Dental Implant Diabetic Patient

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Dental Implants in the Diabetic Patient: A

Retrospective Study

Thomas J. Balshi, DDS, FACP,* Glenn J. Wolfinger, DMD, FACP*

It has become increasinglycommon for controlled diabeticpatients to be considered ascandidates for dental implants.This study reports on the results ofplacing implants in 34 patientswith diabetes who were treatedwith 227 Branemark implants. Atthe time of second-stage surgery,214 of the implants hadosseointegrated, a survival rate of94.3%. Only one failure was

identified among the 177 implantsfollowed through final restoration,a clinical survival rate of 99.9%.Screening for diabetes and trying

to ensure that implant candidatesare in metabolic control arerecommended to increase thechances of successfulosseointegration. Antibioticprotection and avoidance ofsmoking should also beconsidered. (Implant Dent. 1999;8:355-359)

Key Words: dental implants,diabetes, osseointegration,

implant prosthesis

Diabetes mellitus is one of the world'smajor chronic health problems. In theUnited States alone, this metabolicdisorder affects an estimated 15.7million individuals, 5.9% of the

(1)population. Among men andwomen over 65 years of age, wherethe rates of edentulism are highest, anestimated 18.4% of the individualshave some form of disease.

A complex syndrome with more thanone cause, diabetes is responsible for

numerous complications affecting thewhole body. In the oral environment,it has been associated withxerostomia, increased levels ofsalivary glucose, swelling of theparotid gland, and an increased

(2)incidence of caries. Adult diabeticsalso experience a 2.8 to 3.4 timeshigher risk of developing

(3)periodontitis than nondiabetics.Although there has been someconflicting evidence, diabetic patients

(4-6)seem to be more prone to infection.Healing after surgery in the diabeticpatient seems to occur more slowly,exposing the tissues to complications

(7)such as tissue necrosis.Furthermore, animal studies indicatethat streptozotocin-induced diabetesinterferes with the process of

(8,9)osseointegration.

Because of such considerations,diabetes has sometimes beenconsidered a contraindication for the

use of dental implants. The 1988National Institute of HealthConsensus Development Conference

(10)Statement on Dental Implantsstopped short of explicitly stating this,but did include debilitating or

uncontrolled disease and conditions,diseases, or treatment that severelycompromise healing within its list ofcontraindications for dental implants.

Tempering concerns about the increasedrisk of implant failure in the diabetic

patient, however, has been the growingawareness of the benefits provided bymodern dental implants. Firstdeveloped in the 1960s andcommercially introduced 20 years later,implants represent a significantly bettersolution for tooth loss replacement thantraditional dental appliances. Becausethey are anchored directly into bone,they provide complete stability, incontrast to traditional tooth-replacementalternatives such as dentures. They also

minimize bone resorption and atrophy,conditions that can cause facial collapseand the resultant appearance ofpremature aging. Five-year survivalrates of more than 95% in studies ofimplants supporting mandibular

(11,12)overdentures have become common,and research has demonstratedimproved masticatory function andoverall satisfaction in implant

(13,14)patients.

Since 1982, the worldwide market fodental implants has grown toapproximate $450 million. A 1998trend survey in the trade journal DenProducts Report reported that >50% oral surgeons and periodontists

reported placing more implants in 19than in the prior year.

At the same time, as techniques formanaging diabetes have evolved,evidence has accumulated that diabepatients who effectively control theirdisease incur a lower risk of varioushealth complications than uncontrollpatients. For example, it has beendemonstrated that well-controlleddiabetics respond well to periodonta

therapy and have fewer systemiccomplications than poorly controlled(15)

diabetics. Before exogenous insulwas widely available, the cariesincidence in diabetics was high; butsince insulin therapy has becomecommonplace, most studies have faito demonstrate an increased caries

(2)incidence in treated patients.Similarly, rates of infection

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seem to be worse in uncontrolled(5)diabetics.

Awareness of such distinctions hasresulted in a greater degree ofopenness to the idea that diabeticpatients may be good candidates fordental implants. A few studies havedirectly addressed this question inrecent years and yielded promisingpreliminary data. In 1998, Kapur et

(16)al compared 37 diabetic patientswho received conventional

removable mandibular overdenturesversus 52 who were fitted withimplant supported ones andconcluded that implants can besuccessfully used in diabetic patientswith even low to moderate levels ofmetabolic control. A 1994 studyfound a 92.7% implant success ratefor Type II diabetic patients under

(17)acceptable glucose control. Thisarticle reports on results obtained bythe authors after placing 227 implants

in 34 diabetics patients.

