implant for general dissese

7/27/2019 Implant for General Dissese

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Hebrew University andHadassah Medical Center

Faculty of Dental Medicine,Dental Implant Center

Barzilai Medical Center, HighRisk Patients Dental Clinic

Dr. Eli Michaeli


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Peter K Moy. et. al. Dental implant failure rates and associated risk factors. Int J Oral

Maxillfac Implants. 2005; 20: 569 - 577.


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Cigarette smoking impairs soft tissue wound healingby decreasing tissue oxygenation.

nicotine decreases:

blood flow, collagen deposition, neutrophil functionand prostacyclin levels.

nicotine increases:

platelet aggregation, epinephrine levels and bloodviscosity.


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It associated with decreased bone density byenhancing bone resorption and by reduction in boneformation.

In vitro studies showed that aryl hydrocarbons foundin cigarette smoke inhibit osteodifferentiation andosteogenesis.

In vivo animal studies show that nicotine impairs bone

healing.


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Habsha E. Survival of osseointegrated dental implants in smokers and non smokers.

[MS thesis]. Toronto: university of Toronto; 2000.


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Habsha E. Survival of osseointegrated dental implants in smokers and non smokers.

[MS thesis]. Toronto: university of Toronto; 2000.

Studies have shown that smokers have about twice thenumber of failed implants compared with non smokers.

Implant in the maxilla have a higher failure percentage

than those in the mandible.The majority of the failures occurred within the first

year (early failure).


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Osteoporosis results from increase in bone turnover,both resorption and formation, with a net result ofbone loss.

After menopause the decrease in trabecular boneexceeds that of the cortical bone, thus the maxilla ismore susceptible to rapid and severe atrophy.

Biochemical analysis of human osteoporotic femoralhead showed over-hydroxylation of lysine and aconsequent reduction in the stabilizing cross links ofthe collagenous framework, contributing to fragility ofbone.


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Ovariectomy in rats impairs fracture healing up to 4weeks fracture.

When 17--estrdiol was administered there was adose dependent increase in the peak force required tore-break the fracture.


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studies whether osteoporotic patients have higher riskof dental implant failure are few in number andcontradictory.

Following maxillary sinus augmentation, there is asignificantly reduced implant success rate.

In women without estrogen supplementation, there isan increase failure rate for maxillary placed implants,

but women who were given supplementation did notdiffer from the control.

In rats that undergone ovariectomy the cortical bonearea in contact with the implant was only slightly

decrease in comparison with control.


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In severe osteoporosis physiological doses of vitaminD (400-800 IU/day) and calcium (1500 mg/day) arerecommended during the post operative period.

In all cases, a balanced pre and post operative dietshould be maintened.


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up until now there has been controversy whetherhead and neck irradiated patients are suitable fordental implantation.

In the past, insertion of dental implants in irradiatedhypoxic, hypocellular, hypovascular bone wasconsidered as contraindication.

The risk of osteoradionecrosis was calculated to beabout 5% after radiotherpy.

Risk factors for ORN are: age, high radiation dose,hyper fractionation and traumatic surgical procedure.


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Hyperbaric oxygen therapy can reduce the incidenceof ORN by stimulation of vascular growth and markedincrease in arterial and venous pO2.

Dental implant failure rats in the irradiated patientsare slightly higher in the mandible but much morehigher in the maxilla.

Dental implant failure rats in the irradiated patientsare dose dependent.

Interval between the end of tumor therapy andimplantation should be between 1-2 years.


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EM 18

Wagner W. et. al. Osseointegration of dental implant in patients with and without

radiotherapy. Acta Oncologica. 1998;7/8 : 693 696.

A retrospective study of 63 patients (275 implants)with SSC were assessed for Branemark implants 5years success rats.

35 of them (145 implants) were preirradiated withcomplete dose of 60 Gy (6000 rad).

The 5 year success rates of all implants were 97.9%with no significant difference between the gropes.

The only significant influence on osseointegration wasthe time interval between implantation and theabutment phase.


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Wagner W. et. al. Osseointegration of dental implant in patients with and without

radiotherapy. Acta Oncologica. 1998;7/8 : 693 696.

