THEMATIC

ABSTRACT REVIEW
Thomas Oates, DMD, PhD
University of Texas Health Science Center, San Antonio, Texas

Section Editor: Clark Stanford, DDS, PhD

University of Iowa, Iowa City, Iowa

Guy Huynh-Ba, DDS, MS Jan-Eirik Ellingsen, DDS, PhD

University of Texas Health Science Center University of Oslo
San Antonio, Texas Oslo, Norway

Martin Osswald, BDS, MDent Emad Estafanous, BDS, MSD

Institute for Reconstructive Sciences in Medicine University of Iowa
Edmonton, Alberta, Canada Iowa City, Iowa

Systemic Factors Affecting Implant Survival?

G iven the overall success of implant therapy and its

continuing application to an ever broadening ar-
ray of patient situations, an understanding of the true
limits that are placed on this therapeutic approach
by a patient’s systemic conditions is crucial. Systemic
conditions, such as diabetes and smoking, have long
been considered important risk factors compromis-
ing implant survival, so that patients having these
conditions may not be considered acceptable candi-
dates for implant therapy. While our understanding
of the biologic basis of these conditions supports our
concern with the use of implant therapy in many pa-
tients, there is a lack of definitive information for clini-
cians to base their decisions as to the appropriateness
of implant therapy. Over the past year, several studies
have tried to add clarity to the clinical impact of sys-
temic conditions affecting implant survival.
Zupnik et al (2011) provide a retrospective assess-
ment of systemic factors affecting implant therapy
over 4 years. This investigation was able to evaluate
341 implants placed for patients (number of patients
not reported) receiving care in an academic training
program. The overall survival rate for implants was
96.5% and the experience level of resident was not
a factor in implant survival. The patient’s diagnosis
of diabetes was identified as an important risk factor,
with diabetic patients having 2.59 times the risk of
failure compared to implants placed in non-diabetic
patients. Note in this study, smoking was not identi-
fied as an important factor in implant survival. One
of the limitations to this retrospective study is our in-
ability to evaluate the patients’ systemic conditions
in a more specific manner; for example, to know how
diabetes patients were identified and if their diabetes
status was confirmed beyond the patient’s report.
Anner et al (2010) retrospectively evaluated 475
patients having received 1,626 implants. Of these pa-
tients, 13% were self-identified as smokers and 10%
as having diabetes. Their overall survival rate over an
average time period of 2 years was 95.3%. In direct
contrast to the findings from Zupnik et al, this study
did find a relationship between implant survival and
smoking, but failed to find an effect of diabetes on
implant survival. Again, the concerns of this type of
retrospective study with a lack of understanding of
specific and likely important details of the systemic
conditions need to be considered.
In looking at the effects of systemic diseases, Lee
et al (2010) took a slightly more novel approach to
their retrospective study by evaluating 35 geriatric
patients over 70 years of age receiving 118 implants.
Of the 35 patients, 29 had various systemic condi-
tions including hypertension, diabetes, heart or kid-
ney disease. Smoking was not considered. Of the 118
implants, there were two implant failures identified
and 18 complications out of the 118 implants noted
over an average follow-up period of 32 months. Most
postsurgical complications were wound dehiscence
(5.9%) and implant exposure (5.1%), and there were
a few implants with complications following restora-
tion, with screw loosening being the most common.
Important to our discussion, there was no significant
association between implant survival and complica-
tions in the presence of a systemic condition. This
study concluded that implant therapy in geriatric pa-
tients, even with any of several systemic conditions,
should not be considered a high risk.
Consistent with this general finding, Turkyilmaz
(2010) evaluated 10 diabetic patients receiving 23
implants followed over 1 year and found no implant

