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Dental implant survival in diabetic patients; Review and recommendations


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Rising population of diabetic individuals across the world has become a big concern to the society. The persistent hyperglycemia may affect each and every tissue and consequently results in morbidity and eventually mortality in diabetic patients. A direct negative response of diabetes has been observed on oral tissues with few contradictions however, little are known about effect of diabetes on dental implant treatment and the consequent results. Many studies concerned with osteointegration and prognosis of dental implant in diabetic patients have been conducted and published since 1994. These studies have been critically reviewed to understand the impact of diabetes on the success of dental implant and the factors to improve osseointegration and consequently survival of dental implant in diabetic patients. Theoretical literatures and studies in diabetic animals substantiate high failure rate of implants but most of clinical studies indicated statistically insignificant failure of dental implants even in moderately uncontrolled diabetic patients. Success of dental implant in well and fairly controlled diabetic patients with proper treatment planning, prophylactic remedies and adequate postsurgical maintenance appears as good as normal individuals.
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National Journal of Maxillofacial Surgery | Vol 4 | Issue 2 | Jul-Dec 2013 | 142
Review Article
The recent studies in China[1] and India[2] has shown that
the number of diabetic individuals has surpassed the
estimate of IDF-2009[3] i.e., approximately 285 million
people worldwide will have diabetes in 2010 and by
2030, 438 million people of adult population is expected
to have diabetes with majority of eected population
from China, India and USA.
The comforts like natural dentition, conservative treatment
compared to teeth supported FPDs and long term success
for the edentulous patients, as well as partially edentulous
patients have made dental implants supported prosthetic
treatment as an attractive substitute to traditional
removable or xed dental prosthesis besides being costly
and lengthy procedures with surgical intervention.[4-6] The
growing economy of developing nations like china and
India has also been playing a key role in popularizing the
implant dental treatment. In light of above facts, the dental
fraternity may encounter with more number of diabetic
patients for dental implant treatments.
Diabetes mellitus is a chronic disorder of carbohydrate
metabolism characterized by hyperglycemia, reecting
distortion in physiological equilibrium in utilization
of glucose by tissue, liberation of glucose by liver and
production-liberation of pancreatic anterior pituitary and
adrenocortical hormone. The debilitating characteristic
of diabetes mellitus was known as early as in second
century AD, when Areteous named it as diabetes means
“a siphon” as he perceived that the condition was
characterized by melting down of flesh and limb into
urine.[7] Various modern research and discoveries have
Departments of Prosthodontics,
Government Dental College, Raipur,
Chhattisgarh, 1PIDS, Gorakhpur,
Uttar Pradesh, India
Address for correspondence:
Dr. Rajendra Kumar Dubey,
Department of Prosthodontics,
Government Dental College,
Raipur, Chhattisgarh, India.
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Quick Response Code:
Rajendra Kumar Dubey, Deepesh Kumar Gupta,
Amit Kumar Singh1
Rising population of diabetic individuals across the world has become a big concern to the
society. The persistent hyperglycemia may affect each and every tissue and consequently
results in morbidity and eventually mortality in diabetic patients. A direct negative response of
diabetes has been observed on oral tissues with few contradictions however, little are known
about effect of diabetes on dental implant treatment and the consequent results. Many studies
concerned with osteointegration and prognosis of dental implant in diabetic patients have
been conducted and published since 1994. These studies have been critically reviewed to
understand the impact of diabetes on the success of dental implant and the factors to improve
osseointegration and consequently survival of dental implant in diabetic patients. Theoretical
literatures and studies in diabetic animals substantiate high failure rate of implants but most of
clinical studies indicated statistically insignificant failure of dental implants even in moderately
uncontrolled diabetic patients. Success of dental implant in well and fairly controlled diabetic
patients with proper treatment planning, prophylactic remedies and adequate postsurgical
maintenance appears as good as normal individuals.
Key words: Dental implant, hyperglycemia, osteointegration
Dental implant survival in
diabetic patients; review and
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shown that diabetes mellitus, more or less, affects
every tissues of body directly or indirectly through late
complications [Table 1].[8] Concerning the eect on oral
tissues, Loe.[9] recognized the periodontal disease as sixth
major complication of diabetes. Number of studies has
proved the adverse eect of chronic hyperglycemia on oral
mucosa and with some controversies on alveolar bone.
This review caters actual scenario to practicing dentists
regarding success and failure of dental implant treatment
in diabetic individuals observed by various studies. The
experience based suggestions and experimental studies
about increasing osteointegration and consequently
improving success rate of dental implant treatment in
diabetic patients have also been discussed.
Eect of diabetes on bone and osteointegration
The persistent hyperglycemia in diabetic individuals,
inhibit osteoblastic activity and alters the response of
parathyroid hormone that regulates metabolism of
Ca and P,[10] decreases collagen formation during callus
formation,[11] induces apoptosis in lining cells of bone[12]
and increases osteoclastic activity[13,14] due to persistent
inammatory response. It also induces deleterious eect
on bone matrix and diminishes growth and accumulation
of extracellular matrix.[15] The consequent result is
diminished bone formation during healing, which is
observed in number of experimental animal studies.[16-19]
Type -1 diabetes causes decreased bone mineral density,
as well as reduced bone formation and higher bone
resorption[20] whereas Type -2 diabetes produces normal
or greater bone mineral density in some patients.[21] It
has been observed that insulin not only reduces the
deleterious eect of hyperglycemia by controlling it but
also stimulates osteoblastic activity. Hence, bone matrix
formation in insulin treated experimental models is
similar to control ones.[22]
Most of the studies have been performed in
streptozotocin/alloxan induced diabetic experimental
models (rat/rabbit) to observe osseointegration of
implants. Histo-chemical/histomorphic/planimetric/
biomechanical torque/manometric analysis showed that
bone volume formed in diabetic animals was similar
to non-diabetic animals[23] however, bone implant
contact (BIC) in diabetic animals was lesser compared
to non-diabetics.[24] The rate of mineral apposition in
newly formed bone and bone density around implant
was signicantly less in uncontrolled diabetic animals.[25]
The bone volume and bone density around implant in
insulin controlled diabetic animals was observed similar
or greater to non-diabetic but BIC was found signicantly
less[22,26-30] (Even in insulin controlled diabetic animals).
