Diabetes and oral implant failure: a systematic review

Systemic Factors Affecting Prognosis and Outcomes in Periodontal Disease

This review delves into the effects of autoimmune conditions like rheumatoid arthritis, inflammatory disorders such as irritable bowel syndrome, cardiovascular disease, diabetes, infectious ailments like human immunodeficiency virus, and their medications on periodontal therapy outcomes. It also explores the influence of hormones. Understanding these systemic factors is crucial for optimizing periodontal health and treatment efficacy. The review underscores the necessity of considering these variables in periodontal care. Other vital systemic factors are addressed elsewhere in this special edition.

Factors affecting radiographic marginal bone resorption at dental implants in function for at least 5 years: A multicenter retrospective study

OBJECTIVE

To evaluate the influence of patient and implant-related factors on the changes of marginal bone levels (MBL) at implants with a follow-up ≥5 years.

MATERIALS AND METHODS

At baseline (within 6 months from prosthetic insertion) and long-term (≥5 years after implant placement) visits, interproximal (mesial and distal) MBL were radiographically evaluated. To analyze factors predicting MBL change, the site (either mesial or distal) showing the highest MBL change (hChMBL site) was identified for each implant. Multilevel regression models were built to explain MBL change as well as the probability for a bone loss ≥2 mm at long-term.

RESULTS

942 implants in 312 patients with a mean follow-up of 8.02 ± 2.5 years were analyzed. MBL change was significantly predicted by baseline MBL, oral bisphosphonate (BP) intake, history of periodontitis, diabetes, and super-hydrophilic implant surface. Higher risk for a bone loss ≥2 mm was observed in patients with history of periodontitis (OR = 9.52, 95% CI 0.72-3.79) and taking BP (OR = 6.84, 95% CI 0.21-3.63). Mandibular implants had higher odds for bone loss ≥2 mm compared to maxillary implants (OR = 3, 95% CI 0.39-1.87).

CONCLUSIONS

The findings of the present study contribute to the identification of specific clinical scenarios at higher risk for implant-supporting bone loss that need to be strictly monitored during maintenance.

Dental implant considerations in patients with systemic diseases: An updated comprehensive review

BACKGROUND

Various medical conditions and the drugs used to treat them have been shown to impede or complicate dental implant surgery. It is crucial to carefully monitor the medical status and potential post-operative complications of patients with systemic diseases, particularly elderly patients, to minimize the risk of health complications that may arise.

AIM

The purpose of this study was to review the existing evidence on the viability of dental implants in patients with systemic diseases and to provide practical recommendations to achieve the best possible results in the corresponding patient population.

METHODS

The information for our study was compiled using data from PubMed, Scopus, Web of Science and Google Scholar databases and searched separately for each systemic disease included in our work until October 2023. An additional manual search was also performed to increase the search sensitivity. Only English-language publications were included and assessed according to titles, abstracts and full texts.

RESULTS

In total, 6784 studies were found. After checking for duplicates and full-text availability, screening for the inclusion criteria and manually searching reference lists, 570 articles remained to be considered in this study.

CONCLUSION

In treating patients with systemic conditions, the cost-benefit analysis should consider the patient's quality of life and expected lifespan. The success of dental implants depends heavily on ensuring appropriate maintenance therapy, ideal oral hygiene standards, no smoking and avoiding other risk factors. Indications and contraindications for dental implants in cases of systemic diseases are yet to be more understood; broader and hardcore research needs to be done for a guideline foundation.

Risk factors for Peri-implantitis: An umbrella review of meta-analyses of observational studies and assessment of biases

OBJECTIVES

To perform a comprehensive quantitative and qualitative analysis of the findings from previously published meta-analyses and to assess existing biases.

DATA/SOURCES

A search was conducted for meta-analyses of observational studies investigating the association between any risk factor and peri‑implantitis in PubMed, Scopus, Cochrane Database of Systematic Reviews, and Epistemonikos, from inception until October 2023 (PROSPERO: CRD42024512408).

STUDY SELECTION

From a total of 5002 publications, 51 full-text articles were evaluated for eligibility, and 12 articles that described 41 unique meta-analyses evaluating the association between risk factors and periimplantitis were selected. Among 41 associations, 24 associations were significant. None of the associations were graded as convincing evidence. Two associations, presence of periodontitis (OR = 3.84 [95 % CI 2.58,5.72]) and cigarette smoking (RR=2.07 [95 % CI 1.41,3.04]) were graded as highly suggestive. Eight associations, diabetes mellitus, hyperglycaemia, lack of prophylaxis, history of chronic periodontal disease, ongoing or history of periodontal disease, implants located in the anterior region of the jaw (maxillary and mandibular), osteoprotegerin (OPG) gene polymorphisms, and lack of keratinized mucosal width were graded as suggestive evidence.

CONCLUSIONS

Periodontitis and cigarette smoking are highly suggestive risk factors for peri‑implantitis. The remaining risk factors which are suggestive require more high-quality studies to be performed to upgrade the level of evidence.

CLINICAL SIGNIFICANCE

The highly suggestive and suggestive risk factors for peri‑implantitis summarized in this umbrella review should be rigorously assessed, monitored and managed by clinicians to reduce the risk peri‑implantitis, as well as to form part of the preoperative consent process.

Restoration of posterior teeth by narrow diameter implants in hyperglycemic and normoglycemic patients - 4-year results of a case-control study

OBJECTIVES

To investigate the four-year clinical outcome and marginal bone loss around narrow-diameter implants in patients with uncontrolled diabetes mellitus type 2 (T2DM) and normo-glycemic individuals.

MATERIALS AND METHODS

In 11 T2DM patients with a concentration of glycated hemoglobin (HbA1C) > 6.5% (test group) and 15 normoglycemic patients (HbA1C < 6.0%; control group), one narrow-diameter tissue level implant, placed in the posterior maxilla or mandible, was investigated. The clinical parameters probing depth (PD), bleeding on probing (BOP), attachment loss (CAL), recession, and papilla bleeding index (PBI) were assessed manually after 24 and 48 months of function. The paired digital periapical radiographs were analyzed regarding the change in marginal bone level (MBL) from baseline to 48 months post-op. The technical complications were recorded.

RESULTS

In the T2DM group, 11 patients were available for follow-ups. The overall implant survival rate after 48 months was 100%. The differences in means for the clinical parameters and the MBL between the T2DM and normo-glycemic patients for the observation period were statistically non-significant. No technical complications were recorded.

CONCLUSIONS

The study demonstrated an encouraging clinical outcome with ND implants in patients with uncontrolled T2DM compared to non-diabetics after 48 months' post loading.

CLINICAL RELEVANCE

Patients with HbA1C > 6.5% may benefit from the treatment with narrow-diameter implants by avoiding complex surgical interventions with augmentation procedures. REGISTRATION NUMBER (CLINICALTRIALS.GOV): NCT04630691.

Tooth- and implant-related prognostic factors in treatment planning

Following a comprehensive patient examination, including the assessment of periodontal and peri-implant diseases as well as considering the patient's needs, a pretherapeutic prognosis for each tooth and implant is given. Teeth and implants with a secure pretherapeutic prognosis require simple procedures and may be regarded as secure abutments for function and with a doubtful pretherapeutic prognosis usually need a comprehensive therapy. Such teeth and implants must be brought into the category with a secure prognosis by means of additional therapy such as endodontic, restorative, and surgical procedures. Teeth and implants with a hopeless pretherapeutic prognosis should be extracted/explanted during the initial phase of cause-related therapy (i.e., infection control). For example, teeth with vertical root fracture or unrestorable caries and implants with mobility or unrestorable malposition fall into the category of hopeless units. The primary goal of periodontal and peri-implant therapy should be to arrest disease progression. The latest consensus statement highlights that periodontitis can be successfully controlled and treated teeth can be retained for life. Nevertheless, for patients with uncontrolled contributing factors, the endpoints might not always be achievable, and low disease activity may be an acceptable therapeutic goal. Similarly, the management of peri-implantitis frequently requires surgical intervention following nonsurgical therapy due to incomplete treatment outcomes. Different surgical modalities can be effective and lead to significant improvement; however, achieving complete resolution of peri-implantitis is challenging, not always predictable, and can depend on multiple baseline factors. Therefore, this review aims at summarising available evidence on the rationale for incorporating systemic, lifestyle-related, clinical, and radiographic prognostic factors into treatment planning of patients diagnosed with periodontal and peri-implant diseases.

