Patient the use and breakdown of glucose. The

Patient Case Report: Patient C

Amanda Samaan

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New York University College of Dentistry

 

ABSTRACT

Diabetes Mellitus is defined as a
disorder involving the use and breakdown of glucose. The disorder results in the increased level of blood
glucose levels. There
are two types of diabetes: type I and type II. Type I is an autoimmune
disorder which results in the breakdown of beta cells of the pancreas that are
responsible for the breakdown of glucose. Type II is an endocrine
disorder that is characterized by the improper use of insulin resulting in
higher than normal blood glucose levels. In patients who have
diabetes will the success rates of implant placement differ than in patients
who have no significant medical history? Three systematic reviews were used as
a literature review for this clinical question. The PICO for the clinical questions is:

Population: patients undergoing
implant surgery

Intervention: diabetes

Comparison: no significant medical
history

Outcome: success of the implant
placement

The keywords used for the search
were implants and diabetes, and the filter used was systematic review. The results of the systematic
reviews showed that there were no statistically significant changes in implant success
seen in patients with controlled diabetes when compared to patients who had no
significant medical history.
However, when a patient has uncontrolled diabetes, the patient is at an
increased risk of failure of the implant to osseointegrate, peri-implantitis,
and higher level of implant failure.

 

                                                               
INTRODUCTION
Patient C is a 71-year-old Italian, male who I met in the Admissions Clinic. His medical history is significant
for Diabetes Type II, Hypertension, and bypass surgery in 1996. He was diagnosed with hypertension
in 1996 and it is currently controlled with medication.
His diabetes is controlled with medication as well.
Patient C also has osteoarthritis.
He is on quite a few medications for his medical conditions. He is currently on an insulin pen, Diltiazem,
Flurazepam, Levemir, Lisinopril, Novolog Flexpen, Rosuvastatin, and Tramadol. The insulin pen, Levemir, and
Novolog Flexpen are used to control his type II diabetes and none of these
drugs cause any major side effects.
Patient C is taking Diltiazem and Lisinopril which are antihypertensive
medications. The Diltiazem may cause gingival
hyperplasia so careful maintenance and observation of this patient is warranted,
while the Lisinopril causes orthostatic hypotension.
This is important to consider when lowering and higher the chair so that the
patient does not faint.
In addition to these, many of the other medication that he’s taking cause
changes in saliva as well as xerostomia (Lexicomp, lexi-drugs, 2015). The patient was hospitalized in 1996
for a bypass surgery.
One would consider antibiotic prophylaxis for invasive procedures; however, as
per the new guidelines of the American Heart Association AHA antibiotic
prophylaxis is not warranted for bypass surgery.

After going through his medical history, we took his vitals. He
has a blood pressure of 173 over 76. His systolic was elevated and we spoke to the
patient about it. We urged him to talk to his primary care provider
and to keep taking his medications. A thorough head and neck exam was completed
on the patient and there were no abnormal findings seen. Intraoral exam
revealed no significant soft or hard tissue lesions. However, upon examination
of the residual alveolar ridge, the posterior alveolar ridge was severely
resorbed. A panoramic radiograph was requested and on radiograph the
resorption of the posterior ridge was evident. This concluded the initial
visit with Patient C.

He was seen again in my home clinic with a chief concern
that his dentures are not fitting properly. When questioned about the
complete maxillary and mandibular denture, the patient had stated that he had
received these dentures about twenty years ago, and would not be opposed to
doing a reline of the denture since he was, for the most part, satisfied with
the.
When questioned about his current dentures, the patient seemed happy with them
and was indifferent to getting a new set of dentures. Since the dentures
were made outside of New York University College of Dentistry the only option
was to create a new set of dentures for him. The patient agreed with
this and was interested in a more retentive denture. We offered him mandibular
overdenture and he accepted this treatment option. When it came to the
maxillary denture he was interested in having implants placed to increase the
retention in his new dentures. Since this is something that a post graduate
prosthodontist would need to do the patient was referred to PG program. This
raised the question, though, in patients who are undergoing implant placement,
will having diabetes affect the osseointegration of the implant and the
ultimate success to the implant as opposed to a patient whose medical history
is not significant?

Before we begin a literature review, let’s take a look at
Type II Diabetes. Diabetes is not a single disorder, it represents a
series of metabolic conditions associated with hyperglycemia and caused by
defects in insulin secretion and/or insulin action (Siddiqui et.
al, 2011). The basic mechanism in a healthy individual is that glucose
travels in blood where it is delivered to the rest of the body to be used as
fuel.
The way that the glucose is moved out of the blood into the body to be used as
fuel is by an enzyme produce in the pancreas called insulin.
Diabetes is characterized as a lack of insulin (type I) or improper use of
insulin (type II). Since glucose is not moved out of the blood
properly, people who have diabetes have a higher blood glucose level.
Type I diabetes is an autoimmune disorder in which the beta cells of the
pancreas are not creating insulin. Type II diabetes is an endocrine disorder
that is most commonly seen in overweight or obese individuals (Siddiqui et. al.).

