A randomized clinical trial comparing the efficacy of mandibular implant-supported overdentures and conventional dentures in diabetic patients. Part I: Methodology and clinical outcomes

Chewing performance of patients with worn dentition before and after restorations: A scoping review

BACKGROUND

Tooth wear is a multifactorial complex process related to the loss of dental tissue, due to chemical or mechanical processes, by abrasion, attrition, erosion. Restorative treatment represents an attempt to rebuild and recreate the lost structure.

OBJECTIVE

This scoping review aims to investigate whether restorative treatment of worn dentition (either with direct or indirect adhesive composite adhesive procedures or with prosthetic techniques) can have an impact on the masticatory performance parameters.

METHODS

A scoping review was conducted on multiple databases (Pubmed, Medline CENTRAL, ICTRP), following the PRISMA guidelines. Abstracts of research papers were screened for suitability, and full-text articles were obtained for those who satisfied the inclusion and exclusion criteria.

RESULTS

Only one article meet the inclusion criteria of the review. Restorative treatment of worn dentition although have a positive impact on the self-report ability to chew, has no effect on the masticatory performance test.

CONCLUSION

At the moment, not enough evidence to comment on the actual therapeutic role of restorative treatment on tooth wear is available. Clinicians, before taking any clinical decision, should carefully discuss with patients the needs and expectations of the treatment plan.

The impact of implant-retained overdentures on type-2 diabetic and non-diabetic edentulous patients: Satisfaction and quality of life in a prospective cohort study

OBJECTIVES

To evaluate the benefits of implant therapy for patients with diabetes, we compared (i) healthy, (ii) well controlled T2DM and (iii) poorly controlled T2DM patients, in terms of oral health-related quality of life (OHRQoL) and satisfaction with mandibular 2-implant overdentures over 12 months following restoration.

MATERIALS AND METHODS

This single-center, prospective, cohort study recruited 165 edentulous adults (HbA1c<12%) to receive two endosseous implants in the anterior mandible to support mandibular overdentures. Participants were enrolled as having T2DM or not, with T2DM participants divided according to HbA1c into well-controlled (<8.1%) and poorly controlled (≥ 8.1%) groups. Participants provided responses to the OHIP-20 (OHRQoL) and the McGill Denture Satisfaction Questionnaire, before implant therapy and 6 and 12 months after overdenture insertion using Locator attachments. HbA1c was measured at the same time points. The effect of groups and time was verified using generalized estimating equations (α=0.025).

RESULTS

At 12 months, 137 participants provided responses. The two diabetes groups showed improvements in OHRQoL to the same extent as the non-diabetic control group at both 6 and 12 months. Patient satisfaction showed similar improvements with no between-group differences and similar increases identified at 6 and 12 months. HbA1c was not affected by time or groups.

CONCLUSIONS

Dental implant therapy provided significant improvements in patient-perceived benefits of mandibular two-implant overdentures for T2DM individuals, which are similar to those found for healthy edentulous individuals. Importantly, those benefits extend to those individuals with poorly controlled glycaemia. The addition of 2-implant supported mandibular overdentures did not affect glycaemic status over 12 months following insertion.

CLINICAL SIGNIFICANCE

As risks for implant therapy relative to glycaemic status are better understood, this study documents that implant therapy may offer important benefits in QoL for T2DM patients independent of glycaemic status.

Longevity of complete dentures: A systematic review and meta-analysis

STATEMENT OF PROBLEM

Patients and clinicians are aware of the efficacy and benefits of complete dentures, but evidence regarding their longevity is limited.

PURPOSE

The purpose of this systematic review was to examine the literature describing the longevity of complete dentures and to review variations in longevity by denture type and duration of follow-up.

MATERIAL AND METHODS

Four electronic databases were searched by using key terms: MEDLINE, CINAHL (EBSCO), Dentistry and Oral Sciences Databases, and The Cochrane Library. Studies meeting the inclusion criteria were reviewed according to an established protocol and data extracted. Reference lists of identified studies were examined. Risk of bias was assessed by using the AXIS tool. Weighted means and weighted standard deviations were calculated. Pooled complete denture failure proportions were estimated by using random effects models based on the DerSimonian and Laird method.

RESULTS

The search yielded 21 607 unique abstracts, of which 273 met the inclusion criteria. Assessment of the full-text articles reduced this number to 42. Of these, 24 studies were rated as having low risk of bias and 18 as very low. The weighted mean ±standard deviation longevity of maxillary complete dentures was 10.3 ±3.8 years, of mandibular dentures was 8.6 ±2.6 years, and of both maxillary and mandibular dentures was 10.8 ±4.7 years. The pooled failure proportion for complete dentures observed for 2 years or less was 0.05 (95% confidence interval [CI]: 0.00-0.10), 5 to 6 years was 0.12 (95% CI: 0.08-0.16), and 10 years or more was 0.41 (95% CI: 0.28-0.53).

CONCLUSIONS

Complete dentures, fabricated primarily in university settings, were found to have a weighted mean ±standard deviation longevity of 10.1 ±4.0 years. The failure rate of these prostheses increased with denture age, and the longevity of maxillary dentures was greater than that of mandibular dentures.

