REVIEW ARTICLE
Year : 2022 | Volume
: 12 | Issue : 1 | Page : 4--9
Co-relation of Vitamin D and senile osteoporosis in relation to dental implant
Rosy Raheja
Department of Prosthodontics, Crown and Bridges and Implantology, Rama Dental College, Hospital and Research Centre, Kanpur, Uttar Pradesh, India
Correspondence Address:
Dr. Rosy Raheja
NO. 124/399, Block 11a, Govind Nagar, Kanpur, Uttar Pradesh
India
Abstract
In the past few years, the prosthodontic educational and research focus evolved beyond traditional therapeutic approaches. This progress resulted from three major initiatives. First, materials research has simplified impression-making protocol and denture relining technique. Second, improved understanding of the role and particularly the limitations of mechanical analogs for the masticatory system (i.e., articulators). The third initiative, and the major research and educational catalyst, has been the technique of osseointegration, which has had a profound impact on research and education in virtually all our clinical endeavors. As a result, the consequences of an aging edentulous environment or a terminal dentition have been more successfully addressed than ever before and many clinicians even began to forecast the demise of the complete denture technique. Thankfully though, the initial euphoria resulting from the availability of implant-supported solutions has now ablated, and a more realistic assessment has emerged. In this article, emphasis more on correlation of senile osteoporosis and role of Vitamin D in relation to the success of oral implantology.
How to cite this article:
Raheja R. Co-relation of Vitamin D and senile osteoporosis in relation to dental implant.J Dent Implant 2022;12:4-9
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Raheja R. Co-relation of Vitamin D and senile osteoporosis in relation to dental implant. J Dent Implant [serial online] 2022 [cited 2023 Mar 21 ];12:4-9
Available from: https://www.jdionline.org/text.asp?2022/12/1/4/347661 |
Full Text
Introduction
As an implant is introduced into the treatment modality, all of the stomatognathic systems have an effect on the eventual outcome. Certainly, implant dentistry represents a viable alternative for many patients in need of a removable prosthesis, but it is not a guaranteed result, without complications. It is not fair to our profession or to our patients to lump all patient conditions in a success report. The anatomy and health of the patient are always primary determinants of the outcome of the surgical procedure. When establishing a treatment plan and evaluating its prognosis, the restoring dentist must take into account a myriad of elements in dealing with the overall health of the stomatognathic system. Customized treatment and management of complications should be discussed with the patient based on past experience of treatment with similar or like conditions. Hence, the patient with advanced atrophy who wants a fixed prosthesis cannot be compared with the patient who is satisfied with an overdenture and has abundant bone. Not all patients need or can afford implant therapy. Removable partial and complete dentures still have indications, based on anatomic condition, health, and the patient's desires and economic priorities. For partially edentulous patients, traditional fixed prostheses are indicated whenever possible. Implant dentistry does not replace these established criteria but only modifies the boundaries.[1]
Implants should not be used on young patients before the end of their growth, which is approximately at 16 years for girls and 17–18 years for boys. On the other hand, there is no upper age limit. However, elderly patients often present a number of general health problems, which might contraindicate surgery.[2]
Crestal Implantology
Conventional thinking in crestal implantology is focused on placing an implant correctly from a two or three-dimensional view point and once this has been achieved, on adding the prosthetic superstructure in its correct position in the oral cavity. In recent years, three-dimensional planning techniques have been increasingly used for this purpose, although the crestal implants used are essentially two dimensional. If the interfaces of both positions do not coincide, the bony anchoring points are relocated by augmentative measures to make them coincide. According to this philosophy, implants will be placed at the sites that are considered appropriate from a prosthetic viewpoint, even though those sites may be characterized by bone loss. What is regarded as appropriate is incidentally, ultimately determined based on aesthetic rather than biomechanical considerations.