 

LITERATURE REVIEW

To obtain the three systematic reviews used in this patient
case report, I use PubMed search engine. In the advanced search
option, I use keywords implant OR dental implant OR ossseointegration and
diabetes OR diabetes mellitus OR hyperglycemia. These keywords yielded one
thousand five hundred and forty-one articles. I used the systematic
review filter and the most recent filter to get seventy-four articles to go
through. The articles that were chosen were the second article in the
last, the tenth article in the list, and the twelfth article in the list.

The first article is a systematic review found in the
International Journal of Implant Dentistry, and it was published in 2016.
According to the article the main effects that are seen in patients with diabetes
is poor wound healing, impaired response to infection, and an increased
incidence of periodontitis leading to tooth loss. Since this article is a
systematic review it falls under the highest in the quality of evidence pyramid.
Essentially, what a systematic review entails is having one or two researchers
looking through clinical questions that resemble the question that he or she is
asking.
After finding the correct articles that satisfy his or her question they
evaluate the results in conjunction with each other come up with a new set of
results and conclusions using the articles that he or she deemed fit. In
this systematic review, keywords such as implants and diabetes were put into
PubMed, Cochrane Review, and Embase databases to yield over two hundred
articles. One scientist reviewed these articles and based on inclusion and
exclusion criteria narrowed it down to twenty-two acceptable articles.
Some of the inclusion criteria includes English or German and type of study. He
was looking for retrospective studies, prospective studies or cross-sectional
studies. The exclusion criteria were any study published over 15 years
ago was excluded and any study that had less than ten participants was excluded.
The studies were than judged on their bias. Each study was given a
ranking of low risk of bias, moderate risk of bias, or high risk of bias.
This left twenty-two articles that qualified for this systematic review.

The studies were separated based on the type of data that
they provided. The first set of studies discussed diabetes and
osseointegration. According to Naujkot et. Al, osseointegration is
defined as “the process of formation of a direct interface between the implant
and bone, without intervening soft tissue.” This process is a
necessary step for the success of an implant and for an inflammation-free
recovery. Two out of the twenty-studies discussed the effect that diabetes
has on osseointegration. The study divided participants based on HbA1c levels. If
the HbA1c levels were less than 6 the participants were put in the healthy
group, which was the control group. An HbA1c level of 6.1 – 8 was well
controlled, 8.1 – 10 was moderately controlled, and greater than or
equal to 10 was poorly controlled. Initially, in patients who were poorly
controlled the researchers saw less stability than compared to healthy adults.
However, stability was gained in these patients though it took twice as long to
reach stability. At the one year follow-up, there was no difference
seen in the stability of the implants in any of the groups (Naujkot et. al).

The next type of data that this systematic review looked at
was diabetes and peri-implantitis. Peri-implantitis is the destructive
inflammatory process affecting the soft and hard tissue that surrounds an
implant. The results that were found that two years’ post-op patients who
were poorly controlled diabetics were at an increased risk of developing
peri-implantitis. The next type of data that nearly all the twenty-two
studies gave was diabetes and implant survival. Eighteen of the twenty-two
studies gave implant survival rate, so the researcher separated them based on
follow-up period. Seven studies had a one year follow-up and eleven
had longer follow-up periods. In short-term studies that implant survival
rate did not differ in patients with diabetes when compared to healthy
individuals. In long term studies, the survival rate at one year follow-up
was comparable to patients who were healthy. The same goes for studies
that included a 5-year follow-up. However, in studies that included a follow-up
after six years showed that there was a slight prevalence of implant failure in
the patients with diabetes. Moreover, most of the implant failures seen
in this systematic review were seen in the first year.

In conclusion, after careful analysis of this systematic
review, there is no evidence stating that a history of diabetes is a
contraindication for implant surgery. Since there may be a difference in the long-term
success rates of implants careful evaluation of these patients post-operatively
is key.
According to Naujkot et. Al, “We recommend avoiding immediate loading of
the implants. In the first years after implant insertion, there seems to be no
elevated risk of peri-implantitis; but in the long-term observation,
peri-implant inflammation seems to be increased in diabetic patients.”
This means that more frequent recalls should be implemented to catch any early
signs of gingivitis. Also, maintaining a healthy HbA1c level plays a
role, to some degree, in the success of an implant. The practitioner should
ask the patient for the most recent HbA1c level and help the patient to
maintain a healthy level.

The next article is a systematic review investigating
whether or not hyperglycemia or diabetes mellitus has an effect on peri-implant
disease. To minimize risk this study used a priori case definition of
peri-implanitis. This definition is plaque initiated host response
that leads to the destruction of host tissue around an implant. To
be considered peri-implantitis there needed to be inflammation clinically and
greater than two millimeters of marginal bone loss seen radiographically (Monje
et.
Al, 2017).  For a study to be
included in this systematic review, it needed to meet a specific set of
criteria. Each study needed to be an original prospective or retrospective
study, each study needed a control group with more than 10 participants
involved in the study. Lastly, any language was accepted for this
systematic review. If the studies did not meet this inclusion criteria
they were excluded from this systematic review.  This left twelve studies that were reviewed in
this systematic review.

