Diagnosis and treatment planning in implants 1/ dental implant courses by Indian dental academy

Diagnosis and treatment planning in implants. – part 1 INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com

ď ŹHISTORY ď ŹCLINCAL

EXAMINATION

Diagnostic imaging

Mounted study casts.

Joint assessment Surgeon/restortive dentist.

Psychological assessment

Treatment plan Informed consent www.indiandentalacademy.com

Medical assessment 2

History.

It is designed to provide an accurate profile of how the patient’s quality of life is being affected by tooth loss.

It consists of 3 elements Dental  Social/personal  medical 

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Dental It should include identification of all current problme’s from the patients perspective.

Functional       

Unstable or loose denture Inability to masticate efficiently Pain TMJ disorders Difficulties with speech Gagging Ulceration and soreness of mucosa www.indiandentalacademy.com

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Psychological and social.     

Loss of self esteem and confidence Feelings of guilt and insecurity Poor interpersonal relationships Social avoidance Lack of motivation.

Aesthetic  

Loss of labial fullness Decreased vertical dimension.

Unrealistic  

Aging process Paranoid delusions.

Not associated 

Burning tongue due to candida infection www.indiandentalacademy.com

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Social /personal The impact and relevance of the dental condition to the patient’s lifestyle should be explored.

Wind instrument musicians  Singers  Actores may have particular problems 

Absolute need for a fixed appliance. www.indiandentalacademy.com

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Medical A full and comprehensive review of a patients medical history should be undertaken.

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ď ŹHISTORY ď ŹCLINCAL

EXAMINATION

Diagnostic imaging

Mounted study casts.

Joint assessment Surgeon/restortive dentist.

Psychological assessment

Treatment plan Informed consent www.indiandentalacademy.com

Medical assessment 8

Medical assessment It comprises of Vital signs  Laboratory evaluation  Systemic diseases 

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Vital signs Blood pressure Pulse Temperature Respiration.

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Blood pressure.

The blood pressure is measured in the arterial system.  

The maximum pressure is called systolic The minimum pressure is diastolic.

Normal  

systolic Diastolic.

Blood pressure is influenced by     

Cardiac output.

Blood volume.

Viscosity of the blood.

Condition of blood vessels.(especially arterioles) Heart rate. www.indiandentalacademy.com

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Blood Bloodpressure pressure

There are two methods of determining blood pressure.

Direct ď Ź Indirect. ď Ź

Dentist uses the indirect method.

Technique was first developed by Italian physician Riva-Rocca Sphygmomanometer consists of inflatable bag covered by a cuff and monometer to register the force and rate of air within the bag. www.indiandentalacademy.com

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Blood Bloodpressure pressure

Two most common monometer systems Mercury gravity ď Ź Aneroid gauges. ď Ź

Mercury system is more accurate with changing climates.

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Blood pressure

Technique.

Patient is seated comfortably.

Inflatable bag is positioned over the bare upper arm at the level of the patients heart,with the patients palm supine.

The brachial or radial artery is palpated and the bag is inflated to obliterate the vessel,about 30mm Hg above the estimated systolic pressure.

The cuff is deflated 2 to 4 mm Hg at every heartbeat.

Using a stethoscope over the brachial artery, the systolic pressure is recorded at the first tapping sound heard.

When the sounds become muffled or inaudible the diastolic pressure is noted. www.indiandentalacademy.com

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Relevance to implant patient.

Helps in diagnosing hypertensive patients.

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Pulse.

Pulse represents the force of the blood against the aortic walls for each contraction of the left ventricle.

Location to record pulse   

Radial artery in wrist.

Carotid artery in neck.

Temporal artery in temporal region.

It has 3 components   

Rate.

Rhythm.

Strength. www.indiandentalacademy.com

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Pulse rate.

Beats/min >110

medical consultation needed - Tachycardia

100

Upper limit of normal

60-90 beats /min

Normal in a relaxed nonanxious patient.

< 60

Medical consultation needed. Bradycardia

40 to 60

Normal for People in excellent physical condition www.indiandentalacademy.com

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Pulse Pulserate rate

Bradycardia.

Decreased pulse rate of normal rhythm (less than 60 beats /min) Most patients become unconscious below 40 beats/minute (in few its normal) During implant surgery inappropriate Bradycardia may indicate impending sudden death. www.indiandentalacademy.com

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Pulse Pulserate rate

If Pulse rate below 60 accompanied with Sweating  Weakness  Chest pain  Dyspnea 

Implant procedure should be stopped , oxygen administered and immediate medical assistance obtained.

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Pulse Pulserate rate

Tachycardia.

Increase pulse rate of regular rhythm (more than 100 beats per minute) Symptoms • •

Blurred vision Increased bleeding during surgery.

Seen in underlying medical conditions    

Hyperthyroidism Acute or Chronic heart disease Anaemia Severe hemorrhage- as heart rate increases to compensate for oxygen depletion in tissues www.indiandentalacademy.com

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Pulse Pulserate rate

These conditions favors postoperative swelling and occurrence of infections during the first critical weeks after implant placement. This in turn compromises the subsequent years of implant service to the patient.

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Pulse rhythm In history of cardiovascular disease and hypertension, pulse rhythm should be always recorded.

2 types of abnormal pulse rhythm.

Regular ď Ź Irregular. ď Ź

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Pulse Pulserhythm rhythm

Regular irregularity.

Which Increases during exercise indicates Atrial fibrillation • Hyperthyroidism.

• Mitral stenosis.

• Hypertensive heart disease.

Stress reduction protocols.

Implant may be contraindicated.

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Pulse Pulserhythm rhythm

Irregular irregularity.

Premature ventricular contractions(PVC) 



Noticed as a distinct pause in an otherwise normal rhythm.

Associated with    



Fatigue Stress Excessive use of tobacco or coffee Myocardial infarction

Precursor to cardiac arrest.

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Pulse Pulserhythm rhythm

If more than 5 PVC’s are recorded within 1 minute + dyspnea or pain, the surgery should be stopped,  oxygen administered  Patient placed in supine position.  Immediate medical assistance obtained. 

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Pulse strength.

Sometimes pulse rate and rhythm can be normal, yet the blood volume can affect the character of the pulse.

Pulsus alternans 

  

Pulse may alternate between strong and weak beats.

It indicates severe myocardial damage.

Patients life span rarely extends beyond 1-2 years.

Implant surgery is contraindicated. www.indiandentalacademy.com

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Temperature.

Thermometer was invented by Galileo.

First used clinically by Santorio of Padua in 17 th century.

Every degree of fever increases the pulse rate by 5 and respiratory rate by 4 per minute.

Temperature

Condition

Oral temperature of febrile range (feverish).

99.50 or higher 96.8 0 to 99.40 F.

Normal. Lowest in morning, highest in late afternoon or evening. www.indiandentalacademy.com

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Temperature Temperature

Causes of increased body temperature.

Bacterial infection and its toxic products.

Exercise Hyperthyroidism Myocardial infarction Congestive heart failure.

Tissue injury from trauma or surgery.

Dental conditions   

Dental abscess Cellulitis Acute herpetic stomatitis. www.indiandentalacademy.com

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Temperature Temperature

Elevated temperature

Infection Postoperative discomfort.

may complicate the healing

Edema

increases the patient's pulse rate

Hemorrhage

No elective surgery,including implants should be performed in febrile patients. www.indiandentalacademy.com

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Temperature.