Relationship Between Diabetes Mellitus and Periodontal/Peri-Implant Disease: A Contemporaneous Review

The prevalence of diabetes mellitus (DM), a major chronic disease and a leading cause of death and disability around the world, is rising. According to the latest data, the global prevalence of DM has increased to 463 million (9.3% of adults) in 2019 and is estimated to reach 700 million by 2045. Periodontal disease, result of periodontium inflammation, is a common, chronic disease and has long been considered one of the complications of DM. Moreover, literature reflects a spectrum of conflicting viewpoints on the effect of diabetic conditions on the implant treatment strategies. The current review aims to update the recent epidemiologic evidence regarding the relationship between DM and periodontal/peri-implant disease, emphasising the effects of glycaemic control on the severity of these diseases and describing the pathobiological mechanisms underlying this association. This review's findings indicate a bidirectional relationship between DM and periodontal/peri-implant disease and that this relationship seems causal, implying that controlling these two diseases might help prevent each other's incidence. Additionally, the severity of periodontal/peri-implant disease is directly related to metabolic control. Although patients with diabetes can obtain implant success similar to those in systemically healthy individuals, an increased risk of peri-implantitis has been reported in DM patients. Therefore, the importance of glycaemic control and maintaining proper oral hygiene cannot be overstated.

Effect of Antiresorptive Drugs on Osseointegrated Dental Implants: A Systematic Review

Background: This systematic review aimed to evaluate the impact of antiresorptive drug therapy on osseointegrated dental implants and the association with medication-related osteonecrosis of the jaw (MRONJ). Methods: A systematic search, including a computer search of several databases with specific keywords, a reference search, and a manual search of four key maxillofacial journals were performed. Relevant articles were then evaluated and those that fulfilled the five predetermined criteria were chosen to enter the final review. A total of 445 implants in 135 subjects were included in the eight studies analyzed in the final review. Results: The failure rate of dental implants after antiresorptive medication in the included studies was 23%, with 83% of failures attributed to MRONJ. The average time from antiresorptive drug initiation to MRONJ development was approximately 34 months, ranging from 3 months to 16 years. The majority of MRONJ cases were classified as stage 2, and all sites showed either complete healing or substantial mucosal coverage after treatment. Conclusions: This review highlights the significant impact of antiresorptive drugs on osseo- integrated implants, with MRONJ identified as a leading cause of implant failure. The potential role of peri-implantitis as a trigger for MRONJ is emphasized. Regular monitoring and maintaining good periodontal health, especially within the first three years of antiresorptive drug therapy initiation, are crucial for implant success. Physicians and dentists should provide comprehensive information to patients prescribed with antiresorptive drugs, emphasizing the need for an awareness of the risks of MRONJ in the context of osseointegrated implants. A longer term of follow-up is recommended to identify and manage MRONJ around dental implants in an early manner.

Calcium phytate reverses high glucose-inhibited osteogenesis of BMSCs via the MAPK/JNK pathway

OBJECTIVES

Diabetes mellitus (DM) induces oxidative tissue impairment and suppresses bone formation. Some studies have shown that phytic acid has antioxidant and anti-diabetic properties. This study aimed to investigate the potential of calcium phytate (Ca-phytate) to reverse inhibited osteogenesis of human bone marrow mesenchymal stem cells (hBMSCs) in a high glucose (HG) environment and to determine the underlying mechanism.

MATERIALS AND METHODS

hBMSCs were exposed to HG and palmitic acid to simulate DM in vitro. Osteogenic differentiation was measured using alkaline phosphatase staining and activity assay, alizarin red S staining, qRT-PCR, Western blot and immunofluorescence staining. A critical-size cranial defect model of type 2 diabetes mellitus (T2DM) rats was established to evaluate bone regeneration. A specific pathway inhibitor was used to explore whether the MAPK/JNK pathway was involved.

RESULTS

Treatment with 34 μM Ca-phytate had the highest effect on osteogenic differentiation in HG. Ca-phytate improved cranial bone defect healing in T2DM rats. The long-term HG environment inhibited the activation of the MAPK/JNK signalling pathway, which was restored by Ca-phytate. Blocking the JNK pathway reduced the Ca-phytate-mediated osteogenic differentiation of hBMSCs.

CONCLUSION

Ca-phytate induced bone regeneration in vivo and reversed HG-inhibited osteogenesis of hBMSCs in vitro via the MAPK/JNK signalling pathway.

Evaluation of mandibular implant-supported fixed prosthesis retained by 3 dental implants, 1 straight and 2 angled: A retrospective clinical study

STATEMENT OF PROBLEM

The minimum number of implants to support fixed complete dentures is still unclear.

PURPOSE

The purpose of this retrospective clinical study was to evaluate the survival rate of fixed complete dentures supported by 3 immediately loaded implants opposing maxillary complete dentures.

MATERIAL AND METHODS

A retrospective study of edentulous patients rehabilitated with complete dentures opposing mandibular metal-resin implant-supported fixed complete dentures supported by 3 immediately loaded implants was conducted in a 48-hour protocol. Fifty-one machined and 99 rough-surface implants were evaluated from 2.2 up to 8 years. Implant loss, peri-implant outcomes, and mechanical complications were assessed by considering the influence of age, sex, health status, smoking, excessive alcohol consumption, educational level, and socioeconomic status. The presence of comorbidities in relation to the implant surface or the cantilever lengths was also evaluated.

RESULTS

Four machined and 6 rough-surface implants failed, a 6.7% failure rate. The cantilever length varied from 3.3 to 22.9 mm. Mechanical complications were abutment screw loosening (3.0%), prosthetic screw loosening (17%), screw fracture (1%), superstructure detachment and fractures (16%), metal framework fracture (2%), maxillary denture fractures (6%), and mandibular prosthesis loss (4%). Peri-implant mucositis was found in 27% of participants. The cumulative implant and mandibular prosthesis survival rates were 93.3% and 96%, respectively. None of the variables evaluated, including demographic data and health status, were found to influence clinical failures and/or mechanical complications.

CONCLUSIONS

Mandibular fixed complete dentures supported by 3 implants can be considered a successful treatment with reduced costs compared with those of other fixed options for application in public health.

Ozone therapy improves early stages of osseointegration in ovariectomized rats

OBJECTIVE

the aim of this study was to analyze the influence of ozone therapy (OZN) on peri-implant bone repair in critical bones by installing osseointegrated implants in the tibia of ovariectomized rats.

METHODOLOGY

ovariectomy was performed on 30 Wistar rats, aged six months (Rattus novergicus), and, after 90 days, osseointegrated implants were installed in each tibial metaphysis. The study groups were divided into the animals that received intraperitoneal ozone at a concentration of 700 mcg/kg - OZ Group (n=15) - and a control group that received an intraperitoneal saline solution and, for this reason, was named the SAL group (n=15). The applications for both groups occurred during the immediate post-operative period on the 2nd, 4th, 6th, 8th, 10th, and 12th day post-surgery. At various stages (14, 42, and 60 days), the animals were euthanized, and tests were performed on their tibiae. These tests include histomorphometric and immunohistochemical analyses, computerized microtomography, sampling in light-cured resin for calcified sections, and confocal microscopy. The obtained data were then analyzed using One-way ANOVA and the Shapiro-Wilk, Kruskal-Wallis, and student t-tests (P<0.05).

RESULTS

our findings indicate that the OZ group (3.26±0.20 mm) showed better cellular organization and bone neoformation at 14 days (SAL group, 0.90±1.42 mm) (P=0.001). Immunohistochemistry revealed that osteocalcin labeling was moderate in the OZ group and mild in the SAL group at 14 and 42 days post-surgery. The data from the analysis of calcified tissues (microtomography, histometric, and bone dynamism analysis) at 60 days showed no statistically significant differences between the groups (P=0.32).

CONCLUSION

it was concluded that ozone therapy anticipated the initial phases of the peri-implant bone repair process.

Gastrodin improves osteoblast function and adhesion to titanium surface in a high glucose environment

Objective

To investigate the effects of gastrodin on the biological behavior of osteoblasts and osseointegration on the surface of the titanium plate in a high glucose environment, and to explore the possible regulatory mechanisms involved.

Methods

A high glucose-induced oxidative damage model of MC3T3-E1 cells was established in vitro to observe the effects of gastrodin on cellular oxidative stress, cell viability, osteogenic differentiation, mineralization, migration, and adhesion ability on the titanium surface.

