Are Dental Implants Safe For You If You Have Diabetes?
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Peri-implant disease is characterized by plaque-induced inflammation of the oral soft tissue as peri-implant mucositis which can progress to peri-implantitis condition with peri-implant marginal bone loss (MBL) involvement. Nearly half of all implant cases followed up to 19 years reportedly developed peri-implant mucositis with those without maintenance care progressing to peri-implantitis. Current treatment approaches for peri-implantitis is especially challenging in metabolically compromised patients such as in diabetes. Hyperglycemia is considered an important risk factor for peri-implant diseases especially peri-implantitis which adversely affects bone metabolism. Diabetes is a metabolic condition characterized by destruction of hepatic cells in type 1 diabetes and impaired insulin function in type 2 diabetes mellitus (T2DM). Furthermore, microvascular complication of T2DM contributes to impaired immune response and bone remodeling leading to delayed healing and potentiating peri-implant infections.
Similar to the heterogeneity of clinical evidence on dental implant survival, the research on association of peri-implant diseases in patients with diabetes in particular those with poorly-controlled glycemic profile is inconsistent and largely scarce with majority of relevant studies only emerging in the last four years. The evidence for the impact of diabetes on survival of dental implant has been discussed in part one of this series. In this second part we aim to focus on the evaluation of clinical evidence for the main complications of implant therapy as peri-implant diseases in patients with diabetes, in particularly poorly-controlled diabetes.
Altered host response combined with environment inducive to excessive bacterial-plaque accumulation due to hyperglycemia is likely to contribute to more pronounced progression of peri-implant disease in patients with diabetes than metabolically healthy individuals. The underlying molecular mechanisms leading to impaired bone metabolism and poor osseointegration of implants together with the intricate signaling cascade influenced by hyperglycemia have been comprehensively discussed elsewhere. Given that there is lack of predictable therapies for management of peri-implant diseases in general, understanding host response at the bone to dental implant interface could provide important indicators or biomarkers for early diagnosis and design of tailored-therapies in management of metabolically compromised patients. Furthermore, evidence of inflammatory response modulators may help to identify patients with diabetes at increased risk of developing peri-implant disease.
Several lines of evidence indicate specific cytokine levels (eg IL-1β, IL-8 and TNF-ɑ) in peri‐implant crevicular fluid of patients with peri-implantitis compared to that of healthy patients markedly influence the host response leading to bone loss. In particular, in patients with poor glycemic control, high expression of IL-8 and TNF-ɑ has been detected in peri-implantitis sites compared to well-controlled diabetes patient and healthy individuals. In addition to the potential inflammatory mediators of peri-implantitis, in patients with peri-implantitis high levels of the matrix metalloproteinase collagenase MMP-8 has been detected in active peri-implantitis with progressive bone loss14 and considered an early indicator of peri-implant inflammation. MMP-8 belongs to the family of metal-dependent neutral proteases and has a dual role in immune protection as well as inflammatory pathogenesis. Similarly, in patients with diabetes significantly elevated salivary MMP‐8 concentrations compared to healthy patients and independent of periodontal inflammation has been detected. However, it is not known whether MMP-8 levels are different between healthy and poorly-controlled diabetes patients with peri-implantitis and more research is needed to determine diagnostic value of MMP-8 in diabetes. A recent cross-sectional study of diabetic patients with different glycemic profile found abnormal levels of bone metabolism biomarkers vitamin D and osteocalcin in T2DM patients with poorly-controlled glycemic profile and concluded that hyperglycemia was an independent risk factor for these biomarkers.
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Article compiled by Apple Tree Dental