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CLINICAL SCIENCE AND TECHNIQUES

Dental Implants in Patients With Type 2 Diabetes Mellitus: A Clinical Study

Peled, Micha DMD, MD*; Ardekian, Leon DDS**; Tagger-Green, Nirit DMD, MSc, MHA***; Gutmacher, Zvi DMD†; Machtei, Eli E. DMD‡

Author Information

*Head, Department of Oral & Maxillofacial Surgery, Rambam Medical Center, Technion Faculty of Medicine, Haifa, Israel.

**Senior Staff, Department of Oral & Maxillofacial Surgery, Rambam Medical Center, Technion Faculty of Medicine (RMCTFM), Haifa, Israel.

***Resident, Unit of Periodontology, RMCTFM, Haifa, Israel.

†Senior Staff, Maxillofacial Prosthetics, RMCTFM, Haifa, Israel.

‡Head of Unit, Unit of Periodontology, RMCTFM, Haifa, Israel.

Reprint requests and correspondence to:

Leon Ardekian, DDS

Department of Oral & Maxillofacial Surgery

Rambam Medical Center

Technion Faculty of Medicine

Haifa, Israel

Phone: 9724-8542345

Fax: 9724-8542557

E-mail: [email protected]

doi: 10.1097/01.ID.0000058307.79029.B1
  • Free

Abstract

Replacing missing teeth with osseointegrated dental implants is a predictable technique as evidenced by the overall 5-year implant survival rates ranging from 93% to 97%. 1,2 The first clinical application of dental implants was to retain and support a full-mouth prosthetic appliance in edentulous patients who had problems with retention or with adaptation to removable full dentures. 3

In the last 15 years the use of dental implants has been extended to provide mechanical attachment for support and retention of removable overdentures. Some authors described a protocol for placement of four implants in the anterior mandible to support an overdenture. 4,5 The implant-supported overdenture should reduce stress on the tissues and stabilize the prosthesis, 6 making it more bearable to patients. Therefore, an implant-retained overdenture can be considered a good alternative. 6,7 A 5-year survival rate of more than 95% in studies of implant-supporting mandibular overdentures was reported, and research has demonstrated improved masticatory function and overall satisfaction in implants patients. 4,5

Local and systemic factors can influence the success rate of dental implants. Adequate patient selection, treatment planning, implant design, suitable implant materials, good surgical technique, and restorative treatment are crucial for the success of the procedure. Yet it can also be negatively affected by factors such as impaired wound healing, metabolic bone disease, and smoking. 3,8,9 As implant surgery and subsequent prosthodontic restoration are becoming more popular, the demand for implant-retaining overdentures will increase.

The populations that can benefit most from this treatment modality are older persons. Improvements in medical care have created a higher percentage of senior patients suffering from an increased incidence of chronic illnesses, such as diabetes mellitus and metabolic bone disease, which may influence success rates of dental implants. Umino and Nagao 10 investigated 1012 elderly patients and found that one or more systemic diseases were present in approximately 65% of the subjects. In their study, cardiovascular diseases were the most frequent systemic diseases followed by diabetes mellitus, a disease related to an absolute or relative insulin insufficiency and the third leading cause of death in the United States. Diabetes presents in two distinct forms: the insulin-dependent and the non-insulin-dependent types. Diabetic patients are said to be more prone to develop infections and vascular complications. Tissue perfusion and microvascular diseases have an important role in wound healing. Since diabetes is associated with microvascular changes, patients with diabetes have poor wound-healing potential. The healing process of hard and soft tissues in the diabetic patient is also delayed as a result of decreased protein metabolism. It is also affected by impaired function of the neutrophilic leucocytes. 11–13 Because of such considerations, diabetes has sometimes been considered a contraindication for the use of dental implants. 14,15

We describe our experience using the MIS implant system (Medical Implant System, Shlomi, Israel) for retention of overdentures in patients with type 2 diabetes mellitus, and provide data regarding the level of satisfaction of the patients and improvements in function, mucosal and periimplant health, and bone level around implants in this group.