Only few case studies for histological observation of
dental implant osseointegration in human being have
been reported. In one report,[31] an implant was placed and
intended to support an overdenture in 65-year-old diabetic
women was retrieved after 2 months due to prosthetically
unfavorable condition. In histological analysis, no
symptoms of implant failure recognized with 80% bone
implant contact ratio. A case of diabetes mellitus type-2
having implant failure within 6 months, was reported by
Park JB[32] with conclusion that osseointegration was not
aected by diabetes mellitus as there was no sign and
symptoms of failure before loading.
Success/failure of dental implants in diabetic patients
Most of the studies[43,44,46,48] observed slightly high
percentage of early failure of implants in diabetics
compared to late failure. Some reports[45,46,50] indicated
increased failure rate within rst year of placement of
implant. The published retrospective and prospective
studies data, retrieved through various sources from 1994
to 2011 [Table 2], indicated that the success rate of dental
implants in diabetic patients were in range of 85.5-100%
and were comparable to the non-diabetic patients. Most of
the studies were of opinion that success rate in well/fairly
controlled diabetics was either equal or insignicantly
lower than normal individuals. Two studies[36,39], has
taken chance to involve uncontrolled diabetic patients
for dental implantation and observed encouraging results
as early implant success was similar to non-diabetics.
However, it is noteworthy that number of patients and
implants placed (4 implants in 3 patients) in uncontrolled
diabetics was quite low and all the patients selected
were free of micro and macro-vascular complications.
Only two studies[36,41] reported signicantly high failure
of implant in diabetic patients even when glucose level
was adequately under control. One of these studies
retrospectively included early, as well as late failures of
implants over the period of 10 years but did not specify
the glycemic control over that period. While other study,
prospective in nature, observed signicantly high early
failures with probable reason that placement of multiple
adjoining implants in diabetic patients increased the
failure rates due to large wound, delayed healing and
greater force posed over implants. Inadequate time (study
period 90 days only) provided for osseointegration and
regaining stability to implant in the study seems to be the
cause of observing very high failure in diabetic patients.
Most of the studies[43,44,46,48] observed slightly high
percentage of early failure of implants in diabetics
Table 1: Late‑onset complications of diabetes
Microvascular complications Macrovascular complications
Retinopathy Cardiovascular disease
Nephropathy Peripheral vascular disease
Neuropathy-Peripheral and autonomic Cerebrovascular disease
Erectile dysfunction
Periodontal disease
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Table 2: Outcome of studies showing survival/success of dental implant in diabetic patients
Investigator Year Type of
Type of
Nature of
No. of
No. of
Duration of
al‑rate %
et al
2010 Prospective Type-2 Controlled 10 23 1 year 100 No evidence of diminished clinical success
or signicant complication was found with
different implant supported prosthesis
like Cemented/screwed FPD or removable
overdentures placed in well or moderately
well controlled diabetes
et al
2010 Retrospective Type-1
and 2
Controlled 412 1514 2 years Not
Diabetes type-1 and 2 was not associated
with late implant failure
et al
2009 Prospective Type-2 Controlled
20 30 4 months 100 The study demonstrated that person with
poor glycemic control had greater decrease
in implant stability and required longer
time for healing but most of the implants
attained nearly baseline stability in long
duration even in poorly controlled diabetic
ND 10 12 100
Wing Loo
et al
2009 Prospective Type-2 Controlled 138 275 90 days 32 Early implant failure was signicantly
greater in diabetic patients when multiple
adjoining implants were placed
ND140 346 90 days 86
et al
2008 Retrospective Type-2 Well and
45 255 1-12
97.2 No signicant difference in success
rate of dental implant in diabetics and
non-diabetics. No signicant effect of
duration of diabetes
ND45 244 1-12
et al
2007 Prospective Type-2 Controlled
35 50 4 months 100 No evidence of diminished clinical success
or signicant early healing complications
associated with implant therapy based on
the glycemic control levels of patients with
type-2 diabetes mellitus
et al
2007 Prospective Type -2 Controlled 1 18 30 months 100 An immediate loading protocol can be
successful and result in osseointegration in
patients with diabetes
et al
2008 Retrospective Type-1 Controlled 1 1 Not
00 Local and systemic factors interfere with
the osseointegration of dental implants.
Type 1 and 2 diabetics had higher failure
than non-diabetics but insignicant
Type-2 Controlled 283 719 96
Peter Moy
et al
2005 Retrospective Not
48 Not
10 years 68.7 Failure even in adequately controlled diabetic
patients was signicantly high and failure
evenly continued from period of placement
until observational period of 10 years
et al
2004 Prospective Type-2 Controlled 21 52 12-36
90.4 The clinical outcome of dental implants,
restored with FPD, in well-controlled
type 2 diabetes mellitus was satisfying
and encouraging
et al
2003 Prospective Type-2 Controlled 41 141 1 year 97.3 Studied failure of implant supported
overdentures and found no correlation
between failed implant and glucose level
5 years 94.4
et al
2002 Retrospective Not
Controlled 25 136 3-6 months 96.3 The study did not encounter a higher
failure rate in diabetic patients than
normal population, if plasma glucose level
is normal or close to normal which is
assessed by personal interview
1 year 94.1
et al.
2000 Retrospective Type-2 Controlled 255 36 months 92.2 Success rate of implants, supporting
mixed variety prosthesis was marginally
signicant less in diabetics than
non-diabetics. The experience of surgeon
does not produce clinically signicant
improvement in implant survival, while
use of 2% chlorhexidine, preoperative
antibiotics, and hydroxy-appetite implants
improves the survival rate in diabetics by
4.5%, 10.55, and 13.2% respectively
ND 2,
36 month 93.2
et al
2000 Retrospective Not
Controlled 40 215 1 year 88.8 Out of 31 failures, 24 failures occurred
within rst year of functional loading.
Interestingly, implant failure was not
signicantly different from non-diabetic
6.5 years 88.8
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compared to late failure. Some reports[45,46,50] indicated
increased failure rate within first year of loading
suggesting the risk of implant failure is associated with
uncovering of implants and early phase of implant
loading. T W Oates observation[35] also supports high
early failure in diabetic patients as such patients
experienced low implant stability quotient (ISQ) in
period of 2-12 weeks and lower the level of glycemic
control, higher the amount of ISQ reduction and
longer the duration of recovery in ISQ at base level was
required. However, most of implants aained base level
of stability within 4 months even in uncontrolled diabetic
patients, if the patients were refrained with micro- and
macro-vascular complications.