Temperature.

Low body temperature Hypothyroidism.

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Respiration.

Should be noted while patients is at rest.

Breaths per minute

Condition

>20

requires investigation

16-20

normal regular in rate and rhythm. www.indiandentalacademy.com

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Respiration Respiration

Dyspnea It should be suspected when patients Use accessory muscles in the neck or shoulders for inspiration, whether before or during surgery.

Causes:    

drugs –narcotics Congestive heart failure Bronchial asthma.

Advances pulmonary emphysema.

Evaluate the pulse to rule out the presence of PVC or Myocardial infarction. www.indiandentalacademy.com

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Respiration Respiration

Hyperventilation   

due to increase in both rate and depth of respiration. in anxious patients seen after deep sighs.

Sedatives or Stress –reduction protocols is indicated.

Underlying medical conditions.   

Severe Anaemia.

Advanced branchopulmonary disease.

Congestive heart failure.

They can affect surgical procedure and/or healing response of the implant candidate.

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Laboratory Evaluation Bleeding tests.

Urinalysis.

1.

Complete blood cell count

3.

1.

2.

3.

4.

5.

6.

7.

2.

RBC count WBC count WBC differential.

Cellular morphology and maturity.

Hemoglobin determination.

Hematocrit.

Platelet count.

Check the medical history Review the physical examination.

Screen the clinical laboratory tests.

1.

2.

3.

4. 

Platelet count.

Bleeding time Partial thromboplatin time.(PTT) Prothrombin time(PT) Additional tests  Fibrinogen level.  Thrombin clotting time (TCT)

Biochemical profiles.

Serum glucose Serum calcium Inorganic phosphorous.

Alkaline phosphatase.

Lactic dehydrogenase.

Creatinine.

Bilirubin www.indiandentalacademy.com

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Routine laboratory screening of patients in a general dental setting who previously reported a normal health history have found that 12% to 18% have undiagnosed systemic diseases.

Justification of the laboratory procedure should relate to the specific type of surgery and the patients condition. www.indiandentalacademy.com

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Urinalysis.

Not indicated as a routine procedure, and is used rarely in implant dentistry.

Has more Qualitative than Quantitative information.

It is primarily a screening test for 

Diabetes-



Deficiencies or irregularities in Metabolism Renal disease Liver function Suspected infection.

  

Examination of blood is a more reliable test for patients glucose metabolism.

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Complete blood cell count.

Completer blood count (CBC) consists of several individual measurements on a single sample of venous blood.

1.

2.

3.

4.

5.

6.

7.

RBC count WBC count WBC differential.

Cellular morphology and maturity.

Hemoglobin determination.

Hematocrit.

Platelet count. www.indiandentalacademy.com

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Complete Completeblood blood cell cellcount. count.

Indications for CBC. 1.

2.

3.

4.

5.

6.

Suspected dyscrasia (WBC and RBC ) Glucocorticoid therapy within 1 year.

Chemotherapy.

Renal diseases.

Expected major blood loss during surgery.

Bleeding disorders. www.indiandentalacademy.com

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Complete Completeblood blood cell cellcount. count.

1. RBC count.

RBCâ&#x20AC;&#x2122;s are responsible for the transport of oxygen and carbon dioxide throughout the body and for control of the blood pH. No of RBCâ&#x20AC;&#x2122;s per ml

Clinical condition

Men - 4.5-6.5 million.

Woman - 3.8-5.8 million.

Normal

Increase

Polycythemia Congenital heart disease Cushing syndrome.

Decreased

anemia. www.indiandentalacademy.com

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Complete Completeblood blood cell cellcount. count.

2. White blood cell count.(WBC) Can indicate • • • •

infections Leukemic disease Immune diseases.

Chemotherapy.

Inflammatory process may be present without leukocytosis.

WBC count 5000 to 10,000/ml

Normal

increase in WBC .

Leukocytosis

decrease in WBC.

Leukopenia www.indiandentalacademy.com

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Complete Completeblood blood cell cellcount. count.

3. WBC differential.

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Complete Completeblood blood cell cellcount. count.

Neutrophils An increase indicates inflammation.

Helps in finding if infection around an implant is affecting the patients overall health.

Absolute neutrophil management count (ANC) 2000.

normal dental treatment without antibiotic prophylaxis

1000-2000 Less than 1000

need antibiotic coverage. physician referral. www.indiandentalacademy.com

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Complete Completeblood blood cell cellcount. count.

Lymphocytes.

Necessary to evaluate the immune response potential of the patient.

Many immunodeficiency patients ,including HIV positive, may have no systemic symptoms, yet have deficient lymphocytes.

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Complete Completeblood blood cell cellcount. count.

4. Cellular morphology and maturity.

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Complete Completeblood blood cell cellcount. count.

5. Hemoglobin.

It is responsible for the oxygen carrying capacity of the blood.

Threshold is related to the underlying condition of the patient and the anticipated blood loss.. men 13.5-18 g/dl Normal Woman 12-16 g/dl.

10 g/dl : pre-operative threshold

minimum baseline for surgery

8 g/dl.

Many patients can undergo surgical procedure safely www.indiandentalacademy.com

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Complete Completeblood blood cell cellcount. count.

6. Hematocrit.(PCV) Indicates the percentage of red blood cells in a given volume of whole blood.

Prime indicator for Anaemia and blood loss.

0.40-0.54 : men 0.35-0.47 : woman

normal

Values within 75 to 80 % required before sedation of normal are or general anesthesia.

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Complete Completeblood blood cell cellcount. count.

7. Platelet count. per /ml 2,00,000-3,00,000

Normal

below 80,000

A clinical symptoms occur

20,000

Spontaneous bleeding www.indiandentalacademy.com

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Urinalysis.

Urinalysis.

CBC CBC

Bleeding Bleedingtests. tests.

Biochemical Biochemicalprofiles profiles

Bleeding tests.

Bleeding disorders are one of the most critical conditions encountered in surgery.

Ways to detect potential bleeding problems are 1.

2.

3.

Check the medical history Review the physical examination.

Screen the clinical laboratory tests.

Over 90% of bleeding disorders can be diagnosed on the basis of medical history alone. www.indiandentalacademy.com

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Bleeding Bleedingtests tests

1. Medical history History should include questions covering 5 topics.

Bleeding problems in relatives.

Indicate – inherited coagulation disorders.

– Hemophilia – Christmas factor disease.

1.

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Bleeding Bleedingtests tests

2.

3.

4.

Spontaneous bleeding from the nose, mouth, or other apertures.

Bleeding problems after operations, tooth extractions, or trauma.

Use of medications that may cause bleeding disorders.

– – –

Anticoagulants Aspirin Long term antibiotics.

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Bleeding Bleedingtests tests

5.

Past or present illness associated with bleeding disorders.      

Leukemia Anemia Thrombocytopenia Hemophilia Hepatic disease.

Approximately half of the patients with liver disease have a decrease in platelet count.

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Bleeding Bleedingtests tests

2. Physical examination.

Exposed skin and oral mucosa must be examined for objective signs.

Liver disease

Petechiae Ecchymoses. Spider

angioma Jaundice

Genetic bleeding disorders.

Intraoral

Acute or chronic leukemia.

