Failure Rate of Dental Implants in Diabetic Patients: A Systematic Review

Dr. Prachi Rajput ¹, Dr. Anju Aggarwal², Dr. Aditya Chaudhary³ , Dr. Kartika N Kumar⁴ , Dr. Aryen Kaushik⁵

¹Post graduate student,

^2,3 Professor,

⁴Reader,

 ⁵Senior Lecturer

Department of Prosthodontics and Oral Implantology ITS Dental college and Hospital, Greater Noida.

ABSTRACT

Diabetes has long been known to be a risk factor for implant failure due to susceptibility to infection, impaired healing and other complications. Although it has always been considered a relative contraindication to treatment with dental implants, dental implant restoration has been increasingly favoured by the majority of patients with tooth loss due to its advantages of reduced damage to adjacent teeth and reduced impact on alveolar bone compared to fixed bridge treatment and removable restoration, respectively.¹

There is no study exclusively reporting the success or failure rate of implant in Type-1 diabetes however, very few retrospective studies had subject with Type-1 and Type-2 diabetes but little number of type-1 diabetic subjects.

Key Words: Dental Implants, Diabetes Mellitus , Type I Diabetes  and , Type II Diabetes 

Introduction

Diabetes mellitus comprises a group of metabolic disorders that are characterized by hyperglycaemia, which is caused by defective insulin secretion, dysfunction or both.¹

The major subtypes of the disease are type 1 and type 2 Diabetes Mellitus. While type 1 Diabetes Mellitus develops most commonly with autoimmune pancreatic b-cell destruction and accounts for 5–10% of the diabetic population, type 2 DM is associated with insulin resistance and relative insulin deficiency with various metabolic disturbances and accounts for 90–95% of the diabetic subjects.²

It can result in various serious complications including acquired blindness, kidney failure, neuropathy, myocardial infarction and non-traumatic limp amputation² and is closely related to oral health, especially periodontitis, which appears to develop at least twice as often in diabetics as in populations without diabetes. In addition, periodontal infection can affect glycaemic control in diabetic patients. These coexisting conditions can lead to the gradual loss of tooth attachment to alveolar bone, resulting in tooth loss. Becoming partially or totally edentulous is the possible outcome, and is known as the “sixth complication” of diabetes.³

 Because of the microvascular complications seen in DM, it is considered as a relative contraindication for dental implant therapy by some authors (Dowell et al. 2007). Therefore, success of dental implants in patients with diabetes has been the topic of many preclinical and clinical studies.²

 

Materials and method

Information sources

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) principles were followed for the retrieval and analysis of data. An electronic and manual literature searches were performed in several databases, including MEDLINE/Pubmed, EMBASE, Cochrane, Proquest, Scielo, Google Scholar for articles from January 2000 to June 2021 with limitation to English language.

Selection And Data Collection Process

All three-stage screening (titles, abstract and full text) were carried out in duplicate and independently by two reviewers. Irrelevant records were excluded in these stages. Full text of possibly eligible studies was reviewed, and any disagreement was resolved by discussion and, if necessary, a third reviewer was consulted.

Each included study was analysed to obtain data regarding the number of patients and implants at the beginning and the end of the study, the study setting, type of diabetes, medication of diabetes, controlled or uncontrolled diabetes, any antibiotic therapy before or after the surgery, and presence of any other systemic complication. 

Search Strategy

[MeSH Terms]) OR dental implantation [MeSH Terms]) OR dental implants [MeSH Terms])

OR dental implantation, failure rate [MeSH Terms]) AND Diabetes Mellitus [Title/Abstract]) OR Diabetes [Title/Abstract]) AND Humans [Mesh]). Due to the limited number of articles indexed following such strategy, a broader screening was conducted at the same database: (((((dental implants [Title/Abstract]) AND bone loss [Title/Abstract]) OR marginal bone loss [Title/Abstract]) OR crestal bone loss [Title/Abstract]) AND Diabetes Mellitus [Title/For the PubMed library, combinations of controlled terms (MeSH) and keywords were used. MeSH keywords-

“Dental Implants, "Diabetes Mellitus “, "Type I Diabetes” and “, "Type II Diabetes “, “failure rate” "Systematic Review’’. In addition, other terms not indexed as MeSH were searched using the following key terms and Boolean operators (AND, OR, NOT). 

The search string was:

 ((dental implant Abstract]) OR Diabetes [Title/Abstract] or

((diabetes OR diabetic))  AND ((dental implants) OR (implants) OR (endosseous implants) OR (implant restoration) OR (dental implantation) OR (osseointegrated implants) AND (failure rate) AND (bone loss) OR (clinical outcomes) OR (implant failure) OR (marginal bone loss) OR (bone level changes) OR (marginal bone level) OR (marginal bone resorption) OR (marginal bone remodeling) OR (marginal bone preservation) OR (crestal bone level) OR (crestal bone loss) OR (crestal bone resorption) OR (crestal bone remodeling) OR (crestal bone preservation)) AND (peri-implantitis) OR (peri-implant mucositis).

Additional screening was conducted of the websites of most notable scientific journals in the fields of implantology, periodontology, oral surgery, and oral medicine.

PICO Criteria

P: Completely or partially edentulous, diabetic and healthy human adults wearing implant supported prostheses

I: Regular intake of oral, intramuscular, or intravenous medications/ drugs that may affect glycaemic level.

C: Individuals not taking any known relevant medication for Diabetes wearing implant supported prostheses. (Non-specific medication dependent for the treatment of a medical condition)

O: Dental implant failure (primary outcome), peri-implant marginal bone loss (secondary outcome), and biological (i.e., peri-implant mucositis or peri-implantitis) or mechanical complications reported at the implant or patient level (secondary outcomes).