Duration of diabetes signicantly aected the success of
dental implant, observed in one study[48] while another
did not demonstrate signicantly higher late implant
failures in diabetic patients even with longer duration.
Overall lower success of implant in patients with diabetes
of longer duration may be due to higher chance of
micro-vascular complications which consequently lead
to delayed healing around implants and hence higher
early failure.
Few studies,[40] demonstrated signicantly higher failure
of implant in type-1 diabetic patients than patients with
type-2 diabetes (in one study, only one implant placed
in a person with diabetes type-1 and it failed i.e., failure
rate=100%, an extremely unlikely true estimate of risk).
While one study[34] did not nd any signicant dierence
in late failure of dental implant in type-1 and type-2
diabetic patients. Higher failure rate in diabetic type-1
Table 2: Contd...
Investigator Year Type of study Type of
Nature of
No. of
No. of
Duration of
rate %
2000 Retrospective Mixed Controlled 15 59 1-17 years 93 The diabetic patients were no more likely
to experience implant failure than the
non-diabetic patients
ND 111 1-17 years 94
Oslen and
et al.
2000 Prospective Type-2 Controlled 89 178 5 years 88.0 Success rate of implants supporting
overdentures was found satisfactory level in
type-2 diabetic patients. In regression analysis,
duration of diabetes (
<0.025) and implant
length (
<0.001) was found to be statistically
signicant predictors of implant failure
et al.
1999 Retrospective Type-2 Controlled 34 227 At time
of second
94.4 Early implant failure greater than late implant
failure. The success rate in diabetic patients
were comparable to non- diabetics (when
compared with results of other studies as
control group was not provided in this study).
Glycemic control, antibiotic protection and
smoking avoidance protocol recommended
177 After
and Oslen
et al
1994 Prospective Type-2 Controlled 89 178 12 months 92.7 Survival rate of implants for supporting
removable over dentures was 97.8% at
uncovering (4 implants failed), while success
rate decreases up to level of 92.7% as 9
additional implants had failed during 1 year
*ND‑ denotes non‑diabetic controls undertaken in study
may be due to depletion of insulin in tissues whereas
presence of insulin in tissues of type-2 diabetic individuals
may reduce deleterious eect of hyperglycemia. There
is no study exclusively reported the survival/success of
implant in type-1 diabetes however, very few retrospective
studies had subject with type-1 and type-2 diabetes but
lile number of type-1 diabetic subjects.
Immediate loading did not signicantly aect the survival
of dental implant in diabetic patients provided their
plasma glucose level were under normal range.[37,39,44,45]
Balshi SF[39] reported 100% survival of 18 implants after
2.5 years after placement followed by immediate loading
with screwed retained xed prosthesis in a 71-year-old
diabetic patient. The study suggests that controlled
mechanical stimuli over implant can be benecial for
osseointegration and implant survival.
The studies[37,45] observed lower survival of implant in
diabetic patients of very old age group but dierence was
not statically signicant. Although, none of the studies
had compared success of implant in diabetic females and
males but number of studies reported survival as good
as in females compared to males in general population.
The experience of surgeons and advance surgical process
did not signicantly aect success of dental implant in
diabetics as observed in studies.[38,46]
Measures for improving success of dental implant in
Good glycemic control, preoperative and post-operative,
is required to achieve improved osseointegration in
diabetics.[51] Prophylactic antibiotics [Table 3] have
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shown to be eective for success of dental implants
in diabetic patients and use of 0. 12% chlorhexidine
further improves the success rate.[45,48-52] Certain factors
like implant surface characteristics (implant coated
with bioactive material) and higher implant length
and width has been shown to improve success rate of
implant in diabetic patients. Some researcher has found
positive results in experimental studies to improve
osseointegration and results are yet to be veried in
human being. In few studies,[53,54] it was observed that
systemic administration of aminoguanidine reduced
the deleterious eect of diabetes on osseointregration.
Satana et al.[55] used rhFGF2 (recombinant human
fibroblast growth factor-2) encapsulated with poly
glycosylated poly lactide (PGLA) membrane in
calvarial defect of diabetic rat and formation of normal
bone level was observed in histomorphic analysis.
Wang et al.,[56] in a study based on similar concept,
used rrIGF-1(Recombinant rat insulin like growth
factor) encapsulated with PGLA around Ti implant
inserted in calvaria of diabetic rat. It was found in
histomorphic analysis that diabetic rat with rrIGF-1
had higher BIC around the implant compare to rat
without rrIGF-1 after 4-8 weeks of surgical placement.
A recent hypothesis was made by Bai et al.[57] that
adiponectin, an insulin sensitive adipokine may
improve osseointregration in diabetic patients by
infusing it systemically or using locally as it has shown
potent anti-inflammatory properties and increased
bone density by enhancing osteoblast and inhibiting
osteoclast formation.
Most of the experimental studies have been indicated
that the bone matrix formation and bone mineralization
was almost equal in controlled diabetic and non-diabetic
animals but BIC was lower even in controlled diabetic
subjects. Number of studies has proposed and explained
mechanism of deleterious eect of diabetes over wound
healing and true association (osseointegration) of
bone to implant surface [Figures 1 and 2]. However
studies,[31,32] performed in humans specifically with
diabetes type-2, observed insignicant eect over BIC
and consequently good osseointegration of dental
implant in controlled diabetic patients. As most of the
experimental studies conducted in rats and rabbits,
the architectural and compositional dierence in bone,
higher metabolic rate, very permissive bone healing,
faster skeletal changes and bone turnover[58,59] may be
the reason for the dierence in results of experimental
animals and humans. The difference in developing
diabetes (alloxan or streptozotocin destruct beta
cells of Langerhans consequently induces diabetes)
in experimental animals and human being (type-2
diabetes develop due to glucose resistance at cellular
level and higher level of glucose in tissue consequently
suppress the function of beta cells of Langerhans in
long duration) maybe one reason for the difference
in BIC. The result of an experimental study in obese
diabetic rat strengthens the above explanation, as no
difference in BIC was observed in obese diabetic rat
than normal one.[60]
Most of clinical studies reported success of dental
implant in diabetic individual as good as normal
peoples. The reason may appear to be the inclusion
of controlled diabetics in the almost all studies.