Results

High glucose environment can cause oxidative stress damage to MC3T3-E1 cells, leading to a decrease in cell viability, osteogenesis, migration, adhesion and other functions. Gastrodin can upregulate the expression of antioxidant enzymes (Nrf2 and HO-1) and osteogenic differentiation related proteins (RUNX2 and BMP2) in MC3T3-E1 cells in high glucose environment, thereby inhibiting the excessive production of intracellular reactive oxygen species (ROS), reversing the decrease in cell viability, and improving the osteogenic differentiation and mineralization ability of osteoblasts. And gastrodin alleviated the decline in cell migration ability, improved the morphology of the cytoskeleton and increased the adhesion ability of osteoblasts on the surface of titanium plates in high glucose environment. However, gastrodin itself did not affect the cell viability, osteogenic differentiation and mineralization ability of osteoblasts in normal environment.

Conclusions

Gastrodin may protect MC3T3-E1 cells osteogenesis and osseointegration on the surface of the titanium plate in vitro by upregulating antioxidant enzymes expression, and attenuating high glucose-induced oxidative stress. Therefore, gastrodin may be a potential drug to address the problem of poor implant osseointegration in patients with diabetes.

Emerging factors affecting peri-implant bone metabolism

Implant dentistry has evolved to the point that standard implant osseointegration is predictable. This is attributed in part to the advancements in material sciences that have led toward improvements in implant surface technology and characteristics. Nonetheless, there remain several cases where implant therapy fails (specifically at early time points), most commonly attributed to factors affecting bone metabolism. Among these patients, smokers are known to have impaired bone metabolism and thus be subject to higher risks of early implant failure and/or late complications related to the stability of the peri-implant bone and mucosal tissues. Notably, however, emerging data have unveiled other critical factors affecting osseointegration, namely, those related to the metabolism of bone tissues. The aim of this review is to shed light on the effects of implant-related factors, like implant surface or titanium particle release; surgical-related factors, like osseodensification or implanted biomaterials; various drugs, like selective serotonin reuptake inhibitors, proton pump inhibitors, anti-hypertensives, nonsteroidal anti-inflammatory medication, and statins, and host-related factors, like smoking, diet, and metabolic syndrome on bone metabolism, and aseptic peri-implant bone loss. Despite the infectious nature of peri-implant biological complications, these factors must be surveyed for the effective prevention and management of peri-implantitis.

Diagnostic and prognostic value of indicators of markers of bone metabolism in type 2 diabetes mellitus patients with UV functionalised dental implants

BACKGROUND

Diabetes mellitus affects many organ systems, including bone tissue.In diabetic patients, the activity of osteoblasts is suppressed and the activity of osteoclasts in the bone matrix increases, bone formation decreases, which can disrupt the process of osseointegration and ultimately lead to disintegration and failed implants. Based on the foregoing, with diabetes, it is very important to study bone metabolism to predict and dynamically control dental implants.

OBJECTIVES

To assess the indicators of bone metabolism markers Osteocalcin and β-Cross-Laps in blood serum in patients with type 2 diabetes mellitus with intraosseous dental implants.

METHODS

The study included 86 patients, diagnosed type 2 diabetes mellitus in period 2018 - 2023 with partially or complete edentulous. Implant surgery was performed after periodontal therapy using 367 UV functionalized dental implants in patients 1 group. Patients 2 group was performed implant surgery using 54 dental implants that were not UV functionalization. Final dental prosthetics was performed 4-5 months. UV functionalization of the implant surface was carried out using a UV Activator YWJ-QSY001 (Foshan, Wenjian Medikal Enstriman) for 20 s. The content biochemical markers of bone Osteocalcin and β-Cross-Laps serum was determined by enzyme-linked immunosorbent assay ELISA (ELISA, IFA Roche Diagnostics, Basel, Switzerland) before and after dental implantation according to the manufacturers' protocols. Outcomes assessed included; implant survival, men MBL, PPD, BOP, RFA, prosthetic success.

RESULTS

There were no clinical examinations of serious biological or prosthetic complications. There is a correlation between different concentrations of Osteocalcin or β-Cross- Laps and the success rate of implants. Implants were shown to be unsuccessful low concentrations of Osteocalcin and high concentrations β-Cross- Laps in serum compared with average mean biochemical markers of bone in 2 group patients. In patients of the 2nd group, the indicators of biochemical bone markers were within the normal range; no correlation was found between osseointegration failers and the complication of peri-implatitis. Short implants success rate was 96,7 %, standart implants success rate was after 97,5 after 5 years.

CONCLUSION

Implant therapy can be successfully used in diabetic patients with UV photofunctionalized implants, blood glucose levels should be constantly maintained at a normal level. Monitoring of bone metabolism markers in patients with type 2 diabetes mellitus may have prognostic value for implants and will encourage the practitioner to apply corrective drug therapy in case of violation of markers.

Revolutionizing fracture fixation in diabetic and non-diabetic rats: High mobility group box 1-based coating for enhanced osseointegration

Chronic inflammation and hyperglycemia in diabetic patients increase the risk of implant failure and impaired fracture healing. We previously developed and characterized a titanium (Ti) coating strategy using an imidazolium-based ionic liquid (IonL) with a fully reduced, non-oxidizable High Mobility Group Box 1 (HMGB1) isoform (Ti-IonL-HMGB1) to immunomodulate tissue healing. In this study, we used an open reduction fracture fixation (ORIF) model in non-diabetic (ND) and diabetic (D) rats to further investigate the effectiveness of this Ti-IonL-HMGB1 coating on orthopedic applications. Ninety male Lewis rats (12-15 weeks) were divided into D (n = 45) and ND (n = 45) groups that were distributed into three subgroups based on the type of local treatment received: Ti (uncoated Ti), Ti-IonL, and Ti-IonL-HMGB1 implants. Fracture healing and osseointegration were evaluated using microtomographic, histological, and immunohistochemical analysis of proliferating cell nuclear antigen (PCNA), Runt-related transcription factor 2 (RUNX2), and HMGB1 markers at 2, 10, and 21 days post-ORIF. Scanning Electron Microscopy verified the coating stability after placement. Microtomographic and histological analysis demonstrated increased fracture healing and osseointegration for ND rats in all treatment groups at 10 days, with impaired healing for D rats. Immunohistochemical analysis exhibited elevated PCNA+ and RUNX2+ cells for D animals treated with Ti-IonL-HMGB1 at 21 days compared to all other groups. The immunohistochemical marker HMGB1 was elevated at all time points for D animals in comparison to ND animals, yet was lowered for D tissues near the Ti-IonL-HMGB1 treated implant. Improved osseous healing was demonstrated in D animals with Ti-IonL-HMGB1 treatment by 21 days, compared to D animals with other treatments. To the best of our knowledge, this is the first study analyzing Ti-IonL-HMGB1 implantation in an injury site through ORIF procedures in ND and D rats. This surface approach has potential for improving implanted biomaterials in diabetic environments.

SATB1 promotes osteogenic differentiation of diabetic rat BMSCs through MAPK signalling activation

OBJECTIVE

Special AT-rich binding protein 1 (SATB1), a chromatin organizer and global transcriptional regulator, plays an important role in tumorigenesis and immune response. However, its function in the osteogenic differentiation of bone marrow-derived mesenchymal stem cells (BMSCs) remains unknown. Therefore, this study aimed to explore the role of SATB1 in osteogenesis.

METHODS

BMSCs were collected from the type 2 diabetes rat model and the protein and gene expression of SATB1 and osteospecific genes were evaluated post osteogenic induction.

RESULTS

SATB1 protein expression significantly decreased in diabetic rat BMSCs whereas it increased in BMSCs following osteogenic induction. SATB1 knockdown significantly suppressed the expression of osteospecific genes, including alkaline phosphatase (Alp), runt-related transcription factor 2, and osteocalcin, and reduced the number of mineral deposits and ALP activity, whereas SATB1 overexpression yielded the opposite results. Moreover, SATB1 knockdown suppressed activation of the MAPK signalling pathway (phosphorylation of p38 and ERK), and MAPK pathway inhibitors could reverse the inhibitory effect of SATB1 knockdown on osteogenic differentiation of BMSCs.

CONCLUSION

SATB1 plays a key role in the osteogenic differentiation of BMSCs via the p38 MAPK and ERK MAPK signalling pathways. These findings may provide a new strategy for the application of BMSCs in bone regeneration.

