- Email: [email protected]
Implant therapy in type 2 diabetics
Implants Implant therapy in type 2 diabetics Background.—Over 20% of persons older than 65 years has diabetes, and 90% of these cases are type 2 diabetes. Because of their increased susceptibility to infection, delayed wound healing, and microvascular com-
plications, diabetic patients were routinely denied implant therapy in the past. However, studies of implants in diabetic patients have demonstrated an average survival rate of 94.3%, which is reasonably close to the rate for
Table 1.—Analytic Results of Retrospective Studies on Implants in Diabetic Patients Study
Diabetic Patients Implants Follow-up Preparation parameters Diabetic (n) (n) (y) to surgery monitored medication
Survival rate (control)
Peri-Implant Stage 1 bone loss Antiblotic Implant (mm) coverage Rinse* failure
Type of treatment
-
þ
-
-
Not specified
92.70
-
-
-
þ
Overdenture
95.70
-
10 d
-
þ
Not specified
94.30
-
þ
-
þ
0.12
-
-
-
Immediate loading fresh extraction; convertional Overdenture
94.40
0.5
5d
-
þ
Overdenture
-
85.60
-
-
-
þ
No
-
94.10
-
7d
-
þ
Yes
-
90
-
-
-
þ
Convertional therapy Immediate loading and convertional Overdenture
Morris et al10 2000 Shemoff et al18 1994 Abdel Wassi 2002 Baichi 1999
NA
255
3
-
89
178
5
þ
25
113
3
þ
34
227
-
-
No
-
Kapur et al12 1998 Peled et al14 2003 Forellini et al11 2000 Farzad et al17 2002
52
104
5
-
Yes
41
141
5
-
No
Oral insulin, dlet -
40
215
6,5
-
No
25
136
1-9
-
Olson et al13 2000
89
178
5
-
No
Oral insulin 92.20 (93.20)
Not Oral insulin specified No Oral insulin
100
Note: þsign, information is available; -sign, lack of data. (Courtesy of Tawil G, Younan R, Azar P, et al: Conventional and advanced implant treatment in the type II diabetic patient: Surgical protocol and long-term clinical results. Int J Oral Maxillofac Implants 23:744-752, 2008.) * Chlorhexidine.
Table 3.—Implant Distribution According to the Type of Surgery Convertional implant therapy External sinus lift Internal sinus lift Immediate loading Guided bone regeneration
Diabetic (n)
Control (n)
143 33 1 58 20
142 26 2 59 15
(Courtesy of Tawil G, Younan R, Azar P, et al: Conventional and advanced implant treatment in the type II diabetic patient: Surgical protocol and longterm clinical results. Int J Oral Maxillofac Implants 23:744-752, 2008.)
Table 5.—Comparative Survival Rates Between Diabetics and Controls for Conventional and Advanced Implant Surgery Diabetic (n)
Sinus lift GBR Immediate loading Convertional treatment
Control (n)
Implants
Failure
Implants
Failure
34 20 58 143
3 3 0 0
28 15 59 142
0 0 1 0
Abbreviation: GBR, Guided bone regeneration. (Courtesy of Tawil G, Younan R, Azar P, et al: Conventional and advanced implant treatment in the type II diabetic patient: Surgical protocol and longterm clinical results. Int J Oral Maxillofac Implants 23:744-752, 2008.)
Volume 54
Issue 2
2009
79
Table 6.—Relation Between HbA1c and Peri-implant Complications and Survival Rate HbA1c level
Patients (n) Soft tissue complications (no./no. implants) Peri-implantits (no./no. implants) Peri-implant bone loss in mm (M SD) Implant failure (n) Diabetes duration in years (M SD)
<7%
7%-9%
>9%
22 6/103 0/103 0.24 0.28 1 12.7 11.3
22 11/141 6/141 0.5 0.7 5 12.6 7.2
1 1/11 1/11 1.62 1 14
tb
P
.040 .146 .412
.85 .05 .01
Abbreviations: n and no, Number; M SD, mean standard deviation; tb, Kendall’s tb. (Courtesy of Tawil G, Younan R, Azar P, et al: Conventional and advanced implant treatment in the type II diabetic patient: Surgical protocol and long-term clinical results. Int J Oral Maxillofac Implants 23:744-752, 2008.)