Masticatory Adaptation to Occlusal Changes

This review deals with the frequent wide variability of masticatory capacity/incapacity. Neither researchers nor clinicians have taken sufficient account of this variability despite its implications for nutrition. Mastication in normal healthy oral conditions is first described, followed by a short presentation of the mechanisms of masticatory adaptation in the nervous system. Capacity, incapacity, and successful compensatory adaptation of mastication are then defined, along with the different methods used for their evaluation. Examples of adaptation needs are given, such as those concomitant with dental wear or occlusal changes. Finally, given its vital importance for deeply impaired mastication/deglutition function, the impact of masticatory adaptation processes on nutrition is examined.

European Society for Swallowing Disorders - European Union Geriatric Medicine Society white paper: oropharyngeal dysphagia as a geriatric syndrome

This position document has been developed by the Dysphagia Working Group, a committee of members from the European Society for Swallowing Disorders and the European Union Geriatric Medicine Society, and invited experts. It consists of 12 sections that cover all aspects of clinical management of oropharyngeal dysphagia (OD) related to geriatric medicine and discusses prevalence, quality of life, and legal and ethical issues, as well as health economics and social burden. OD constitutes impaired or uncomfortable transit of food or liquids from the oral cavity to the esophagus, and it is included in the World Health Organization's classification of diseases. It can cause severe complications such as malnutrition, dehydration, respiratory infections, aspiration pneumonia, and increased readmissions, institutionalization, and morbimortality. OD is a prevalent and serious problem among all phenotypes of older patients as oropharyngeal swallow response is impaired in older people and can cause aspiration. Despite its prevalence and severity, OD is still underdiagnosed and untreated in many medical centers. There are several validated clinical and instrumental methods (videofluoroscopy and fiberoptic endoscopic evaluation of swallowing) to diagnose OD, and treatment is mainly based on compensatory measures, although new treatments to stimulate the oropharyngeal swallow response are under research. OD matches the definition of a geriatric syndrome as it is highly prevalent among older people, is caused by multiple factors, is associated with several comorbidities and poor prognosis, and needs a multidimensional approach to be treated. OD should be given more importance and attention and thus be included in all standard screening protocols, treated, and regularly monitored to prevent its main complications. More research is needed to develop and standardize new treatments and management protocols for older patients with OD, which is a challenging mission for our societies.

European Society for Swallowing Disorders - European Union Geriatric Medicine Society white paper: oropharyngeal dysphagia as a geriatric syndrome

This position document has been developed by the Dysphagia Working Group, a committee of members from the European Society for Swallowing Disorders and the European Union Geriatric Medicine Society, and invited experts. It consists of 12 sections that cover all aspects of clinical management of oropharyngeal dysphagia (OD) related to geriatric medicine and discusses prevalence, quality of life, and legal and ethical issues, as well as health economics and social burden. OD constitutes impaired or uncomfortable transit of food or liquids from the oral cavity to the esophagus, and it is included in the World Health Organization's classification of diseases. It can cause severe complications such as malnutrition, dehydration, respiratory infections, aspiration pneumonia, and increased readmissions, institutionalization, and morbimortality. OD is a prevalent and serious problem among all phenotypes of older patients as oropharyngeal swallow response is impaired in older people and can cause aspiration. Despite its prevalence and severity, OD is still underdiagnosed and untreated in many medical centers. There are several validated clinical and instrumental methods (videofluoroscopy and fiberoptic endoscopic evaluation of swallowing) to diagnose OD, and treatment is mainly based on compensatory measures, although new treatments to stimulate the oropharyngeal swallow response are under research. OD matches the definition of a geriatric syndrome as it is highly prevalent among older people, is caused by multiple factors, is associated with several comorbidities and poor prognosis, and needs a multidimensional approach to be treated. OD should be given more importance and attention and thus be included in all standard screening protocols, treated, and regularly monitored to prevent its main complications. More research is needed to develop and standardize new treatments and management protocols for older patients with OD, which is a challenging mission for our societies.

Retrospective Analysis of Implant Overdenture Treatment in the Advanced Prosthodontic Clinic at the University of Illinois at Chicago

The aim of the present retrospective study was to evaluate the clinical outcomes of implant-supported overdenture treatment provided by prosthodontic specialty residents. Twenty-three patients with 25 implant-supported overdentures (IODs) participated in the study. Seventy-four implants were placed by periodontic, prosthodontics, or oral and maxillofacial surgery students. All prostheses were fabricated in the advanced prosthodontics clinic at University of Illinois at Chicago. The condition of the peri-implant soft tissue, implants, and prostheses were evaluated. Complications and any maintenance were documented. Patients completed an oral health impact profile-14 and semantic differential scale questionnaires. Statistical analyses were performed using SPSS statistical software. Twenty mandibular and 5 maxillary IODs were evaluated. Ninety-seven percent of the attachments were locators (Zest Anchors) and 3% ball attachments. None of the implants had lost osseointegration, but 14 implants (19%) had developed marginal bone loss in one-third of the implant length or more. Fourteen (19%) implants had developed dehiscence, which ranged from 1 to 4 mm. A variation in the width of the keratinized tissue, gingival, plaque, and calculus index was observed. There was a statistically significant relationship between the presence of plaque and the bleeding on probing on the buccal aspect of implants (P = .012). The incidence of dehiscence was significantly higher on the midfacial when the keratinized tissue was less than 2 mm (P &lt; .0001). The majority of the complications were prosthetic in nature, such as broken denture teeth (74%) and worn or loose matrices (35%). Debris was observed in 19% of the locator abutments, and 36% of the overdentures were not stable in application of anterior force. Patients were compliant with oral hygiene protocols and their chewing ability was high (mean = 8.0). The overall experience was pleasant (mean = 7.5); the treatment provided good esthetics (mean = 8.3) and great satisfaction (mean = 8.5). From an educational and clinical perspective, IOD therapy has been documented to be a predictable and successful treatment option. Patients should be informed of the required maintenance and the possible complications related to IOD therapy.