The Effect of Diabetes and Hyperglycemia on Horizontal Guided Bone Regeneration: A Clinical Prospective Analysis

Guided bone regeneration (GBR) is a reconstructive procedure for treating atrophic alveolar ridges. This study aims to assess the correlation between different glycemic control levels and clinical findings in patients undergoing horizontal GBR before implant placement. The study population consisted of all patients requiring horizontal GBR. Patients were divided into three groups based on HbA1c levels: non-diabetic normoglycemic patients (HbA1c < 5.7%), non-diabetic hyperglycaemic patients (HbA1c < 6.5%), and patients with controlled diabetes (HbA1c < 7%). The primary outcomes were the horizontal (mm) and vertical (mm) dimensional changes of the alveolar ridge 6 months after the procedure. The study sample consisted of 54 patients. Sixty-eight implants (95.8%) were classified as "successful," meaning the possibility of inserting a standard-sized implant following the GBR (diameter ≥ 4 mm). There was a statistically significant difference between the three groups in terms of horizontal gain at 6 months: in particular, there was a statistically significant difference between group 1 and group 2 (p = 0.026) and between group 1 and group 3 (p = 0.030). The present investigation showed that patients with HbA1c levels below 7% could undergo GBR and obtain a statistically significant horizontal bone gain.

Avoiding implant-related complications in medically compromised patients with or without unhealthy lifestyle/Elevated oxidative stress

Increased human life expectancy broadens the alternatives for missing teeth and played a role in the widespread use of dental implants and related augmentation procedures for the aging population. Though, many of these patients may have one or more diseases. These systemic conditions may directly lead to surgical complications, compromise implant/bone healing, or influence long-term peri-implant health and its response to biologic nuisances. Offering patients credible expectations regarding intra- and postoperative complications and therapeutic prognosis is an ethical and legal obligation. Clear identification of potential types of adverse effects, complications, or errors is important for decision-making processes as they may be related to different local, systemic, and technical aspects. Therefore, the present review structures the underlying biological mechanisms, clinical evidence, and clinical recommendations for the most common systemic risk factors for implant-related complications.

Marginal bone loss around dental implants: comparison between diabetic and non-diabetic patients-a retrospective clinical study

OBJECTIVES

The aim of the present retrospective study was to compare the marginal bone loss (MBL) around dental implants in a group of diabetic patients in relation to a matched group of non-diabetic patients.

MATERIALS AND METHODS

The present dental record-based retrospective study included patients selected from individuals treated with dental implants at one specialist clinic in Malmö, Sweden. Patients were excluded if they had history of periodontitis and/or were treated for periodontal disease. The study group included 710 implants installed in 180 patients (mean age 60.3±13.0 years), 349 implants in 90 diabetic (21 T1DM and 69 T2DM patients), and 361 implants in 90 non-diabetic patients.

RESULTS

The results suggested that jaw (greater MBL in the maxilla), diabetes (greater MBL for diabetic patients, and worse for T1DM patients), bruxism (greater MBL for bruxers), and smoking (greater MBL for smokers and former smokers) had a statistically significant influence on MBL over time.

CONCLUSIONS

Patients with diabetes have an estimated greater MBL over time compared to non-diabetic patients. The difference was greater in patients with diabetes type 1 compared to patients with diabetes type 2. Bruxism, smoking, and implant location (maxilla) were also associated with a higher loss of marginal bone around implants over time.

CLINICAL RELEVANCE

Awareness of the possible influence of diabetes on the long-term outcomes of dental implant treatment is important, in order to be able to minimize the possibility of a high MBL with time, which can eventually lead to the loss of the implant.

Nanohydroxyapatite-Coated Titanium Surface Increases Vascular Endothelial Cells Distinct Signaling Responding to High Glucose Concentration

Aim: The success of dental implants depends on osseointegration can be compromised by well-known related adverse biological processes, such as infection and diabetes. Previously, nanohydroxyapatite-coated titanium surfaces (nHA_DAE) have been shown to contain properties that promote osteogenesis by enhancing osteoblast differentiation. In addition, it was hypothesized to drive angiogenesis in high-glucose microenvironments, mimicking diabetes mellitus (DM). On the other hand, the null hypothesis would be confirmed if no effect was observed in endothelial cells (ECs). Materials and methods: Titanium discs presenting the differential surfaces were previously incubated in an FBS-free cell culture medium for up to 24 h, which was, thereafter, supplemented with 30.5 mM of glucose to expose human umbilical vein endothelial cells (HUVECs, ECs) for 72 h. They were then harvested, and the sample was processed to provide molecular activity of specific genes related to EC survival and activity by using qPCR, and the conditioned medium by ECs was used to evaluate the activity of matrix metalloproteinases (MMPs). Results: Our data guaranteed better performance of this nanotechnology-involved titanium surface to this end once the adhesion and survival characteristics were ameliorated by promoting a higher involvement of β1-Integrin (~1.5-fold changes), Focal Adhesion Kinases (FAK; ~1.5-fold changes) and SRC (~2-fold changes) genes. This signaling pathway culminated with the cofilin involvement (~1.5-fold changes), which guaranteed cytoskeleton rearrangement. Furthermore, nHA_DAE triggered signaling that was able to drive the proliferation of endothelial cells once the cyclin-dependent kinase gene was higher in response to it, while the P15 gene was significantly down-regulated with an impact on the statement of angiogenesis. Conclusions: Altogether, our data show that a nanohydroxyapatite-coated titanium surface ameliorates the EC performance in a high-glucose model in vitro, suggesting its potential application in DM patients.

The burden of diabetes on the soft tissue seal surrounding the dental implants

Soft tissue seal around implant prostheses is considered the primary barrier against adverse external stimuli and is a critical factor in maintaining dental implants' stability. Soft tissue seal is formed mainly by the adhesion of epithelial tissue and fibrous connective tissue to the transmembrane portion of the implant. Type 2 diabetes mellitus (T2DM) is one of the risk factors for peri-implant inflammation, and peri-implant disease may be triggered by dysfunction of the soft tissue barrier around dental implants. This is increasingly considered a promising target for disease treatment and management. However, many studies have demonstrated that pathogenic bacterial infestation, gingival immune inflammation, overactive matrix metalloproteinases (MMPs), impaired wound healing processes and excessive oxidative stress may trigger poor peri-implant soft tissue sealing, which may be more severe in the T2DM state. This article reviews the structure of peri-implant soft tissue seal, peri-implant disease and treatment, and moderating mechanisms of impaired soft tissue seal around implants due to T2DM to inform the development of treatment strategies for dental implants in patients with dental defects.

Effects of metformin on the bioactivity and osseointegration of dental implants: A systematic review

Dental implants are prosthetic devices that are surgically placed in direct contact with the jawbone to support intra-oral functions and esthetics. Diabetes mellitus may contribute to peri-implant bone loss. During the last few years, there have been attempts to reduce this bone loss and improve the survival rate of implants. Metformin, an anti-diabetic drug known for its osteogenic properties, is thought to prevent peri-implant bone loss in diabetic patients. Although several studies have been conducted to study metformin's effect on diabetic and non-diabetic study models, no systematic review has analyzed and summarized these studies critically. Therefore, the objectives of this systematic review were to summarize the outcomes of these studies and critically appraise them. Seven studies were included in this systematic review. Four studies used only animal models, two used both animal and cell culture models, and one used only cell culture studies. The general characteristics and outcomes of the included studies were summarized, and Animal Research: Reporting of In Vivo Experiments (ARRIVE) guidelines were used to assess the quality of the animal studies. In vitro studies indicate that metformin may induce stem cells to undergo osteoblastic differentiation to produce a higher amount of bone and may also improve osseointegration. Nevertheless, several studies had potential sources of bias. Therefore, it is recommended that emphasis be placed on increasing the quality of future animal studies and human trials to determine the effects of metformin on the osseointegration of dental implants. Future studies are needed with adequate follow-up to evaluate the efficacy of metformin in improving the osseointegration of dental implants.

Bone Remodeling in Mandible of Wistar Rats with Diabetes Mellitus and Osteoporosis

OBJECTIVES

 This study aimed to determine some of bone molecular expressions and its possible bone remodeling pathway between diabetes mellitus (DM) and osteoporosis model in the mandibular bone of Wistar rats.