Materials and Methods

The group under investigation included patients with well-controlled type 2 diabetes mellitus who were referred to our clinic for insertion of dental implants in the anterior mandible, destined to serve for retention of overdentures. A prosthodontist determined the treatment planning, an oral and maxillofacial surgeon examined the patients, and these specialists then decided whether there was an indication for implant insertion and restoration as defined. Blood glucose levels were monitored and tabulated for all patients 1 week preoperatively, on the day of the operation, and 1 week following implantation. Each patient’s condition was managed and controlled by their assigned family physician. Efforts were made to meet the plasma glucose levels recommended by the American Diabetes Association (fasting plasma glucose of 140 mm/dL and 2-hour postprandial glucose of 200 ml/dL). The implants used in this study were the MIS implant system (Medical Implant System) screw type, with a 3.75-mm diameter and ranging in length from 10 to 16 mm. The second stage, uncovering, was accomplished 3 months after osseointegration of implants. Fabrication of the infrastructures, ball attachment, or bar-supporting overdenture was then started.

Periimplant health was evaluated during the observation period 3 weeks and 6 and 12 months after implantation in relation to periimplantitis, periimplant mucositis, mucosal hyperplasia, and fistula formation.

Each patient completed a questionnaire related to his or her level of satisfaction and to the improvement of function with the new dentures. All patients underwent standardized panoramic radiography preoperatively and at 3, 6, 12, 24, and 36 months after implantation. All x-rays were digitized and stored electronically using a computer-based measurement software (X-View Inc, Jerusalem), the height of the alveolar bone was measured from the top of the implant to the most apical end, all implants were submerged.

Patients were advised to continue taking their regular medication as prescribed. Eighteen patients were instructed to receive 2 g amoxicillin daily 1 day before the operation and for 5 additional days, whereas those who were allergic to penicillin (16 patients) received 600 mg clindamycin daily.

Using local anesthesia, implants were inserted in the anterior aspect of the mandible using a standard surgical technique. Patients were scheduled for follow-up visits 1 and 3 weeks and 3, 6, 12, and 36 months after implantation.

The criteria for success of the implant were stable implants and superstructures with no symptoms of pain and without signs of inflammation and purulent discharge, loss of no more than 1 mm bone around the implant in the first year, and radiolucency around implants. For the purpose of analysis we divided the patients into subgroups according to age (over 65 years and 65 years and under) and to the number of implants.

Pearson correlation coefficient test was used for statistical analysis. The Pearson coefficient of correlation measures the strength of a relationship between two variables in a population; its values range between −1 for a negative correlation to +1 for a positive correlation.

Results

The study group consisted of 41 patients (26 males and 15 females) with type 2 diabetes mellitus who were treated with dental implants. A total of 141 implants were placed; every patient received three or four implants at the anterior aspect of the mandible for retention of overdentures (Figs. 1 and 2). Four implants failed during the observation period; two during the second surgical stage and two during the 2-year period after implantation and restoration. The failed implants were mobile during the clinical examination. Success rates of 97.2% and 94.4% were observed during the first and fifth years, respectively.

F1-8
Fig. 1:
Preoperative and postoperative radiographs of a 65-year-old man before and 6 months after implantation. Fig. 2. Twelve months after implantation and restoration. Fig. 3. Clinical view of the restoration. Note the mucosal health.

Three months after implantation, implants were uncovered and restored; 24 patients received ball attachments for retention of overdentures while 17 patients received bars (Fig. 3).

A gradual elevation in glucose level occurred during the intraoperative and immediate postoperative period. One week after implantation, levels returned to near-preoperative values (Fig. 4). No correlation was found between failed implants and glucose levels in our study group.

F2-8
Fig. 4:
Graph indicating the average glucose levels in the general population versus patients with failing implants.