Influence of Glycemic Control on Peri-Implant Bone Healing: 12-Month Outcomes of Local Release of Bone-Related Factors and Implant Stabilization in Type 2 Diabetics

BACKGROUND

The poor glycemic status seems to be an important factor affecting implant complication rates, including peri-implant bone loss.

PURPOSE

This trial evaluated the influence of glycemic control of type 2 diabetes mellitus (T2DM) patients on implant stabilization and on the levels of bone markers in peri-implant fluid during the healing.

MATERIALS AND METHODS

Systemically healthy patients (SH,n = 19), better-controlled T2DM (BCDM,n = 16), and poorly controlled T2DM (PCDM,n = 16) indicated for implant therapy were recruited. The implant stability quotient (ISQ) was determined at implant placement, 3, 6, and 12 months. Levels of transforming growth factor- β (TGF-β), fibroblast growth factor (FGF), osteopontin (OPN), osteocalcin (OC), and osteoprotegerin (OPG) in the peri-implant fluid were quantified at 15 days, and 3, 6, and 12 months, using the Luminex assay.

RESULTS

OPG and OPN levels were higher in SH at 12 months than at15 days (p < .05), whereas OC and TGF-β were lower in PCDM at 12 months compared with the 15-day and 3-month follow-ups, respectively (p < .05). Inter-group analyses showed lower OPN levels in PCDM compared with SH at 12 months (p < .05). The ISQ was higher at 12 months when compared with baseline and 3 months in SH (p < .05), whereas no differences were observed during follow-up in diabetics, regardless of glycemic control (p > .05). No difference in ISQ was observed among groups over time (p > .05).

CONCLUSION

Poor glycemic control negatively modulated the bone factors during healing, although T2DM, regardless of glycemic status, had no effect on implant stabilization.

Changes in mastication after an immediate loading implantation with complete fixed rehabilitation

OBJECTIVE

This study aimed to measure modifications of mastication after immediate loading full-arch prosthesis (ILFAP) rehabilitation.

MATERIALS AND METHOD

Fourteen patients were observed before and 6 months after ILFAP rehabilitation when masticating two natural, standardized foods (peanut and carrot) and three model foods with increasing hardness. The granulometry of the expectorated boluses from carrot and peanuts was characterized by median particle size (D50), determined at the natural point of swallowing. Chewing time (CT), number of chewing cycles (CC), and chewing frequency (CF) were video recorded. A self-assessment questionnaire for oral health-related quality of life [Geriatric Oral Health Assessment Index (GOHAI)] was also used.

RESULTS

After ILFAP rehabilitation, the mean D50 values for carrot and peanuts were smaller [Repeated Model Procedures (RMP), F = 41, p < 0.001]. Mean CT and CC values recorded with the three model foods decreased, while CF increased regardless of the model food hardness (RMP, F = 14, F = 10, and F = 11, respectively, p < 0.001). The GOHAI score increased from 43 ± 9 to 56 ± 3 (t test, p < 0.001).

CONCLUSION

ILFAP rehabilitation improves the ability to reduce the bolus particle size and the ability to discriminate between different food hardnesses in the 6 months post-surgery period.

CLINICAL RELEVANCE

This study encourages the clinical development of immediate loading implantation with a fixed full-arch prosthesis protocol.

A critical review of diabetes, glycemic control, and dental implant therapy

OBJECTIVES

To systematically examine the evidence guiding the use of implant therapy relative to glycemic control for patients with diabetes and to consider the potential for both implant therapy to support diabetes management and hyperglycemia to compromise implant integration.

MATERIAL AND METHODS

A systematic approach was used to identify and review clinical investigations directly assessing implant survival or failure for patients with diabetes. A MEDLINE (PubMED) database search identified potential articles for inclusion using the search strategy: (dental implants OR oral implants) AND (diabetes OR diabetic). Inclusion in this review required longitudinal assessments including at least 10 patients, with included articles assessed relative to documentation of glycemic status for patients.

RESULTS

Although the initial search identified 129 publications, this was reduced to 16, for inclusion. Reported implant failure rates for diabetic patients ranged from 0% to 14.3%. The identification and reporting of glycemic control was insufficient or lacking in 13 of the 16 studies with 11 of these enrolling only patients deemed as having acceptable glycemic control, limiting interpretation of findings relative to glycemic control. Three of the 16 studies having interpretable information on glycemic control failed to demonstrate a significant relationship between glycemic control and implant failure, with failure rates ranging from 0% to 2.9%.

CONCLUSIONS

Clinical evidence is lacking for the association of glycemic control with implant failure while support is emerging for implant therapy in diabetes patients with appropriate accommodations for delays in implant integration based on glycemic control. The role for implants to improve oral function in diabetes management and the effects of hyperglycemia on implant integration remain to be determined.

