Diabetes Mellitus and Dental Implant Considerations
10 Dec 2024
Over 500 million people worldwide live with metabolic disease, and a large portion of this population is still undiagnosed. Almost (67.2%) of the world population visits Dentist than physicians (52.2%) thus increasing the chances of encountering a patient with DM, either diagnosed or not, amongst the practicing dentists (Magliano & Boyko, 2021; Mirza et al. 2018). (1) Diabetic patients presented a statistically significant higher risk of dental implant failure and higher marginal bone loss than non-diabetic patients attributed to the deleterious effects of diabetes mellitus on physiological functions of the human body. Hyperglycemia associated DM worsens bone mineral density resulting in increased risk of fractures. This arises from the release of increased urinary calcium excretion and advanced accumulation of glycation products inducing pro-inflammatory state resulting in lower insulin-like growth factor 1 (IGF-1) and lower pH/ acidosis. Dental implant placement is a controlled surgical aggression to the bone tissues, healing begins by deposition of blood clot, vascularization and proliferation of mesenchymal stem cells (MSCs) from the adjoining bone marrow. Under suitable circumstances MSCs differentiate into osteoblasts followed by osteogenesis promoting compaction of woven bone resulting in bone remodeling around the surgical site in due course of time. (2) Clarity on essential information regarding DM patient care is required by synthesizing the available guidelines and scientific papers to help in decision-making.
According to numerous guidelines, "therapy targets" for glycemic levels are often recommended based on the patient's glycated hemoglobin level (HbA1c). The level suggests the patient’s average blood glucose for the last 2-3 months; therefore, it holds specific information on the quality of glycemic control thus stating the impact on intraoral health (Diabetes Care, 2021; Mauri-Obradors et al. 2017). The two most widely accepted practices to assess the patient’s HbA1c level are:
1. Conventional blood testing through laboratory analysis,
2. Point-of-care devices, which uses just a few drops of capillary blood right in the dental office.
In Diabetic patients, hyperglycemia causes dysfunction of immunological response by following cascade of mechanisms:
1. Suppression of cytokine production
2. Initiation of innate immune response
3. Inflammation
4. Adaptive immune response
5. Phagocytosis
6. Impairment
7. Inhibition of complement effectors
8. Dysfunction of immune cells
9. Reduced leukocytes
All these micro-vascular complications contributing to undermined bone healing and reduced bone matrix results in delayed osseo-integration and neo-angiogenesis, causing delayed development of blood vessels, proliferation and differentiation of endothelial cells resulting in negative clinical outcome on dental implant stability. Higher HbA1c suggestive of elevated and poor glycemic levels are linked with greater prevalence of Peri-implantitis with greater MBL (Marginal Bone Loss).
According to International Diabetes Federation, MBL is defined as “loss in apical direction of an alveolar bone marginally adjacent to dental implant, in relation to the marginal bone level initially detected after the implant was surgically placed (only long-cone parallel technique for Peri-apical radiographs were considered). While numerous studies have focused on various periodontal therapy in attaining improved glycemic control in DM patients, only a limited number of studies have actually reviewed the peri-implantitis associated and the impact of Diabetes on oral bone regeneration and augmentation techniques during implant placement.
The International Diabetes Foundation (IDF) and European Federation of Periodontology (EFP) has recommended to measure the patient’s HbA1c level during the treatment planning phase of dental implant placement (Madrid consensus conference in 2017). According to Sanz et al. 2018 a regular dental visit can prevent long-term oral complications in patients with DM. A recent meta-analysis by Monje et al. 2017, has shown a significant association between Diabetes Mellitus and peri-implant inflammation, with DM patients having a 50% higher risk of developing peri-implantitis compared to those without systemic health issues, also the survival rate of dental implants in well-controlled diabetes patients ranges between 92.3-92.4%, which resulting in a safe and well-accepted Osseo-integration of the implant and Peri-radicular structures. Prescription consisting of non-alcoholic antiseptic oral rinses and suitable antibiotic regime further ensures and improves the chance of success in the critical healing period (Singh et al. 2019; Wagner et al. 2022). Poorly controlled DM significantly impacts implant stability, leading to a notable decrease during surgical placement compared to well-controlled cases. Moreover, the duration for stability to revert to baseline is nearly twice as long in these scenarios (Oates et al. 2009). Wagner et al. concluded a higher occurrence of Peri-implantitis resulting in implant loss in poorly controlled DM.