The majority of patients reported improvement of function, chewing, and general satisfaction from the new treatment. Only four patients (2.8%) were completely dissatisfied with their treatment and five patients (3.4%) reported no change in function with the new implant -retained overdenture. Periimplant complications were observed in three patients; these complications were confined to the mucosa only, or a combination of the mucosa and the bone. The complications appeared to be due to poor adaptation of the denture. Periimplant mucositis or hyperplasia was observed in 1 of 26 patients (3.8%) in the In the ball attachment-retained overdenture group and in 2 of 15 patients (13.3%) in the bar-retained group. A high correlation was observed between mucosal health and satisfaction from the treatment (R = 0.933)(Fig. 4). In addition a good correlation was observed between mucosal health and improvement in function (R = 0.737) and chewing (R=0.842). In the bar-retained overdenture group a good correlation was founded between mucosal health and satisfaction from the treatment (R = 0.865) and between mucosal health and improvement of function (R = 0.859) and chewing (R = 0.712). A low correlation was observed between glucose level and improvement of function. The analyses of our results show a very good correlation between males and females regarding improvement in chewing (R = 0.996), while the male:female correlation concerning satisfaction from the new treatment and mucosal health was much lower (R = 0.528)

Analysis of our results by patient age showed a better satisfaction from the new treatment in patients older than 65 years, while the improvement of chewing was equal between older and younger age groups. The analysis of the results by number of implants showed a very low correlation between number of implants and improvement of function (R = 0.217).

The main bone loss around implants was approximately 0.5 mm in the first year, and no correlation was found between bone loss and glucose level.

Discussion

Proper selection of patients for dental implants treatment is one of the most important factors that can influence the prognosis and integration of implants. A primary complication in the integration of dental implants includes traumatic surgery, in which the frictional heat generated during placement of implant causes necrosis to the surrounding tissues and consequently lack of healing and integration. 3 A second complication that interferes with bone integration is an implant recipient site of low healing potential. Some authors 10,14–17 claim that various systemic factors such as osteoporosis, diabetes, severe alcoholism, renal disease, and uncontrolled metabolic disorders increase the rate of implant failure. However, there is a lack of data regarding the influence of systemic diseases, especially diabetes mellitus, on dental implant integration and long-term success rate in humans. 18,19

Takeshita et al 18 studied differences between diabetic and nondiabetic rats treated with hydroxyapatite-coated implants in the tibia. The diabetes group showed a 30% reduction in bone contact and 50% reduction in bone thickness around implants. El-deeb et al 20 studied the response of hydroxyapatite in diabetes-induced rats. The results of the histologic analysis revealed that the reaction of the collagen fibers in the diabetic group showed a less organized healing response compared with the nondiabetic group. Nevines et al 21 observed the osseointegration of dental implants in diabetic and nondiabetic animals, histometric results indicated that the quality of bone formation was similar for diabetic and control animals; however, less bone-implant contact was observed among diabetic animals.

There are limited series and sporadic reports on the use of dental implants in diabetic patients. Some authors claim that systemic diseases decrease vascular supply to the implant bed, thus decreasing wound-healing potential—a possible risk factor for placement of dental implants. In a retrospective analysis of 104 consecutive patients treated with 313 NobelBiocare implants in a different location in both jaws, Smith et al 14 studied the potential medical risk associated with dental implant failure and found no increase in implant failure in patients with a compromised medical status, including those with diabetes mellitus. Shernoff et al 19 studied 187 implants in 89 patients with type 2 diabetes mellitus and showed a short-term failure rate of 2.2%; however, the failure rate rose to 7.3% after 1 year. This study raised the question of whether failure is related to diabetes or improper implant loading. Balshi et al 18 reported a 94.3% survival rate for implants placed in diabetic patients. The finding of our study is in agreement with others, and suggest that dental implants can be used safely in diabetic patients if a proper patient’s selection is done and if diabetes is well controlled. The majority of patients in our study reported satisfaction and improvement with treatment, though treatment satisfaction was higher in patients older than 65 years. As our results show, mucosal health is the strongest predictive value related to treatment satisfaction in this patient group. Another parameter concerning this factor is that the diabetes did not affect mucosal health. Although it can cause discomfort and impair wound healing, diabetes should not alter mucosal health if the disease well controlled.