ORN accrued in one patient 1.6%. Patients were notreferred to hyperbaric oxygen treatment.

Dental implantation in head and neck irradiatedpatients will lead significant improvement on thequality of life: food intake, speech and self-esteem.


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A group of metabolic disorders that arecharacterized by hyperglycemia induced byimpaired insulin activity, insulin secretion orboth.


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In Israel there are estimated to be around380,000 people suffering from diabetes. Thisrepresents around 6.3% of the population.[Israeli Diabetic Association].

In the United States there are 20.8 milliondiabetic patients. Only 14.6 million arediagnosed which represents 7% of the

American population in 2005.

Last year an additional 1.5 million new caseswere diagnosed [American Diabetes Association].


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The most prevalent endocrine disease and the3th leading cause of morbidity and mortality inthe United States.


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Type 2 diabetes mellitus:

accounts for 90 -95 % of the cases.

onset in age grater than 45.

induced by insulin intolerance of target

organs.

genetic predisposition.


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Secondary diabetes mellitus:

the etiology includes:

diseases of the pancreas: pancreatitis, neoplasia.

endocrine diseases: Cushings syn., acromegaly.

drugs: glucocorticoids, thiazides, blockers.

infections: CMV, congenital rubella.


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Gestational diabetes mellitus:

glucose intolerance appears during pregnancy.

transforms to diabetes mellitus on 3050% of thecases.


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Symptoms of diabetes mellitus: polydipsia,polyurea and polyphagia together with plasmaglucose levels grater than 200 mg/dl.

Fasting plasma glucose levels grater than 126mg/dl on tow separate tests.

Tow hour post prandial plasma glucose levels

grater than 200 mg/dl during an oral tolerancetest on tow separate tests.


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Monitoring glycemic control with HbA1c levels (aspercentage of total hemoglobin):

4 to 6 normal

6 to 7.5 good control7.6 to 8.9 fair control

9 to 20 poor control


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cardiovascular disease

Peripheral vascular disease

Stroke

Retinopathy

Nephropathy

Neuropathy

Poor wound healing

Susceptibility to infection


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Periodontitis

Xerostomia \ hyposalivation

Caries

Opportunistic infection

Burning mouth syndrome


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EM 33Diabetic patient


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Surgical Implant

Osteotomy

Blood clot

formation

Bone resorption

phase

Matrix formation

phase

Bone deposition\

Osteoid mineralization

Maintenance of

Osseointegration

Changes in wound healing proteins

Decreased number of osteoclasts

Inhibition of collagen formation

Decreased number of osteoblasts

Reduced mineralization proteins

Reduced bone turnover

Alternation in bone homeostasis

Change in diabetes status


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Morris H. F. et. al. Implant survival in patients with type 2 diabetes: Placement to 36

months. Ann priodontology. 2000; 5: 157 165.

A total of 2887 implants (663 patients) were surgicallyplaced, restored, and followed for a period of 36months. Of these, 2632 (91%) implants were placedin non diabetic patients and 255 (8.8%) in Type 2

patients.


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Total failure rate for non Type 2 diabetic patients was 6.8%and for the diabetic group was 7.8%, which was statisticallysignificant (p=0.02).

The use ofchlorhexidinerinses for implant placement resultedin a slight improvement (2.5%) in survival in non Type 2

patients and a greater improvement in Type 2 patients (9.1%).For the diabetic group this represents a clinically significantimprovement.

The use ofpre operative antibiotics for implant placementresulted in a 4.5% improvement in survival in non Type 2

patients and a greater improvement in Type 2 patients (10.5%).For the diabetic group this represents a clinically significantimprovement.

Morris H. F. et. al. Implant survival in patients with type 2 diabetes: Placement to 36months. Ann priodontology. 2000; 5: 157 165.


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The following criteria were examined:

Baseline and follow up FPG values.

Baseline and follow up HbA1c values.

Subject Age.

Duration of diabetes.

Baseline diabetic therapy.

Smoking history.

Implant length.

Olson J. W. et. al., Dental endosseous implant assessments in a Type 2 Diabeticpopulation: A prospective study. Int. J Oral Maxillofacial Implants. 2000; 15: 811818.