MATERIALS AND METHODS

 Twenty-seven female Wistar rats were divided randomly into control and treatment groups. Treatment groups were injected with streptozotocin intraperitoneally to induce DM (P1) and underwent bilateral ovariectomy to generate osteoporosis (P2). All groups were terminated after 12 weeks. Immunohistochemical and hematoxylin-eosin staining were performed to determine the expression of Runt-related transcription factor 2 (RUNX2), Osterix, vascular endothelial growth factor (VEGF), receptor activator of nuclear factor κB ligand (RANKL), osteoprotegerin (OPG), tartrate-resistant acid phosphatase (TRAP), and observed the osteoblast and osteoclast. Statistical analysis was performed using one-way analysis of variance.

RESULTS

 The lowest mean of RUNX2 and VEGF expression was found in the P2 group. The lowest mean of Osterix expression was found in the P1 group. Both P1 and P2 groups of osteoblast/osteoclast ratio were decreased. There were no significant differences in the expression of TRAP between all groups; however, increased expression of RANKL/OPG ratio was only found in the P2 group.

CONCLUSION

 DM and osteoporosis induce changes in the bone remodeling pathway which are represented by a decrease in osteoblast biomarkers and an increase in osteoclast biomarkers.

Diabetes Mellitus and Dental Implants: A Systematic Review and Meta-Analysis

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.

Insulin growth factor binding protein-3 enhances dental implant osseointegration against methylglyoxal-induced bone deterioration in a rat model

PURPOSE

The aim of this study was to determine the effect of insulin growth factor binding protein-3 (IGFBP-3) on the inhibition of glucose oxidative stress and promotion of bone formation near the implant site in a rat model of methylglyoxal (MGO)-induced bone loss.

METHODS

An in vitro study was performed in MC3T3 E1 cells treated with chitosan gold nanoparticles (Ch-GNPs) conjugated with IGFBP-3 cDNA followed by MGO. An in vivo study was conducted in a rat model induced by MGO administration after the insertion of a dental implant coated with IGFBP-3.

RESULTS

MGO treatment downregulated molecules involved in osteogenic differentiation and bone formation in MC3T3 E1 cells and influenced the bone mineral density and bone volume of the femur and alveolar bone. In contrast, IGFBP-3 inhibited oxidative stress and inflammation and enhanced osteogenesis in MGO-treated MC3T3 E1 cells. In addition, IGFBP-3 promoted bone formation by reducing inflammatory proteins in MGO-administered rats. The application of Ch-GNPs conjugated with IGFBP-3 as a coating of titanium implants enhanced osteogenesis and the osseointegration of dental implants.

CONCLUSIONS

This study demonstrated that IGFBP-3 could be applied as a therapeutic component in dental implants to promote the osseointegration of dental implants in patients with diabetes, which affects MGO levels.

Early crestal bone loss around implants placed at previously failed sites compared with initially integrated implants: A retrospective cohort study

BACKGROUND

There is minimal information on early crestal bone loss (CBL) associated with implants placed at failed sites.

PURPOSE

This retrospective cohort study aimed to evaluate CBL of surviving and restored implants placed at previously failed sites (replaced implants [RIs]) compared to that of implants initially integrated and restored (pristine implants [PIs]), within the same subjects from implant placement to 17 months post-delivery of restoration.

METHODS

Subjects who had both PI(s) and RI(s) were recruited. The following data were retrieved: patient demographics, implant locations, types of implant failure, use of bone graft procedure(s), and intraoral radiographs at implant placement (T0), restoration delivery (T1), and the post-restoration follow-up (T2). A blinded evaluator measured crestal bone levels at T0, T1, and T2.

RESULTS

Forty-four implants (22 in the RI and 22 in the PI group) from the 22 subjects were reviewed. The 22 implants in the RI group were placed either at early failure (17) or late failure (5) sites. There was a 4.6 times higher likelihood of bone graft procedures performed in association with RIs compared to PIs when using a generalized linear mixed model. Differences in crestal bone levels were compared between the two groups at each time point. There were no significant differences in the mesial and mean crestal bone levels between the PI and RI groups. The RI group exhibited lower crestal bone levels on the distal side compared to the PI group at all time points. However, this difference was due to crestal bone level at T0 (p = 0.039) not due to implant replacement (p = 0.413) or bone graft procedure (p = 0.302) when using mixed regression modeling.

CONCLUSION

The effect of replacements of implants at failed sites on CBL was not significant. RIs, once integrated, exhibited the same pattern of CBL as pristine implants.

Mapping Bone Marrow Cell Response from Senile Female Rats on Ca-P-Doped Titanium Coating

Chemical and topographical surface modifications on dental implants aim to increase the bone surface contact area of the implant and improve osseointegration. This study analyzed the cellular response of undifferentiated mesenchymal stem cells (MSC), derived from senile rats’ femoral bone marrow, when cultured on a bioactive coating (by plasma electrolytic oxidation, PEO, with Ca²⁺ and P⁵⁺ ions), a sandblasting followed by acid-etching (SLA) surface, and a machined surface (MSU). A total of 102 Ti-6Al-4V discs were divided into three groups (n = 34). The surface chemistry was analyzed by energy dispersive spectroscopy (EDS). Cell viability assay, gene expression of osteoblastic markers, and mineralized matrix formation were investigated. The cell growth and viability results were higher for PEO vs. MSU surface (p = 0.001). An increase in cell proliferation from 3 to 7 days (p < 0.05) and from 7 to 10 days (p < 0.05) was noted for PEO and SLA surfaces. Gene expression for OSX, ALP, BSP, and OPN showed a statistical significance (p = 0.001) among groups. In addition, the PEO surface showed a higher mineralized matrix bone formation (p = 0.003). In conclusion, MSC from senile female rats cultured on SLA and PEO surfaces showed similar cellular responses and should be considered for future clinical investigations.

Impaired dental implant osseointegration in rat with streptozotocin-induced diabetes

OBJECTIVE

Few studies have reported on the impact of oxidative stress on the dental implant failure. The aim of this study was to investigate the impact of hyperglycemia-induced oxidative stress on dental implant osseointegration in diabetes mellitus (DM).

METHODS

Acid-treated titanium implants were bilaterally placed in the maxillary alveolar ridge of streptozotocin-induced diabetic (DM group) and control rats after extraction of first molars. Histological analysis and micro-push-out test were performed 4 weeks after surgery. Oxidative stress and osteogenic markers in the surrounding bone were quantified by real-time polymerase chain reaction. In the in vitro study, rat bone marrow-derived mesenchymal stem cells (BMMSCs) were cultured on acid-treated titanium discs in a high-glucose (HG) or normal environment. Intracellular reactive oxygen species (ROS), cell proliferation, alkaline phosphatase (ALP) activity, and extracellular calcification were evaluated following antioxidant treatment with N-acetyl-L-cysteine (NAC).

RESULTS

The implant survival rate was 92.9% and 75.0% in control and DM group, respectively. Bone-implant contact and push-out loads were significantly lower in the DM group. Expression of superoxide dismutase 1 at the mRNA level and on immunohistochemistry was significantly lower in the DM group. In vitro experiments revealed that the HG condition significantly increased ROS expression and suppressed the proliferation and extracellular calcification of BMMSCs, while NAC treatment significantly restored ROS expression, cell proliferation, and calcification. The ALP activity of both groups was not significantly different.

CONCLUSION

In diabetes, high-glucose-induced oxidative stress downregulates proliferation and calcification of BMMSCs, impairing osseointegration and leading to implant failure.

Should the Quality of Glycemic Control Guide Dental Implant Therapy in Patients with Diabetes? Focus on Implant Survival

INTRODUCTION

Optimal glycemic control is crucial to dental implant long-term functional and esthetic success. Despite HbA1c levels of 7% or lower used is as an indicator for good glycemic control, however, this level may not be attainable for all diabetic patients. Most dentists do not consider patients with poor glycemic control candidates for implant therapy due to higher implant failure, infection or other complications.

AIM

This review challenges the concept of one size fits all and aims to critically appraise the evidence for the success or failure rate of dental implants and peri-implant health outcomes in patients with less than optimal glycemic control.

DISCUSSION

Evidence suggests that estimating glycemic control from HbA1c measurement alone is misleading. Moreover, elevated preoperative HbA1c was not associated with increased mortality and morbidity after major surgical procedures. Literature for the survival or success of implants in diabetic patients is inconsistent due to a lack of standardized reporting of clinical data collection and outcomes. While a number of studies report that implant treatment in patients with well controlled diabetes has a similar success rate to healthy individuals, other studies suggest that the quality of glycemic control in diabetic patients does not make a difference in the implant failure rate or marginal bone loss. This discrepancy could indicate that risk factors other than hyperglycemia may contribute to the survival of implants in diabetic patients.