Impact of facial form on the relationship between conventional or implant-assisted mandibular dentures and masticatory function

STATEMENT OF PROBLEM

It is not clear if the interaction of craniofacial form with type of prosthetic restoration (conventional or implant-assisted) is related to masticatory function in complete denture patients.

PURPOSE

The purpose of this study was to investigate the relationships among facial form, skeletal class, alveolar residual ridge heights and masticatory function in subjects treated with implant-assisted or conventional mandibular dentures with lateral cephalometric evaluation.

MATERIAL AND METHODS

Data from a previously reported randomized controlled clinical trial were accessed to compare treatment success rates, functional and perceptual outcomes, dietary intake, and craniofacial relationships between mandibular complete dentures and implant overdentures in edentulous diabetic subjects. Evaluation of the digitized post-insertion lateral cephalometric radiographs provided measures of facial form (mesocephalic "medium", brachycephalic "broad and square", dolichocephalic "vertical and long"), skeletal class (Class I, Class II, Class III), and alveolar ridge height (mm), which were compared to results of standardized masticatory tests as evaluated using MANOVA and REGW post-hoc evaluation (α=.05).

RESULTS

Masticatory performance on the preferred side was slightly reduced in the dolichocephalic group, compared to brachycephalic and mesocephalic groups (P=.085). Swallowing threshold performance was significantly less in skeletal Class II subjects compared to Class I (P=.034). Maxillary residual alveolar ridge height was significantly less in the brachycephalic group compared to the dolichocephalic group (P<.001). No differences in mandibular ridge height were seen associated with facial form or skeletal class groups.

CONCLUSIONS

Facial form may be related to masticatory function with conventional and implant-assisted mandibular dentures, but larger controlled studies are needed to confirm this relationship. Alveolar ridge height is reduced in edentulous subjects with a brachycephalic facial form.

Impact of implant support for mandibular dentures on satisfaction, oral and general health-related quality of life: a meta-analysis of randomized-controlled trials

OBJECTIVES

The aim of this study was to examine systematically the data published on the efficacy of mandibular implant-retained overdentures from the patient's perspective.

MATERIAL AND METHODS

Medline, Embase, The Cochrane Central Register of Controlled Trials and The Cochrane Systematic Reviews Database were searched and complemented by hand searching. All randomized-controlled trials published in English or French up to April 2007 were included, in which conventional dentures and mandibular implant overdentures in adult edentulous individuals were compared. The outcomes of interest were patient satisfaction, oral and general health-related quality of life. Random effects models were used to pool the effect sizes (ES) of all included studies.

RESULTS

Ten publications of seven randomized-controlled trials were identified and eight were included in the meta-analysis. When compared with mandibular conventional dentures, implant overdentures were rated to be more satisfactory at a clinically relevant level [pooled ES 0.80, z=3.56, 95% confidence intervals (CI) 0.36-1.24, P=0.0004], but a statistical heterogeneity was found (chi(2)=31.63, df=5, P<0.00001, I(2)=84%). The pooled ES for oral health quality of life was -0.41 (z=1.31, 95% CI, -1.02 to 0.20; P=0.19, chi(2)=11.53, df=2, P<0.003, I(2)=83%). There was a lack of evidence to show the impact of mandibular implant overdenture on perceived general health.

CONCLUSIONS

Our findings suggest that, although mandibular implant-retained overdentures may be more satisfying for edentulous patients than new conventional dentures, the magnitude of the effect is still uncertain. There is a need for additional evidence including cost-effectiveness analyses on the impact of mandibular implant overdentures and conventional dentures.

Implant success in people with type 2 diabetes mellitus with varying glycemic control: a pilot study

BACKGROUND

The authors conducted a prospective cohort study to explore the relationship between implant success and glycemic control in patients with type 2 diabetes mellitus.

METHODS

The authors used a two-phased enrollment, stratified by glycated hemoglobin (HbA1c) levels, to evaluate 50 implants in 35 subjects. The authors assessed nonsubmerged, nonrestored implants after placement, during healing and at abutment placement (35 newton centimeters) for restoration after four months. Outcomes assessed included implant success or failure, clinical complications and adverse events.

RESULTS

The HbA1c levels of the subjects ranged from 4.5 to 13.8 percent. All 50 implants were integrated clinically. The authors identified three minor complications in three patients having HbA1c levels ranging from 7.4 to 8.3 percent. None of these complications affected the clinical management of the cases, and the authors did not identify any adverse events.

CONCLUSIONS

There was no evidence of diminished clinical success or significant early healing complications associated with implant therapy based on the glycemic control levels of subjects with type 2 diabetes mellitus.

CLINICAL IMPLICATIONS

These findings support the continued investigation of the effects of glycemic control on implant therapy toward the development of therapeutic guidelines that will optimize implant therapy in patients with diabetes.