Oral

petechia bleeding gingiva ecchymoses Hemarthroses hematomas mucosa ulceration. Hyperplasia of gingiva. Petechiae or ecchymoses of skin or oral mucosa Lymphadenopathy. www.indiandentalacademy.com

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Bleeding Bleedingtests tests

Clinical laboratory testing.

If health history and physical examination do not reveal bleeding disorder routine screening with a coagulation profile is not indicated.

If extensive surgical procedures are expected a coagulation profile is indicated.

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Bleeding Bleedingtests tests

Tests used to screen patients for bleeding disorders.

Platelet count.

Bleeding time Partial thromboplatin time.(PTT) Prothrombin time(PT)

I. II. III. IV.

Additional tests

  

Fibrinogen level.

Thrombin clotting time (TCT) www.indiandentalacademy.com

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Bleeding Bleedingtests tests

Bleeding time.

Ivy bleeding time 

Measures Coagulation pathways.  Platelet function.  Capillary activity. 



Normal 2-8 minutes.

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Bleeding Bleedingtests tests

Partial thromboplastin time.

(PTT) Used to determine the ability of blood to coagulate within the blood vessels.

It tests the intrinsic and common pathways of coagulation.

Normal 30-40 secs

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Bleeding Bleedingtests tests

Normal PT Abnormal PTT

Hemophilia

Abnormal PT Normal PTT

Factor VII deficiency

Abnormal PT Abnormal PTT

Deficiency of factors II,V,X or fibrinogen.

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Bleeding Bleedingtests tests

Prothrombin time (PT).

Determines the ability of the blood to coagulate outside the vessels.

It tests the extrinsic and common pathways of coagulation.

Normal 10.5 -14.5 sec.

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Bleeding Bleedingtests tests

Patients on Aspirin: Tests to be obtained. ď Ź ď Ź

bleeding time PTT.

One 5 gm tablet can affect platelet agglutination for 3 days.

4 or more tablets taken a day for a period of more than a week will affect both bleeding time and PTT. & www.indiandentalacademy.com

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Bleeding Bleedingtests tests

bleeding complications associated with aspirin are one of the most common complications in implant surgery.

Is rarely life threatening,but constant oozing of blood concerns the patient and can result in considerable blood loss.

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Bleeding Bleedingtests tests

&Patients on anticoagulant medication.

Mainly coumarin derivatives(coumadin).

Usually due to recent myocardial infarction, cerebrovascular accident, or thrombophlebitis.

PT should be checked Normal range is 12-14 seconds.

Recently the international normalized ratio(INR) is used to asses bleeding and anticoagulation potentials.

2.0 INR are acceptable for routine treatment. www.indiandentalacademy.com

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Bleeding Bleedingtests tests

There are several studies now that support the continuation of anticoagulant therapy during surgery.

Others studies support the reduction of anticoagulant to bring PT to a normal value.

ADA guidelines states that patients on anticoagulant therapy can even undergo surgical procedures.

Still majority of physician surveyed recommend anticoagulant alteration for a single surgical extraction. www.indiandentalacademy.com

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Bleeding Bleedingtests tests

In light of such controversial opinions.it is advisable to consult with the physicians administering the medication regarding the need and amount of reduction and sequencing.

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Bleeding Bleedingtests tests

Patients on Heparin therapy.

• • • •

•

it is an anticoagulant prescribed for renal dialysis patients.

It is a short acting anticoagulant.

Implants are usually contraindicated.

These patients often experience healing and maintenance complications with their natural teeth.

A dentist may have to treat a dialysis patient who has previously had implant therapy. www.indiandentalacademy.com

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Bleeding Bleedingtests tests

Patients on long term antibiotics.

Long term antibiotic therapy can affect the intestinal bacteria that produce the vitamin K necessary for prothrombin production in the liver.

PT should be obtained to evaluate possible bleeding complications.

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Bleeding Bleedingtests tests

Alcoholics liver dysfuction patients.

The liver is the primary site of synthesis of the vitamin K dependent clotting factors 2 ,7 9 and 10 Alcoholism,independent of liver disease too has been shown to decrease platelet production and increases platelet destruction.

The bleeding time and PT should be evaluated in these patients. www.indiandentalacademy.com

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Biochemical profiles(Serum chemistry).

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Interpretation of biochemical profiles and the ability to communicate effectively with medical consultants will enhance the treatment of many patients.

This discussion is limited to the factors of most benefit to the implant dentist.

The patient should fast before the blood is collected to avoid artificial elevations of blood glucose and depressed inorganic phosphorus. www.indiandentalacademy.com

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Serum Serumglucose glucose Serum calcium Serum calcium Inorganic phosphorous.

Inorganic phosphorous.

Alkaline phosphatase.

Alkaline phosphatase.

LDH LDH Creatinine.

Creatinine.

Bilirubin Bilirubin

Serum glucose.

Normal range. 70-110 mg/ 100ml.

3.6-5.8 mmol/l

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Serum Serumglucose glucose Serum calcium Serum calcium Inorganic phosphorous.

Inorganic phosphorous.

Alkaline phosphatase.

Alkaline phosphatase.

LDH LDH Creatinine.

Creatinine.

Bilirubin Bilirubin

Hyperglycemia.

Is a relatively common finding.

Cause diabetes mellitus.  Cushing’s disease. 

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Serum Serumglucose glucose Serum calcium Serum calcium Inorganic phosphorous.

Inorganic phosphorous.

Alkaline phosphatase.

Alkaline phosphatase.

LDH LDH Creatinine.

Creatinine.

Bilirubin Bilirubin

Hypoglycemia.

It is unusual and can be due to varied causes.

Addison’s disease.  Bacterial sepsis.  Excessive insulin administration. 

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Serum glucose Serum glucose

Serum Serumcalcium calcium Inorganic phosphorous.

Inorganic phosphorous.

Alkaline phosphatase.

Alkaline phosphatase.

LDH LDH Creatinine.

Creatinine.

Bilirubin Bilirubin

Serum calcium.

Normal- 2.12 - 2.62 mmol/L Implant dentist may be the first to detect disease affecting the bones.

Confirmation of disease is dependent on levels of calcium,phosphorous and alkaline phosphatase.

Medical evaluation and treatment are indicated before implant surgery. www.indiandentalacademy.com

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Serum glucose Serum glucose

Serum Serumcalcium calcium Inorganic Inorganic phosphorous. phosphorous.

Alkaline Alkaline phosphatase. phosphatase.

LDH LDH Creatinine.

Creatinine.

Bilirubin Bilirubin

Increased calcium.

Reasons     

Bone resorption.- as in Carcinoma of bones Intestinal absorption.- Dietary and absorptive disturbances.

Renal reabsorption.

Hyperparathyroidism Paget’s disease. Also Increased alkaline phosphatase.

All other biochemical values being normal an elevated calcium value may be the result of laboratory error. www.indiandentalacademy.com

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Serum glucose Serum glucose

Serum Serumcalcium calcium Inorganic phosphorous.

Inorganic phosphorous.

Alkaline phosphatase.

Alkaline phosphatase.

LDH LDH Creatinine.

Creatinine.

Bilirubin Bilirubin

Decreased calcium.

Seen in Hypoproteinemic conditions ď Ź Renal disease. ď Ź

Diet of potential implant patient may be severely affected by the lack of denture comfort and stability.