The persistent hyperglycemia is responsible for
development of micro-vascular complication and
consequently the early or late implant failure. Hence
the uncontrolled level of diabetes, reected through
measurement of glycated hemoglobin HbAc1 (indicate
average glucose level over preceding 2-3 months
period,[61] level 6 to 8 shows well controlled, 8.1 to 10
moderately controlled and more than 10 shows poorly
controlled diabetes), persistent for longer duration
with sign of micro-vascular complication may aect
the success of dental implant signicantly. However,
none of the study included such uncontrolled patients
or in other word it can be concluded that none of the
surgeon had taken risk to insert dental implant in such
human beings.
Table 3: Prophylactic antibiotics and their doses
Name of antibiotic Preoperative (1 hour prior to surgery) Post‑operative (after surgery)
Adult dose Pediatric dose Adult dose Pediatric dose
Amoxicillin 2 gm VO 50 mg/kg of
body weight VO
500 mg orally every 8 h 25-50 mg/kg/day in divided dose 8 hourly
Amoxicillin+Clavulanate 2 g+125 mg VO 25-50 mg+2.5
mg/kg VO
500 mg+125 mg orally
every 12 h
25-45 mg/kg/day in doses divided every 12 h
Clindamycin 600 mg VO 20 mg/Kg VO 150-450 mg every 6 h 8-20 mg/kg/day in 3-4 divided doses as hydrochloride
Cephalexin or cefadroxil 2 g VO 50 mg/Kg VO 250-1000 mg every 6 h 25-100 mg/kg/day in divided doses every 6-8 h
Clarithromycin and
500 mg VO 15 mg/kg VO 250-500 mg once a day 5-20 mg/kg once a day
Note: *The total dose in children should not surpass the adult dose, *Cephalosporins should not be used in patients with type‑1 penicillin hypersensitivity reaction, *Post‑oper‑
ative regimen should be prescribed minimum for 5‑7 days in diabetic patients, *Placement of dental implant in diabetic children is very rare, *Gentamycin, Metronidazole and
Vancomycin are also used as prophylactic antibiotics in I.V form but unusually nowadays
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Figure 1: Mechanism of development of diabetic complication
0RGLI\ EORRGDOEXPLQ
7*)EHWD DQG3$,
Even the fairly or moderately controlled diabetes
persisting for very longer duration (more than 10 years)
may produce complications and diminish the health of
tissues. The compromised condition along with some
unfavorable restorative factors may bargain the success of
dental implants. Therefore, numerous factors associated
with rehabilitation and diabetes itself, more or less, aect
the survival of dental implant in diabetic subjects[62]
[Table 4]. Cautious consideration of the mentioned factors
during rehabilitation improves the success and hence the
survival of dental implants in diabetic individuals.
The survival of dental implant in well/fairly
controlled diabetic patients appears as good as in
general population. Use of prophylactic antibiotic,
longer duration of post surgical antibiotic course,
chlorhexidine mouth rinse, bioactive material coated
implants and implant with higher width and length
seems to further improve the survival of implant in
diabetic individuals. Systemic administration of some
insulin sensitive adipokine and use of local growth
factors have been found to improve osseointegration
in diabetic experimental animals but yet to be veried
in human beings. However, it is advisable to delay the
placement of implant in poorly controlled diabetics till
the control of diabetes. Longer duration prospective
clinical studies with greater number of diabetic
individuals and non-diabetic controls are still required
to develop beer understanding of impact of diabetes
over dental implant success.
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Figure 2: Possible effects of diabetes over mechanism of osteointegration
3RO\RO$*(63.& DQG +H[DPLQH3DWKZD\
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Table 4: Probable factors affecting survival of dental implants
Factors associated with diabetes Rehabilitative factors
Type of diabetes Type of restoration
Diabetes duration Fixed/removable
Long span/short span
Diabetic condition i.e., level of
diabetes control reected through
HbAc1 level
Implant location
Status of diabetic complication
i.e., micro- and/or
Implant length
Bone type and quality
Method of controlling hyperglycemia-
through dietary control/oral
hypoglycemic/insulin administration
Surgical protocols
Surgical complexity
Duration for
osteointegration before
second surgery and
functional loading
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National Journal of Maxillofacial Surgery | Vol 4 | Issue 2 | Jul-Dec 2013 | 149
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How to cite this article: Dubey RK, Gupta DK, Singh AK. Dental
implant survival in diabetic patients; review and recommendations. Natl J
Maxillofac Surg 2013;4:142-50.
Source of Support: Nil. Conict of Interest: None declared.
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... In addition, dental implants have become an efficient and necessary treatment to replace missing teeth [9]. However, the effectiveness of dental implants in monitored diabetic patients should be reasonable with appropriate treatment plans, prophylactic treatments, and sufficient post-operative monitoring tend to be as effective as normal individuals [10]. A persistent food accumulation is a causative factor of periodontal or peri-implant soft tissue inflammation (bleeding, pain, and edema) around the implant [11]. ...
... Many studies were reported that survival of dental implants in well-controlled diabetic patients shows as good results as healthy individuals [10,19,20], with adequate postoperative follow-up [10]. However, continual trapping of food particles may lead to peri-implantitis [11]. ...
... Many studies were reported that survival of dental implants in well-controlled diabetic patients shows as good results as healthy individuals [10,19,20], with adequate postoperative follow-up [10]. However, continual trapping of food particles may lead to peri-implantitis [11]. ...
... Therefore, studies aimed at improving osseointegration in the diabetic environment are needed. Several methods have been proposed to improve the success rate of implants in the detrimental environment of DM, such as the use of prophylactic antibiotics, higher implant length and width, and implants loaded with bioactive material [14]. Implants loaded with bioactive material can demonstrate various effects depending on the loaded drug [14][15][16]. ...
... Several methods have been proposed to improve the success rate of implants in the detrimental environment of DM, such as the use of prophylactic antibiotics, higher implant length and width, and implants loaded with bioactive material [14]. Implants loaded with bioactive material can demonstrate various effects depending on the loaded drug [14][15][16]. For drug application, nanotubes are fabricated through anodic oxidation on the implant surface. ...
