

First appeared in print edition of Dentistry Today | April 1, 2020 | Volume 39 No. 4 | pg. 72-29
Introduction
Dental implants are generally considered a safe and highly predictable surgical procedure performed by many clinicians with the aim of replacing missing teeth. Yet, to this day, a number of implants placed in adequate bone volume are lost each year within a 2- to 8-week period following implant placement for unexplained reasons. As society continues to consume lower-quality foods and rely more heavily on fast foods, a large percentage of today’s population is increasingly demonstrating generic vitamin deficiency upon testing, owing to this lack of nutritional intake. These deficiencies are even more pronounced in the aging population, where a greater percentage of dental implants are placed. Unfortunately, one of the most prominent deficiencies known to mankind is that of vitamin D, a water-soluble vitamin critical for proper immune function as well as bone homeostasis.
VITAMIN D DEFICIENCY Vitamin D deficiency is a worldwide public health problem that spans across all age groups from children to adults. Naturally, as we age, our ability to absorb vitamin D is also decreased. The major source of vitamin D is directly from sunlight exposure along with the very few foods that naturally contain sufficient doses. Unfortunately, direct sunlight has tremendously decreased in modern society with the increased number of desk-related jobs. Epidemiological studies have now shown that roughly 70% of society is deficient.1


Supplemental Recovery Program: The Science Behind Dental Healing

The Role of Antioxidants in Wound Healing
In addition to bone-related deficiencies, several additional factors can impair wound healing, such as infection found in periodontal disease, poor diet, aging, diabetes, alcohol overuse, smoking, stress, and impaired nutritional status.14-16 In recent years, reactive oxygen species (ROS) have gained attention because of their central role to the progression of many inflammatory diseases.17 Excessive production of ROS or impaired ROS detoxification causes oxidative damage, which has been shown to be a main cause of non-healing chronic wounds and tissue degeneration.18,19 To combat oxidative stress, all cells in the body require an intrinsic store of molecules known as “antioxidants,” which prevent tissue damage.20 When this balance is shifted, however, high levels and activity of ROS cause DNA damage, protein damage, and lipid peroxidation. This leads to impairments in wound healing and many long-term chronic degenerative diseases and whole-body tissue inflammation, which are linked to common diseases such as dementia and various cancers. Unfortunately, a large percentage of the population today suffers from vitamin and mineral deficiencies directly linked to antioxidant levels (Table 3). As a result, it is clear that prior to any major surgery, vitamin recovery programs are indispensable to help restore the patient’s levels prior to surgery to prevent failure and/or delayed wound healing. Furthermore, restoring patient antioxidant levels remains a relatively easy and inexpensive task. Vitamin C is, perhaps, one of the most well-known antioxidants and has a primary function as a radical scavenger and in the synthesis of collagen hydroxylation in humans.21 It also contributes to immune defense by supporting various cellular functions of both the innate and adaptive immune systems. Vitamin C deficiency results in impaired immunity and higher susceptibility to infections.22 Vitamin C is found in many natural fruits and vegetables, yet the population remains relatively deficient, owing to the poor nutritional status encountered in many patients.
CASE REPORT
Example of Early Implant Failure as a Suspected Result of Vitamin D Deficiency
Routinely, dental implants are placed with long-term success rates of 90% to 95%.28-31 However, for relatively unknown reasons, a small percentage of implants are lost each year with unexplained findings. Figure 3 demonstrates an initial ridge in a 73-year-old male patient with sufficient bone ridge width for implant placement. The patient was not on any medication and was considered healthy. Following midcrestal full-thickness flap elevation, a bone reduction alveoplasty procedure was done to allow adequate width for implant placement with 1.0 to 2.0 mm of remaining width on the buccal and lingual aspects (Figure 4). Note the excellent ridge width. Figure 5 demonstrates the implant osteotomies with adequate bone width on either side. Following implant placement at torque values of 40 Ncm (Figure 6), soft-tissue closure was obtained, and the patient was advised to maintain good-hygiene home care that included saltwater rinses following meals (Figure 7). A periapical radiograph was taken following implant placement, demonstrating adequate bone levels (Figure 8). At the 2-week recall, suture removal was performed, and the patient was advised to be seen 1 month later. At 1-month postoperative, a subsequent periapical radiograph was taken in which severe bone loss was noted around the implant and clinical mobility was observed (Figure 9). The implants were therefore removed, and the patient was sent for medical analysis. This highlights a typical case whereby simple osseointegration was expected in a relatively straightforward case, and yet unexplained early implant failure occurred. Upon testing of a full blood workup, the main finding was the patient’s low vitamin D levels. The patient reported levels of vitamin D deficiency. The patient was then supplemented with a 12-week recovery program of supplements (DentaMedica), and implant placement was successful thereafter. This case represents a standard recovery program and timeline following early implant failure for unknown reasons to promote local healing and recovery of vitamin and mineral levels. Vitamin D testing post-early implant failure almost always results in cases reported to be vitamin D-deficient.Patient Testing and Supplementation
Owing to recent evidence suggesting a strong correlation between vitamin D deficiency and early implant failure, vitamin D testing before bone grafting and implant placement has therefore been recommended. While blood work is not always common and/or available within a dental office, the ability to adequately test vitamin D levels within 10 minutes with a simple finger-prick test becomes a highly valuable tool within dental offices (Figure 1). Upon discovery of low patient vitamin D levels, it becomes essential to supplement patients adequately prior to implant placement or bone grafting procedures. Another alternative is the use of supplementation prior to implant surgery and bone graft surgery. A minimum 4-week supplementation program is recommended to elevate all vitamin and mineral levels prior to surgery, followed by an additional 2 weeks post-op.CLOSING COMMENTS
This article highlights the effects of vitamin D deficiency on early implant failure and bone graft complications. Vitamin D remains one of the most highly prevalent vitamin deficiencies known to man, and a direct link with bone tissue homeostasis and remodeling has been reported in the literature. It’s noteworthy that vitamin D is also linked with the immune system, whereby introduced biomaterials in the body (especially in bone) such as dental implants may be compromised when vitamin D deficiency is observed. Recent studies have demonstrated a marked and significant additional increase in early dental implant failure of roughly 300% higher in implants placed in vitamin D-deficient patients than in healthy patients. Furthermore, supplementation and a recovery program are discussed as a means to assist patients both pre-surgically as well as in the recovery phase.References
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