The most important determinant for a successful long-term outcome is, however, the consideration of the time factor inherent to bony tissues. This fourth dimension will determine whether stable bone conditions will be present at the site of implantation under long-term loading and functional patterns. Time is critical since the healing and remodeling processes inside the bone may turn out to be influenced by factors that the implantologist would not think of right away. We will therefore look at some facts and developments closely connected with everyday implant work.[3]
Bone healing–remodeling
Bone multicellular units (BMUs) consist of osteoclasts and osteoblasts which are combining their activities to a cutting cone that eats bone ahead of osteon and deposition bone inside the newly formed cavity. The zone between cutting and deposition is called reversal zone. The tunneling takes place at approximately forty micrometers a day. On histological sections, BMUs may be seen in from the side or they may be cut as shown in the upper three sections. Newly deposited bone can be labeled with several stains, usually with tetracycline. This substance deposits in high concentration in newly mineralized bone, thus telling us which osteons or which areas of woven bone are new and refilling at the time of labeling [Figure 1].[4]{Figure 1}
The life cycle of osteons covers the following stages:
Activation phaseResorption phaseReversal phaseDormant phase.
This cascade of processes will always develop in a uniform manner if nothing interferes with them [Figure 2]. The term (bone morphological unit [BMU]) as used hereinafter is commonly used to refer to this “cutting cone.” BMU covers the whole process outlined above in its cellular and partial entirety - i.e., the activity of osteoclasts as well as the deposition of matrix and the process of mineralization.[5]{Figure 2}
The 0–1 property and the self trabeculation model-micromodeling.
Bone is a material that is capable of developing a trabecular structure by itself. Bone is also capable of changing the distribution of the load transmission task between different areas inside the bone or within the cortical bone (Mullender et al. 1994). A hypothetical perfectly homogenous isotropic bone block would become increasingly anisotropic on being subjected to functional loading. In this process, it would develop both areas of heightened and areas of reduced mineralization. This behavior is known as the 0–1 property.
When the implant is inserted into the bone, the macrotrajectories in the slot area are interrupted. In the healing phase, the situation may arise that the bone areas near the disk are mineralized better than the immediate area of insertion due to self trabeculation of the cortical bone. In other words, the immediate area of insertion becomes the 0-area, while areas in the extended vicinity become 1-areas. The risk that this situation may arise is smaller in the mandible than in the maxilla. The stress-related mineralization pressure in the mandible is higher at strategic implant positions. Whenever a large number of implants are inserted in the maxilla (particularly triple disk or double disk BOI implants in conjunction with long screws), the vestibular macrotrajectories are largely destroyed, and a healing process ensues that is undefined in terms of trajectory orientation and in which the effects of the implant surface prevail. Biomechanically, the situation can be compared to the grafting of the large bone blocks (e.g., from the skull). Bone grafts of this type are not subject to any defined function during healing either. Therefore, implants to be loaded at a later time can basically be inserted right away in the same session. However, treatment with BOI implants offers greater advantages compared to grafting because these implants are inserted into native vital bone that will recover its macrotrajectorial properties faster.
The anisotropic properties of bone are massively changed or neutralized by inserting BOI implants in large numbers so that the bone becomes virtually isotropic. When the anisotropic properties are later recovered, some portions of the BOI disks or even the implants themselves come to be located in 1-areas while other parts will be located in 0-areas. This will, of course, influence the clinical mobility of individual implants. As functional alterations converting 1-areas to 0-areas and vice versa are always possible over the years, implant mobility does not change the probability of implant survival in any significant manner. Therefore, it takes a lot of experience to appreciate whether a BOI implant should be removed.[6]
Hormonal influences and drug treatment
Osteoporosis offers a chance to study the nature and extent of hormonal influences on bone behavior in a borderline situation. The bone marrow spaces within the bone expand in this disease, i.e., bone resorption takes place from the inside. The trabecular structures are weakened. If bone is functionally induced to increase its volume, the apposition processes will take place on the outside of the bone. The affected bone structures will become thicker. Bone training is the only useful long-term treatment for osteoporosis although drugs that will increase the degree of mineralization (e.g., Fosamax) may be needed as well so that exercise without incurring bone fracture becomes possible in the first place.[7]