Conclusion

The clinical outcome of dental implant placement in a selected group of patients with well-controlled type 2 diabetes mellitus is encouraging. Further investigations and clinical trails over a longer period are needed to determinate the long-term survival of implants in diverse groups of patients with diabetes mellitus.

Disclosure

The authors claim to have no financial interest in any company or product mentioned in this article.

References

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Abstract Translations [German, Spanish, Portuguese, Japanese]

AUTOR(EN): Micha Peled D.M.D., M.D.*, Leon Ardekian D.D.S.**, Nirit Tagger-Green D.M.D., M.Sc., M.H.A.***, Zvi Gutmacher D.M.D.****, Eli E. Machtei D.M.D.*****. *Leiter des Bereiches Gesichts- und Kieferchirurgie, medizinisches Zentrum Rambam, Technion medizinische Fakultät, Haifa, Israel. **Leitender Angestellter, Bereich Gesichts- und Kieferchirurgie, medizinisches Zentrum Rambam, Technion medizinische Fakultät, Haifa, Israel. ***Assistenzarzt, Abteilung fĂ¼r Orthodontie, medizinisches Zentrum Rambam, Technion medizinische Fakultät, Haifa, Israel. ****Leitender Angestellter, Kiefer- und Gesichtsprothetik, medizinisches Zentrum Rambam, Technion medizinische Fakultät, Haifa, Israel. *****Abteilungsleiter, Abteilung fĂ¼r Orthodontie, medizinisches Zentrum Rambam, Technion medizinische Fakultät, Haifa, Israel. Schriftvehrker: Leon Ardekian, DDS, Bereich Kiefer- und Gesichtschirurgie (Dept. Of Oral & Maxillofacial Surgery), medizinisches Zentrum Rambam (Rambam Medical Center), Technion medizinische Fakultät (Technion Faculty of Medicine), Haifa, Israel. Telefon: 9724 - 8542345, Fax: 9724 - 8542557.eMail: [email protected]

Klinische Studie zum Thema: Zahnimplantateinsatz bei Patienten mit Typ II Diabetes

ZUSAMMENFASSUNG: Der Erfolg einer Implantierungsbehandlung kann durch systemische Faktoren, wie zum Beispiel durch das Vorliegen eines Diabetes Mellitus (DM), gefährdet sein. SchwerpunktmĂ¤ĂŸig befasst sich die vorliegende Studie daher mit unseren Erfahrungen bei der Zahnbehandlung von Typ II Diabetes Patienten, bei denen eine Deckprothese mittels Implantaten durch Verwendung des so genannten MIS-Implantierungssystems (Medical Implant System (System fĂ¼r medizinische Implantate), Shlomi, Israel) befestigt wurde. Im Einzelnen soll die Studie Informationen bezĂ¼glich der Zufriedenheit der Patienten mit dem Behandlungsergebnis, der Verbesserung der Funktionalität, des Zustandes der Schleimhäute und des um das Implantat gelegenen Gewebes und der Knochengewebsdichte im das Implantat umlagernden Knochen liefern. Methoden: Zur Untersuchung wurden 41 Patienten mit festgestelltem Typ II Diabetes herangezogen. Insgesamt wurden dieser Patientengruppe 141 Implantate zur Deckprothesenbefestigung eingepflanzt. Ergebnisse: Die bei den Nachuntersuchungen ein Jahr bzw. fĂ¼nf Jahre nach erfolgter Implantation ermittelte Erfolgsrate lag bei 97,3% bzw. 94.4%. Nach Meinung der meisten Patienten erhöhte sich die Funktionalität in Folge der neuartigen Behandlungsmethode. Enorme Bedeutung wurde dem Zusammenwirken von gesunder Schleimhaut und Funktionsverbesserung beigemessen. Die Untersuchungsergebnisse lassen keinen RĂ¼ckschluss auf einen Zusammenhang zwischen dem Fehlschlagen einer Implantationsbehandlung und dem Blutzuckerspiegel zu. Schlussfolgerung: Innerhalb der von uns zur Implantierungsbehandlung ausgewählten Gruppe von Patienten mit einer guten Einstellung des Typ II Diabetes zeigten die klinischen Versuchsreihen bei Zahnimplantierungsbehandlungen sehr zufrieden stellende Ergebnisse. Sind diese Ergebnisse auch ermutigend, so bedarf es doch noch weiterfĂ¼hrender Forschungsreihen und Untersuchungen Ă¼ber einen längeren Zeitraum hinweg, um detaillierte Erkenntnisse Ă¼ber den langfristigen Behandlungserfolg nach Einsatz von Zahnimplantaten bei verschiedenen Gruppen von an Typ II Diabetes erkrankten Patienten zu gewinnen.