 

Discussion

The aim of this systematic review was to investigate the hypothesis that there is no difference in implant failure rate between Type 1 or 2 diabetes subjects and non-diabetic subjects. A broad search for studies was conducted, including electronic, manual, and grey literature searches. Despite diabetes being considered a relative contraindication to treatment with implants, diabetic subjects with controlled glucose may have success rates that are similar to those of non-diabetic subjects. 

This systematic review sought to analyse the differences in failure rate between diabetic and non-diabetic patients, along with comparing between Type I and Type 2 diabetic patients also keeping in account the glycaemic level and medications of the patient undergoing treatment.

According to Cabrera Domínguez et al (2017) no differences in MBL change and survival and success rates of narrow-diameter TiZr alloy implants with a hydrophilic surface were found between implants placed in patients with and without type 2 diabetes mellitus after a 2-year follow-up period. They conclude that reduced-diameter TiZr alloy implants with a hydrophilic surface represent a safe and predictable treatment option in patients with type 2 diabetes with well-controlled glycemia (HbA1c). The clinical performance of the implants is comparable with that observed in individuals without type 2 diabetes mellitus in the medium term. 

Nouf -al Shibani (2018) also in her prospective study on 86 subjects in which 86 Implants were placed concluded that NDIs show reliable clinical stability and radiographic bone levels as RDIs placed in T2DM and non-diabetic individuals, provided oral hygiene and glycaemic status are strictly maintained.

Gerardo Gomez-Moreno et all’s peri-implant evaluation on Type2 Diabetic patients showed that Marginal bone loss was found to increase in relation to increases in HbA1c levels. Bleeding on probing showed statistically significant differences between groups. When the peri implant area was probed, mean levels of bleeding varied from 0.43 in  Group 1 (control group without diabetes), at 1 year after implant surgery to 0.62 in Group 4, HbA1c levels higher than 10.1, ( (P = 0.042 between the four study groups). After the second year, greater bleeding on probing was observed in Group 4 (0.63) in comparison with groups with lower HbA1c levels. It was concluded that Implant therapies for diabetic patients can be predictable, providing these

 

patients fall within controlled ranges of glycemia over time, assessed by monitoring HbA1c levels. Similar results were also confirmed by T.W Oates (2009), Mohammad N Alasqah (2012), Tariq Abduljabbar (2017) that Implant therapies for diabetic patients can be predictable, providing these patients fall within controlled ranges of glycemia over time, assessed by monitoring HbA1c levels.

 

Mohammad D. Al.Amri (2016) in his study on Comparison of clinical and radiographic status around dental implants placed in patients with and without prediabetes with 1 year follow up proved that At 12 months of follow-up, there was no clinical evidence for the presence of plaque, BOP and peri-implant pockets with PPD ≥ 4 mm in both groups. At 12-month followup, the mean MBL among implants placed in groups 1 and 2 were 0.2 +/- 0.1 mm and 0.1+/-

0.01 mm, respectively. Overall, the periodontal status (PI, BOP and PPD ≥ 4 mm) at 12-month follow-up was comparable among patients in both groups.  They concluded that dental implants inserted in prediabetic and healthy patients have similar success rates and remain clinically and radiographically stable after 1-year follow-up.

Payam Farzad’s (2002 ) retrospective study on 136 implants  showed that 5 of the 136 implants installed in 25 patients were lost after first-stage surgery, yielding a success rate of 96.3% during the healing period. Of the 131 implants followed through final restoration and final checkup 1 year after surgery, three additional failures were identified, resulting in an overall success rate of 94.1%. Moreover Namita Khandelwal’s (2011) study showed clinically successful implant placement even in poorly controlled diabetic patients. She evaluated the potential for a chemically modified Sand blasted, Large grit, Acid etched (SLA) surface, compared with a conventional SLA surface, to enhance implant healing and integration in poorly controlled diabetic patients, a group previously demonstrated to have compromises and delays in implant stabilization during the metabolically active healing period following implant placement.

 

Conclusion

Diabetes mellitus, a systematic disorder, was once considered as a contraindication to the use of dental implant therapy, it has been associated with comorbidities, including increased susceptibility to infection, impaired wound healing, and dental abscess. Today, diabetic patients are being successfully treated for all types of edentulism, including bone-grafting treatment. Dental-implant surgery is feasible in selected diabetic patients with the proviso of careful patients’ preparation and follow-up. These conditions reinforce the need for a dialogue between dental clinicians and diabetologists in order to offer diabetic patients the best chances of success with tooth-replacement procedures. 

Diabetics that undergo dental implant treatment do not encounter a higher failure rate than the normal population if the patients’ plasma glucose level is normal or close to normal as assessed by personal interviews. Also based on the findings it can be concluded that the use of endosseous dental implants in Type 2 diabetic patients involves a marginal risk to long-term implant survival. There is no study exclusively reporting the success or failure rate of implant in Type-1 diabetes however, very few retrospective studies had subject with Type-1 and Type-2 diabetes but little number of type-1 diabetic subjects. In some studies, slightly higher rate of failure in type I Diabetic patients may be due to depletion of insulin in tissues whereas presence of insulin in tissues of type-2 diabetic individuals may reduce deleterious effect of hyperglycemia.

 

It can be concluded that Dental implants can be used successfully in patients who are diabetic provided that blood sugar levels are under control. The results of this study show a high success rate that can be achieved if treatment is properly planned, executed, and followed-up.

 

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