The International Journal of Oral & Maxillofacial Implants 469

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Thematic Abstract Review
failures. This case series supports our limited under-
standing of the effects of glycemic control by evalu-
ating four patients receiving eight implants with
glycated hemoblobin A1c levels above 8%. While this
is a small number of patients, it does reinforce earlier
findings of high levels of implant survival and mini-
mal clinical complications for a study including 15
patients with elevated A1c levels greater than 8%, in-
cluding three patients with A1c levels over 10%.1
In summary, these studies do not clarify the role of
diabetes or smoking in implant failure, but together
they support our continuing need to question the in-
fluences of systemic factors on implant survival. With
our limited understanding of the influences of sys-
temic conditions, it becomes important to consider
not only the possible complications from systemic
conditions on implant survival, but also to consider
the potential benefits that implant therapy may of-
fer. That is, the benefits of implant therapy that may
be denied to a patient because of a systemic condi-
tion must be weighed against the risks and our level
of understanding of those risks. As can be seen from
our most recent research in this area, there are many
unanswered questions that remain.
—T. Oates
REFERENCE
1. Dowell S, Oates TW, Robinson M. Implant success in people
with type 2 diabetes mellitus with varying glycemic control:
A pilot study. J Am Dent Assoc 2007;138:355–361.
Zupnik JT, Kim S-W, Ravens DP, Karimbux NY, Guze
KA. Factors associated with dental implant surviv-
al: A four-year retrospective analysis. J Periodontol
2011 Mar 21 [epub ahead of print].
Dental implants are a predictable treatment option for
replacing missing teeth with strong survival and success
outcomes. However, previous research shows a wide ar-
ray of potential risk factors that may contribute to den-
tal implant failures. The objectives of this study were to
study if implant survival rates are affected by known risk
factors and risk indicators that may contribute to implant
failure. The secondary outcomes measures were whether
the level of expertise of the periodontal residents affect-
ed success rates, and how the rate of implant success
at the Harvard School of Dental Medicine compares to
published standards. A retrospective chart review was per-
formed for patients at the Harvard School of Dental Medi-
cine (HSDM) who had one of two types of rough surface
implants placed (Group A or Group B) by periodontology
residents from 2003 to 2006. Demographic, health, and
implant data was collected and analyzed by multimodel
analyses to determine failure rates and any factors that
470 Volume 26, Number 3, 2011
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may have increased the likelihood of implant failure. The
study cohort included 341 dental implants. The odds ratio
for implant failure was most clearly elevated with diabetes
(2.59), Group B implant surface (7.84), and male gender
(4.01). There was no significant difference with resident
experience. The success rate for HSDM periodontology
residents was 96.48% over the 4-year study period. This
study demonstrates that HSDM implant success rates
fall within the accepted published standards, confirms
previously identified risk factors for failure, and potentially
suggests that other acknowledged risk factors can be con-
trolled for. Furthermore, the level of experience of the peri-
odontology resident does not have an impact on survival
outcomes.
Reprints available from: Kevin A. Guze, DMD, DMSc, Harvard
School of Dental Medicine, Department of Oral Medicine, Infec-
tion, and Immunity, Division of Periodontology, 188 Longwood Av-
enue, Boston, MA 02115. Email: Kevin_guze@hsdm.harvard.edu
Anner R, Grossmann Y, Anner Y, Levin L. Smoking,
diabetes mellitus, periodontitis, and supportive
periodontal treatment as factors associated with
dental implant survival: A long-term retrospective
evaluation of patients followed for up to 10 years.
Implant Dent 2010;19:57–64.
To evaluate the factors associated with long-term implant
survival in a large cohort of patients in regular follow-up
until data collection. The study population consisted of
475 patients who were referred to a private clinic lim-
ited to periodontics and implantology between November
1995 and July 2006. Data were collected from patient
files with regards to smoking habits, periodontal condi-
tion, diabetes mellitus, implant survival, and time when
implant failure occurred. Patients were divided into those
who participated in a supportive periodontal program in
the clinic and those who only attended the annual free-
of-charge implant examination. A total of 1,626 implants
were placed with a follow-up ranging from 1 to 114
months (average 30.82 ± 28.26 months). Overall, 77
(4.7%) implants were lost in 58 (12.2%) patients after a
mean period of 24.71 ± 25.84 months. More than one
half of the patients (246; 51.7%) participated in a struc-
tured supportive periodontal program in the clinic, and
229 (48.3%) only attended to the annual free-of-charge
implant examination. Smoking and attendance in a regu-
lar supportive periodontal program were statistically as-
sociated with implant survival. Patients with (treated)
moderate-to-advanced chronic periodontal disease dem-
onstrated higher implant failure rates but this difference
did not reach statistical significance. Diabetes mellitus
was not related to implant survival in this patient cohort.
Smoking and attendance in a regular supportive periodon-
tal program were found to be strongly related to implant
survival. Special attention should be given to continuous
periodontal supportive programs to implant patients.
Reprints available from: Liran Levin, DMD, Department of
Oral Rehabilitation, The Maurice and Gabriela Goldschleger,
School of DentalMedicine, Tel Aviv University, Tel Aviv, Israel.
Email: liranl@post.tau.ac.il