CONCLUSION

In the era of personalized medicine, the clinician should utilize individualized information and analyze all risk factors to provide the patient with evidence-based treatment options.

Adipose Tissue Dysfunction: Impact on Bone and Osseointegration

Bone metabolism may be adversely affected in metabolic diseases such as obesity and metabolic syndrome, which are characterised by weight gain, due to the expansion of adipose tissue deposits. As an important regulator of energy metabolism, adipose tissues synthesise and secrete several key regulatory adipokines that influence a range of metabolic functions. This narrative review outlines the evidence for the mechanisms by which adipose tissue dysfunction may alter bone metabolism prior to the development of frank hyperglycaemia and presents the emerging evidence for the impact of diet-induced expansion of adipose tissue on implant osseointegration. Successful osseointegration requires normal bone cell function, and the expansion of adipose tissue deposits results in dysregulated adipokine production favouring an increase in pro-inflammatory adipokines, contributing to the development of a chronic inflammatory state and insulin resistance. The increase in inflammatory cytokines promotes the growth and differentiation of osteoclasts indirectly through the modulation of osteoblastic RANKL production and directly by reducing osteoclast apoptosis and increased osteoclastic expression of RANK. Conversely, the suppression of osteoblastic regulatory genes results in reduced osteoblast numbers and function contributing to compromised bone turnover. Compromised osseointegration has been established in hyperglycaemia; however, as discussed in this review, it may not be the only driver of altered bone metabolism. The incidence of metabolic disease in the community is rising, patients may present for implant treatment with undiagnosed, underlying changes to bone cell metabolism due to adipose tissue dysmetabolism.

Smoking and Dental Implants: A Systematic Review and Meta-Analysis

Background and Objectives: Tobacco is today the single most preventable cause of death, being associated with countless diseases, including cancer and neurological, cardiovascular, and respiratory diseases. Smoking also brings negative consequences to oral health, potentially impairing treatment with dental implants. The present review aimed to evaluate the influence of smoking on dental implant failure rates and marginal bone loss (MBL). Materials and Methods: Electronic search was undertaken in three databases, plus a manual search of journals. Meta-analyses were performed, in addition to meta-regressions, in order to verify how the odds ratio (OR) and MBL were associated with follow-up time. Results: The review included 292 publications. Altogether, there were 35,511 and 114,597 implants placed in smokers and in non-smokers, respectively. Pairwise meta-analysis showed that implants in smokers had a higher failure risk in comparison with non-smokers (OR 2.402, p < 0.001). The difference in implant failure between the groups was statistically significant in the maxilla (OR 2.910, p < 0.001), as well as in the mandible (OR 2.866, p < 0.001). The MBL mean difference (MD) between the groups was 0.580 mm (p < 0.001). There was an estimated decrease of 0.001 in OR (p = 0.566) and increase of 0.004 mm (p = 0.279) in the MBL MD between groups for every additional month of follow-up, although without statistical significance. Therefore, there was no clear influence of the follow-up on the effect size (OR) and on MBL MD between groups. Conclusions: Implants placed in smokers present a 140.2% higher risk of failure than implants placed in non-smokers.

Dental Implants Inserted in Fresh Extraction Sockets versus Healed Sites: A Systematic Review and Meta-Analysis

The present review aimed to evaluate the difference of dental implant failure rates and marginal bone loss (MBL) between implants inserted in fresh extraction sockets or healed sites. Electronic search was undertaken in three databases, plus manual search of journals, including studies randomized or not. Meta-analyses were performed besides meta-regressions, in order to verify how the odds ratio (OR) and MBL were associated with follow-up time. The review included 163 publications. Altogether, there were 17,278 and 38,738 implants placed in fresh extraction sockets and healed sites, respectively. Pairwise meta-analyses showed that implants in sockets had a higher failure risk in comparison to healed sites: OR 1.349, all studies included; OR 2.070, only prospective non-RCTs; OR 2.487, only RCTs (all p < 0.001). The difference in implant failure between the groups was statistically significant in the maxilla (OR 1.616, p = 0.029), but not in the mandible (OR 2.192, p = 0.075). The MBL mean difference (MD) between the groups was −0.053 mm (p = 0.089). There was an estimated decrease of 0.003 in OR (p = 0.284) and an increase of 0.006 mm (p = 0.036) in the MBL MD between groups for every additional month of follow-up. In conclusion, implants placed in fresh extraction sockets present higher risk of failure than implants placed in healed sites.

Oral Osteomicrobiology: The Role of Oral Microbiota in Alveolar Bone Homeostasis

Osteomicrobiology is a new research field in which the aim is to explore the role of microbiota in bone homeostasis. The alveolar bone is that part of the maxilla and mandible that supports the teeth. It is now evident that naturally occurring alveolar bone loss is considerably stunted in germ-free mice compared with specific-pathogen-free mice. Recently, the roles of oral microbiota in modulating host defense systems and alveolar bone homeostasis have attracted increasing attention. Moreover, the mechanistic understanding of oral microbiota in mediating alveolar bone remodeling processes is undergoing rapid progress due to the advancement in technology. In this review, to provide insight into the role of oral microbiota in alveolar bone homeostasis, we introduced the term “oral osteomicrobiology.” We discussed regulation of alveolar bone development and bone loss by oral microbiota under physiological and pathological conditions. We also focused on the signaling pathways involved in oral osteomicrobiology and discussed the bridging role of osteoimmunity and influencing factors in this process. Finally, the critical techniques for osteomicrobiological investigations were introduced.

Occurrence and severity of spontaneous exposure of cover screw after dental implant placement

Background. Perforation of the soft tissues overlying the dental implant, resulting in early and spontaneous exposure of cover screws between stages I and II of the two-staged implant placement procedure, is a common problem that can disrupt the primary repair and osseointegration process. The present study aimed to investigate the prevalence of spontaneous exposure of cover screws in dental implants and identify the related risk factors.Methods. The present retrospective, descriptive-analytical study enrolled 40 patients with 182 dental implants in the second stage of the implant placement procedure. Data on patient-related and implant-related classified variables were collected, and all the samples were examined for cover screw exposure based on the classification by Tal. First, the overall prevalence of cover screw exposure was calculated. Then, statistical analysis was performed using SPSS 24 to investigate the effect of different variables on this exposure. The chi-squared test was used at the bivariate level, while the logistic regression was used at the multivariate level.Results. Of 40 participants with 182 implants, 17 implants (9.3%) in 9 patients (22.5%) became exposed to the oral cavity. In terms of severity, Class I exposure was the most common with seven implants. Moreover, Class III was the least common with only one implant. Using the logistic regression analysis, we found significant relationships between the dental implant exposure and the variables of overlying mucosal thickness (OR=24.7, P≤0.001), the duration between tooth extraction and implant placement (OR=9.6, P=0.005), and implant location in the jaw (OR=3.8, P=0.033). Moreover, exposure was more common in the maxillary premolar area (22.5%) than in other locations. Also, there was a significant relationship between implant exposure and lateral augmentation (OR=0.20, P=0.044), indicating the higher risk of exposure in implants with lateral augmentation than those without augmentation.Conclusion. Despite the limitations of this retrospective study, its results showed that three factors, including the overlying mucosal thickness of <2 mm, implant placement in fresh extraction sockets, and maxillary implants, especially at the location of maxillary premolars, were strong predictors of spontaneous implant exposure.

A novel chlorhexidine-hexametaphosphate coating for titanium with antibiofilm efficacy and stem cell cytocompatibility

Dental implants are an increasingly popular way to replace missing teeth. Whilst implant survival rates are high, a small number fail soon after placement, with various factors, including bacterial contamination, capable of disrupting osseointegration. This work describes the development of chlorhexidine-hexametaphosphate coatings for titanium that hydrolyse to release the antiseptic agent chlorhexidine. The aim was to develop a coating for titanium that released sufficient chlorhexidine to prevent biofilm formation, whilst simultaneously maintaining cytocompatibility with cells involved in osseointegration. The coatings were characterised with respect to physical properties, after which antibiofilm efficacy was investigated using a multispecies biofilm model, and cytocompatibility determined using human mesenchymal stem cells. The coatings exhibited similar physicochemical properties to some implant surfaces in clinical use, and significantly reduced formation of multispecies biofilm biomass up to 72 h. One coating had superior cytocompatibility, with mesenchymal stem cells able to perform normal functions and commence osteoblastic differentiation, although at a slower rate than those grown on uncoated titanium. With further refinement, these coatings may have application in the prevention of bacterial contamination of dental implants at the time of surgery. This could aid a reduction in rates of early implant failure.

