Dr.

Eli Michaeli
Barzilai Medical Center, High Risk Patients Dental Clinic Hebrew University and Hadassah Medical Center Faculty of Dental Medicine, Dental Implant Center

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Peter K Moy. et. al. Dental implant failure rates and associated risk factors. Int J Oral Maxillfac Implants. 2005; 20: 569 - 577.

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Cigarette smoking impairs soft tissue wound healing by decreasing tissue oxygenation.

nicotine decreases:
blood flow, collagen deposition, neutrophil function and prostacyclin levels.

nicotine increases:
platelet aggregation, epinephrine levels and blood viscosity.

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It associated with decreased bone density by enhancing bone resorption and by reduction in bone formation. In vitro studies showed that aryl hydrocarbons found in cigarette smoke inhibit osteodifferentiation and osteogenesis. In vivo animal studies show that nicotine impairs bone healing.

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Habsha E. Survival of osseointegrated dental implants in smokers and non smokers. [MS thesis]. Toronto: university of Toronto; 2000.

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Studies have shown that smokers have about twice the number of failed implants compared with non smokers.

Implant in the maxilla have a higher failure percentage than those in the mandible.
The majority of the failures occurred within the first

year (early failure).

Habsha E. Survival of osseointegrated dental implants in smokers and non smokers. [MS thesis]. Toronto: university of Toronto; 2000.

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Osteoporosis is a skeletal condition characterized by decreased mineral density (mass/volume unit) of normally mineralized bone. The WHO criteria for osteoporosis are based on bone density measurements determined by dual energy X ray absorptiometry: osteopenia, density is 1-2.5 S.D. below the mean of young population. osteoporosisdensity is 2.5 S.D. above the mean of young population.
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Osteoporosis results from increase in bone turnover, both resorption and formation, with a net result of bone loss. After menopause the decrease in trabecular bone exceeds that of the cortical bone, thus the maxilla is more susceptible to rapid and severe atrophy. Biochemical analysis of human osteoporotic femoral head showed over-hydroxylation of lysine and a consequent reduction in the stabilizing cross links of the collagenous framework, contributing to fragility of bone.
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Ovariectomy in rats impairs fracture healing up to 4 weeks fracture.

When 17--estrdiol was administered there was a dose dependent increase in the peak force required to re-break the fracture.

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studies whether osteoporotic patients have higher risk of dental implant failure are few in number and contradictory. Following maxillary sinus augmentation, there is a significantly reduced implant success rate.

In women without estrogen supplementation, there is an increase failure rate for maxillary placed implants, but women who were given supplementation did not differ from the control. In rats that undergone ovariectomy the cortical bone area in contact with the implant was only slightly decrease in comparison with control. EM 13

In severe osteoporosis physiological doses of vitamin D (400-800 IU/day) and calcium (1500 mg/day) are recommended during the post operative period. In all cases, a balanced pre and post operative diet should be maintened.

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up until now there has been controversy whether head and neck irradiated patients are suitable for dental implantation. In the past, insertion of dental implants in irradiated hypoxic, hypocellular, hypovascular bone was considered as contraindication. The risk of osteoradionecrosis was calculated to be about 5% after radiotherpy. Risk factors for ORN are: age, high radiation dose, hyper fractionation and traumatic surgical procedure.
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Hyperbaric oxygen therapy can reduce the incidence of ORN by stimulation of vascular growth and marked increase in arterial and venous pO2. Dental implant failure rats in the irradiated patients are slightly higher in the mandible but much more higher in the maxilla. Dental implant failure rats in the irradiated patients are dose dependent. Interval between the end of tumor therapy and implantation should be between 1-2 years.
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A retrospective study of 63 patients (275 implants) with SSC were assessed for Branemark implants 5 years success rats. 35 of them (145 implants) were preirradiated with complete dose of 60 Gy (6000 rad). The 5 year success rates of all implants were 97.9% with no significant difference between the gropes. The only significant influence on osseointegration was the time interval between implantation and the abutment phase.
Wagner W. et. al. Osseointegration of dental implant in patients with and without radiotherapy. Acta Oncologica. 1998;7/8 : 693 696.
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ORN accrued in one patient 1.6%. Patients were not referred to hyperbaric oxygen treatment.

Dental implantation in head and neck irradiated patients will lead significant improvement on the quality of life: food intake, speech and self-esteem.