Purpose: Some systemic conditions, especially diabetes mellitus (DM), adversely affect dental implant success. This study aimed to investigate the effects of ibuprofen-loaded TiO2 nanotube (ILTN) dental implants in alloxan-induced diabetic rabbits. Methods: Twenty-six New Zealand white rabbits were treated with alloxan monohydrate to induce DM. At 2 weeks following DM induction, 3 types of implants (sandblasted, large-grit, and acid-etched [SLA], ILTN, and machined) were placed into the proximal tibia in the 10 rabbits that survived following DM induction. Each type of implant was fitted randomly in 1 of the holes (round-robin method). The animals were administered alizarin (at 3 weeks) and calcein (at 6 weeks) as fluorescent bone markers, and were sacrificed at 8 weeks for radiographic and histomorphometric analyses. Results: TiO2 nanotube arrays of ~70 nm in diameter and ~17 μm in thickness were obtained, and ibuprofen was loaded into the TiO2 nanotube arrays. A total of 26 rabbits were treated with alloxan monohydrate and only 10 rabbits survived. The 10 surviving rabbits showed a blood glucose level of 300 mg/dL or higher, and the implants were placed in these diabetic rabbits. The implant stability quotient (ISQ) and bone-to-implant contact (BIC) values were significantly higher in the ILTN group (ISQ: 61.8, BIC: 41.3%) and SLA group (ISQ: 62.6, BIC: 46.3%) than in the machined group (ISQ: 53.4, BIC: 20.2%), but the difference in the BIC percentage between the SLA and ILTN groups was not statistically significant (P=0.628). However, the bone area percentage was significantly higher in the ILTN group (78.0%) than in the SLA group (52.1%; P=0.000). Conclusions: The ILTN dental implants showed better stability (ISQ) and BIC than the machined implants; however, these values were similar to the commercially used SLA implants in the 2-week diabetic rabbit model.
... All these problems affect osseointegration and long-term success of dental implants. Therefore, preservation of alveolar bone dimensions following tooth extraction is advantageous [7]. ...
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Background: The healing of an extraction socket leads to alveolar ridge resorption that can hinder future implant placement and further rehabilitation with special concerns in diabetes mellitus. Coenzyme Q10 (CoQ10) has been developed as a new material for alveolar socket augmentation. The aim of this study was to investigate the effect of CoQ10 hydrogel on bone regeneration after extraction of mandibular teeth in Type II diabetic patients. Methods: This trial was registered under the number NCT05122299 and included eighteen patients. The hydrogel was first prepared and characterized. After tooth extraction, the hydrogel was placed in the extraction sockets. Bone formation was evaluated three months after tooth extraction. Results: The bone density was significantly higher in the CoQ10 group than the other two groups measured on cone beam computed tomography (CBCT). The relative gene expression of Runt-related transcription factor 2 (RUNX2) and Osteopontin (OPN) showed significant increase in the presence of CoQ10. Histomorphometry revealed significantly less fibrous tissue in the CoQ10 group in comparison to the control or collagen group. Conclusion: The local application of CoQ10 after tooth extraction provided a simple, inexpensive, yet effective treatment facilitating bone formation and healing in the extraction sockets of diabetic patients.
... This is not the first review on the subject. However, previous reviews either failed to conduct any statistical analysis [23] or were based on much fewer clinical studies [14,24,25]. The present review adds much more data (from 89 studies) for the analyses and is the first one in many aspects: (a) to perform a sub-analysis comparing dental implant failure rates between type 1 and type 2 diabetic patients; (b) to perform subgroup analyses for implant failure when only studies evaluating implants inserted in maxillae, as well as when only studies evaluating implants inserted in mandibles; (c) to perform a meta-regression testing the association between the odds ratio of implant failure between diabetic and non-diabetic individuals, and the follow-up time; (d) to perform a meta-analysis on the difference of MBL between diabetic and non-diabetic patients; and (e) to perform a meta-regression testing the association between follow-up and the MBL mean difference between diabetic and non-diabetic individuals. ...
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The present review aimed to evaluate the impact of diabetes mellitus on dental implant failure rates and marginal bone loss (MBL). An electronic search was undertaken in three databases, plus a manual search of journals. Meta-analyses were performed as well as meta-regressions in order to verify how the odds ratio (OR) and MBL were associated with follow-up time. The review included 89 publications. Altogether, there were 5510 and 62,780 implants placed in diabetic and non-diabetic patients, respectively. Pairwise meta-analysis showed that implants in diabetic patients had a higher failure risk in comparison to non-diabetic patients (OR 1.777, p < 0.001). Implant failures were more likely to occur in type 1 diabetes patients than in type 2 (OR 4.477, p = 0.032). The difference in implant failure between the groups was statistically significant in the maxilla but not in the mandible. The MBL mean difference (MD) between the groups was 0.776 mm (p = 0.027), with an estimated increase of 0.032 mm in the MBL MD between groups for every additional month of follow-up (p < 0.001). There was an estimated decrease of 0.007 in OR for every additional month of follow-up (p = 0.048). In conclusion, implants in diabetic patients showed a 77.7% higher risk of failure than in non-diabetic patients.
... Among the patients who experienced implant failure, 2 patients were smokers and 3 patients had diabetes mellitus (DM) ( Table 3). DM is a highly prevalent chronic disease [30], and various studies have attempted to understand the influence of DM on the osseointegration and survival of dental implants [31,32]. Generally, pre-clinical studies in DM-induced animals have reported a high failure rate of dental implants [33]; however, the results of clinical studies remain inconsistent. ...
Purpose: This study aimed to evaluate the effectiveness of the partial split-flap technique with a K-incision on vertical guided bone regeneration (vGBR) and to retrospectively analyze the clinical and radiographic outcomes of dental implantation using this approach. Methods: In total, 78 patients who received 104 dental implants with vGBR, categorized as (1) pre-GBR and post-implantation and (2) simultaneous GBR and implantation, were enrolled. Data analysis was based on periapical radiographs, clinical photos, and dental records. The 2-sample t-test was used to compare the 2 surgical procedures. Results: The baseline vertical bone level, augmented bone height (ABH), and treatment duration were significantly higher in the pre-GBR procedure group. The survival rates of the implants were 96.1% and 94.8% in implant- and patient-based analyses, respectively. In Cox regression analysis, high rates of implant failure were found in the presence of ABH of ≥4 mm, smoking, and diabetes. Conclusions: Within the limitations of this retrospective study, the partial split-flap technique using a K-incision for vGBR showed stable clinical outcomes and favorable dental implant survival.