Table 7.—Relation Between Diabetes Duration, Implant Survival, and Occurrence of Complications Group
Diabetes duration (y) Patients (n) Implants (n) Implant survival (%) Complications (soft tissue; %) Early infection (%) Bone loss (mm; m sd) Peri-implantitis
1
2
3
4
<2 3 10 100 0 0 0.20 0.10 0
2-5 8 54 100 12.9 0 0.42 0.39 0
5-10 9 27 96.3 3.7 3.7 0.72 0.65 7.4
>10 25 164 96.3 3.7 1.2 0.34 0.61 3
Abbreviations: M SD, mean standard deviation.
nondiabetic patients (Table 1). All of these studies emphasized the need to control the diabetic condition before considering implant therapy but did not cite specific limits for hyperglycemia or HbA1c values. In reality, glucose levels fluctuate frequently even in well-controlled diabetics, and the effect of these fluctuations on implant survival and maintenance of osseointegration is unknown. A study was undertaken to determine the implant survival rate in well-controlled type 2 diabetics, to define a protocol for the treatment of these patients, to determine the effects of various other factors, and to determine the effects of periodontal parameters on implant survival and complication rates. Methods.—The 45 participants had type 2 diabetes and suffered edentulism, receiving 255 implants. Their mean perioperative HbA1c level was 7.2% and all were compliant with their maintenance program. Dental and periodontal examinations as well as laboratory verifications of HbA1c, fasting plasma glucose, blood lipid, and microalbuminuria status were conducted. A control group of 45 nondiabetic individuals had similar implant therapy indications and received 244 implants. Analysis was conducted to determine the influence of clinical diabetes-related factors and periodontal parameters, such as plaque index (PI), bleeding on probing (BOP), and probing depth (PD), on implant survival. Follow-up ranged from 1 to 12 years.
80
Dental Abstracts
Results.—One hundred forty-three of the diabetic patients’ implants were done according to conventional protocol and 112 were done where sinus floor elevation, guided bone regeneration, or immediate loading was required (Table 3). Among the patients whose HbA1c level was < 7%, the overall survival rate was 99.1%, with failure of one implant for which sinus floor elevation was required. Mean bone loss was 0.24 mm. In patients whose HbA1c level was between 7% and 9%, five implants failed, for an overall survival rate of 96.5%. The mean bone loss was 0.52 mm. One patient’s HbA1c level was over 9% and one of the 11 implants placed in this patient failed. Comparison of the survival among diabetics to that among nondiabetics showed no statistically differences regardless of the approach used (Table 5). Soft tissue complications developed at similar rates between the two groups, but peri-implantitis and peri-implant bone loss rates were greater with higher HbA1c levels (Table 6). Patients were subgrouped based on diabetic duration, with four groups: < 2 years, 2 to 5 years, 5 to 10 years, and > 10 years (Table 7). Comparing these groups, there were no significant differences in the implant survival, peri-implantitis, or early infection data. With respect to age, 13 patients were 60 years or younger and 32 were over 60 years old, but age did not appear to influence the rates of soft tissue complications, peri-implantitis, or
implant failure. Neither type of treatment (insulin, oral hypoglycemic agents, or other) nor smoking behavior had a significant impact on soft tissue complications, peri-implantitis, or implant failure rates. However, a fair correlation was noted between PI and peri-implant bone loss. Overall, multivariate ordinal regression analysis found only HbA1c level was significantly related to implant success rates. Discussion.—The survival rate for implant therapy, whether conventional or advanced, was similar between well-controlled diabetic patients and nondiabetic controls. Age, gender, diabetes duration, and smoking had no significant influence on outcomes. The most important factor for a successful result was the patient’s HbA1c level.
Clinical Significance.—Absolute control of blood glucose levels for diabetic patients is highly unlikely, but good control is essential in reducing the microvascular and macrovascular complications of the disease. An acceptable level of HbA1c appears to be < 7.2% for patients undergoing implant therapy. Patients with this level underwent conventional or advanced surgery and achieved implant survival and complication rates comparable to those of nondiabetic patients. We need to emphasize repeatedly the importance of maintaining good glucose control to our patients with diabetes so they can achieve good outcomes regardless of the intervention that is needed.