Wagner W. et. al. Osseointegration of dental implant in patients with and without radiotherapy. Acta Oncologica. 1998;7/8 : 693 696.

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A group of metabolic disorders that are characterized by hyperglycemia induced by impaired insulin activity, insulin secretion or both.

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In Israel there are estimated to be around 380,000 people suffering from diabetes. This represents around 6.3% of the population.
[Israeli Diabetic Association].

In the United States there are 20.8 million diabetic patients. Only 14.6 million are diagnosed which represents 7% of the American population in 2005. Last year an additional 1.5 million new cases were diagnosed [American Diabetes Association].
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The most prevalent endocrine disease and the 3th leading cause of morbidity and mortality in the United States.

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Type 1 diabetes mellitus: accounts for 5 -10 % of the cases. onset in puberty. induced by autoimmune destruction of cells

in the pancreas.
significant or absolute decrease of insulin.

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Type 2 diabetes mellitus: accounts for 90 -95 % of the cases. onset in age grater than 45. induced by insulin intolerance of target

organs.
genetic predisposition.

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Secondary diabetes mellitus: the etiology includes: diseases of the pancreas: pancreatitis, neoplasia. endocrine diseases: Cushings syn., acromegaly.

drugs: glucocorticoids, thiazides, blockers.

infections: CMV, congenital rubella.

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Gestational diabetes mellitus:

glucose intolerance appears during pregnancy. transforms to diabetes mellitus on 3050% of the cases.

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Symptoms of diabetes mellitus: polydipsia, polyurea and polyphagia together with plasma glucose levels grater than 200 mg/dl. Fasting plasma glucose levels grater than 126 mg/dl on tow separate tests.

Tow hour post prandial plasma glucose levels grater than 200 mg/dl during an oral tolerance test on tow separate tests.

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Monitoring glycemic control with HbA1c levels (as percentage of total hemoglobin):

4 to 6
6 to 7.5 7.6 to 8.9 9 to 20

normal
good control fair control poor control

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cardiovascular disease Peripheral vascular disease Stroke Retinopathy

Nephropathy
Neuropathy

Poor wound healing

Susceptibility to infection
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Periodontitis Xerostomia \ hyposalivation Caries Opportunistic infection

Burning mouth syndrome

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Non diabetic patient

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Diabetic patient

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Surgical Implant Osteotomy Blood clot formation

Changes in wound healing proteins

Decreased number of osteoclasts

Bone resorption phase

Inhibition of collagen formation

Decreased number of osteoblasts Reduced mineralization proteins Reduced bone turnover Alternation in bone homeostasis

Matrix formation phase

Bone deposition\ Osteoid mineralization

Maintenance of Osseointegration

Change in diabetes status

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A total of 2887 implants (663 patients) were surgically placed, restored, and followed for a period of 36 months. Of these, 2632 (91%) implants were placed in non diabetic patients and 255 (8.8%) in Type 2 patients.

Morris H. F. et. al. Implant survival in patients with type 2 diabetes: Placement to 36 months. Ann priodontology. 2000; 5: 157 165.

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Total failure rate for non Type 2 diabetic patients was 6.8% and for the diabetic group was 7.8%, which was statistically significant (p=0.02). The use of chlorhexidine rinses for implant placement resulted in a slight improvement (2.5%) in survival in non Type 2 patients and a greater improvement in Type 2 patients (9.1%). For the diabetic group this represents a clinically significant improvement. The use of pre operative antibiotics for implant placement resulted in a 4.5% improvement in survival in non Type 2 patients and a greater improvement in Type 2 patients (10.5%). For the diabetic group this represents a clinically significant improvement.
Morris H. F. et. al. Implant survival in patients with type 2 diabetes: Placement to 36 months. Ann priodontology. 2000; 5: 157 165.

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A prospective multicenter study that assessed the success of 187 implants placed in the mandibular symphysis of 89 male type 2 diabetes subjects. After 4 months the implants were uncovered and restored with an implant supported bar retained overdenture. 16 (9%) of the implants failed after a 60 month follow up.

Olson J. W. et. al., Dental endosseous implant assessments in a Type 2 Diabetic population: A prospective study. Int. J Oral Maxillofacial Implants. 2000; 15: 811 EM 40 818.

The following criteria were examined: Baseline and follow up FPG values. Baseline and follow up HbA1c values. Subject Age. Duration of diabetes. Baseline diabetic therapy. Smoking history.