... The anti-inflammatory effects of dental implants are critical to their success in diabetic patients because peri-implantitis is the result of hyperglycemia-mediated inflammatory reaction [163]. CNMs have anti-inflammatory properties that can regulate immune cell activity and reduce the secretion of proinflammatory cytokines [164], and along with their large surface area and biocompatibility, help in their use as anti-inflammatory agent carriers [164]. ...
Full-text available
Dental implants are used broadly in dental clinics as the most natural-looking restoration option for replacing missing or highly diseased teeth. However, dental implant failure is a crucial issue for diabetic patients in need of dentition restoration, particularly when a lack of osseointegration and immunoregulatory incompetency occur during the healing phase, resulting in infection and fibrous encapsulation. Bio-inspired or biomimetic materials, which can mimic the characteristics of natural elements, are being investigated for use in the implant industry. This review discusses different biomimetic dental implants in terms of structural changes that enable antibacterial properties, drug delivery, immunomodulation, and osseointegration. We subsequently summarize the modification of dental implants for diabetes patients utilizing carbon nanomaterials, which have been recently found to improve the characteristics of biomimetic dental implants, including through antibacterial and anti-inflammatory capabilities, and by offering drug delivery properties that are essential for the success of dental implants.
... In contrast, another systematic review from 2016 proved that diabetic patients have similar success outcomes when compared to healthy patients [48]. However, the literature agrees that the major requirement to achieve success in implant placement surgery is satisfactory glycemic control pre-and postoperatively [32,48,49]. Multiple studies in the literature warn about the highest failure of dental implants in uncontrolled diabetic patients, regardless of the technique [32]. ...
Full-text available
Objectives To evaluate the survival rate, success rate, and peri-implant biological changes of immediately loaded dental implants (ILs) placed in type 2 diabetic patients (DM2). Materials and methods The present study was registered on PROSPERO and followed the PRISMA checklist. The search was performed by the first reviewer in January 2021. The electronic databases used were MEDLINE via PubMed, Cochrane, BVS, Web of Science, Scopus, LIVIVO, and gray literature. The risk of bias analysis was performed using an instrument from the Joanna Briggs Institute. Results A total of 3566 titles and abstracts were obtained. The qualitative synthesis included 7 studies, while the quantitative synthesis included 5 studies. The meta-analysis of IL in individuals with DM2 compared to nondiabetic individuals showed no significant difference among the groups regarding the survival rate of dental implants (RR = 1.00, 95% CI 0.96–1.04; p = 0.91; I ² = 0%), even if the patient had poor glycemic control (RR = 1.08, 95% CI 0.87–1.33; p = 0.48; I ² = 70%). Meta-analysis of marginal bone loss in IL compared to conventional loading in DM2 patients also showed no significant difference (mean difference = − 0.08, 95% CI − 0.25–0.08; p = 0.33; I ² = 83%). Conclusions Type 2 diabetes mellitus does not seem to be a risk factor for immediately loaded implants if the glycemic level is controlled, the oral hygiene is satisfactory, and the technical steps are strictly followed. Clinical relevance Rehabilitation in diabetic individuals is more common due to the highest prevalence of edentulism in this population. It is essential to establish appropriate protocols for loading dental implants.
... The contraindication is related to delayed wound healing due to impairment of microvasculature and activation of inflammatory pathways that may affect a cell's apoptosis. [22][23][24] The American College of Cardiology and American Heart Association set new guidelines for hypertension in 2017, lowering the reading that is considered hypertensive to 130/ 80 mmHg less than the previous guideline (140/90 mmHg). 25 Singh et al found that 20.8% of 832 implants failed due to hypertension, several studies and meta-analysis showed a positive relationship between hypertension and periodontal problems. ...
Full-text available
Purpose: The aim of this study was to investigate the priority of periodontal plaque as a risk factor compared to other risk factors, namely hypertension and diabetes mellitus type II, regarding the initiation and severity of peri-implant mucositis, eventually reinforcing the importance of plaque control, periodic maintenance and supportive periodontic treatment after implant placement in order to prevent peri-implant diseases. Patients and methods: A total of 58 patients (84 implants) were enrolled; each individual implant was considered as a separate sample first, then sampling by patient was also applied, implants were divided into group A: systemically healthy patients and B: patients with hypertension and diabetes mellitus type II, the status of peri-implant tissue was followed after the healing abutment placement, with regard to implant mucosal index (IMI), probing pocket depth (PPD) and bleeding on probing (BOP); when sampling was done by patient, the mean of scores of all examined implants in each patient was taken to represent one sample. Results: Group A implants showed higher mean scores of PPD (5.2 mm) than group B (4.2 mm) with significance (P = 0.014), and higher mean scores of BOP, group A = 0.71, group B = 0.45 with (P = 0.015); there was no statistical difference with regard to IMI, group A = 1.35, group B = 1.16 with (P = 0.172). Similar results were obtained when the sampling was calculated by patient; PPD: group A (5.31 mm), group B (4.75 mm) and P = 0.008, IMI: group A (1.34), group B (1.16) and P = 0.131, BOP: group A (0.75), group B (0.48) and P = 0.03. Conclusion: In the absence of proper plaque control, systemic diseases showed no impact on the initiation and severity of peri-implant mucositis when compared to systemically healthy patients.
Statement of problem Dental implants are susceptible to early failure when placed in patients diagnosed with type 2 diabetes mellitus. The osteoinductive potential of insulin-like growth factor-1 (IGF-1) has been widely investigated in animals with type 2 diabetes mellitus, but studies investigating the osteoinductive potential of IGF-1 around dental implants in patients diagnosed with type 2 diabetes mellitus are lacking. Purpose This randomized controlled trial was conducted to assess the osteogenic efficacy of poly(lactide-co-glycolide)– (PLGA) encapsulated IGF-1 microspheres around dental implants placed in patients diagnosed with type 2 diabetes mellitus. Material and methods A split-mouth, randomized controlled trial was conducted in 10 participants diagnosed with type 2 diabetes mellitus and with bilaterally missing mandibular posterior teeth. The 20 sites were randomly allotted to receive the PLGA encapsulated IGF-1 or placebo microspheres followed by the placement of Ø3.8×11-mm implants. Osteoblastic activity was quantitatively assessed with bone scintigraphy scanning on the thirtieth, sixtieth, and 90th day after implant placement. The Shapiro-Wilks test was used to analyze the normality of data, followed by the independent t test to compare the experimental and placebo groups. Intragroup comparison was performed by using repeated-measures ANOVA and the post hoc Bonferroni test (α=.05). Results Statistical analysis revealed that the mean osteoblastic activity was higher in the experimental group which received the PLGA–encapsulated IGF-1 than in the placebo group at the 30th, 60th, and 90th day after implant placement (P≤.001). Conclusions This randomized controlled trial indicated that the PLGA–encapsulated sustained release of IGF-1 microspheres enhanced the process of osseointegration in patients diagnosed with type 2 diabetes mellitus until the 90th day after implant placement.