SCHLĂœSSELWĂ–RTER: Erfolgsrate, Diabetes, Zahnimplantate, Periimplantitis, Blutzuckerspiegel

Implantes dentales en pacientes con diabetes tipo II; un estudio clĂ­nico

AUTOR(ES): Micha Peled D.M.D., M.D.*, Leon Ardekian, D.D.S.**, Nirit Tagger-Green, D.M.D., M. Sc., M.H.A.***, Zvi Gutmacher DMD****, Eli E. Machtei D.M.D.*****. *Jefe del Departamento de CirugĂ­a Oral y Maxilofacial, Centro MĂ©dico Rambam, Facultad de Medicina de Technion, Haifa, Israel. **Personal Superior, Departamento de CirugĂ­a Oral y Maxilofacial, Centro MĂ©dico Rambam, Facultad de Medicina de Technion, Haifa, Israel. ***Residente, Unidad de PeriodontologĂ­a, Centro MĂ©dico Rambam, Facultad de Medicina de Technion, Haifa, Israel. ****Personal Superior, ProstĂ©tica Maxilofacial, Centro MĂ©dico Rambam, Facultad de Medicina de Technion, Haifa, Israel. *****Jefe de Unidad, Unidad de PeriodontologĂ­a, Centro MĂ©dico Rambam, Facultad de Medicina de Technion, Haifa, Israel. Correspondencia a: Leon Ardekian, DDS, Dept. of Oral & Maxillofacial Surgery, Rambam Medical Center, Technion School of Medicine, Haifa, Israel. TelĂ©fono: 9724-8542345, Fax: 9724-8542557. Correo electrĂ³nico: [email protected]

ABSTRACTO:PROPĂ“SITO: Factores sistĂ©micos, tales como la diabetes mellitus (DM) pueden influenciar el Ă©xito de los implantes dentales. El propĂ³sito de este estudio es describir nuestra experiencia usando el sistema de implante MIS (Medical Implant System Shlomi, Israel) para la retenciĂ³n de sobredentaduras en pacientes con diabetes tipo II. DeberĂ­a proporcionar datos sobre el nivel de satisfacciĂ³n de los pacientes, la mejora de la funciĂ³n, salud mucosal y periimplante y el nivel del hueso alrededor de los implantes en este grupo. MÉTODOS: El grupo de estudio consistiĂ³ de 41 pacientes con diabetes mellitus tipo II quienes recibieron 141 implantes para la retenciĂ³n de sobredentaduras. RESULTADOS: El Ă©xito fue del 97,3% y 94,4% luego de uno y cinco año posteriores a la colocaciĂ³n del implante. La mayorĂ­a de los pacientes indicaron una mejora en la funciĂ³n luego del nuevo tratamiento. Se observĂ³ una alta correlaciĂ³n entre la salud mucosal y la mejora de la funciĂ³n. No se encontrĂ³ correlaciĂ³n entre los implantes fallados y el nivel de glucosa. CONCLUSIĂ“N: El resultado clĂ­nico de los implantes dentales en un grupo seleccionado de pacientes con diabetes mellitus II bien controlada es satisfactorio y positivo. Se necesitan investigaciones adicionales y pruebas clĂ­nicas durante un perĂ­odo largo de tiempo para poder determinar le supervivencia a largo plazo de los implantes en diversos grupos de pacientes que sufren de diabetes mellitus.