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Serum glucose Serum glucose Serum calcium Serum calcium

Inorganic Inorganic phosphorous phosphorous. .

Alkaline phosphatase.

Alkaline phosphatase.

LDH LDH Creatinine.

Creatinine.

Bilirubin Bilirubin

Inorganic phosphorus.

It maintains a ratio of 4 to 10 compared with calcium ,and there is usually a reciprocal relationship.

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Serum glucose Serum glucose Serum calcium Serum calcium

Inorganic Inorganic phosphorous. phosphorous.

Alkaline phosphatase.

Alkaline phosphatase.

LDH LDH Creatinine.

Creatinine.

Bilirubin Bilirubin

1.

2.

3.

4.

5.

Elevated phosphorous.

Chronic glomerular disease (common ).

Hypoparathyroidism. Decrease calcium and normal renal function.

Hyperthyroidism Increases growth hormone.

Cushingâ&#x20AC;&#x2122;s syndrome. www.indiandentalacademy.com

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Serum glucose Serum glucose Serum calcium Serum calcium

Inorganic Inorganic phosphorous. phosphorous.

Alkaline phosphatase.

Alkaline phosphatase.

LDH LDH Creatinine.

Creatinine.

Bilirubin Bilirubin

Decreased phosphorus.

Hyperparathyroidism. With associated hypercalcemia.

In chronic userâ&#x20AC;&#x2122;s of aluminium hydroxide antacids.

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Serum glucose Serum glucose Serum calcium Serum calcium Inorganic phosphorous.

Inorganic phosphorous.

Alkaline Alkaline phosphatase. phosphatase.

LDH LDH Creatinine.

Creatinine.

Bilirubin Bilirubin

Alkaline phosphatase.

Its level helps in determining hepatobiliary and bone diseases.

Normal : 40-125 U/L

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Serum glucose Serum glucose Serum calcium Serum calcium Inorganic phosphorous.

Inorganic phosphorous.

Alkaline Alkalinephosphatase. phosphatase.

LDH LDH Creatinine.

Creatinine.

Bilirubin Bilirubin

High levels

Extreme- indicate hepatic disease In absence of hepatic disease –indicate osteoblastic activity in the skeletal system.    

Bone metastases Fractures.

Paget’s disease.

Hyperparathyroidism.

Normal in patients with adult osteoporosis.

Low levels – of no clinical significance to dentist. www.indiandentalacademy.com

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Serum glucose Serum glucose Serum calcium Serum calcium Inorganic phosphorous.

Inorganic phosphorous.

Alkaline phosphatase.

Alkaline phosphatase.

LDH LDH Creatinine.

Creatinine.

Bilirubin Bilirubin

Lactic dehydrogenase.

It is an intracellular enzyme present in all tissues.

Normal : 0 to 625 U/L. False elevated LDH levels occur as result of hemolyzed blood specimens .

Elevations are seen in   

Myocardial infarction.

Hemolytic disorders such as pernicious Anaemia.

Liver disorders. www.indiandentalacademy.com

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Serum glucose Serum glucose Serum calcium Serum calcium Inorganic phosphorous.

Inorganic phosphorous.

Alkaline phosphatase.

Alkaline phosphatase.

LDH LDH Creatinine Creatinine. .

Bilirubin Bilirubin

Creatinine

Normal: 0.7 - 1.5mg/dl Creatinine is freely filterable by glomeruli and not reabsorbed.

The constancy of formation and excretion permits creatinine levels to be an index of renal function.

Kidney dysfunction may lead to osteoporosis and decreases bone healing because the kidney is required for complete formation of vitamins D. www.indiandentalacademy.com

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Serum glucose Serum glucose Serum calcium Serum calcium Inorganic phosphorous.

Inorganic phosphorous.

Alkaline phosphatase.

Alkaline phosphatase.

LDH LDH Creatinine.

Creatinine.

Bilirubin Bilirubin

Bilirubin.

Total Bilirubin: 2-17 Âľmol/L For evaluation of liver disease,bilirubin measurement is of primary importance.

Liver function should be adequate for proper healing,drug pharmacokinetics,and long term health.

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Systemic disease and oral implants.

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Classification of Pre surgical Risk.

Formulated by American society of anesthesiology.

Class I

Patients who are physiologically normal Has no medical diseases Lives a normal daily lifestyle.

Class II

Patients who have some type of medical disease but the disorder is controlled with various medications.the patient can thus engage in normal daily activity. E.g. Controlled hypertension.

Class III Patient who has multiple medical problems,such as advanced â&#x20AC;&#x201C;stage hypertensive cardiovascular disease or insulin dependent diabetes with impaired normal activity www.indiandentalacademy.com

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Class IV

Serious medical condition requiring immediate attention. E.g acute Gallbladder disease.

Class V Patient is usually Moribund and will not survive the next 24 Hours.

Most patients who seek implant reconstruction fall in class 1 or II categories.

Same patients fall in Class III and preparatory measures have to be taken before treatment. www.indiandentalacademy.com

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Cardiovsascular diseases.

Hypertension.

Angina pectoris.

Myocardial infarction.

Congestive heart failure.

Sub acute bacterial endocarditis.

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Hypertension.

A patient is classified as hypertensive When the mean value after 3 or more blood pressure readings taken at three or more medical visits reveals a resting arterial systolic blood pressure at or above 140mm Hg and /or mean diastolic blood pressure at or above 90mm Hg.

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Hypertension Hypertension

90% of hypertensive patients have essential or idiopathic hypertension.

Essential hypertensive patients are susceptible to   

Coronary disease 3 times more cardiac failure 4 times more Strokes 7 times more

Than normaotensive paitents.

Predisposing factors.       

Excessive alcohol intake.

History of renal disease.

Stroke.

Cardiovascular disease.

Diabetes Obesity smoking www.indiandentalacademy.com

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Hypertension Hypertension

Essential hypertension is treated with medications many of which have an impact on implant therapy because of their side effects. common Side effects of hypertensive drugs  

Xerostomia Orthostatic hypotension. When the patient is suddenly brought from supine position to upright position , patient may feel lightheaded or even faint.

   

Dehydration Sedation Depression.

Gingival hyperplasia. www.indiandentalacademy.com

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Hypertension Hypertension

Rapid increase in blood pressure during an injection or surgery in severe hypertensive can lead to Angina pectoris.  congestive heart failure.  Cerebrovascular episode. 

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90

Hypertension Hypertension

Mild hypertension Single diuretics drugs are used. ď Ź Fewest complications that can modify implant treatment. ď Ź

Combination drugs indicate a more severe hypertension.

Patients taking additional drugs like clonidine exhibit severe hypertension and need medical consultation. www.indiandentalacademy.com

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Hypertension Hypertension

Implant management.

Stress reducing protocol As anxiety greatly affects blood pressure.

Flurazepam 30mg or diazepam 5 to 10mg in the evening to help the patient sleep quietly night before the operation.

An early appointment.as medication may still be effective in elderly. www.indiandentalacademy.com

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Type 3 Type Risk Systolic Diastolic Type Type 2 1.

Type2 3 Type4 Type extractions mm hg mm hg Multiple 1 Scaling and root GingivectomyExamination. planning.

High 13085-89 + + Sedatio sedatio Typeperoseal 4 Radiographs.

