Take consideration of vitamin D deficiency as a contributing factor that could impact your patient’s dental health and healing after surgery.
Dental implants are considered a highly predictable and successful therapy for restoring function and aesthetics. Yet, to this day, an unacceptable number of implants are lost every year in the hands of skilled surgeons for unexplained reasons. This loss occurs despite research focusing on the perfection of implant surfaces, fixture design, as well as surgical and prosthetic protocols.
Emerging studies are pointing to a likely connection between vitamin D deficiency and dental implant osseointegration failure. One should not be surprised by that statement as it has been extensively demonstrated in medicine that vitamin D repletion mediate bone growth and bone remodeling by osteoblasts and osteoclasts [1, 2, 3]. Recognition of systemic risk factors such as vitamin D insufficiency may reduce the early dental implant failure rate and increase the predictability of dental implant treatment.
Epidemiological studies [1] have shown that roughly 42% of the United States population is vitamin D deficient with some populations having even higher levels of deficiency, including premenopausal women, those with poor nutrition habits, people over age 65, Caucasians who avoid even minimal sun exposure, as well as those who take long-term prescription medication for heartburn, acid reflux, and constipation. Studies show people with darker skin, such as African Americans and Latinos, are also at risk for lower vitamin D levels because high amounts of melanin in skin reduce the body’s ability to produce vitamin D from sunlight. In addition, certain chronic conditions, such as celiac disease, bariatric surgery, obesity, and chronic kidney or liver disease, can contribute to deficiency. Few realize, however, its drastic and substantial role in various other diseases, including depression, dementia, Alzheimer’s disease, asthma, osteoporosis, cancer, cardiovascular disease, and diabetes.
Importantly, vitamin D is also linked with the immune system, whereby introduced biomaterials into the body (especially an endosseous, transmucosal such as dental implants) may be compromised when vitamin D deficiency is observed [5].
In 2019, Mangano et al published a retrospective study in which nearly 2000 implants were investigated in nearly 1000 patients [4]. To date, this study represents the largest on the topic. Implant failure rates were gathered, then correlated with known complications of dental implant failure such as smoking and generalized periodontitis. In that study, it was reported that heavy smoking (defined as 15 cigarettes per day) was found to be associated with approximately a 50% increase in early implant failure. Similarly, generalized periodontitis was also associated with an approximate 50% increase in dental implant failure. Interestingly, severe vitamin D deficiency (defined as serum levels <10ng/mL) was associated with nearly a 300% increase in overall implant failure rates when compared to controls [4]. The conclusions from this study demonstrate the need for adequate testing, prevention and supplementation prior to dental implant placement and maintenance [4]. Optimizing levels prior to surgery therefore becomes fundamental for maximizing wound healing and minimizing dental implant-related failures and bone grafting complications.
Serum 25-hydroxyvitamin D (25(OH)D) is a reliable marker of vitamin D status and a level below 20 ng/ml defines deficiency [5]. Optimal levels above 30 ng/ml is required to maximize bone health and non-skeletal benefits of vitamin D (Table 1) [5]. For individuals undergoing any type of dental related procedures, levels between 40-60 ng/ml are generally recommended (Table 1) [5].
Testing Vitamin D Levels
Standard tests are routinely performed to measure vitamin D levels in whole blood serum. Although one could plan accordingly to obtain blood work prior to dental surgery, let’s face it, it is inconvenient to the patient seeking routine dental work — especially for those in need of urgent surgical care. Companies such as NanoSpeed (https://nanospeed.ca/) have developed a novel vitamin D test kit that is based on a simple finger prick test. Within 10 minutes, vitamin D levels can be reported in office. The easy-to-use test is cost effective as compared to competing technologies that require venous blood [5]. In addition, with an adequate understanding of the patient’s demographics and medical history (including all supplements taken), it is still reasonable to recommend that your patient take vitamin D pre- and post-surgically if his/her vitamin D serum levels are unknown.
Conclusion
This update is not intended to be a deep dive into vitamin D metabolism or synthesis pathways leading to successful bone-dental implant contact (osseointegration), nor is it meant to imply that vitamin D testing and supplementation are now the standard of care. Instead, it is intended to encourage a consideration of vitamin D deficiency as a contributing factor that could impact your patient’s dental health and healing after surgery.
Multiple large studies are presently being conducted to correlate low serum levels of vitamin D to early dental implant failures. Given the potentially catastrophic (and often unrepairable) aesthetic and functional consequences of a failed dental implant, it is only prudent that you evaluate your patient’s risk for vitamin D deficiency when placing dental implants and bone grafts in the meantime.
Resources
- Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: National Academy Press, 2010.
- Norman AW, Henry HH. Vitamin D. In: Erdman JW, Macdonald IA, Zeisel SH, eds. Present Knowledge in Nutrition, 10th ed. Washington DC: Wiley-Blackwell, 2012.
- Jones G. Vitamin D. In: Ross AC, Caballero B, Cousins RJ, Tucker KL, Ziegler TR, eds. Modern Nutrition in Health and Disease, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2014.
- Guido Mangano F, Ghertasi Oskouei S, Paz A, Mangano N, Mangano C. Low serum vitamin D and early dental implant failure: Is there a connection? A retrospective clinical study on 1740 implants placed in 885 patients. Journal of dental research, dental clinics, dental prospects 2018;12:174-82.
- Miron RJ, Pikos MA, Bishara M. Vitamin D deficiency and early implant failure: what every clinician should know. Dent Today. 2020;39(4):72-79.