American Diabetes Association 2021 proposed to necessary measure patient’s HbA1c level at least twice a year in the case of reasonable control and quarterly in the case of poor control DM. Failure rates among patients with different types of diabetes suggested that Type 1 DM are much probable to lose an implant than Type 2 DM. Both Type1 & Type 2 are heterogeneous metabolic diseases, where Type 1 DM is caused by cellular-mediated autoimmune destruction of the pancreatic Beta-cells with unknown etiology, Type 2 DM have relative insulin deficiency leading to peripheral insulin resistance with progressive loss of Beta-cells function. Type 1 DM is earlier onset resulting in micro & macro vascular complications, early bone loss, compromised implant site, higher loss of life expectancy due to higher cardiovascular diseases and acute metabolic disorders. Type 2 is abnormal osseous architecture with compromised skeletal quality. A Well-controlled glycemic status is under 7% HbA1c (53 mmol/ml) for most non-pregnant adults without significant hyperglycemia and less stringent 8%HbA1c for patients with short life expectancy (Diabetes Care, 2021). The proposed baseline varies with many personal attributes such as age, pregnancy, health and hemoglobin disorders. In 2018 consensus report for the Study of Diabetes by ADA and the European Association most non-pregnant adults with a longer life expectancy, the goal of glycemic control is set around 7% HbA1c (53 mmol/ml) (Buse et al. 2020). The Australian Diabetes Society recommends maintaining glycemic control around 7%, with the option to adjust it to 6% or 8% depending on individual factors and needs (Cheung et al. 2009). American Academy of Periodontology and the European Federation of Periodontology, the new classification of periodontal diseases according to the glycemic control levels, grades periodontitis to “B” if the patient suffers from DM, with HbA1c below 7%, and grade is upgraded to a more severe “C” category if the glycemic score is above 7% (53 mmol/ml) (Tonetti & Sanz, 2019).
The German Society of Dentistry and Oral Medicine (DGZMK) and the German Association of Implantology (DGI) states more significant glycemic indexing in recent Implantology guidelines as good control having HbA1c value between 6-8%, Moderate control between 8-10%, and finally, poor control when HbA1c glycemic index is above 10% (Wiltfang, 2023). Concluding, the guidelines suggested by various significant diabetes associations, the relaxing acceptable well controlled glycemic status applied to most patients is suggested as 7-8% (53-60mmol/ml) HbA1c. Based on the most recently available scientific evidences and guidelines issued by various world associations, suggests a glycemic target of 8% HbA1c for most patients with DM in order to mitigate potential unfavorable complications associated with this metabolic disorder. We are determined to emphasize the importance of HbA1c measurement, individual considerations, and co-operation between Dentists and Diabetologists for the success of the implant treatment. The negative effect of disease on bone metabolism has raised concerns on long term survival of dental implants. However, a recent study with finite sample size suggested no evident influence of diabetic or non- diabetic metabolism on the success or failures of the surgically placed implants. However, this limited spectrum of study is not enough to suggest a conclusive results thus additional studies are needed for better understanding and comparison of the data.
About Author:
Dr. Pankaj Dhawan, a renowned Prosthodontist, holds a Bachelor of Dental Surgery from Kuvempu University and a Master of Dental Surgery from AIIMS, New Delhi. He is currently the Professor and Head of the Department of Prosthodontics at Manav Rachna Dental College, Faridabad. With over 22 years of teaching experience, he has published over 75 papers and authored 10 books. Dr. Dhawan is a member of several prestigious dental societies and has received multiple awards, including the Medal of Excellence in Academics and the Best Teacher award. His expertise lies in dental implants, lasers, and full mouth rehabilitation.
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