Implant length.
Olson J. W. et. al., Dental endosseous implant assessments in a Type 2 Diabetic population: A prospective study. Int. J Oral Maxillofacial Implants. 2000; 15: 811 EM 41 818.

Duration of diabetes and implant length were found to be the only statistically significant predictors of implant success.

Olson J. W. et. al., Dental endosseous implant assessments in a Type 2 Diabetic population: A prospective study. Int. J Oral Maxillofacial Implants. 2000; 15: 811 EM 42 818.

A total of 89 edentulous diabetic patients received new dentures: 37 conventionals and 52 implantsupported. Fallow up was for 24 months. 50 of theme were insulin treated with an average of 9.8% HbA1c and 39 were non-insulin treated with an average of 8.5% HbA1c.

Kapur K. et. al. A randomized clinical trial comparing the efficacy of mandibular implant-supported overdentures and conventional overdentures in diabetic patients. Part I: Methodology and clinical outcomes. J Prosthet Dent. 1988; 79: 555-569.
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Non of the failures occurred because of implant failure.

Treatment was judged as failure when patient was unable to wear or was dissatisfied with study dentures.
Treatment was successful 56.9% of the patients with conventional dentures and 72.1% with overdentures (P>0.05).
Kapur K. et. al. A randomized clinical trial comparing the efficacy of mandibular implant-supported overdentures and conventional overdentures in diabetic patients. Part I: Methodology and clinical outcomes. J Prosthet Dent. 1988; 79: 555-569.
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32 rats were assigned to 8 different treatment groups (4 per group).

TPS implants were placed in the femora of each animal and osseointegrated for 28 days before diabetic induction.
In 4 groups the diabetes was controlled with insulin injections, while the others were not treated. The rats were sacrificed at 1, 2, 3 and 4 months following diabetic induction.
Kwon P. T. Maintenance of osseointegration utilizing insulin therapy in a diabetic rat model. J Periodontology. 2005; 76: 621 626.

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The results indicated more BIC in the insulin controlled group compared to the uncontrolled group at each time period, which was statistically significant. Moreover, BIC appears to decrease with time in uncontrolled diabetic rats.

Kwon P. T. Maintenance of osseointegration utilizing insulin therapy in a diabetic rat model. J Periodontology. 2005; 76: 621 626.

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Controlled diabetes

Uncontrolled diabetes

Kwon P. T. Maintenance of osseointegration utilizing insulin therapy in a diabetic rat model. J Periodontology. 2005; 76: 621 626.

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Type of diabetes Age of onset Regiment of glycemic control Incidents of hypo or hyperglicemia HbA1c levels Blood glucose levels Target organ involvement

Poor or insufficient wound healing history

Smoking or other cofactors for implant failure History of tooth loss due to periodontitis
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Consult patients physician

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Type of Prosthetic Restoration Removable vs. Fixed

Implant location
Mandible vs. Maxilla Anterior vs. Posterior

Implant length
Quality of bone Surgical procedure Time between implant insertion and restoration Bone augmentation
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Evaluate patients diabetic condition Measure plasma glucose before and after dental procedure Make short appointments usually during the mornings when time of meals and hypoglicemic drugs are not interrupted

Consider adding single dose of rapid acting insuin to type 1 diabetic patients
Use antiseptic rinses

Use prophylactic antibiotics

Consider using post operative antibiotic
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When acute infection exists determine type of antibiotic using culture Analgesia with salicilats is not recommended due to interference with sulfonylurea activity and increases insulin secretion If signs of hypoglicemia appear give orange juice, administer intravenous solution of dextrose 50% or inject IM 1 mg of glucagon Keep in mind infection including oral may aggravate the glycemic control and when treated improve it

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N. Y., a 61 years old woman was referred to the dental implant center to restore her posterior upper left missing teeth. She was not able to use dentures due to severe gag reflex. She was diagnosed as suffering from diabetes mellitus type 2 five years prior to referral and has been treated with oral hypoglycemics since. Her HgA1c value was 7.2%.

Two years prior to her referral she underwent Lt. lumpectomy, chemotherapy and regional irradiation due to Breast carcinoma.
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Surgery by Prof. R. Zeltser, Department of oral and Maxillofacial surgery, Hebrew University and Hadassah Medical Center Faculty of Dental Medicine.

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9 months post sinus augmentation.

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6 months after implant insertion. Impressions were taken using Inh. N2O 60% (total flow of 8 liter/min)
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