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Duration of diabetes and implant length werefound to be the only statistically significant predictorsof implant success.

Olson J. W. et. al., Dental endosseous implant assessments in a Type 2 Diabeticpopulation: A prospective study. Int. J Oral Maxillofacial Implants. 2000; 15: 811818.


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Kapur K. et. al. A randomized clinical trial comparing the efficacy of mandibular

implant-supported overdentures and conventional overdentures in diabeticpatients. Part I: Methodology and clinical outcomes. J Prosthet Dent.

1988; 79: 555-569.

A total of 89 edentulous diabetic patients receivednew dentures: 37 conventionals and 52 implant-supported. Fallow up was for 24 months.

50 of theme were insulin treated with an average of

9.8% HbA1c and 39 were non-insulin treated with anaverage of 8.5% HbA1c.


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Kapur K. et. al. A randomized clinical trial comparing the efficacy of mandibularimplant-supported overdentures and conventional overdentures in diabetic patients.Part I: Methodology and clinical outcomes. J Prosthet Dent.

1988; 79: 555-569.

Non of the failures occurred because of implantfailure.

Treatment was judged as failure when patient wasunable to wear or was dissatisfied with study

dentures.

Treatment was successful 56.9% of the patients withconventional dentures and 72.1% with overdentures(P>0.05).


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Kwon P. T. Maintenance of osseointegration utilizing insulin therapy in a diabetic ratmodel. J Periodontology. 2005; 76: 621 626.

32 rats were assigned to 8 different treatment groups(4 per group).

TPS implants were placed in the femora of eachanimal and osseointegrated for 28 days before

diabetic induction.

In 4 groups the diabetes was controlled with insulininjections, while the others were not treated.

The rats were sacrificed at 1, 2, 3 and 4 monthsfollowing diabetic induction.


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The results indicated more BIC in the insulincontrolled group compared to the uncontrolled groupat each time period, which was statistically significant.Moreover, BIC appears to decrease with time in

uncontrolled diabetic rats.


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Controlled diabetes Uncontrolled diabetes


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Type of diabetes

Age of onset

Regiment of glycemic control

Incidents of hypo or hyperglicemia

HbA1c levels

Blood glucose levels

Target organ involvement

Poor or insufficient wound healing history

Smoking or other cofactors for implant failure

History of tooth loss due to periodontitis


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Consult patients physician


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Type of Prosthetic RestorationRemovable vs. Fixed

Implant location

Mandible vs. Maxilla

Anterior vs. Posterior

Implant length

Quality of boneSurgical procedure

Time between implant insertion and restoration

Bone augmentation


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Evaluate patients diabetic conditionMeasure plasma glucose before and after dentalprocedure

Make short appointments usually during the mornings

when time of meals and hypoglicemic drugs are notinterrupted

Consider adding single dose of rapid acting insuin totype 1 diabetic patients

Use antiseptic rinses

Use prophylactic antibiotics

Consider using post operative antibiotic


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When acute infection exists determine type ofantibiotic using culture

Analgesia with salicilats is not recommended due tointerference with sulfonylurea activity and increasesinsulin secretion

If signs of hypoglicemia appear give orange juice,administer intravenous solution of dextrose 50% orinject IM 1 mg of glucagon

Keep in mind infection including oral may aggravatethe glycemic control and when treated improve it


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N. Y., a 61 years old woman was referred to the dentalimplant center to restore her posterior upper leftmissing teeth.

She was not able to use dentures due to severe gag

reflex.

She was diagnosed as suffering from diabetes mellitustype 2 five years prior to referral and has been treatedwith oral hypoglycemics since. Her HgA1c value was

7.2%.

Two years prior to her referral she underwent Lt.lumpectomy, chemotherapy and regional irradiationdue to Breast carcinoma.


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Surgery by Prof. R. Zeltser, Department of oral and Maxillofacial surgery, HebrewUniversity and Hadassah Medical Center Faculty of Dental Medicine.


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9 months post sinus augmentation.


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6 months after implant insertion.

Impressions were taken using Inh. N2O 60% (total flow of 8 liter/min)


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implant for general dissese

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