Lee HJ, Kim YK, Park JY, Kim SG, Kim MJ, Yun PY.
Short-term clinical retrospective study of implants
in geriatric patients older than 70 years. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 2010;110:
442–446.
The objectives of this study were to analyze the presence
of systemic diseases, associated complications, and oth-
er problems occurring after loading of an implanted pros-
thesis, and to evaluate the amount of bone resorption
occurring at the apex of alveolar bone. Therefore, this
study analyzed these effects on dental implants in elder-
ly patients with systemic diseases. In total, 35 patients
over the age of 70 years who had been operated on at
Seoul National University Bundang Hospital (Seongnam,
Korea) between June 2003 and December 2006 were in-
cluded. According to the types of additional surgical pro-
cedures, implant site, implant prosthesis, and systemic
diseases, statistical comparisons were made of peri-
implant bone resorption at last follow-up. Following the
completion of prosthodontic treatment, after a mean peri-
od of 32.7 months, the mean peri-implant bone resorption
was 0.27 mm, and the peri-implant bone resorption was
not significantly related to the type of upper prosthesis
(P = .383), the surgical procedures accompanying place-
ment (P = .933), or the presence/absence of systemic
disease (P = .484). According to this analysis, implant ther-
apy in geriatric patients with controlled systemic disease
should not be considered to be of particularly high risk.
Reprints available from: Su-Gwan Kim, DDS, PhD, Department
of Oral and Maxillofacial Surgery, School of Dentistry, Chosun
University, 375, SeoSukDong, DongGu, GwangJu City, Korea.
Email: sgckim@chosun.ac.kr
© 2011 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY..
NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Thematic Abstract Review
Turkyilmaz I. One-year clinical outcome of dental
implants placed in patients with type 2 diabetes
mellitus: A case series. Implant Dent 2010;19:
323–329.
Diabetes mellitus is a prevalent medical disorder. It is of-
ten accompanied with systemic adverse sequelae, such
as wound healing alterations, which may affect osseoin-
tegration of dental implants. The use of dental implants
in patients with diabetes mellitus remains controversial
because altered bone healing around implants has been
reported. The purpose of this study was to present 1-year
clinical outcomes of 23 implants placed in 10 patients
with well-, or moderately well, controlled type 2 diabetes
mellitus. All implants were uneventfully placed in the
mandible or maxilla. Three different types of definitive
implant-supported prostheses, cement- or screw-retained
fixed dental prostheses, and overdentures were delivered
to the patients. At 1-year follow-up recall, no implants
were lost, and 0.3 ± 0.2 mm marginal bone loss was
noted. No periapical radiolucencies, no bleeding on prob-
ing, or pathologic probing depth were recorded at these
recalls. This clinical report supports the use of dental
implants in patients with well-, or moderately well, con-
trolled type 2 diabetes mellitus as a dental treatment
modality. No evidence of diminished clinical success or
significant complication related to implant treatment was
found for this patient population.
Reprints available from: Ilser Turkyilmaz, DDS, PhD, Department
of Prosthodontics, Dental School, University of Texas Health
Science Center at San Antonio, 7703 Floyd Curl Drive, MSC 7912,
San Antonio, TX 78229-3900. Email: turkyilmaz@uthscsa.edu
The International Journal of Oral & Maxillofacial Implants 471