Tawil G, Younan R, Azar P, et al: Conventional and advanced implant treatment in the type II diabetic patient: Surgical protocol and long-term clinical results. Int J Oral Maxillofac Implants 23:744752, 2008 Reprints available from G Tawil, Elias Sarkis Ave, Achrafieh, Beirut, Lebanon; e-mail: [email protected]
Operative Dentistry Er:YAG laser to remove caries Background.—Laser fluorescence has been an adjunctive method to detect occlusal caries combined with visual inspection and radiographs. Caries removal in vitro has been accomplished by conventional bur treatment under the guidance of fluorescence. A more recent development has been the use of a fluorescence-controlled Er:YAG laser to selectively remove carious dentin, also performed in vitro. The extensions of cavities after caries removal with either a conventional bur or the Er:YAG laser were compared in vitro. Methods.—Treatment was carried out in 65 human teeth with dentin caries that had been bisected through the caries lesion. The methods used were fluorescencecontrolled Er:YAG laser in noncontact mode, the laser in contact mode, or a rotary bur. Results were verified as caries free by two independent examiners using dental explorers. The samples then underwent histological staining and computer-assisted alignment to determine the extension of the cavity area quantitatively. Results.—Less dentin was removed using the conventional bur than the noncontact laser handpiece in six of 29 cavities, with the other 23 cavities smaller after use of the noncontact laser handpiece. However, the differences
were not statistically significant. At a threshold level of seven, the cavity size differed significantly between the bur-prepared and the noncontact laser-prepared specimens. For a threshold of six or eight, the differences were not statistically significant. The number of dentins removed was somewhat greater when the contact handpiece was used than with the noncontact handpiece. However, no statistically significant differences in median cavity size were noted between the use of the two handpieces at thresholds of six, seven, or eight. Staining after treatment of the carious lesions with a bur demonstrated an average of 1.33% of the test squares staining positive for bacteria in the residual dentin of the cavity floor. Discussion.—Laser fluorescence allows the detection of early lesions on the occlusal surface. Using fluorescence to guide an Er:YAG laser to remove carious dentin proved quite successful in the current in vitro study. Various thresholds were used, with the cavities after excavation with the noncontact laser significantly smaller than those using the bur at a threshold of seven. The bacterial counts with the two methods were similar. Thresholds of six or eight were not as effective. The variation in dentin removal may result from structural irregularities or differences in light transmission.
Volume 54
Issue 2
2009
81
plications, diabetic patients were routinely denied implant therapy in the past. However, studies of implants in diabetic patients have demonstrated an average survival rate of 94.3%, which is reasonably close to the rate for
Table 1.—Analytic Results of Retrospective Studies on Implants in Diabetic Patients Study
Diabetic Patients Implants Follow-up Preparation parameters Diabetic (n) (n) (y) to surgery monitored medication
Survival rate (control)
Peri-Implant Stage 1 bone loss Antiblotic Implant (mm) coverage Rinse* failure
Type of treatment
-
þ
-
-
Not specified
92.70
-
-
-
þ
Overdenture
95.70
-
10 d
-
þ
Not specified
94.30
-
þ
-
þ
0.12
-
-
-
Immediate loading fresh extraction; convertional Overdenture
94.40
0.5
5d
-
þ
Overdenture
-
85.60
-
-
-
þ
No
-
94.10
-
7d
-
þ
Yes
-
90
-
-
-
þ
Convertional therapy Immediate loading and convertional Overdenture
Morris et al10 2000 Shemoff et al18 1994 Abdel Wassi 2002 Baichi 1999
NA
255
3
-
89
178
5
þ
25
113
3
þ
34
227
-
-
No
-
Kapur et al12 1998 Peled et al14 2003 Forellini et al11 2000 Farzad et al17 2002
52
104
5
-
Yes
41
141
5
-
No
Oral insulin, dlet -
40
215
6,5
-
No
25
136
1-9
-
Olson et al13 2000
89
178
5
-
No
Oral insulin 92.20 (93.20)
Not Oral insulin specified No Oral insulin
100
Note: þsign, information is available; -sign, lack of data. (Courtesy of Tawil G, Younan R, Azar P, et al: Conventional and advanced implant treatment in the type II diabetic patient: Surgical protocol and long-term clinical results. Int J Oral Maxillofac Implants 23:744-752, 2008.) * Chlorhexidine.