Quadrant normal 139 n n reflections Endodontics implants Study model Hyperte 14090-99 Impacted + Full arch Sedatio Sedatio Sedatio Simple impressions. nsion 159 n n n extractions Orthognathic surgery extractions Stage 1 Apicoectomy Oral hygiene Autogenous bone Curettage instructions.

Plate augmentation form implants Stage 2 160100-109 + Sedatio Simple Postpone all RidgeBilateral sinus Gingivectomy. graft.

179 n Supragingival elective augmentation.prophylaxis. procedures.

Unilateral sinus Advanced Simple restorative Stage 3 180110-119 graft.

Refer andpostmpone all elective restorative dentistry.

209 procedure. procedures.

Unilateral subperiosteal Stage 4 >210 >120 Refer and postpone all elective Simple implants. implants. procedures. www.indiandentalacademy.com 93

Angina Anginapectoris pectoris

Angina pectoris.

Angina pectoris or chest pain or cramp of the cardiac muscle, is a form of coronary heart disease.

It is a symptomatic expression of temporary myocardial ischemia.

Classical symptoms;   

Retrosteranl pain with stress or physical exertion.

Radiates to the shoulder, left arm or mandible, Or right arm neck palate and tongue.

Symptoms are relived by rest. www.indiandentalacademy.com

94

Angina Anginapectoris pectoris

Risk factors for Angina     

Smoking Hypertension High cholesterol Obesity Diabetes.

Angina is classified as   

Mild. moderate.

Severe. www.indiandentalacademy.com

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Angina Anginapectoris pectoris

Precipitating factors.

Exertion.

Cold.

Heat.

Large meals.

Humidity.

Psychological stress.

Dental related stress. www.indiandentalacademy.com

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Risk Mild

Type 1 Type 2

Type3

Type 4

One or + + Sedation Moderate less supplemental oxygen /month Type 2 and 3: vasoconstrictor is contraindicated.

with supplemental oxygen Moderat Antianxiety One orMildsedation + Sedation Premedicat e less/wee premedicate e Type 4 may require a hospital setting.

Type 3 and 4nitrates k Sedation Appointmentssupplemental should be as short as Outpatient possible. oxygen hospitilizati Concentrations of vasoconstrictor greater than on 1/100000 avoided Severe Daily/mo + Physicia Elective procedures re n contraindicated.

Unstable www.indiandentalacademy.com

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Angina Anginapectoris pectoris

Dental emergency kit should include nitroglycerin tablets (0.3 to 0.4 mg) or translingual spray,which are replaced every 6 months.

During angina attack all dental treatment should e stopped immediately.

Nitroglycerin is administered sublingually 100% oxygen given at 6L/min with the patient in a semi supine or 45 degree position.

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Angina Anginapectoris pectoris

Vital signs should be monitored as Transient hypotension can occur after nitroglycerin administration.

If systolic BP falls below 100mm Hg patients feet should be elevated.

Pain if not relived in 8 to 10 minutes with the use of nitroglycerin at 5 minute intervals, the patient should be transported by ambulance to a hospital. www.indiandentalacademy.com

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Angina Anginapectoris* pectoris*

Side effects of nitroglycerin Decrease in blood pressure â&#x20AC;&#x201C;can cause fainting. Patient should be sitting or lying down during administration.

As heart attempts to compensate decreased BP-pulse rate may increase as much as 160 beats /min.

Blushing of face and shoulders.

Headache â&#x20AC;&#x201C;analgesics may be needed.

Tolerance to drug can occur and so 2 tablets may be needed www.indiandentalacademy.com

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Myocardial infarction.

Myocardial infarction(MI) is a prolonged ischemia or lack of oxygen that causes injury to the heart.

10% of patients 40 years or older undergoing noncardiac surgery in a hospital setting indicate a history of previous MI. It is of interest as implant dentist primarily treats patients in this age group. www.indiandentalacademy.com

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Myocardial Myocardial infarction infarction

Signs and symptoms.

Cyanosis  Cold sweat  Weakness  Nausea or vomiting  Irregular or increased pulse rate.  Severe chest pain in the substernal or left precordial area.it may radiate to left arm or mandible.  Pain is similar to angina pectoris but more severe. 

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Myocardial Myocardial infarction* infarction*

Complications of MI ď Ź ď Ź

Arrhythmias Congestive heart failure.

The risk of MI is less than 1% in general population in preoperative setting.

18-20% of patients with a recent history of MI will have complications of recurrent MI (mortality rate 40-70 %) Surgery done within 3 months 3-6 months 12 months

Risk of another MI 30% 15% 5%

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Myocardial Myocardial infarction infarction

Risk

Type 1 Type 2

Type 3

>12 months

+

+

Physicia Physician n hospitaliza tion if anesthesia required.

Modera 6-12 te months

+

Postpone all elective procedures.

< 6months +

Postpone all elective procedures.

Mild

Severe

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Type 4

104

Congestive Heart failure.

CHF is a chronic heart condition in which the heart is failing as a pump.

Symptoms of congestive Heart failure.          

Abnormal tiredness.

Shortness of breath.

Wheezing.

Edema of legs or ankles.

Frequent urination Paroxysmal nocturnal dyspnea.

Excessive weight gain.

Orthopnea.

Pulmonary edema Jugular venous distention. www.indiandentalacademy.com

105

Medications for CHF. Digitalis.(digoxin, Lanoxin) increases the heart pumping action.  

Lethal dose is only twice the treatment dose.

Common side effects.      



Nausea Vomiting Anorexia Decreases heart rate Premature ventricular contractions.

Less common.  Chromatopsia  Spots  Halo around objects.

Decrease of medication dose partially relieves the symptoms. www.indiandentalacademy.com

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Congestive Congestiveheart heart failure* failure*

Diuretics.(furosemide) eliminate excess salt and water.

Dilators. Expands the blood vessels so that pressure decreases.

Calcium channel blockers. ď Ź

Gingival hyperplasia around teeth implants,or superstructure bars of overdentures, especially with nifedipine.

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107

Subacute bacterial Endocarditis.

Bacterial endocarditis is an infection of the heart valves or the endothelial surfaces of the heart.

Results from growth of bacteria on damaged /altered cardiac surfaces.

Organisms most often associated in dentistry. ď Ź ď Ź

Alpha-hemolytic streptococcus viridans Sometimes staphylococci and anaerobes.

Mortality rate is about 10%. www.indiandentalacademy.com

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SABE SABE

Dental procedures causing transient bacteremia are a major cause of bacterial endocarditis.

High risk   

Previous endocarditis.

Prosthetic heart valve Surgical systemic pulmonary shunt.

Significant.     

Rheumatic valvular defect.

Acquired valvular disease Congenital heart disease.

Intravascular prostheses.

Coarctation of the aorta. www.indiandentalacademy.com

109

SABE* SABE*

Minimal risk Transvenous pacemaker.  Rheumatic fever history and no documented rheumatic heart disease. 

Least risk.

Innocent of functional heart murmur.  Uncomplicated atrial septal defect.  Coronary artery bypass graft operations. 

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110

SABE* SABE*

Any patient with one previous episode of endocarditis has a 10% per year risk of second infection.

Once the second infection occurs, the risk factor increases to 25 %.