State of Evidence on Oral Health Problems in Diabetic Patients: A Critical Review of the Literature

Diabetes mellitus (DM) is a global health problem, having recognized that in the next 20 years the number of diabetic patients in the world will increase to 642 million. DM exerts enormous repercussions on general health diabetic (especially derived from vascular, cardiac, renal, ocular, or neurological affectation). It entails in addition a high number of deaths directly related to the disease, as well as a high health care cost, estimated at $673 billion annually. Oral cavity is found among all the organs and systems affected in the course of DM. Important pathologies are developed with higher prevalence, such as periodontitis (PD), alterations in salivary flow, fungal infections, oral cancer, and oral potentially malignant disorders (OPMD). It has been proven that PD hinders the metabolic control of DM and that the presence of PD increases the possibility for developing diabetes. Despite the relevance of these oral pathologies, the knowledge of primary care physicians and diabetes specialists about the importance of oral health in diabetics, as well as the knowledge of dentists about the importance of DM for oral health of patients is scarce or non-existent. It is accepted that the correct management of diabetic patients requires interdisciplinary teams, including dentists. In this critical review, the existing knowledge and evidence-degree on the preventive, clinical, diagnosis, prognosis, and therapeutic aspects of oral diseases that occur with a significant frequency in the diabetic population are developed in extension.

State of Evidence on Oral Health Problems in Diabetic Patients: A Critical Review of the Literature

Diabetes mellitus (DM) is a global health problem, having recognized that in the next 20 years the number of diabetic patients in the world will increase to 642 million. DM exerts enormous repercussions on general health diabetic (especially derived from vascular, cardiac, renal, ocular, or neurological affectation). It entails in addition a high number of deaths directly related to the disease, as well as a high health care cost, estimated at $673 billion annually. Oral cavity is found among all the organs and systems affected in the course of DM. Important pathologies are developed with higher prevalence, such as periodontitis (PD), alterations in salivary flow, fungal infections, oral cancer, and oral potentially malignant disorders (OPMD). It has been proven that PD hinders the metabolic control of DM and that the presence of PD increases the possibility for developing diabetes. Despite the relevance of these oral pathologies, the knowledge of primary care physicians and diabetes specialists about the importance of oral health in diabetics, as well as the knowledge of dentists about the importance of DM for oral health of patients is scarce or non-existent. It is accepted that the correct management of diabetic patients requires interdisciplinary teams, including dentists. In this critical review, the existing knowledge and evidence-degree on the preventive, clinical, diagnosis, prognosis, and therapeutic aspects of oral diseases that occur with a significant frequency in the diabetic population are developed in extension.

State of Evidence on Oral Health Problems in Diabetic Patients: A Critical Review of the Literature

Diabetes mellitus (DM) is a global health problem, having recognized that in the next 20 years the number of diabetic patients in the world will increase to 642 million. DM exerts enormous repercussions on general health diabetic (especially derived from vascular, cardiac, renal, ocular, or neurological affectation). It entails in addition a high number of deaths directly related to the disease, as well as a high health care cost, estimated at $673 billion annually. Oral cavity is found among all the organs and systems affected in the course of DM. Important pathologies are developed with higher prevalence, such as periodontitis (PD), alterations in salivary flow, fungal infections, oral cancer, and oral potentially malignant disorders (OPMD). It has been proven that PD hinders the metabolic control of DM and that the presence of PD increases the possibility for developing diabetes. Despite the relevance of these oral pathologies, the knowledge of primary care physicians and diabetes specialists about the importance of oral health in diabetics, as well as the knowledge of dentists about the importance of DM for oral health of patients is scarce or non-existent. It is accepted that the correct management of diabetic patients requires interdisciplinary teams, including dentists. In this critical review, the existing knowledge and evidence-degree on the preventive, clinical, diagnosis, prognosis, and therapeutic aspects of oral diseases that occur with a significant frequency in the diabetic population are developed in extension.

Carbon Nanomaterials Modified Biomimetic Dental Implants for Diabetic Patients

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.

A Comparative Study Evaluating Implant Success and Bone Loss in Diabetes and Nondiabetes

BACKGROUND

Diabetes is seen to be associated with increased rate of failure of implants. The implant failure can be categorized as ailing, failing, and failed implants. The review of literature did not form any consensus on the effect of diabetes on the implant success rates. The reason we found was many confounding factors and nonconsideration of glycemic status of diabetic patients. Hence, in our study, we eliminated the confounding factors and took glycemic index in consideration.

MATERIALS AND METHODS

Forty-six participants were included in this study, out of which 26 were nondiabetic and 20 diabetic. Diabetics were further divided into two groups based on the HBA1C values, as controlled and uncontrolled diabetics.

RESULTS

We found that the uncontrolled diabetics had highest rate of implant failure as compared to other two groups. Furthermore, the controlled diabetics and nondiabetics had similar implant successes and failure rates.

CONCLUSION

This suggests that controlled diabetics are comparable to nondiabetics in terms of implant success rates.

The Impact of Dental Implant Length on Failure Rates: A Systematic Review and Meta-Analysis

The present review aimed to evaluate the impact of implant length on failure rates between short (<10 mm) and long (≥10 mm) dental implants. An electronic search was undertaken in three databases, as well as a manual search of journals. Implant failure was the outcome evaluated. Meta-analysis was performed in addition to a meta-regression in order to verify how the risk ratio (RR) was associated with the follow-up time. The review included 353 publications. Altogether, there were 25,490 short and 159,435 long implants. Pairwise meta-analysis showed that short implants had a higher failure risk than long implants (RR 2.437, p < 0.001). There was a decrease in the probability of implant failure with longer implants when implants of different length groups were compared. A sensitivity analysis, which plotted together only studies with follow-up times of 7 years or less, resulted in an estimated increase of 0.6 in RR for every additional month of follow-up. In conclusion, short implants showed a 2.5 times higher risk of failure than long implants. Implant failure is multifactorial, and the implant length is only one of the many factors contributing to the loss of an implant. A good treatment plan and the patient’s general health should be taken into account when planning for an implant treatment.

Long-term observation of periodontal condition following placement of removable partial dentures with rigid retainers and major connector in patients with/without diabetes: A retrospective study

PURPOSE

This retrospective study evaluated the periodontal tissues of the abutment teeth of removable partial dentures (RPDs) with rigid retainers and major connectors in patients with and without type 2 diabetes mellitus (T2D).

METHODS

A total of 313 patients who had been treated with RPDs, including rigid retainers and major connectors, were divided into two groups: T2D and non-T2D. The periodontal parameters and radiographic bone heights of the abutment teeth were evaluated at baseline and at a 5-year examination during supportive periodontal therapy (SPT). For patients with accessible standardized radiographs, bone density was analyzed based on the gray level (GL) using digital subtraction radiography (n = 83).

RESULTS

Overall, 739 abutment teeth (86 in the T2D group) of 235 patients (25 in the T2D group) were analyzed, and 95.0% (94.2% in the T2D group, and 95.2% in the non-T2D group) were maintained. The mean probing pocket depth significantly increased in both groups ( p < 0.001). There were significant changes in the radiographic bone height (p = 0.038) and GL on the side of the denture base area (p = 0.048) in the T2D group compared to those in the non-T2D group.

CONCLUSIONS

Regardless of T2D, RPDs with rigid retainers and major connectors could prevent the progression of periodontal disease and successfully maintain most of the abutment teeth during 5-years of SPT. However, T2D may be significantly associated with loss of bone height reduction and density on the side of the denture base area.

Development of a rat model for type 2 diabetes mellitus peri-implantitis: A preliminary study

OBJECTIVE

To develop an in vivo model to simulate the complex internal environment of diabetic peri-implantitis (T2DM-PI) model for a better understanding of peri-implantitis in type 2 diabetic patients.

MATERIALS AND METHODS

Maxillary first molars were extracted in Sprague-Dawley (SD) rats, and customized cone-shaped titanium implants were installed in the extraction sites. Thereafter, implants were uncovered and customized abutments were screwed into implants. A high-fat diet and a low-dose injection of streptozotocin were utilized to induce T2DM. Finally, LPS was locally injected in implant sulcus to induce peri-implantitis.