Pathophysiology of osteoporosis
Osteoporosis has been defined by the WHO in 1994 as “a disease characterized by low bone mass and microarchitectural deterioration of bone tissue leading to enlarged bone fragility and a consequent increase in fracture risk.”[8],[9] Osteoporosis is classified as primary osteoporosis (having traceable etiology). Primary osteoporosis is further classified as Type-I postmenopausal (between 50 and 70 years of age) and Type II age related (SENILE) (more than 70 years of age affecting both trabecular and cortical bone).[10] Osteoporosis can also be classified as localized and generalized osteoporosis. The generalized can be primary or secondary osteoporosis.[11]
When serum calcium levels are falling, parathyroid hormone is released that will stimulate osteoclasts to induce bone loss, so that calcium is released into the circulating blood. By the same token, calcitonin is released when calcium levels are high so that the process is reversed. In other words, osteoporosis develops when the equilibrium can be influenced by drug treatment. Drugs such as Fosamax will improve calcium deposition by adjusting the calcium balance.[12]
Fractures after implant therapy
Patients with hormonal deficiencies in bone strength have a greater risk of jaw fractures due to crack propagation on immediate loading. These jaw fractures occur predominantly in the mandible. Peri-implant fractures with crestal implants will always necessitate explanation. After all, such fractures will invariably occur along the vertical implant axis whose surface is micromechanically roughened, thereby promoting infection, in addition to the fact that crestal implants have no additional stabilizing components such as disks and rings. In jaw fractures near BOI implants, the spectrum of applicable treatment options is broader.
Patients with pronounced osteoporosis are liable to incur spontaneous fractures, notably in the distal segments of the mandible. These fractures occur usually symmetrical. That is to say after the first side has fractured, the contralateral side will soon follow suit.
Osteoporotic jaw fractures after insertion of BOI implants cannot usually be verified by radiography, as there is hardly any space left for dislocation due to the comminuted nature of the fracture and the implantological splinting. Furthermore, the fracture ends will interlock immediately. While a single BOI implant can per SE provide effective splinting, this effect is even more pronounced when the bridge is in place. More importantly, the bridge will prepare the ground for normal jaw function to be reestablished. The patient should stick with soft food over 2–4 weeks. Antibiotic coverage is unnecessary in our experience. The pronounced modeling may give rise to strains, distensions, and reddening at the fracture site. These symptoms are not to be confused with those of bacterial inflammation.[13]
Vitamin D
Vitamin D in its inactive form (Vitamin D 3 or cholecalciferol) is a steroid hormone that is synthesized in the skin with adequate exposure to the sun and/or acquired through diet. Vitamin D is a key player in bone growth and metabolism as it promotes the intestinal absorption of calcium and phosphorous. In addition, Vitamin D is vital for health of the brain, cardiovascular system, respiratory tract, skin, and immune and endocrine systems. It is also important in healing after periodontal, oral, and implant surgery.
Bone metabolism-Vitamin D plays an important role in the metabolism of bone. In the bone, Vitamin D stimulates the activity of osteoclasts and increases the production of extracellular matrix proteins by osteoblasts. Deficient Vitamin D levels have been correlated with low bone density, pathologic fracture, and poor bone healing after dental surgery. A large percentage of patients with osteoporosis also suffer from Vitamin D insufficiency. In addition, case reports have suggested that low Vitamin D levels can be correlated with failure of bone grafts and regenerative materials. Since osseointegration of dental implants depends on bone metabolism, there is a possibility that low levels of Vitamin D in the blood can negatively affect healing processes and a new bone formation on the implant surface.[14]
According to Judd Sher et al., patients with a history of bisphosphonate treatment for osteoporosis are not at increased risk of implant failure in terms of osseointegration. However, all patients with a history of bisphosphonate treatment, whether taken orally for osteoporosis or intravenously for malignancy, appear to be at risk of “implant surgery-triggered” MRONJ. In contrast, the risk of MRONJ in patients treated with denosumab for osteoporosis was found to be negligible. In conclusion, general and specialist dentists should exercise caution when planning dental implant therapy in patients with a history of bisphosphonate and denosumab drug therapy. Importantly, all patients with a history of bisphosphonates are at risk of MRONJ.[15]