There is correlation between the incidence of endocarditis and the number of teeth extracted or the degree of a preexisting inflammatory disease of the mouth, www.indiandentalacademy.com

111

SABE* SABE*

Bacteremia has also been reported with    

traumatic tooth brushing, Endodontic treatment, chewing paraffin.

Denture sores in edentulous patients.

Scaling and root planning before soft tissue surgery reduces the risk of endocarditis.

Chlorhexidine painted on isolated gingiva or irrigation of the sulcus 3 to 5 minutes before tooth extraction reduces post extraction bacteremia. www.indiandentalacademy.com

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SABE* SABE*

Antibiotic regimens

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SABE* SABE*

Edentulous patients restored with implants must contend with transient bacteremia from chewing, brushing,or periimplant disease.

Therefore implants are contraindicated for patients with a limited oral hygiene potential and for those with a history of stroke.

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SABE* SABE*

Intramucosal inserts maybe contraindicated for many of these patients because a slight bleeding can occur on a routine basis for several weeks during initial healing process.

Endoosteal implants with adequate width of attached gingiva,are the implants of choice for patients who need implant supported prosthesis. www.indiandentalacademy.com

115

Diabetes mellitus Diabetes mellitus is related to an absolute or relative insulin insufficiency.

It is the most common metabolic disorder and major cause of blindness in adults.

The increase in number of diabetics is expected due to   

Increase in population size Greater life expectance.

Obesity. www.indiandentalacademy.com

116

Diabetes Diabetes mellitus* mellitus*

Symptoms are: Polyuria  Polydypsia  Polyphagia  Weight loss. 

Diabetics are more prone to Delayed soft and hard tissue healing  Altered nerve regeneration.  Infections  Vascular complications. 

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117

Diabetes Diabetesmellitus* mellitus*

Specific questions to be asked in medical history to evaluate the level of control achieved in Diet  Insulin dosage  Oral medication  Method used to monitor the blood glucose  Recent glucose levels. 

A glycohemoglobin determination test is a good indicator of a diabetic’s long term blood glucose level. www.indiandentalacademy.com

118

Diabetes Diabetesmellitus* mellitus*

Diabetic patients are subject to greater incidence and severity of Periodontal disease Dental caries due to xerostomia Candidiasis Burning mouth Lichenoid reactions.

Increased alveolar bone loss Inflammatory gingival changes.

Tissue abrasions in denture wearers

oxygen tension decreases the rate of epithelial growth and decrease tissue thickness.

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119

Diabetes Diabetesmellitus* mellitus*

Implant protocol.

Most serious complication during implant procedure is hypoglycemia.

It can be due to   

Excessive insulin level Hypoglycemic drugs Inadequate food intake.

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Diabetes Diabetesmellitus* mellitus*

Symptoms

Weakness Nervousness Tremor Palpitations sweating

Can

be treated with sugar inform of candy or orange juice.

Confusion Agittion Seizure Coma death www.indiandentalacademy.com

121

ď ŹDiabetes mellitus* ď ŹDiabetes mellitus*

Insulin therapy is adjusted to half the dose in the morning of surgery if oral intake is expected to be compromised.

Oral medications are discontinued after the patient has taken a morning dose on the day of surgery.

Intravenous conscious sedation and infusion of glucose and saline solution(D5 W) can be used for lengthy procedures. www.indiandentalacademy.com

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Diabetes Diabetes melllitus* melllitus*

Corticosteroids often used to decrease edema,swelling,and pain may not be used in the diabetic patient because they adversely effect blood sugar levels.

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123

Risk

Type 1

Type 2

Type 3

Type 4

Mild

< 150 mg /dl Glyc.0-1+ ketonuria 0

+

+

Sedation Premedication Diet/insulin Adjustment.

Moderate

< 200 mg/dl GLYC 03+ ketonria 0

+

+

Sedation Premedica tion Diet/insulin Adjustmen t.

Physician

Severe

Uncontroll ed> 250 mg/dl glyc 3+ Ketonuria 0

+

Postpone all elective procedures

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Diet/insulin Adjustmen t.

Physician Hospitaliza tion.

124

Thyroid disorders.

Affects proximately 1% of general population, primarily woman.

As the vast majority of patients in implant dentistry are woman, a slightly higher prevalence of this disorder is seen in the dental implant practice.

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Thyroid Thyroid

Hyperthyroidism.

Excessive production of hormone thyroxin(T4).

Symptoms          

Increased pulse rate.

Nervousness Intolerance to heat Excessive sweating Weakness of muscles Diarrhea Increased appetite Increased metabolism Weight loss Can led to • atrial fibrillation • angina • congestive heart failure.

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126

Thyroid Thyroid

Hypothyroidism Symptoms are related to decrease in metabolic rate.

Cold intolerance  Fatigue  Weight gain  Hoarseness  Decreased mental activity  Coma. 

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Thyroid Thyroid

Potential implant patients.

Patients with hyperthyroidism are sensitive to epinephrine in LA and gingival retraction cords.

Exposure to catecholamines (LA)+ stress+tissue damage(implant surgery) 

“thyroid storm”    

high temperature Agitation and psychosis Life threatening arrhythmias Congestive heart failure. www.indiandentalacademy.com

128

Thyroid Thyroid

Hypothyroid patients are sensitive to CNS depressant drugs.(diazepam or barbiturates) The risk of respiratory depression,Cardiovascular depression or collapse should be considered.

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129

Risk Mild

Type Type 2 1 Med exam < + 6 months normal fct last 6 months

Moderat No symptom + e no med exam no Fct test

Severe

Symptoms

+

Type 3

Typ e4

+

+

Decreas Physician e consultation. epinephr ine steroids CNS depress ants

+

Postpone all elective www.indiandentalacademy.com procedures.

130

Adrenal gland disorders.

Epinephrine and nor epinephrine are produced by the cells of adrenal medulla.

These hormones are responsible for the Control of blood pressure.  Myocardial contractility and excitability.  General metabolism. 

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131

Adrenal Adrenalgland glanddisorder disorder

Addisons's disease It corresponds to the decrease in the adrenal function.

Dentist can notice hyper pigmented areas on the   

face lips gingiva.

These patients cannot increase their steroid production in response to stress and in the midst of surgery may have cardiovascular collapse. www.indiandentalacademy.com

132

Adrenal Adrenalgland glanddisorder disorder

Corticosteroids are potent anti-inflammatory drugs used to treat a number of systemic diseases and one of the most prescribed drugs in medicine.

Continued administration of exogenous steroids suppress the natural function of the adrenal glands.

Therefore patients under long term steroid therapy are placed on the same protocol as patients with hypo function of the adrenal gland. www.indiandentalacademy.com

133

Adrenal Adrenalgland glanddisorder disorder

Cushing's syndrome.

Characteristic

symptoms

Hyper function of adrenal cortex.

Symptoms Bruise easily  Poor wound healing  Experience osteoporosis  Increased risk of infection. 

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Moon

facies Trunca l obesity or “buffalo hump” Muscl e wasting hirsuti sm 134

Adrenal Adrenalgland glanddisorder disorder

Potential implant patient Whether hypo or hyper functioning a patient with adrenal gland disease face similar problems related to dentistry and stress.

Their body is unable to produce increased levels of steroids during stressful situations and cardiovascular collapse may occur.