How do patients perceive the benefit of reconstructive dentistry with regard to oral health-related quality of life and patient satisfaction? A systematic review

BACKGROUND

Reconstructive dentistry encompasses an enormous range of treatment modalities from the restoration of single teeth to the reconstruction of the whole dentoalveolar complex in edentulous patients. Some treatment modalities have been assessed in terms of quality-of-life (QoL) outcomes and satisfaction

OBJECTIVES

The aim of the present investigation was to search and review studies published between 1996 and 2006 in which the impact of the treatment was measured in terms of QoL outcome, ideally, oral health-related quality of life (OHRQoL). Patient satisfaction was also accepted as an outcome.

MATERIALS AND METHODS

The primary search engine used was NICB PubMed based on MeSH headings. Hand searching of the cited references in the included papers identified a number of additional studies. The primary focus of the search was to link treatment to QoL outcomes.

RESULTS

The majority of included studies involved the treatment of edentulous patients, particularly the mandible. The preponderance of the studies comparing conventional dentures (CDs) and implant-supported overdentures (IODs) were randomized-controlled trials (N = 18). There was compelling evidence that patients were more satisfied with IODs than CDs. There was strong evidence that OHRQoL can be significantly improved using IODs. Evidence suggesting that one retention system is superior to another needs further clarification. Although high satisfaction ratings have been reported for maxillary implant prostheses, the overall ratings given to the maxillary implant prostheses were not significantly greater than for CDs. There was only sparce information regarding QoL or satisfaction outcomes for the majority of other forms of reconstructive dentistry.

CONCLUSION

Apart from the restoration of the edentulous mandible with IODs or CD, where there is an accumulating body of evidence on the effect of treatment choice, there are many procedures for which there are little or no such data at all. As yet, the entire range of reconstructive treatment has witnessed insufficient investigations relating treatment to its effect on QoL or satisfaction. This is an area that needs to be expanded as a way of quantifying the effect of treatment choices.

Bone Healing at a Failed Implant Site in a Type II Diabetic Patient: Clinical and Histologic Evaluations: A Case Report

Placement of endosseous dental implants in diabetic patients may be compromised because of altered wound healing. Additionally there is no established timetable for implant healing in these patients. A case report is presented that evaluates implant healing at the site of a failed implant after its removal. This report documents bone remodeling in a diabetic patient 6 months after removing the failed implant. The prostheses was delivered within 4 months in the upper arch despite the complications during the healing period.

Systemic diseases affecting osseointegration therapy

OBJECTIVES

To evaluate the impact of systemic diseases and their treatment on the success of osseointegration therapy.

MATERIAL AND METHODS

A search was made to find human studies including subjects treated with osseointegrated oral implants, with a diagnosis of 11 systemic diseases, and reporting at least implant survival.

RESULTS

For most conditions, no studies comparing patients with and without the condition in a controlled setting were found. The evidence to recommend implant therapy was low and consisted in presentations of some successfully treated cases. With regard to diabetes, three types of reports were found: eight case series of diabetic patients treated with implants, six cross-sectional, longitudinal or retrospective evaluations of groups of subjects treated with implants, including some diabetic patients, and one matched control retrospective chart survey. The heterogeneity of the material and the method of data reporting precluded a formal meta-analysis. No unequivocal tendency for subjects with diabetes to have higher failure rates emerged, but the largest of these studies indicated a significant increase in the relative risk of implant failure with diabetes. The data obtained from 17 papers reporting data from osteoporotic patients were also heterogeneous. The evidence for an association of osteoporosis and implant failure was low.

CONCLUSIONS

The level of evidence indicative of absolute and relative contraindications for implant therapy due to systemic diseases is low. Many conditions have been listed as potentially critical, but studies comparing patients with and without the condition in a controlled setting are sparse.

Influence of oral characteristics and food products on masticatory function

Mastication is a complex process that involves activities of the facial muscles, the elevator and suprahyoidal muscles, and the tongue. These activities result in patterns of rhythmic mandibular movements, food manipulation, and the crushing of food between the teeth. Saliva facilitates mastication by moistening food particles, making a bolus, and assisting swallowing, whereas food consistency modifies masticatory forces, the mandibular jaw movements, the duration of the mastication cycle, and the number of cycles preceding the first swallow. Jaw elevator EMG activity research shows a clear relation between muscular activity and food properties. The teeth, masticatory muscles, and temporomandibular joints are also important because together they form the mechanism by which the food particles are fragmented. Hard and dry foods require more chewing cycles and a longer time in the mouth until swallowing for sufficient breakdown to take place and for enough saliva to be added to form a coherent bolus safe enough for swallowing. Product characteristics, the amount of saliva, dentition, and bite force affect the chewing performance. This study presents an update and synopsis of the effects of saliva, food, dentition, muscle force, and temporomandibular disorders on the masticatory process.

Maintenance of Osseointegration Utilizing Insulin Therapy in a Diabetic Rat Model

BACKGROUND

Normal wound healing processes have been shown to be altered in diabetes, and the effect of the diabetes on bone-to-implant contact (BIC) once osseointegration has been established is still unknown. The purpose of this study was to histologically evaluate the bone-to-implant contact in uncontrolled and insulin-controlled rats in which diabetes was induced following the establishment of osseointegration.

METHODS

Thirty-two rats were assigned to eight different treatment groups of four each. Titanium plasma-sprayed (TPS) implants were placed in the femora of each animal, and allowed to osseointegrate for 28 days before diabetic induction. Daily insulin injections were given to four groups of rats and the other four groups received no insulin (uncontrolled). The rats were sacrificed at 1, 2, 3, and 4 months following diabetic induction.