PALABRAS CLAVES: tasa de Ă©xito, diabetes, implantes dentales, perimplantitis, nivel de glucosa

Implantes odontolĂ³gicos em pacientes com diabetes do tipo II: estudo clĂ­nico

AUTOR(ES): Micha Peled, D.M.D., M.D.*, Leon Ardekian, D.D.S.**, Nirit Tagger-Green, D.M.D., M.Sc., M.H.A.***, Zvi Gutmacher, D.M.D.****, Eli E. Machtei, D.M.D.*****. *Chefe do Departamento de Cirurgia Oral e Maxilofacial, Centro MĂ©dico Rambam, Faculdade de Medicina do Technion, Haifa, Israel. **Equipe SĂªnior, Departamento de Cirurgia Oral e Maxilofacial, Centro MĂ©dico Rambam, Faculdade de Medicina do Technion, Haifa, Israel. ***Residente, Unidade de Periodontologia Centro MĂ©dico Rambam, Faculdade de Medicina do Technion, Haifa, Israel. ****Equipe SĂªnior, ProtĂ©tica Maxilofacial, Centro MĂ©dico Rambam, Faculdade de Medicina do Technion, Haifa, Israe. *****Chefe da Unidade, Unidade de Periodontologia Centro MĂ©dico Rambam, Faculdade de Medicina do Technion, Haifa, Israel. CorrespondĂªncias devem ser enviadas a: Leon Ardekian, DDS, Department of Oral & Maxillofacia Surgeryl, Rambam Medical Center, Technion Faculty of Medicine, Haifa, Israel. Telefone: 9724-8542345, Fax: 9724-8542557. email: [email protected]

SINOPSE: Objetivo: fatores sistĂªmicos, como diabetes mellitus (DM) podem influenciar o Ă­ndice de sucesso de implantes odontolĂ³gicos. Este estudo tem como propĂ³sito descrever nosso experimento ao usarmos o sistema de implante mĂ©dico (MIS, ou Medical Implant System, Shlomi, Israel) para a retenĂ§Ă£o de sobredentaduras em pacientes com diabetes do tipo II. Os dados provenientes deste estudo devem fornecer informações a respeito do grau de satisfaĂ§Ă£o dos pacientes, de aprimoramento das funções, da saĂºde mucosal e periimplantĂ¡ria e do nĂ­vel Ă³sseo em redor dos implantes neste grupo. Metodologia: o grupo de estudo avaliou 41 pacientes com DM do tipo II, os quais receberam 141 implantes para retenĂ§Ă£o de sobredentaduras. Resultados: o Ă­ndice de sucesso foi 97,3% e 94,4% para, respectivamente, um e cinco anos seguidos da implantaĂ§Ă£o. A maioria dos pacientes registrou melhoria de funções consecutivas ao novo tratamento. Observou-se uma alta correlaĂ§Ă£o entre a saĂºde das mucosas e o a melhoria das funções. NĂ£o registrou-se correlaĂ§Ă£o entre implantes fracassados e nĂ­vel de glicose. ConclusĂ£o: o resultado clĂ­nico de implantes odontolĂ³gicos em um seleto grupo de pacientes com diabetes mellitus do tipo II bem controlada Ă© satisfatĂ³rio e estimulador.Faz-se necessĂ¡rio um nĂºmero maior de investigações e experimentos clĂ­nicos ao londo de um maior perĂ­odo de tempo, a fim de determinar a sobrevivĂªncia de implantes a longo prazo em diversos grupos de pacientes portadores de diabetes mellitus.

PALAVRAS-CHAVES: Ă­ndice de sucesso, diabetes, implantes odontolĂ³gicos, periimplantite, nĂ­vel de glicose

FIGURE

FU3-8
Figure
Keywords:

success rate; diabetes; dental implants; periimplantitis; glucose level

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