Additional steroids are prescribed just before surgery and stopped within 3 days. www.indiandentalacademy.com

135

Adrenal Adrenalgland glanddisorder disorder

Steroids in implant surgery patient.

Decrease inflammation,swelling and related pain. ď Ź Also decrease protein synthesis and delay healing. ď Ź Decrease leukocytes and therefore reduce ability to fight infection. ď Ź

Therefore antibiotics are always prescribed whenever steroids are given to patients for surgery. www.indiandentalacademy.com

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Risk Mild

Type 1 Equiv. + Prednisone alternate day >1 year

Modera Equiv te prednisone >20 mg or > 7 days in past year.

+

Severe. Euiv. + Prednisone 5mg/day

Type 4

Type 2

Type 3

Surgery on day of steroids

Sedation and antibiotics Steroids < 60mg prednisone day1 dose X/2 day 2 maintenance dose day 3

Sedation and antibiotics 20-40 mg day 1 Dose X /2 day 2 Dose X /4 day 3

60 mg day1 Dose X/2 day 2 Dose X /4 day 3

Elective procedures contraindicated www.indiandentalacademy.com

137

Hematologic disorders.

Erythrocytic disorders.

Polycythemia ď Ź Anemia ď Ź

Leukocytic disorders.

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Polycythemia.

It is a rare chronic disorder characterized by splenic enlargement, hemorrhages and thrombosis of peripheral veins.

Death usually occurs in 6 to 10 years.

Implant or reconstruction procedures are usually contraindicated. www.indiandentalacademy.com

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Anemia.

It is the most common hematologic disorder.

It is not a disease entity; rather it is a symptom complex that results from a   

decreased production of erythrocytes, an increased rate of their destruction.

Deficiency of iron.

It is defined as a reduction on the oxygencarrying capacity of the blood and results from a decrease in the number of erythrocytes or abnormality of hemoglobin. www.indiandentalacademy.com

140

Anemia Anemia

General signs.     

Jaundice Pallor Spooning or cracking of nails Hepatomegaly and splenomegaly Lymphadenopathy

Oral signs.     

Sore painful smooth tongue.

Loss of papillae Redness Loss of taste sensation Paresthesia. www.indiandentalacademy.com

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Anemia Anemia

Mild anemia   

Fatigue Anxiety Sleeplessness

Men mild anemia in man may indicate a serious underling medical problem  

Peptic ulcer Carcinoma of colon.

Female may normally be anemic in  

Mensus Pregnancy www.indiandentalacademy.com

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Anemia Anemia

Chronic anemia.

Shortness of breath.

Abdominal pain Bone pain Tingling of extremities Muscular weakness Headaches Fainting Change of heart rhythm nausea www.indiandentalacademy.com

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Anemia Anemia

Potential implant patients.

Bone maturation and development are often impaired in the long term anemic patients.

Sometimes radiographically a faint ,large trabecular pattern of bone may even appear â&#x20AC;&#x201C; it indicates 25-40% loss in trabecular pattern.

Decreased bone density affects ď Ź ď Ź

Initial implant placement Initial amount of lamellar bone formation at interface. www.indiandentalacademy.com

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Anemia Anemia

Other complications.

Abnormal bleeding.-decreased field of vision.

Increased edema and discomfort postoperatively.

Increased risk of postoperative infection and its consequences.

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Anemia Anemia

Diagnosis of anemia.

Hematocrit. Most accurate Men 40%- 54%  Woman 37-47 % 

Hemoglobin. 

Minimum base line recommended for surgery is 10 mg/dl especially for elective implant surgery.

Red blood cell count. least accurate. www.indiandentalacademy.com

146

Anemia Anemia

For majority of anemic patients implant procedures are not contraindicated.

Aspirin should be avoided.

Preoperative and postoperative antibiotics should be administered.

Hygiene appointments should be scheduled more frequently.

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Leukocytic disorders.

Leukocytosis –increase in circulating WBC in excess of 10,000/mm3.

Can be due to Infection.  Leukemia  Neoplasm  Acute hemorrhage  Exercise,emotional stress,pregnancy. 

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WBC WBCdisorders disorders

Leukopenia Reduction of WBC below 5000/mm3.

Can be due to Certain infections (infectious hepatitis)  Bone marrow damage (radiation therapy)  Nutritional deficiency.  Blood diseases. 

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WBC WBCdisorders disorders

Consequences of WBC disorder.

Infection.  Delayed healing.  Severe bleeding.  Increases edema  Postoperative discomfort and secondary infection. 

Complications are more common than in Erythrocytic disorders. www.indiandentalacademy.com

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WBC WBCdisorders disorders

Implant patient.

Oral implant procedures are contraindicated in acute or chronic leukemia.

Treatment planning modifications should shift toward a conservative approach when dealing with leukocyte disorders. www.indiandentalacademy.com

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Chronic obstructive pulmonary diseases.

It is the second most common cause of death after cardiovascular disease.

Two common forms of COPD are emphysema and chronic bronchitis.

3% of population has COPD. This disease affects men over the age of 40 and is closely related to smoking. www.indiandentalacademy.com

152

COPD COPD

Symptoms   

Chronic cough Sputum production Shortness of breath

Dentist should enquire about carbon dioxide retention capability of these patients.

Patients who retain CO2 have a severe condition and are prone to respiratory failure when given sedatives,oxygen or nitrous oxide,and oxygen analgesia.

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153

Risk •Previously

Mild

•Acute

Type 1 Type 2 unrecognized COPD

+

+

Type 3

Type 4

+

+

exacerbation of respiratory infection •Moderat Difficulty breathing + PHYSICIAN PHYSICIAN/MODE •only on significant ePatients RATE with dyspnea at rest exertion TREATMENT. ••Those with history of CO2 retention Normal laboratory blood gases severe + POSTPONE•Procedure ELECTIVE should be in hospital (HOSPITALI PROCEDURES •Difficulty breathing upon exertion performed setting •Those on chrnic bronchodilator ZATION) CONTRAINDICATE therapy.

•those who have used corticosteroids. •No D.vasoconstrictor to be added to anesthetics or gingival cord if patient is on bronchodilators www.indiandentalacademy.com 154

Cirrhosis.

Major cause is alcoholic liver disease.

Important to implant dentist as liver is involved  

in synthesis of clotting factors –abnormal bleeding.

Ability to detoxify drugs- can result in oversedation or respiratory depression.

Elective implant therapy is a relative contraindication in the patient with symptoms of active alcoholism. www.indiandentalacademy.com

155

Implant patient management.

No abnormal laboratory values

Low risk

normal protocol

Elevated PT less than 1-1.5 times control value Bilirubin slightly affected

Moderat e risk

referred to physician.

Nonsurgical and simple surgical procedure follow normal protocol.

Strict attention to hemostasis is indicated.

Moderate or advanced surgical procedures may require hospitalization

PT greater tan 1.5 times control value Mild to severe thrombocytopenia Liver related enzymes affected.

High risk

Hospitalization recommended for surgical procedures.

Elective procedures on previously inserted implants usually contraindicated.

Platelet transfusion required for even scaling and nerve block www.indiandentalacademy.com

156

Bone diseases.

Diseases of the skeletal system and specifically the jaws often influence decisions regarding treatment in the field of oral implants.

Bone and calcium metabolism are directly related.

Regulators of extracellular calcium.       