RESULTS

The results indicated that at 1, 2, 3, and 4 months, there was more BIC in the insulin-controlled groups compared to the uncontrolled groups. The differences were significantly greater at 2, 3, and 4 months (P < or =0.001).

CONCLUSIONS

This study demonstrated that osseointegrated dental implants in insulin-controlled diabetic rats maintained bone-to-implant contacts over a 4-month period. However, boneto- implant contact appears to decrease with time in uncontrolled diabetic rats.

Association between nutrition and the prosthetic condition in edentulous elderly

OBJECTIVES

The aim of this study was to assess the possible risk of malnutrition among the elderly population.

SUBJECTS

twenty-three pairs of complete dentures were made for a group of patients and 17 upper complete dentures with implant-supported lower dentures were made for a different group.

METHODS

The study was performed at the University of São Paulo--Dental Branch, Brazil. The patients were submitted to a nutritional test, as well as to a clinical examination and interview. Chewing ability and patient's satisfaction with their prostheses were evaluated. The nonparametric statistics proof of chi-squared, level 0.05 was performed and because of the low frequencies. The Fischer test was also used.

RESULTS

Patients wearing mandibular implant-supported dentures were considered well nourished (76.47%) when compared with complete dentures users (43.48%). There was a significant difference between the two groups, concerning to chewing ability (chi2 = 5.79) and nutritional status (chi2 = 4.35).

CONCLUSION

The risk of malnutrition was higher for elderly wearing complete dentures. The psychological state influences the interest in diet and choice of food.

A review of selected dental literature on evidence-based treatment planning for dental implants: Report of the Committee on Research in Fixed Prosthodontics of the Academy of Fixed Prosthodontics

This literature review summarizes research with the aim of providing dentists with evidence-based guidelines to apply when planning treatment with osseointegrated implants. Peer-reviewed literature published in the English language between 1969 and 2003 was reviewed using Medline and hand searches. Topics reviewed include systemic host factors such as age, gender, various medical conditions, and patient habits, local host factors involving the quantity and quality of bone and soft tissue, presence of present or past infection and occlusion, prosthetic design factors, including the number and arrangement of implants, size and coatings of implants, cantilevers and connections to natural teeth, and methods to improve outcomes of implant treatment in each category. The review demonstrated that there is no systemic factor or habit that is an absolute contraindication to the placement of osseointegrated implants in the adult patient, although cessation of smoking can improve outcome significantly. The most important local patient factor for successful treatment is the quality and quantity of bone available at the implant site. Specific design criteria are provided, including guidelines for spacing of implants, size, materials, occlusion, and fit. Limitations in the current body of knowledge are identified, and directions for future research are suggested.

Implant-retained maxillary overdentures

Overdentures supported by osseointegrated implants overcome many of the complications observed with overdentures supported by natural teeth. Dental implants are free of biologic consequences associated with natural teeth, such as dental caries and periodontal disease. Bone undercuts adjacent to implants do not mimic those found adjacent to natural tooth roots. Implants are used to provide predictable retention, support, and stability for overdenture prostheses. When lip or facial support is required, the overdenture is the treatment of choice. Likewise the overdenture may improve phonetic deficiencies associated with alveolar bone loss.

Impact of Human Genome Project on treatment of frail and edentulous patients*

OBJECTIVE

Because of ongoing increases in life expectancy and deferment of edentulousness to older age, dentists are facing a different challenge to satisfy elderly denture wearers with a higher prevalence of chronic diseases. This discussion introduces the Human Genome databases as novel and powerful resources to re-examine the core problems experienced by frail and edentulous patients.

BACKGROUND

Recent studies demonstrated that mandibular implant overdentures do not necessarily increase masticatory function, perception and satisfaction in denture wearers with adequate edentulous residual ridges. It has been demonstrated that the rate of edentulous residual ridge resorption significantly varies among individuals. The prognosis and cost-effectiveness of denture treatment, with or without implants, may largely depend on how the edentulous ridge is maintained. However, reliable clinical methods permitting dentists to predict the long-term health of the edentulous residual ridge are lacking.

MATERIALS AND METHODS

With the completion of the Human Genome Project, the genomic sequence database from this multinational consortium will provide a unique resource to determine the genetic basis of similarity and diversity of humans.

RESULTS

One base pair in every 100 to 300 base pairs of the genome sequence varies among humans, suggesting that genetic diagnosis using the single nucleotide polymorphisms (SNPs) may provide a novel opportunity to differentiate our edentulous patients.

CONCLUSIONS

Future dental service for the elderly will require a personalized care paradigm, using highly sensitive diagnostic technology such as SNP genomic analysis, for recommending the treatment with greatest potential benefit.

Implants in the medically compromised patient

Dental clinicians are confronted with an increasing number of medically compromised patients who require implant surgery for their oral rehabilitation. However, there are few guidelines on dental implant therapy in this patient category, so that numerous issues regarding pre- and post-operative management remain unclear to the dental clinician. Therefore, the aim of the present review is to offer a critical evaluation of the literature and to provide the clinician with scientifically based data for implant therapy in the medically compromised patient. This review presents the current knowledge regarding the influence of the most common systemic and local diseases on the outcome of dental implant therapy, e.g., abnormalities in bone metabolism, diabetes mellitus, xerostomia, and ectodermal dysplasias. Specific pathophysiologic aspects of the above-mentioned diseases as well as their potential implications for implant success are critically appraised. In line with these implications, guidelines for pre- and post-operative management that may assist in the successful implant-supported rehabilitation of this patient category are proposed.