Table 3.—Implant Distribution According to the Type of Surgery Convertional implant therapy External sinus lift Internal sinus lift Immediate loading Guided bone regeneration
Diabetic (n)
Control (n)
143 33 1 58 20
142 26 2 59 15
(Courtesy of Tawil G, Younan R, Azar P, et al: Conventional and advanced implant treatment in the type II diabetic patient: Surgical protocol and longterm clinical results. Int J Oral Maxillofac Implants 23:744-752, 2008.)
Table 5.—Comparative Survival Rates Between Diabetics and Controls for Conventional and Advanced Implant Surgery Diabetic (n)
Sinus lift GBR Immediate loading Convertional treatment
Control (n)
Implants
Failure
Implants
Failure
34 20 58 143
3 3 0 0
28 15 59 142
0 0 1 0
Abbreviation: GBR, Guided bone regeneration. (Courtesy of Tawil G, Younan R, Azar P, et al: Conventional and advanced implant treatment in the type II diabetic patient: Surgical protocol and longterm clinical results. Int J Oral Maxillofac Implants 23:744-752, 2008.)
Volume 54
Issue 2
2009
79
Table 6.—Relation Between HbA1c and Peri-implant Complications and Survival Rate HbA1c level
Patients (n) Soft tissue complications (no./no. implants) Peri-implantits (no./no. implants) Peri-implant bone loss in mm (M SD) Implant failure (n) Diabetes duration in years (M SD)
<7%
7%-9%
>9%
22 6/103 0/103 0.24 0.28 1 12.7 11.3
22 11/141 6/141 0.5 0.7 5 12.6 7.2
1 1/11 1/11 1.62 1 14
tb
P
.040 .146 .412
.85 .05 .01
Abbreviations: n and no, Number; M SD, mean standard deviation; tb, Kendall’s tb. (Courtesy of Tawil G, Younan R, Azar P, et al: Conventional and advanced implant treatment in the type II diabetic patient: Surgical protocol and long-term clinical results. Int J Oral Maxillofac Implants 23:744-752, 2008.)
Table 7.—Relation Between Diabetes Duration, Implant Survival, and Occurrence of Complications Group
Diabetes duration (y) Patients (n) Implants (n) Implant survival (%) Complications (soft tissue; %) Early infection (%) Bone loss (mm; m sd) Peri-implantitis
1
2
3
4
<2 3 10 100 0 0 0.20 0.10 0
2-5 8 54 100 12.9 0 0.42 0.39 0
5-10 9 27 96.3 3.7 3.7 0.72 0.65 7.4
>10 25 164 96.3 3.7 1.2 0.34 0.61 3
Abbreviations: M SD, mean standard deviation.
nondiabetic patients (Table 1). All of these studies emphasized the need to control the diabetic condition before considering implant therapy but did not cite specific limits for hyperglycemia or HbA1c values. In reality, glucose levels fluctuate frequently even in well-controlled diabetics, and the effect of these fluctuations on implant survival and maintenance of osseointegration is unknown. A study was undertaken to determine the implant survival rate in well-controlled type 2 diabetics, to define a protocol for the treatment of these patients, to determine the effects of various other factors, and to determine the effects of periodontal parameters on implant survival and complication rates. Methods.—The 45 participants had type 2 diabetes and suffered edentulism, receiving 255 implants. Their mean perioperative HbA1c level was 7.2% and all were compliant with their maintenance program. Dental and periodontal examinations as well as laboratory verifications of HbA1c, fasting plasma glucose, blood lipid, and microalbuminuria status were conducted. A control group of 45 nondiabetic individuals had similar implant therapy indications and received 244 implants. Analysis was conducted to determine the influence of clinical diabetes-related factors and periodontal parameters, such as plaque index (PI), bleeding on probing (BOP), and probing depth (PD), on implant survival. Follow-up ranged from 1 to 12 years.
