procedure, diabetic patients for implants should preferably be treated in the morning with short appointment durations, with insulin or oral hypoglycemic drug taken and after eaten a normal breakfast.[8] Glycosylated hemoglobin (HbA1c) level should be determined before implant placement. HbA1c reflects the glucose levels in the blood over the previous 6–12 weeks before the test. It is expressed as a percentage of the total hemoglobin.[10] Depending on HbA1c levels, diabetic patients have been grouped into three categories, i.e., 6%–8% as well-controlled diabetes, 8%–10% as moderately controlled diabetes, and >10% poorly controlled diabetes.[11]

Balshi and Wolfinger[12] in 1999 published a study in which 227 Branemark implants were placed in 34 diabetic patients. At the time of second-stage surgery, 214 of the implants had osseointegrated giving a survival rate of 94.3%. After the final prosthesis, only one implant failed. They suggested that metabolic control is important to increase the chances of successful osseointegration of implants in diabetic patients.

Morris et al.[13] in 2000 reported the findings of 3-year follow-up of 255 dental implants placed in type 2 diabetic patients with a success rate of 92.2%. From the study, they concluded that use of preoperative antibiotic, use of hydroxyapatite plasma spray-coated implants, and use of 0.12% chlorhexidine mouthwash following implant placement resulted in the improvement in implant survival in type 2 diabetic patients compared to nondiabetic patients. The use of preoperative antibiotics improved survival by 4.5% in nondiabetic patients and 10.5% in type 2 diabetic patients.

Olson et al.[14] in 2000 reported the findings of a prospective multicenter study conducted to assess the success of 178 implants placed in the mandibular symphysis region of 89 well-controlled type 2 diabetic patients. The implants were restored with an implant-supported, Hader bar clip-retained overdenture and followed up for 5 years after loading. Of 178 implants, a total of 16 (9.0%) implants failed at various stages. After analyzing this outcome against variables such as baseline (before implant placement) and follow-up (4 months later at surgical uncovering) fasting plasma glucose, HbA1c values, subject age, duration of diabetes, baseline diabetic therapy, smoking history, and implant length, they found only duration of diabetes and implant length to be statistically significant predictors of implant failure. From this study, they supported the use of dental implants in type 2 diabetic patients.

Fiorellini et al.[15] in 2000 published the findings of a retrospective study in which 215 implants were placed in 40 diabetic patients at two clinical centers. They found that of 31 failed implants, 24 (11.2%) occurred within 1st year of prosthetic loading. Their analysis showed a survival rate of 85.7% after 6.5 years of function which is lower than that documented for the general population, but still a reasonable success rate.

Farzad et al.[16] in 2002 found a 94.1% success rate after 1 year in 25 diabetic patients in whom 38 implant-supported bridges were placed (136 implants). They concluded that diabetics who undergo dental implant treatment do not encounter a higher failure rate than the normal population if the diabetics' plasma glucose level is normal or close to normal.

Peled et al.[17] in 2003 published the findings of a study in which 41 well-controlled type 2 diabetic patients received 141 implants for retention of overdentures. A success rate of 97.3% and 94.1% was found 1 and 5 years after loading, respectively.

A study published in 2003 by Al Jabbari et al.[18] showed that diabetic patients with acceptable glucose control demonstrated a success rate of 92.7% 1 year after first-stage surgery.

Balshi et al.[19] in 2007 published a report in which 18 implants were placed in a 71-year-old diabetic patient and it was followed by immediate loading with screw-retained fixed prosthesis. They reported 100% survival rate for implants after 2.5 years.