The prevalence of calcified carotid artery atheromas on the panoramic radiographs of patients with type 2 diabetes mellitus

BACKGROUND

People with type 2 diabetes mellitus are disproportionately at risk of experiencing stroke, because hyperglycemia and other risk factors associated with diabetes accelerate development of cervical carotid artery atheromas. Removal of these atheromas may reduce the incidence of stroke. The authors conducted a study to ascertain if those treated without insulin (noninsulin-treated, or NIT) would have a lower prevalence of atheromas on their radiographs and a lower prevalence of risk factors than those treated with insulin (insulin-treated, or IT).

METHODS

The authors evaluated the panoramic radiographs and medical records of 46 neurologically asymptomatic men (n = 34) and women (n = 12) (age range 62-77 years, mean age 68.5 years) with type 2 diabetes. They used Fisher exact test to perform a statistical comparison of the prevalence of atherogenic atheromas and risk factors between groups.

RESULTS

The radiographs showed that 24 percent of the NIT patients and 36 percent of the IT patients had atheromas; this difference was not statistically significant (P = .52). The groups had similar risk factors--that is, high levels of glycosylated hemoglobin A, or HbA1c; smoking; hypertension; and obesity (P > .05). When compared with the 4 percent atheroma prevalence rate among healthy people of similar age, the rates were significantly higher in both the NIT (P = .02) and IT (P = .0006) patients.

CONCLUSION

These results demonstrate that people with type 2 diabetes, irrespective of treatment modality, have high rates of atheromas as visualized on their panoramic radiographs.

CLINICAL IMPLICATIONS

Dentists treating patients with type 2 diabetes mellitus must review their panoramic radiographs carefully for evidence of atheroma formation. Patients with atheromatous lesions must be referred to their physicians for further evaluation and treatment, because the modification of atherogenic risk factors and the surgical removal of atheromas in certain people have been shown to reduce the likelihood of stroke.

Dental Implant Treatment in Diabetic Patients

The purpose of the present study was twofold: (1) to investigate how many diabetic patients and types of cases that are treated with dental implants in our clinic; and (2) assess the outcome of such treatment. Medical records from 782 patients were examined in patients treated by the Brånemark method for partial or total edentulism with implant supported bridges. From these records, 25 patients (3.2%) with diabetes before implant treatment (136 implants) were identified and further studied with respect to age, gender, type of diabetes, treated jaw, degree of edentulism, bone graft, implant survival, periimplant inflammation, bleeding on probing, and radiographic bone loss. Furthermore, the patients' opinion about the outcome of the treatment was registered. The implant success rate was 96.3% during the healing period and 94.1% 1 year after surgery. Of all 38 bridges, one was lost. Few complications occurred and all patients, except for one, were satisfied with the treatment. Today, diabetic patients are being treated successfully for all types of edentulism, including bone-grafting treatment. Diabetics that undergo dental implant treatment do not encounter a higher failure rate than the normal population, if the diabetics' plasma glucose level is normal or close to normal as assessed by personal interviews.

Diabetes mellitus and dental implants: a clinical study

Diabetes mellitus is no longer considered to be a contraindication for implant-supported prostheses, provided that the patient's blood sugar is under control, and that there is motivation for oral hygiene procedures. This paper presents the experiences of treating diabetic patients using implants with good success rates.

Biting and chewing in overdentures, full dentures, and natural dentitions

It has been suggested that the provision of dental implants can improve the oral function of subjects with severely resorbed mandibles, possibly restoring function to the level experienced by satisfied wearers of conventional complete dentures. Nevertheless, a quantitative comparison has never been made and can be drawn from the literature only with difficulty, since studies differ greatly in methodology. To make such a comparison, we measured bite force and chewing efficiency by using identical methods in subjects with overdentures, complete full dentures, and natural dentitions. Our results indicated that bite forces achieved with overdentures on dental implants were between those achieved with artificial and natural dentitions. Chewing efficiency was significantly greater than that of subjects with full dentures (low mandible), but was still lower than that of subjects with full dentures (high mandible) and overdentures on bare roots. Differences in the height of the mandible revealed significant differences in chewing efficiency between the two full-denture groups. Furthermore, subjects with a shortened dental arch exerted bite forces similar to those of subjects with a complete-natural dentition, but their chewing efficiency was limited due to the reduced occlusal area. For all groups combined, a significant correlation was found between maximum bite force and chewing efficiency. Nearly half of the variation in chewing efficiency was explained by bite force alone.

Randomized clinical trial comparing the efficacy of mandibular implant-supported overdentures and conventional dentures in diabetic patients. Part III: comparisons of patient satisfaction

STATEMENT OF PROBLEM

There is insufficient evidence to indicate the functional superiority of mandibular implant-supported overdentures to justify their use in edentulous patients.

PURPOSE

This study compared the benefits perceived by patients who received a new maxillary denture and a mandibular conventional denture (CD) and an implant-supported overdenture (IOD).