The results of the systematic review showed that the risk of
peri-implantitis was about fifty percent higher in patients with diabetes when
compared to patients who were healthy. The article also stated that if the patient
smokes and has hyperglycemia there are three times more likely to have
peri-implantitis. However, the association between peri-implantitis
and hyperglycemia was not statistically significant (Monje et. al.
2017).
Since the results are not statistically significant this would lead one to fail
to reject the null hypothesis. The null hypothesis states that there is no
correlation between peri-implantitis and diabetes. Based on these results,
the conclusion is that there is a greater risk of peri-implantitis in patient
who are hyperglycemic.

The strengths of this study are that it is a systematic
review which is on the top of the pyramid for quality of evidence.
Also, this article had inclusion criteria and exclusion criteria when deciding
which studies pertained to the clinical question at hand. The weaknesses of
the study are that they did allow articles that had only ten participants which
is a rather small sample size. There is also a lack of a universal
definition of peri-implantitis so this study had to choose a definition that
was slowly becoming the norm and accepted definition of peri-implantitis. This
article is important to consider when dealing with a patient who is
hyperglycemic and looking to have an implant placed. The practitioner needs to
exercise caution when considering this a treatment plan option since there may
be an increased risk of developing peri-implantitis in patients who are
hyperglycemic.

The last article is also a systematic review from the Implant
Dentistry Journal. The
Survival Analysis of Implants with Diabetes Mellitus: A systematic review was
published in 2016. To
find the articles for this systematic review the keywords that were used were dental
implants and diabetes mellitus.
These keywords were used in Cochrane, Medline and Embase search engines to
yield the initial articles. These articles were then reviewed by two
reviewers who went through a list of inclusion and exclusion criteria. The
inclusion criteria included case studies, retrospective, and prospective
studies. The definition of implant failure that this article differed
depending on what each study defined implant failure as. The systematic
review included all of the definitions of implant failure in the examination of
each study.

After careful consideration, the two reviewers narrowed down
the articles from two hundred and fifty-seven to seven articles that were used
in this systematic review. Each study included the demographic for each
participant, and the median age for participants in this systematic review was
forty-seven to sixty-three with a minimum age of thirty-five and a maximum age
of seventy-nine. In total, one thousand one hundred and forty-two
implants were placed in this systematic review. The results of this study
state that there is no statistical significance in the two groups of
participants. This means that once again we cannot reject the null hypothesis.
The null hypothesis for this systematic review states that there is no
correlation between implant success rate and diabetes mellitus. However,
when implant failure was seen it was seen in the osseointegration phase and
within the first year or loading. This means that in practice the clinician should
be mindful of this information and perform antibiotic prophylaxis and keep the
patient on a strict recall regimen to avoid implant failure.

The strengths of this study include the study design, being
that it is a systematic review it falls at the top of the pyramid of quality of
evidence. Also, there was inclusion criteria and there were widely
accepted definitions of implant failure. This is good because it
does not limit what implant failure is to just one definition and allows for
clinicians to decide for themselves. The weaknesses of this study include the fact
that some of the studies only allowed for male participants so its ability to
generalize to the population is slightly diminished. Also, the age range for
individuals varied so there was no way to control confounding variables. In
short, when interpreting these results, the clinician should wary of these
confounding variables and treat his or her patients accordingly.

In practice, the clinician should always be cautious about
treatment after reading these articles. The clinician has to take account the
specific patient and his or her medical conditions and tailor each treatment to
the specific patient. However, after reading these articles the clinician
should be confident in placing an implant in his or her patients if they have
diabetes. Furthermore, he or she should put the patient on a strict recall
regimen to avoid and post-operative infection and, ultimately, implant failure.

 

CONCLUSION

Ptatient C first came into the admissions clinic in hopes of
replacing or fixing his current maxillary and mandibular dentures. His
medical history was significant for hypertension and diabetes. He
is on several medications that could lead to xerostomia and gingival
hyperplasia. After speaking with the patient about his expectations and his
needs the treatment plan that we came up with included a mandibular overdenture
and implant supported maxillary denture. After speaking to
prosthodontics faculty, we were unable to do a reline of the denture since it
was over twenty years old and it was not fabricated at New York University
College of Dentistry. When we told the patient that he would need a new
set of dentures, his immediate concern was the retention of the denture and how
well it would old in his mouth. We gave him the option of a mandibular
overdenture and he accepted that option. He was curious about
implant placement for the maxillary denture so we sent him to post graduate
prosthodontics where he consulted with a resident to receive the implants.
The significance of the literature review that was conducted was to see if
there was any contraindication for implant placement in patients with diabetes.
Since this patient also has other medical conditions, the clinician needs to
keep all of this in mind. The clinician also needs to keep in mind the
patients medications. The main concern is the patient is on a baby aspirin
so after implant placement the clinician needs to achieve homeostasis. In
practice, however, the clinician needs to be mindful of the patients medical
and social history and customize a treatment plan that accommodates the
patients needs and expectations.