80
Dental Abstracts
Results.—One hundred forty-three of the diabetic patients’ implants were done according to conventional protocol and 112 were done where sinus floor elevation, guided bone regeneration, or immediate loading was required (Table 3). Among the patients whose HbA1c level was < 7%, the overall survival rate was 99.1%, with failure of one implant for which sinus floor elevation was required. Mean bone loss was 0.24 mm. In patients whose HbA1c level was between 7% and 9%, five implants failed, for an overall survival rate of 96.5%. The mean bone loss was 0.52 mm. One patient’s HbA1c level was over 9% and one of the 11 implants placed in this patient failed. Comparison of the survival among diabetics to that among nondiabetics showed no statistically differences regardless of the approach used (Table 5). Soft tissue complications developed at similar rates between the two groups, but peri-implantitis and peri-implant bone loss rates were greater with higher HbA1c levels (Table 6). Patients were subgrouped based on diabetic duration, with four groups: < 2 years, 2 to 5 years, 5 to 10 years, and > 10 years (Table 7). Comparing these groups, there were no significant differences in the implant survival, peri-implantitis, or early infection data. With respect to age, 13 patients were 60 years or younger and 32 were over 60 years old, but age did not appear to influence the rates of soft tissue complications, peri-implantitis, or
implant failure. Neither type of treatment (insulin, oral hypoglycemic agents, or other) nor smoking behavior had a significant impact on soft tissue complications, peri-implantitis, or implant failure rates. However, a fair correlation was noted between PI and peri-implant bone loss. Overall, multivariate ordinal regression analysis found only HbA1c level was significantly related to implant success rates. Discussion.—The survival rate for implant therapy, whether conventional or advanced, was similar between well-controlled diabetic patients and nondiabetic controls. Age, gender, diabetes duration, and smoking had no significant influence on outcomes. The most important factor for a successful result was the patient’s HbA1c level.
Clinical Significance.—Absolute control of blood glucose levels for diabetic patients is highly unlikely, but good control is essential in reducing the microvascular and macrovascular complications of the disease. An acceptable level of HbA1c appears to be < 7.2% for patients undergoing implant therapy. Patients with this level underwent conventional or advanced surgery and achieved implant survival and complication rates comparable to those of nondiabetic patients. We need to emphasize repeatedly the importance of maintaining good glucose control to our patients with diabetes so they can achieve good outcomes regardless of the intervention that is needed.
Tawil G, Younan R, Azar P, et al: Conventional and advanced implant treatment in the type II diabetic patient: Surgical protocol and long-term clinical results. Int J Oral Maxillofac Implants 23:744752, 2008 Reprints available from G Tawil, Elias Sarkis Ave, Achrafieh, Beirut, Lebanon; e-mail: [email protected]
Operative Dentistry Er:YAG laser to remove caries Background.—Laser fluorescence has been an adjunctive method to detect occlusal caries combined with visual inspection and radiographs. Caries removal in vitro has been accomplished by conventional bur treatment under the guidance of fluorescence. A more recent development has been the use of a fluorescence-controlled Er:YAG laser to selectively remove carious dentin, also performed in vitro. The extensions of cavities after caries removal with either a conventional bur or the Er:YAG laser were compared in vitro. Methods.—Treatment was carried out in 65 human teeth with dentin caries that had been bisected through the caries lesion. The methods used were fluorescencecontrolled Er:YAG laser in noncontact mode, the laser in contact mode, or a rotary bur. Results were verified as caries free by two independent examiners using dental explorers. The samples then underwent histological staining and computer-assisted alignment to determine the extension of the cavity area quantitatively. Results.—Less dentin was removed using the conventional bur than the noncontact laser handpiece in six of 29 cavities, with the other 23 cavities smaller after use of the noncontact laser handpiece. However, the differences
were not statistically significant. At a threshold level of seven, the cavity size differed significantly between the bur-prepared and the noncontact laser-prepared specimens. For a threshold of six or eight, the differences were not statistically significant. The number of dentins removed was somewhat greater when the contact handpiece was used than with the noncontact handpiece. However, no statistically significant differences in median cavity size were noted between the use of the two handpieces at thresholds of six, seven, or eight. Staining after treatment of the carious lesions with a bur demonstrated an average of 1.33% of the test squares staining positive for bacteria in the residual dentin of the cavity floor. Discussion.—Laser fluorescence allows the detection of early lesions on the occlusal surface. Using fluorescence to guide an Er:YAG laser to remove carious dentin proved quite successful in the current in vitro study. Various thresholds were used, with the cavities after excavation with the noncontact laser significantly smaller than those using the bur at a threshold of seven. The bacterial counts with the two methods were similar. Thresholds of six or eight were not as effective. The variation in dentin removal may result from structural irregularities or differences in light transmission.
Volume 54
Issue 2
2009
81