Inflammation is a complex biological process where there are elevated levels of free radicals and reactive oxygen species (ROS), which may cause structural damage to the cells. Inflammation and oxidative stress are associated with numerous range of chronic diseases, including atherosclerosis, diabetes mellitus, neurological disorders, pulmonary diseases, cancer, and rheumatoid arthritis. ¹ Carnitine is widely effective in preventing the accumulation of end products related to lipid peroxidation due to its anti-inflammatory and antioxidant effects. The major physiologic role of carnitine is transporting long-chain fatty acids through the mitochondrial membrane and contributing to the oxidative release of energy. ² It not only helps with long-chain fatty acids but also helps to remove the short- and medium-chain fatty acids from mitochondria. ³ Any differences in carnitine homeostasis will have an impact on the metabolism and function of lipids, red blood cells, and cardiac muscle cells. ⁴

L-carnitine (L-C) constant infusion improves insulin sensitivity in insulin-resistant diabetic patients; a significant effect on whole-body insulin-mediated glucose uptake is also observed in normal subjects. In diabetics, glucose, taken up by the tissues, appears to be promptly utilized as fuel since glucose oxidation is increased during L-C administration. ⁵ L-C, a shuttle for the acetyl groups through the mitochondrial membrane and a cofactor in the oxidation of fatty acids, has been shown to stimulate human osteoblast functions and intracellular calcium signaling. Increased mitochondrial performance, particularly from L-C, may have favorable effects on high-energy-demanding organs such as muscle and bone. It is noteworthy that L-C has a direct impact on human osteoblasts, causing them to proliferate and operate more actively, as well as express collagen Type I, bone sialoproteins (BSPs), and osteopontin (OPN).

L-C has recently demonstrated antioxidant action that prevents age-related mitochondrial dysfunction and maintains the equilibrium of ROS generation in several types of cells. ⁶ The development of myotubes and their hypertrophy were seen to speed the differentiation of C2C12 myoblasts, ⁷ counteract mitochondrial malfunction, and reduce oxidative stress. Glycemia depicts the level of sugar in the blood, which plays a vital role in the consequences of osseointegration, ⁸ as a correlation between glycemic control and the development of microvascular and macrovascular complications was observed specifically during implant placement. ⁹ Tight and intensive glycemic control in diabetic patients can delay the onset and the progression of many microvascular-related complications associated with the condition. ¹⁰

Our team has extensive knowledge and research experience that have translated into high-quality publications. ¹¹ , ¹² , ¹³ , ¹⁴ , ¹⁵ , ¹⁶ , ¹⁷ , ¹⁸ , ¹⁹ , ²⁰ , ²¹ , ²² , ²³ , ²⁴ , ²⁵ , ²⁶ The aim of the study was to estimate the L-C levels in diabetic completely edentulous patients, where the null hypothesis stated that there is no difference in the level of L-C patients completely edentulous patients when compared to healthy individuals.

Study design

This was a cross-sectional study.

Sample size calculation

In the prosthodontics department of a well-known university hospital, a clinical trial was conducted. The G*Power software (Version 3.1.9.4) Mac OS X and windows XP/ vista/7/8 was used to estimate the sample size, and the sample included 60 patients (30 diabetics and 30 nondiabetics). All of the chosen patients were told of the study and provided with voluntarily informed written permission.

Method of sampling

Patients with chief complaints of the replacement of completely edentulous teeth participated in the study. The study was on patients who were undergoing implant-supported complete denture treatment which included 30 diabetic and 30 nondiabetic participants with ages ranging between 40 and 65 years. A simple random sampling method was followed Figure 1. Figure 1

Flow chart of the study population selection including patient recruitment, exclusion criteria, and refusals. CD = Complete denture.

The L-C levels have higher levels in nondiabetic patients than in diabetic patients Table 1. The difference in the mean value between the groups was statistically significant (P = 0.00).{Table 1}

The goal of the current study was to measure the L-C levels of diabetic patients with no remaining teeth. The current investigation demonstrated that there was a statistically significant difference between the groups in the mean value at the baseline (P = 0.00). Although it is statistically significant (P = 0.00), the mean value for diabetic individuals is 0.19 when compared to 0.29 for nondiabetic patients. Studies done in the past found that diabetic patients had dental implant chances of success that were similar to those of healthy individuals. The fact that diabetics under control are virtually always included in research could be the cause. The development of microvascular complications and subsequent early or late implant failure is brought on by continuous hyperglycemia.

Osseointegration is the process by which an alloplastic substance is rigidly fixed in bone and retained therein under functional loads while exhibiting no clinical symptoms. Dental implants undergo osseointegration during the healing process, resulting in a functioning unit that may restore one or more lost teeth and support dental prostheses. The immune and nutritional state of the host should be considered in addition to important aspects that influence osseointegration, such as surgical technique, bone quality and quantity, postoperative inflammation or infection, smoking habits, and implant material and surface. ²⁷

L-C improves the mitochondria's overall functionality and guards against oxidative stress. In addition, L-C stimulates the CaMKII and ERK/AKT signaling pathways, favoring the activation of genes related to bone growth. ²⁸ Reduced energy supply for altered mitochondrial biogenesis and activity could be blamed, at least in part, for the age-related structural degradation of bone caused by dysregulation of bone remodeling. Studies have shown that L-C improves the mitochondria's overall performance, which suggests that L-C might help meet the high metabolic demand of osteoblasts during bone production. L-C, a coenzyme in fatty acid oxidation, has been shown to promote the actions of human osteoblasts. The expression of collagen Type I, BSPs, and OPN are also all greatly increased, as are osteoblast activity and proliferation. L-C can prevent oxidative damage and support maintaining bone quality. ²⁹

A flaw in the regulation of mitochondrial ROS concentration leads to an imbalance between superoxide radical production and destruction, which is greater than the capacity of osteoblasts to detoxify them, and suppresses the expression of osteogenic genes and matrix mineralization. The ability of L-C to boost mitochondrial superoxide dismutase-2 production and lower osteoblast ROS concentration indicates that L-C therapy improves the mitochondrial-mediated equilibrium between ROS production and catabolism. Through the ERK pathway, L-C increases the expression of the RUNX2 and OSX genes, supporting a role for L-C in promoting osteogenic cell activities. ³⁰

Based on all these findings as well as the results from the present study, carnitine supplementation can be an effective intervention for the improvement of oxidative stress and promotes osteogenic activity when associated with implant placement; however, these findings need to be confirmed by more research and have to be performed for clinical significance. The null hypothesis was removed as there were increased levels of L-C in diabetically edentulous patients.

The present study demonstrated that L-C potentiates the anti-osteoporotic effect by suppressing the overexpressed inflammatory cytokines and ameliorates bone osteoporotic histopathological changes. L-C can be considered a new therapeutic regimen to maintain bone health and limit the worsening of osteoporotic bony changes in diabetic completely edentulous patients associated with implant placements.

Acknowledgment

This study was supported by saveetha dental college and hospital. Lab support was from Dr. Selvaraj J and his team, saveetha institute of medical and technical sciences.

Financial support and sponsorship

Nil.

Conflicts of interest

The authors of this manuscript declare that they have no conflicts of interest, real or perceived, financial or non-financial in this article.