METHOD

New maxillary and mandibular dentures were delivered to 89 diabetic denture wearers with clinically acceptable metabolic control who treated their diabetes either with insulin (IT) or without insulin (NIT). Of the 89 patients, 37 received maxillary and mandibular CDs and 52 received a maxillary CD and an IOD. Two questionnaires with categorical responses were used; the first contained 13 questions to ascertain a patient's absolute assessments of original dentures at entry and study dentures at 6- and 24-months after treatment completion; the second questionnaire had 11 questions that assessed the relative change perceived by patients with study dentures. Of the 78 patients who completed the posttreatment (PT) assessments at 6 months, 68 patients provided longitudinal data for questionnaire I and cross-sectional data for questionnaire II. In addition, 46 patients (18 CD and 28 IOD) also provided PT assessments at 24 months.

RESULTS

Both mean scores and percentage distributions of longitudinal data for questionnaire I showed perceptual improvements with both types of study dentures. Improvements were higher in the IOD than in the CD group. Mean scores failed to show any significant differences between the 2 treatment groups. The only significant difference was found in the change in percentage distributions for perceptual chewing ability in favor of the IOD group. Even this advantage was lost at 24 months. With the comparative questionnaire, a higher percentage of patients in the IOD group than in the CD group perceived improvements with study dentures from their original dentures in chewing ability, chewing comfort, and denture security. However, mean differences were statistically significant in favor of the IOD group only for chewing ability and less difficulty to chew hard foods.

CONCLUSION

The mandibular implant-supported overdenture offers same advantage in terms of perceived chewing function over the conventional denture.

A within-subject comparison of mandibular long-bar and hybrid implant-supported prostheses: evaluation of masticatory function

Sixteen edentulous subjects participated in a within-subject crossover clinical trial to test the hypotheses that a long-bar overdenture attached to 4 implants gives greater patient satisfaction and masticatory efficiency than a two-implant hybrid overdenture. All subjects were given a new maxillary conventional denture. Ten received mandibular long-bar overdentures first and six the hybrid overdentures. Two months later, psychometric assessments and functional tests were repeated 3 times at one-week intervals. The mandibular prosthesis was then changed, and recordings were repeated after another 2 months. Mandibular movements and electromyographic activity of jaw muscles were recorded while subjects chewed standard-sized pieces of 5 foods: bread, cheese, apple, sausage, and carrot. Measurements included masticatory time, cleaning time (the time between the end of mastication and the last swallow), and duration and amplitude of masticatory cycles and phases. Multilevel analyses were performed. No significant differences in masticatory time were found between prostheses for any test food. However, cleaning time for carrot [estimated mean of difference (delta) +/- SE: 1.6 sec +/- 0.7] and bread (delta = 1.0 sec +/- 0.4) was slightly but significantly longer for subjects wearing long-bar overdentures. Cycle duration was longer with the long-bar overdenture only for subjects chewing carrot. The opening phase was shorter and the closing phase longer with the long-bar overdenture for almost all test foods. Vertical amplitude was significantly less with the long-bar overdenture for cheese (delta = -2.6 mm +/- 1.1), apple (delta = -2.6 mm +/- 1.0), and sausage (delta = -2.9 mm +/- 1.3). These results suggest that mastication with the 2 prostheses is equally efficient, although clearance of some foods from the mouth is longer with the long-bar overdentures. They also indicate that patients adapt their masticatory movements to the characteristics of different prostheses.

A randomized clinical trial comparing the efficacy of mandibular implant-supported overdentures and conventional dentures in diabetic patients. Part II. Comparisons of masticatory performance

STATEMENT OF PROBLEM

Convincing evidence is lacking to demonstrate the functional superiority of mandibular implant-supported overdentures over conventional dentures.

PURPOSE

This randomized clinical trial was conducted to compare masticatory functional effectiveness of mandibular implant-supported overdentures and conventional dentures in diabetic denture wearers with clinically acceptable metabolic control.

METHODS

A total of 102 edentulous diabetic patients, treated with or without insulin, were randomized to receive a new maxillary and either a mandibular conventional denture or an implant-supported overdenture. Treatment was completed in 89 patients, 37 with conventional dentures and 52 with Hader bar-clip attachment overdentures supported by two IMZ implants. Besides data from medical and dental histories, oromaxillofacial examinations, and questionnaires, masticatory tests were performed by patients before and at 6 and 24 months after treatment completion. Although 78 patients (28 in the conventional, 50 in the overdenture group) performed tests at 6 months after treatment, 68 (25 in the conventional, 43 in the overdenture) had performance data for both entry and 6-month posttreatment intervals.

RESULTS

The two treatment groups were highly comparable in terms of general characteristics, quality of original dentures, tissue support, and past denture experience. No significant differences were found between patients treated for diabetes with or without insulin. All four masticatory performance scores with original dentures were higher in the conventional denture group than the overdenture group. The posttreatment performance scores for the two treatment groups became similar because of the higher gains in the overdenture group. Patients with low initial performance scores showed greater posttreatment gains with both conventional dentures and overdentures.

CONCLUSIONS

The implant-supported overdenture showed no significant advantage over the conventional denture for improving the ability to comminute food in this group of diabetic patients with higher than average initial functional levels observed for other groups of denture wearers in previous studies.