RESULTS

In the present study, T2DM-PI model has been successfully established. Imaging analysis revealed that abundant inflammatory cells infiltrated in the soft tissue in T2DM-PI group with concomitant excessive secretion of inflammatory cytokines. Moreover, higher expression of MMP and increased number of osteoclasts led to collagen disintegration and bone resorption in T2DM-PI group.

CONCLUSIONS

These results describe a novel rat model which stimulate T2DM-PI in vivo, characterized by overwhelming inflammatory response and bone resorption. This model has a potential to be used for investigation of initiation, progression and interventional therapy of T2DM-PI.

Bone quality analysis of jaw bones in individuals with type 2 diabetes mellitus-post mortem anatomical and microstructural evaluation

OBJECTIVES

With the higher risk of dental implant failure with type 2 diabetes mellitus (T2DM), there is a need to characterize the jaw bones in those individuals. The aim of this post mortem study was to compare jaw bone quality of individuals with T2DM to healthy controls.

MATERIAL AND METHODS

Bone cores from the edentulous lower first molar region and the region of mandibular angle were collected from male individuals with T2DM (n = 10, 70.6 ± 4.5 years) and healthy controls (n = 11, 71.5 ± 3.8 years) during autopsy. Within the T2DM, a subgroup treated with oral antidiabetics (OAD) and one on insulin were identified. Bone quality assessment encompassed evaluation of bone microstructure, matrix composition, and cellular activity, using microcomputed tomography (micro-CT), quantitative backscattered electron imaging (qBEI), Raman spectroscopy, and bone histomorphometry.

RESULTS

In the mandibular angle, T2DM showed 51% lower porosity of the lingual cortex (p = 0.004) and 21% higher trabecular thickness (p = 0.008) compared to control. More highly mineralized bone packets were found in the buccal cortex of the mandibular angle in insulin-treated compared to OAD-treated T2DM group (p = 0.034). In the molar region, we found higher heterogeneity of trabecular calcium content in T2DM insulin compared to controls (p = 0.015) and T2DM OAD (p = 0.019). T2DM was associated with lower osteocyte lacunar size in the trabecular bone of the molar region (vs. control p = 0.03).

CONCLUSIONS

Alterations in microstructure, mineralization, and osteocyte morphology were determined in jaw bone of individuals with T2DM compared to controls.

CLINICAL RELEVANCE

Future studies will have to verify if the mild changes determined in this study will translate to potential contraindications for dental implant placements.

Impact of hyperglycemia on the rate of implant failure and peri-implant parameters in patients with type 2 diabetes mellitus: Systematic review and meta-analysis

BACKGROUND

The impact of hyperglycemia on dental implant therapy remains unclear. In this systematic review and meta-analysis, the authors compared the rates of implant failure and peri-implant bleeding on probing (BOP), probing depth (PD), and peri-implant bone loss (PIBL) among patients with type 2 diabetes mellitus and nondiabetic patients. The authors performed subgroup analyses based on glycemic level to evaluate whether patients with higher glycemic levels were more prone to peri-implant inflammation.

TYPE OF STUDIES REVIEWED

The authors searched 4 databases for original clinical studies. Studies in which the researchers provided information on the rate of implant failure or peri-implant parameters were included.

RESULTS

Nine clinical studies were identified on the basis of the inclusion criteria. No significant differences were found in rates of implant failure (P = .46) and PD (P = .1) between diabetic and nondiabetic patients. Significant differences in BOP (P < .00001) and PIBL (P = .02), favoring nondiabetic patients, were observed. Results of subgroup analyses indicated that the increase in glycemic level did not significantly influence BOP, PD, and PIBL values among diabetic patients.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

Patients with type 2 diabetes mellitus seem to be able to achieve a rate of implant survival similar to that of healthy patients. Regarding peri-implant parameters, BOP and PIBL were higher in patients with type 2 diabetes mellitus, indicating that hyperglycemia is an important risk factor for peri-implant inflammation. No association was found between peri-implant parameters and glycemic level among patients with type 2 diabetes mellitus, providing oral hygiene was strictly maintained.

DOES GLYCEMIC CONTROL HAVE A DOSE-RESPONSE RELATIONSHIP WITH IMPLANT OUTCOMES? A COMPREHENSIVE SYSTEMATIC REVIEW AND META-ANALYSIS

OBJECTIVES

To comprehensively evaluate implant survival, clinical and biochemical parameters, as well as possible dose-response relationship with hemoglobin A1c (HbA1c) in patients with differing diabetic control.

METHODOLOGY

Five electronic databases were searched for studies that compared implant outcomes in patients with differing HbA1c values. Research quality was evaluated using Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) tool. Narrative synthesis and meta-analysis were performed for survival rate, plaque index (PI), bleeding on probing (BOP), probing pocket depth, and marginal bone loss (MBL). Categorical dose-response meta-analysis (DRMA) was conducted according to length of follow-up.

RESULTS

Twenty-two studies met the inclusion criteria. Prospective studies were mostly of moderate quality, but non-prospective papers had serious to critical risk of bias. Survival rate was high for the first 3 years (92.6%-100%) for patients with HbA1c less than 8%. Meta-analysis revealed worsening clinical parameters with increasing HbA1c. DRMA further established a significant dose-response relationship between glycemic control with BOP (10% more bleeding, 95% CI 0.05-0.16, P = .008) and MBL (0.05 mm more bone loss, 95% CI 0.01-0.09, P = .002) per HbA1c category, but no association with probing pocket depth. Osseointegration progressed at a slower rate, and inflammatory cytokines and bone biomarkers were adversely affected in patients with HbA1c above 8%.

CONCLUSION

Moderate evidence suggests a high short-term survival but possible dose-response trend of worsening BOP and MBL in association with glycemic control. Clinically, HbA1c values must be considered for risk assessment before placement and throughout the lifespan of the implant placed in a patient with diabetes.

An evaluation of peri-implant marginal bone loss according to implant type, surgical technique and prosthetic rehabilitation: a retrospective multicentre and cross-sectional cohort study

To evaluate implant loss (IL) and marginal bone loss (MBL); follow-up period of up to 10 years after prosthetic loading. Retrospective multi-centre cross-sectional cohort study. Double analysis: (1) all the implants (n = 456) were analysed; (2) to allow for possible cluster error, one implant per patient (n = 143) was selected randomly. Statistical analysis: Spearman's correlation coefficient; Kruskal-Wallis (post-hoc U-Mann-Whitney); Chi-square (post-hoc Haberman). (1) Analysing all the implants (456): IL was observed in patients with past periodontitis (6 vs. 2.2%, p < 0.05), short implants (12 vs. 2.8%, p < 0.001) and when using regenerative surgery (11.3 vs. 2.9%, p < 0.001); greater MBL was observed among smokers (0.39 ± 0.52 vs. 0.2 ± 0.29, p < 0.01), maxillary implants (0.28 ± 0.37 vs. 0.1 ± 0.17, p < 0.0001), anterior region implants (0.32 ± 0.36 vs. 0.21 ± 0.33, p < 0.001), external connection implants (0.2 ± 0.29 vs. 0.63 ± 0.59, p < 0.0001), and 2-3 years after loading (p < 0.0001). (2) analysing the cluster (143): IL was observed in smokers (18.8 vs. 3.5%, p < 0.05), splinted fixed crowns (12.9%, p < 0.01), short implants (22.2 vs. 4.0%, p < 0.01) and when using regenerative surgery (19.2 vs. 3.4%, p < 0.01); greater MBL was observed in maxillary implants (0.25 ± 0.35 vs. 0.11 ± 0.18, p < 0.05), in the anterior region (p < 0.05), in the first 3 years (p < 0.01), in external connection implants (0.72 ± 0.71 vs. 0.19 ± 0.26, p < 0.01) and in short implants (0.38 ± 0.31 vs. 0.2 ± 0.32, p < 0.05). There is greater risk in smokers, patients with past periodontal disease, external connection implants, the use of short implants and when regenerative techniques are used. To prevent MBL and IL, implantologists should be very meticulous in indicating implants in patients affected by these host factors.

[Oral implant treatment for elderly patients]

With the advance of materials and technologies, modern oral implantology developed rapidly. Dental implant has become the first choice to restore the missing teeth. Although it achieves a high success rate among healthy adults, for elderly patients, with the decline of physical function and other systemic diseases, the risks of implant treatment increase accordingly. Doctors should pay more attention to the factors that may affect the implant treatment of the elderly and ways of preventing possible risks and complications. Here we discuss the specificity, success rate, effect of systemic diseases and drug considerations of implant treatments in elderly patients.