Dowell et al.[7] in 2007 published the findings of a prospective study in which the effect of glycemic control in type 2 diabetic patients on early implant success and clinical complications was assessed. A total of 50 implants were placed in 35 individuals (10 without diabetes and 25 with type 2 diabetes). Depending on HbA1c level, diabetic individuals were grouped into well-controlled (6.0%–8.0%), moderately controlled (8.1%–10%), and poorly controlled (>10%). Over a period of 8 weeks, 48% diabetic individuals had HbA1c level changes which required them to be reclassified into another glycemic control group. All 50 implants were clinically integrated at the time of abutment placement and restoration 4 months after implant placement. There was no evidence of diminished clinical success or significant early healing complications with implants based on the glycemic control levels. They used a delayed restorative protocol that was approximately twice the time the manufacturer recommended and prescribed antibiotics to diabetic subjects for 7–10 days after placement which was longer than that for patients without diabetes (3 days).

Tawil et al.[20] published the results of a prospective study in 2008 in which 45 controlled type 2 diabetes patients and 45 nondiabetic patients received 255 and 244 implants, respectively. A survival rate was 97.2% and 98.8%, respectively, for a follow-up period of 1–12 years.

Oates et al.[21] in 2009 published the results of a prospective clinical study in which effect of glycemic control on implant stability over 4 months following implant placement was evaluated. Forty-two implants placed in 30 individuals (10 nondiabetic and 20 type 2 diabetic) were evaluated. Patients were categorized according to the HbA1C levels as follows: well controlled (6%–8%), moderately controlled (8.1%–10%), and poorly controlled (>10%). All nondiabetic individuals had HbA1c ≤6.0%. Implant stability was assessed by resonance frequency analysis at baseline and 2, 4, 6, 8, 12, and 16 weeks following implant placement. The follow-up time at which the stability returned to a level ≥baseline value, defined as the “time to healing,” was determined. They found that the time required for stability to return to baseline level (time to healing) for the moderately and poorly controlled diabetic groups was approximately double that required for the nondiabetic and well-controlled diabetic groups.

Turkyilmaz[22] in 2010 reported 1-year clinical outcome of 23 implants placed in 10 patients with well-, or moderately well-, controlled type 2 diabetes mellitus. Cement- or screw-retained fixed dental prostheses and overdentures were delivered to the patients. At 1-year follow-up, recall success rate of implants was 100%.

Inbarajan et al.[6] in 2012 published a report in which five implants were placed in five well-controlled diabetic patients. They checked crestal bone loss, bleeding on probing, and microbiological colonization around the implants for 3 months. They found a significant reduction in bleeding on probing and colonization at the end of 3 months and the bone loss was not statistically significant. All implants were well integrated in bone for the duration of the study. They concluded that dental implants can be placed in well-controlled diabetic patients.

Oates and Vargas[23] in 2012 reported the finding of their study in which the implants were placed in 100 patients with HbA1c levels over 12%. There was no difference in early healing (1 week following implant surgery) based on glycemic control. They observed that the levels of implant integration return to levels consistent with that of nondiabetic patients within the first 4–6 months following placement. Due to this delay in bone integration, they recommended delaying restoration/loading of implants for those diabetes patients who lack good control for 4 months following placement compared to the manufacturer's recommendation of 6–8 weeks in healthy patients.

Oates et al.[24] in 2014 published a study in which two implants each were placed in edentulous mandible of 117 patients. At the time of implant placement, patients received systemic antibiotic treatment for 7 days and used chlorhexidine rinse for 2 weeks to minimize postoperative complications. Implant-retained mandibular overdentures were given after a 4-month healing period (prosthetic loading was delayed for twice the time used in standard protocols). After 1 year, the survival rate was 95% in poorly controlled type 2 diabetes patients, 92.6% with well-controlled diabetes patients, and 93% in nondiabetes patients. From the study, they concluded that implant survival was not affected by elevated HbA1c levels in type 2 diabetes patients.

Gómez-Moreno et al.[25] in 2015 published a study in which one implant each was placed in 67 type 2 diabetes mellitus patients. Patients were divided into four groups according to their HbA1c levels: group 1 (<6%); Group 2 (6.1%–8%); Group 3 (8.1%–10%), and Group 4 (>10.1%). They found that bleeding on probing and marginal bone loss increased in patients with increased HbA1c levels over a period of 3 years following dental implant placement. They concluded that implant therapies for diabetic patients can be predictable if blood glucose level is well controlled.