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Dental implant is one of the restorative methods to replace missing teeth. As implants are directly anchored into bones, they provide stability, a more natural appearance, and minimize the risk of bone resorption and atrophy. However, studies found that diabetes mellitus patients had a slower healing process after surgery because of the reduction of vascular supply due to microangiopathies, decreased host defense, formation of advanced glycation end-products (AGEs), reduction of collagen production and increased collagenase activity. Diabetes mellitus patients may pose contraindications to dental implants. As a result of that, dental implantation failure rate in diabetic patients is much higher than that in non-diabetic patients. In this clinical experiment, we compared the amount of blood cells, and cytokines production 24 h post implantations, and the implant mobility 90 days post-surgery between controlled type 2 diabetic patients and the non-diabetic patients. It was aimed to investigate the suitability of diabetic patients to have dental implants and the efficacy of the amount of dental implants related to the success rates. 138 patients with type 2 diabetics and 140 healthy subjects, who had one to three adjacent edentulous spaces, were selected. Dental implantation surgeries were performed under local anesthesia. Wounds were sutured and all subjects were given 0.2% chlorohexidine mouthwash for 14 days. Complete blood picture and cytokines production were assayed before operation, as well as on days 1, 2, and 5 after implantation. Implant mobility and periodontal wound healing were monitored once in a fortnight up to 90 days. There were no statistically significant differences in the production of cytokines. In 138 diabetic patients, 255 implants were presented with second degree mobility 90 days after surgery while the same was demonstrated in 48 out of 346 implants from the healthy subjects. These implants were considered failures and were extracted. Implant failure in diabetics was significantly greater than that in non-diabetics when multiple adjoining implants were placed.
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We aimed to estimate the prevalence of diabetes mellitus and study the associated factors in a rural population in Goa, India. A cross-sectional study was done in the rural area of Mandur, Goa. Participants>20 years of age were selected by systematic random sampling. They were interviewed with the help of a structured, pretested questionnaire. This was followed by clinical examination, anthropometry and relevant laboratory investigations. Diabetes mellitus was defined as per the American Diabetes Association (ADA) criteria. Statistical analysis was done using the SPSS software package (version 14.0). The prevalence of diabetes mellitus in the study population was 10.3% (130/1266) with a prevalence of 8.4% among men and 12% among women. On bivariate analysis, the prevalence of diabetes mellitus was found to be significantly associated with age, occupation, family income, family history of diabetes, smoking, obesity, hypertension, and high serum cholesterol and triglycerides levels. Multiple logistic regression analysis identified age, family history, hypertension, smoking, total cholesterol and triglyceride as the Independently associated variables for diabetes mellitus. Innovative community outreach programmes are required to create awareness, and for screening and treatment of diabetes mellitus to curb the growing epidemic of diabetes in the population.
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Because of the rapid change in lifestyle in China, there is concern that diabetes may become epidemic. We conducted a national study from June 2007 through May 2008 to estimate the prevalence of diabetes among Chinese adults. A nationally representative sample of 46,239 adults, 20 years of age or older, from 14 provinces and municipalities participated in the study. After an overnight fast, participants underwent an oral glucose-tolerance test, and fasting and 2-hour glucose levels were measured to identify undiagnosed diabetes and prediabetes (i.e., impaired fasting glucose or impaired glucose tolerance). Previously diagnosed diabetes was determined on the basis of self-report. The age-standardized prevalences of total diabetes (which included both previously diagnosed diabetes and previously undiagnosed diabetes) and prediabetes were 9.7% (10.6% among men and 8.8% among women) and 15.5% (16.1% among men and 14.9% among women), respectively, accounting for 92.4 million adults with diabetes (50.2 million men and 42.2 million women) and 148.2 million adults with prediabetes (76.1 million men and 72.1 million women). The prevalence of diabetes increased with increasing age (3.2%, 11.5%, and 20.4% among persons who were 20 to 39, 40 to 59, and > or = 60 years of age, respectively) and with increasing weight (4.5%, 7.6%, 12.8%, and 18.5% among persons with a body-mass index [the weight in kilograms divided by the square of the height in meters] of < 18.5, 18.5 to 24.9, 25.0 to 29.9, and > or = 30.0, respectively). The prevalence of diabetes was higher among urban residents than among rural residents (11.4% vs. 8.2%). The prevalence of isolated impaired glucose tolerance was higher than that of isolated impaired fasting glucose (11.0% vs. 3.2% among men and 10.9% vs. 2.2% among women). These results indicate that diabetes has become a major public health problem in China and that strategies aimed at the prevention and treatment of diabetes are needed.