Methods and Materials

The study population (Table 1)included 17 males and 17 femalesranging in age from 34 to 79 years.The average age was 62.1 years (SD,11.4). Two of the subjects, bothmale, were smokers. Diabetic statuswas generally determined frompatient health histories or personalinterviews. All patients werequestioned about how their disease

was being treated, and all were urgedto strive for optimal metaboliccontrol at the time of implantplacement. In addition, a 10-daycourse of wide-spectrum antibioticswas begun for all subjects on the dayof surgery.

Between April 1987 and May 1998,the study subjects were treated with atotal of 227 implants, an average of

6.7 implants per person. Table 2 showsthe anatomical distribution. Virtuallyall of the fixtures placed wereBranemark System implants. Implantlengths ranged from 7.0 to 20.0mmApproximately 190 were between 10and 18 mm long. Table 3 details thedistribution of implants by length.

Of the 227 total implants, 91 wereplaced in fresh extraction sites. Theremaining 136 implants were placed inosteotomies created by standard drilling

techniques. Four of the 227 implantswere loaded immediately afterplacement, all in the same patient. Thisindividual was fitted simultaneouslywith 11 other implants that were notimmediately loaded. Bone grafting wasutilized at 31 of the 227 sites.

Thirty of the original 34 patients werefollowed through uncovering and thefinal restoration of 177 implants. Thehealing period between the first- and

second-stage surgeries ranged from 0 to15.5 months, with 5.9 months being theaverage healing period per implant.

Results

Upon uncovering, 214 of the 227implants were found to haveosseointegrated, a success rate of94.3%. Of the thirteen failed implants,

four occurred in each of two patients(both nonsmokers), two occurred inone patient (also a nonsmoker), andone occurred in each of three patients.Of the latter, one was a smoker.

Of the four implants that were loaded(18)

immediately, three failed. In thesame patient, a second implant thatwas not immediately loaded also

failed.

Six of the 13 surgical failures werelocated in the posterior mandible,four were in the posterior maxilla,two were in the anterior maxilla, andone was in the anterior mandible.Table 4 summarizes the location,diameter, length, and healing periodof all the failed implants.

Of the 31 grafted sites, one (3.2%)failed. Autogenous bone, Grafton

Gel (Musculoskeletal TransplantFoundation, Holmdel, NJ), and amembrane also were used at this site.

Of the 177 implants that werefollowed through final restoration,one failure was identified; a failurerate of only 0.06%. This implant,which was initially placed in a graftedsite in the left maxilla and


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restored 5 months later, had a 3.75-mm diameter and a length of 10mm.The cause of the failure seemed tobe occlusal overload caused bybruxism. Table 5 summarizes theresults achieved by the patients ateach stage.

Discussion

Although the result of this study

indicate that excellent results can beobtained when Branemark implantsare placed in diabetic patients,certain precautionary measures canincrease the likelihood of asuccessful outcome.

1-- Adequate screening isessential. A comprehensivehealth history should beobtained from every candidatefor implant therapy, withattention given to fundamentalsystemic problems. If the

patient has a history of diabetes,

additional information shouldbe gathered about his or hercurrent treatment.

5--The deleterious impact ofsmoking on osseointegratedimplants has been well

(19)documented.

Although the results of this studysuggest that diabetics who smoke

can experience success with dentalimplants, the authors believe that

2-- If the diabetic patient'smetabolic control seems to beclinically inadequate, it is bestto delay implant therapy untilbetter control is achieved.3-- The doctor should stress tothe patient the importance oftaking all diabetic medicationson the days of surgery and

maintaining an acceptable levelof metabolic control throughoutthe healing period 4-- A 10-dayregimen of broad spectrumantibiotics should be started onthe day of surgery to reduce therisk of infection .

the combination of smoking anddiabetes may substantially increasethe risks of implant failure. For thatreason, diabetic patients who smokeshould be urged to enter a smokingcessation program before implantsurgery.

Conclusion

Dental implants offer significantbenefits that require that they beconsidered for the treatment of a

wide spectrum of patients, includingthe growing number of individualswith diabetes mellitus. Althoughuncontrolled diabetes has beenshown to interfere with variousaspects of the healing process, theresults of this retrospective studyindicate that a high success rate isachievable when dental implants areplaced in diabetic patients whosedisease is under control.

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Dental Implant Diabetic Patient