Erdogan et al.[26] in 2015 published a study in which 22 implants were placed in type 2 diabetes mellitus patients and 21 implants in nondiabetic patients in the maxillary anterior/premolar regions. Fixed restorations supported by one or two implants were given. They reported 95% success rate in diabetic patients and 100% success rate in nondiabetic patients after 1 year of follow-up.

Aguilar-Salvatierra et al.[27] in 2016 published a study which evaluated survival of immediately loaded implants in patients with different levels of HbA1c over a period of 2 years. Thirty-three implants were placed in nondiabetic patients, 30 in patients with HbA1c value of 6.1%–8% (well-controlled), and 22 in patients with HbA1c value of 8.1%–10% (moderately controlled). They found that marginal bone loss and bleeding on probing increased in relation with higher HbA1c levels, but implant failure did not occur. They concluded that diabetic patients with moderate HbA1c values can receive implant-based treatments with immediate loading safely.

de Araújo Nobre et al.[28] in 2016 published a retrospective study that found 90.5% implant survival rate in 64 type 2 diabetic patients at 5 years.

Eskow and Oates[29] in 2017 reported the findings of their study in which two or more implants were placed in 24 poorly controlled type 2 diabetic patients (HbA1c between 8% and 12.0%). They found 98.6% survival rate after 1 year and 96.6% after 2 years. Peri-implant mucositis was identified in 29% of participants, but there was no correlation between HbA1c and the occurrences of mucositis. Their study supported the use of implants in type 2 diabetes individuals with poor glycemic control.

The key findings of this review can be summarized as follows:

  1. Success rate of implants in type 2 diabetic patients varied from 85.7% to 100% for a follow-up period of 3 months to 12 years
  2. Bleeding on probing and marginal bone loss increased in patients with increased HbA1c levels
  3. Implant survival was not affected by elevated HbA1c levels in type 2 diabetes patients
  4. There was no difference in early healing (1 week following implant surgery) based on HbA1c levels
  5. There was no correlation between HbA1c levels and the occurrences of peri-implant mucositis
  6. Time to healing for the moderately and poorly controlled diabetic groups was approximately double that required for the nondiabetic and well-controlled diabetic groups
  7. Delayed restorative protocol in poorly controlled diabetes patients resulted in clinical success of implants (loading of implants after 4 months following placement compared to 2 months in healthy patients)
  8. Immediate loading implant in diabetic patients with moderate HbA1c values was successful
  9. Duration of diabetes and implant length were statistically significant predictors of implant failure.



  Conclusion Top


From the review, it can be said that implant treatment in type 2 diabetic patients has success rate comparable to nondiabetic patients. Although it is good and also advisable to have blood sugar under control for diabetic patients, dental implants cannot be denied to a poorly controlled diabetic patient; as with some modifications (delayed protocol), good success rate has been achieved in human studies. There are good numbers of human studies in well-controlled diabetic patients but paucity of studies in poorly controlled diabetic patients. Hence, more studies should be undertaken and findings to be reported regarding implants in poorly controlled diabetic patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dubey RK, Gupta DK, Singh AK. Dental implant survival in diabetic patients; review and recommendations. Natl J Maxillofac Surg 2013;4:142-50.  Back to cited text no. 1
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World Health Organization, editor. Global Health Risks: Mortality and Burden of Disease Attributable to Selected Major Risks. Geneva, Switzerland: World Health Organization; 2009.  Back to cited text no. 5
    
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Inbarajan A, Veeravalli PT, Vaidyanathan AK, Grover M. Short-term evaluation of dental implants in a diabetic population: An in vivo study. J Adv Prosthodont 2012;4:134-8.  Back to cited text no. 6
    
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Farzad P, Andersson L, Nyberg J. Dental implant treatment in diabetic patients. Implant Dent 2002;11:262-7.  Back to cited text no. 16
    
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