Dental consideration in osteoporosis
Some studies have experimentally concluded that in postmenopausal women, BMD is related to interproximal bone loss and pointed at osteopenia as a possible risk factor for periodontal disease. Women with low BMD and high calculus apposition had greater clinical gingival attachment loss than in women with normal BMD and similar calculus apposition. Serum estradiol supplementation reduces gingival inflammation and attachment loss which is the cause for early loss of teeth in early menopausal osteoporotic women.[16],[17] Taguchi et al. suggested that the loss of posterior teeth may be with a decrease not only in alveolar bone height but also alveolar BMD.[18]
Residual ridge resorption in complete denture patients is a biological phenomenon which results as a decrease in biomechanical loading on bone which reduces the stresses within and on the periosteal surface of the bone leading to resorption. Hirai et al. indicated that osteoporosis strongly affects reduction of the residual ridge in edentulous patients.[19],[20]
Osteoporosis and implant-supported overdenture
Overdentures supported by implants improve the masticatory force and thus the loading on the mandibular bone compared to that of conventional full dentures. Hutton et al. performed a multinational and multicentre study involving 133 persons treated with implant-supported overdentures in the mandible and/or maxilla.[21] The results indicate that persons with inferior bone quality (very thin cortical bone with low-density cancellous bone of poor strength) and pronounced alveolar ridge resorption at the implant site show the highest risk of implant failure. The above study failed to demonstrate relationship between the implant failure and age. The mandibular osteoporosis before implant treatment may present a risk for minor accentuation of peri-implant marginal bone loss but not implant failure within 5 years. Hence, considering the above study, the implant-supported overdentures are the treatment of choice after total tooth loss because of their bone sparing effect and may also be recommended to persons with osteoporosis.[22],[23],[24],[25]
Prosthodontic management
Humphries et al. conducted a study on bone resorption of mandibular alveolar bone in elderly edentulous adults and they concluded that women above 50 years with osteoporosis required new dentures three times more frequently than women of same age. Reducing the stresses on the bone by modifying the treatment plan with specific precautions is considered in these patients.[26],[27] Curtis and Wae reported that largest amount of resorption has been shown to occur in the mid-lateral aspects of the body of the mandible, while less resorption occurred anteriorly. It was also reported that the clinical height of the region on distal to the mental foramen was more closely correlated with the general bone loss status than the anterior region.[28]
When fabricating the removable dentures, the main area of focus should be on reduction of the forces on residual ridge. Mucostatic open mouth impression techniques, selective pressure impression technique, should be employed to reduce mechanical forces while narrow buccolingual width should be selected. Optimal use of soft liners extended tissue intervals by keeping the dentures out of mouth for 10 h a day can be advised. While fabricating fixed partial denture (FPD) in periodontally compromised abutments, it may accelerate the bone loss in osteoporotic patients. Hence, the fabrication of FPD should follow the treatment of osteoporosis rather than preceding it.
Established systemic osteoporosis does not imply that a jaw bone is unsuitable for osseous integration nor is it an absolutely contraindication to implant therapy. Augat et al. found more number of maxillary implant failures than mandibular implants in postmenopausal women.[29] They found that postmenopausal women not taking hormone replacements had the highest failure rates. They reasoned that because osteoporosis affects trabecular bone more than cortical bone and the maxilla has more trabecular bone content than the mandible, the maxilla is more susceptible to the effects of systemic osteoporosis. During dental implant therapy, it may be wise to be cautious with maxillary implant treatment planning. Reduced bone density does effect the treatment planning surgical approach, length of healing, necessitates need of progressive bone loading, and hydroxyapatite coating on implants. Daily calcium uptake should be up to 1500 mg/day pre and postsurgically.[30],[31]
Clinical relevance
Osteoporosis is a health condition that greatly affects the bones, weakens them, and makes them capable of fracture easily. Vitamin D deficiency has also be seen in osteoporosis patients. Besides hampering overall health and well being, osteoporosis also has a direct relationship on oral and dental health.
Osteoporosis has been suggested as a risk factors in dental implant failure, but data supporting such a link are limited.[32]
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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