Subjects: The subjects in this retrospective case series were derived from a review of 700 patient files within the implant practice of the Department of Periodontology, University Hospital, Catholic University of Leuven. Inclusion criteria were met by 412 patients (240 females, 172 males) receiving a total of 1514 Nobel Biocare dental implants. These patients were included based on data availability for the time period 2 years after abutment surgery (considered to represent late implant failure). Key exposure/study factor: Given the concern of the authors to assess the probability of late implant failure among clinic patients with certain local and systemic factors, the potential factors were multiple. The local factors included the following: implant length and diameter, bone quality and quantity, insertion site, type of edentulism, antibiotic use perioperatively, dehiscence and/or perforation of the site during surgery, and stability at insertion (measured by Periotest values). The related health and behavioral factors included the following: medications, smoking (<10 cigarettes/day, 10-20 cigarettes/day, >20 cigarettes/day), hypertension, ischemic cardiac problems, coagulation anomalies, gastric ulcers, thyroid disorders, hypercholesterolemia, rheumatoid arthritis, asthma, diabetes (types 1 and 2), Crohn's disease, and chemotherapy. Main outcome measure: The primary outcome was described as "late implant failure." The current study, which follows a similar study on early implant failure,(1) aims to identify negative influences on maintenance of integration. The authors used the clinical experience related to the 412 patients with 1514 implants to identify whether the observed failure rates were influenced by local and systemic factors. Failure was defined as "late" when occurring between abutment connection surgery and 2 years after this date. Patients/implants that were not available for this interval of time were not included. However, even when records were available, not all patient records provided all data sought. Main results: Regarding local factors, the authors reported that implant diameter and location were relevant to late implant loss, whereas implant length was not (P value = .01, = .34, respectively; univariate generalized estimating equation [GEE] logistic regression). Regarding implant diameter, significantly more loss was noted for 5.00-mm implants when compared with the 4.00-mm or 4.75-mm implants. Failure related to location revealed that the maxilla compared with the mandible, posterior jaws compared with anterior jaws, and the posterior maxilla compared with all other oral locations were associated with more late failures (Table 1). Assessment of systemic factors revealed radiotherapy to be related to more late implant loss (P = .003). Neither systemic disease nor smoking exposure was associated with late failure. Conclusions: The authors concluded that late implant failure was influenced by the local factor "implant location" and the systemic factor "radiotherapy." Neither smoking nor systemic health factors were found to adversely influence implant integration from abutment connection through 2 years' performance.
The present study aimed to assess the effects of induced diabetes and the administration of aminoguanidine in the biomechanical retention of implants in rats. Thirty-six rats were randomly divided into six groups: group 1, healthy rats (no aminoguanidine); group 2 and group 3, healthy rats receiving 10 and 20 mg/kg of aminoguanidine daily, respectively; group 4, diabetic rats (no aminoguanidine); and group 5 and group 6, diabetic rats receiving 10 and 20 mg/kg of aminoguanidine daily, respectively. In each rat an implant was inserted in the femur. After 28 d of healing, the rats were killed. The implants were removed by applying a counter-torque, and the maximum force required for the rupture of the bone-implant interface was recorded using an analog torque meter. The data were evaluated using analysis of variance and the Student's t-test. In the healthy groups, no statistically significant difference could be observed in the average counter-torque values for implant removal, whereas in the diabetic groups, a daily dose of 20 mg/kg of aminoguanidine raised the counter-torque values to the values found in healthy rats. The administration of 20 mg/kg of aminoguanidine daily in diabetic rats raised the biomechanical retention of the implants to the level observed in the healthy rat group.
Type 2 diabetes mellitus (T2DM) is the most common form of diabetes. Compared with the general population, a higher failure rate is seen in T2DM patients. There is also evidence that chronically high levels of plasma glycemia leads to inflammatory effect and a negative influence on bone formation and remodeling, and reduce osseointegration of implants. Recently studies reveal that adiponectin is an insulin-sensitizing adipokine, and closely associated with T2DM. Adiponectin has potent anti-inflammatory properties and has been shown to increase bone density by inhibiting osteoclast formation and promoting the formation of osteoblasts. We therefore hypothesize systemically infused or locally used adiponectin could accelerate osseointegration of dental implants in T2DM. Our hypothesis could help to create an option to improve success ratio of dental implants in T2DM by the replenishment of adiponectin in T2DM patients.
Diabetes mellitus is a prevalent medical disorder. It is often accompanied with systemic adverse sequelae, such as wound healing alterations, which may affect osseointegration of dental implants. The use of dental implants in patients with diabetes mellitus remains controversial because altered bone healing around implants has been reported. The purpose of this study was to present 1-year clinical outcomes of 23 implants placed in 10 patients with well-, or moderately well, controlled type 2 diabetes mellitus. All implants were uneventfully placed in the mandible or maxilla. Three different types of definitive implant-supported prostheses, cement- or screw-retained fixed dental prostheses, and overdentures were delivered to the patients. At 1-year follow-up recall, no implants were lost, and 0.3 +/- 0.2 mm marginal bone loss was noted. No periapical radiolucencies, no bleeding on probing, or pathologic probing depth were recorded at these recalls. This clinical report supports the use of dental implants in patients with well-, or moderately well, controlled type 2 diabetes mellitus as a dental treatment modality. No evidence of diminished clinical success or significant complication related to implant treatment was found for this patient population.
Dental implantation is an effective and predictable treatment modality for replacing missing teeth and repairing maxillofacial defects. However, implants in patients with type 2 diabetes mellitus are likely to have a high failure rate and poor initial osseointegration. In the current study, we established an effective drug delivery system designed to improve osseointegration of dental implants in an animal model of type 2 diabetes. Twenty type 2 diabetic rats were divided into two groups: a group receiving recombinant rat Insulin-like Growth Factor 1 (rrIGF-1) Microsphere Therapy (MST) (10 rats) and a control group (10 rats). The rrIGF-1 was encapsulated into poly(lactide-co-glycolide) (PLGA) microspheres to produce a sustained-release effect around titanium (Ti) dental implants in the rrIGF-1 MST group. Scanning electron microscopy, confocal laser scanning microscopy, and cumulative-release studies were conducted to verify the release effect of the microspheres as well as rrIGF-1 bioactivity. Five rats from each group were sacrificed at weeks 4 and 8 post surgery, and a histological analysis was performed on the rats from both groups. Compared to the control group, rats that received rrIGF-1 by PLGA microsphere treatment were observed to have a higher bone-implant contact percentage around the Ti implants at week 4 or week 8 post surgery (P<0.05). This result clearly indicates that sustained release of rrIGF-1 through encapsulation by PLGA microspheres positively affects osseointegration of dental implants in type 2 diabetic rats.
Article Title and Bibliographic Information: Impact of local and systemic factors on the incidence of late oral implant loss. Alsaadi G, Quirynen M, Komarek A, van Steenberghe D. Clin Oral Implants Res 2008;19(7):670-6. Reviewer: Alan B. Carr, DMD, MS. Purpose/Question: The aim of this retrospective chart review study was to assess implant failure between the time of abutment connection and 2 years (termed "late implant failure") as influenced by a variety of systemic and local factors. Source of Funding: Information not available. Type of Study/Design: Retrospective case series. Level of Evidence: Level 3: Other evidence. Strength of Recommendation Grade: Not applicable.