الفهرس 
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Abstract
1. Title: Prognosis of Dental Implants in Diabetic Patients: A Systematic Review and Meta-Analysis
2. Structured summary
2.1 Background
Diabetes mellitus is worldwide chronic metabolic disease, characterized by
persistent hyperglycemia, delayed wound healing, increased susceptibility for infections, in addition to decreased osteoblastic functions and increased osteoclastic one. It has been considered a relative contraindication for implant placement, depending on the level of glucose in blood stream and glycosylated hemoglobin HbA1c.
2.2 Objectives:This systematic review aims to evaluate the effect of diabetes on dental implant failure.
PECOTS Participants/population: Patients requiring dental implants.
Exposure 1: Well controlled diabetic patients
Exposure 2: Uncontrolled diabetic patients
Comparator/control: Non-diabetic patients Primary outcome: Implant failure (pain, parathesia, mobility, stability, infection and inflammation)
Secondary Outcome: Peri-implant radiolucency, peri-implant bone changes.
Time: At least one year following implant placement Study Design: Systematic review and meta-analysis. 2.3 Data sources: The reviewers independently and in duplicate searched Medline,Lilacs and Cochrane databases and performed hand searching of 11 journals.Authors of the included studies were contacted for unreported data. They extracted the data of the included studies. 2.4 Study eligibility criteria Participants: Patients restored with implant prostheses, whether fixed or removable. Studies comparing between different levels of the glycosylated haemoglobin were considered eligible. 2.5 Study appraisal: The reviewers assessed the risk of bias for the included studies independently and in duplicate based on the outcome level within and across the studies.
2.6 Data analysis: Depending on the level of heterogeneity either fixed or random effects model was used for combining the results of clinically and
methodologically homogenous studies.
2.7 Results: A Total of 14 studies; 9 prospective and 5 retrospective studies, involving 1398 participants and 3282 implants, were included in this systematic review. 10 evaluated implant failure, 11 marginal bone loss, and 5 implant stability, 8 was judged at critical risk of bias and 6 at serious risk of bias. The quantitative and
qualitative comparisons of diabetic and healthy patients regarding implant loss and marginal bone loss after a follow up period ≥ 5 years following implant placement, showed no significant difference at RR=2.27 [0.38, 13.53], P=.37; Heterogeneity: Tau² = 0.55; Chi² = 1.34, df = 1 (P = 0.25); I² = 26% and MD= 2.20 [1.61, 2.79], P=.00001; Heterogeneity: Tau² = 0.17; Chi² = 21.85, df = 1 (P < 0.00001); I² = 95%, respectively.. Implant stability between both groups of patients was statistically insignificant after 6 months of implant placement with MD= -0.48 [-2.23, 1.26], P=.59; Heterogeneity: Chi² = 0.13, df = 1 (P = 0.72); I² = 0% for the well controlled diabetic versus healthy patients and MD= -1.02 [-2.96,0.92],P=.3;
Heterogeneity: Chi² = 0.16, df = 1 (P = 0.69); I² = 0% for the moderately
controlled diabetic versus healthy patients.
2.8 Conclusions:
Implications for Practice:
Based on the results of implant loss 5 years following implant placement,
implant therapy in diabetic patients seems to be possible. However, results should be taken with extreme cautions, since the quality of evidence is very low and results of marginal bone loss, especially for poorly controlled diabetics, could suggest increased risk of implant failure for these patients. 26.2 Implications for Research 1. Properly designed RCTs with preplanned subgroups of the different diabetic levels and properly designed prospective cohort studies are highly recommended, while adhering to the relevant reporting guidelines for the writing the corresponding design. Follow-up periods not less than 5 years and proper sample
size calculation are mandatory. Adjusted analyses for confounding factors, like prosthetic design, type, material and opposing occlusion should be also considered. 2. Diabetes should be properly defined and classified according to well knownclassification systems as the ADA, while considering the duration of the condition.
3. The main outcomes should be set by the COMET (Core Outcome Measures of
Effectiveness Trial) initiatives, while considering a universally accepted measuring tool for each of them. This reduces the impact of a major source of variabilityamong the studies.