Parathyroid hormone.

Vitamin D Prostaglandins.

Lymphocytes.

Insulin Glucocorticoids Estrogen. www.indiandentalacademy.com

157

Osteoporosis.

Most common disease of bone metabolism for implant dentist.

Its an age related disorder characterized by a decrease in bone mass and susceptibility for fracture.

Above 60 years one third of population is affected.

Denture is less secure and patient may not be able to follow the good diet. www.indiandentalacademy.com

158

Osteoporosis Osteoporosis

Osteeoporotic changes in the jaws are similar to other bones in the body.

The structure of bone is normal; however due to uncoupling of the bone resorption/formation process with emphasis on resorption, ď Ź ď Ź ď Ź

the cortical plates become thinner, the trabecular bone pattern more discrete, and advanced demineralization occurs.

Bone mass

Men

woman

peaks at 35- 30 % more 40 years. than woman At 80 years

27 % loss.

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40 % loss

159

Osteoporosis Osteoporosis

Persons at risk   

 

Thin Postmenopausal.

Caucasian woman with history of poor dietary intake.

Cigarette smoking British or north European ancestry.

Estrogen replacement therapy [ERT] 



Premarin can halt or retard severe bone demineralization caused by osteoporosis.

Can reduce fractures by about 50% compared with fracture rate of untreated woman. www.indiandentalacademy.com

160

Osteoporosis Osteoporosis

Recommended calcium intake 800 mg/day.

Average intake in United states 450 to 550 mg.

Postmenopausal woman 1,500 mg is required.

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161

Osteoporosis Osteoporosis

Osteoporosis is a significant factor for bone volume and density, but is not a contraindication for dental implants.

The bone density does affect the    

treatment plan surgical approach length of healing and need for progressive loading.

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162

Osteoporosis Osteoporosis

The implant dentist can benefit the patient by noteing the loss of trabecular bone and by early referral.

Treatment is controversial and concentrates more on the prevention.  

Regular exercise has shown to help maintain bone mass and increase bone strength.

Adequate dietary intake is essential.

Implant designs  

should e Greater in width.

Coated with hydroxyapatite. Increases bone contact and density.

Bone stimulation increases bone density even in advanced osteoporotic changes. www.indiandentalacademy.com

163

Osteomalacia.

Caused by the deficiency of vitamin D in adults.

Risk factors.

Homebound elderly(lack of sunlight)  Those Unable to wear dentures.  Strict vegetarians.  Those on anticonvulsant drugs.  Gastrointestinal disorders. 

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Osteomalacia Osteomalacia

Oral findings Decrease in trabecular bone  Indistinct lamina dura.  Increase in chronic periodontal disease. 

Treatment is similar to osteoporatic patient.

Implants are not contraindicated.

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Hyperparathyroidism.

Mild

Asymptomatic

Moderate

Renal colic.

Severe

Disturbances in Bone- alveolar bone depletion.  Renal  Gastric 

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Hyperparathyroidism.

Hyperparathyroidism.

Oral changes occur in advanced disease   

Loss of lamina dura Loose teeth.

Ground glass appearance of trabecular bone.

Implants are not contraindicated if no bony lesions are present in the region of the implant placement.

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Fibrous dysplasia.

It is a disorder in which fibrous connective tissue replaces areas of normal bone.

Twice as common in woman and in maxilla.

It may affect single bone or multiple bone.

IN jaws it begins as a painless, progressive lesion.

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Fibrous Fibrousdysplasia dysplasia

â&#x20AC;˘Increase

in trabeculation Radiographically seen as the mottled appearance. â&#x20AC;˘Facial

plate usually expands moving the teeth along with it.

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Fibrous Fibrousdysplasia dysplasia

Implant dentistry is contraindicated in the regions of this disorder.

Lack of bone and increased firous tissue Decreases rigid fixation. ď Ź Susceptible to local infection processes. ď Ź

Excision of fibrous dysplasia is treatment of choice.

Excised area may receive implant in long term. www.indiandentalacademy.com

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Paget’s disease (Osteitis Deformans).

Is a slowly progressing chronic bone disease.   

Predeliction for men and those over 40 years of age.

Jaws are affected in 20% of cases.

Maxilla is more often involved.

Symptoms    

Tooth mobility Discomfort in wearing prosthesis.

Bony enlargements can be palpated Spontaneous fractures. www.indiandentalacademy.com

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Pagetâ&#x20AC;&#x2122;s Pagetâ&#x20AC;&#x2122;sdisease disease

Cotton or wool appearance radiographically.

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Pagetâ&#x20AC;&#x2122;s Pagetâ&#x20AC;&#x2122;sdisease disease

There is no specific treatment.

Patients are predisposed to development of osteosarcoma.

Oral implants are contraindicated in the regions affected.

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Multiple Myeloma.

It is a plasma cell neoplasm that originates in the bone marrow.    

Affects several bones. wide spread destruction.

Symptoms of skeletal pain.

Usually found in patients of 40-70 years.

Causes Pathologic fracture due to bone destruction Oral manifestations are common.    

Paresthesia Swelling Tooth mobility and movement.

Gingival enlargements www.indiandentalacademy.com

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Multiple MultipleMyeloma Myeloma

Punched out lesions radiograph ically.

â&#x20AC;˘There

is no treatment and condition is usually fatal 2 to 3 years after onset. â&#x20AC;˘Implants are usually contraindicated. www.indiandentalacademy.com

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Use of tobacco.

There is established relationship between smoking andâ&#x20AC;Ś 1.

2.

3.

..Periodontal attachment loss. ..Bone loss. ..decreased resistance to 1. Inflammation.

2. Infection.

4.

5.

..Impaired wound healing. ..Reduced mineral content in bone in 1.

2.

aging smokers Postmenopausal female smokers. www.indiandentalacademy.com

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Tobacco Tobacco

Lower success of endosteal implants in smokers.

Failure  

is more in maxilla. occurs in clusters.

When incision line opening after surgery occurs, smokers will   

delay the secondary healing, contaminate a bone graft, and contribute to early bone loss during initial healing.

Smokers should be told of detrimental effect on their treatment.

Should be encouraged to start a smoking cessation program. www.indiandentalacademy.com

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Pregnancy.

Implant surgery procedures are contraindicated in pregnant patient.

Reasons for postponement.    

Radiographs Medications Surgery Stress

However, after implant surgery has occurred ,the patient may become pregnant while waiting for the restorative procedures. www.indiandentalacademy.com

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Pregnancy Pregnancy

Procedures which can be carried out.

Caries control  Emergency procedures.  Dental prophylaxis. 

Drugs approved Lidocaine  Penicillin  Erythromycin  Acetaminophen. 

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Pregnancy Pregnancy

Drugs usually contraindicated.

Aspirin  Epinephrine(Vasoconstrictor)  Narcotics analgesics (cause respiratory depression) 

Always contraindicated.

Diazepam  Nitrous oxide  Tetracycline. 

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Prosthetic joints.

Literature reports there is association between prosthetic joint infection and dental treatment.

It is hypothesized that bacteria from the dental treatment may seed the prosthesis and produce infection.

The joint ADA â&#x20AC;&#x201C; AAOS( American academy of orthopedic surgeons) advisory statement recommends

- the aggressive treatment of acute orofacial infections in patients with total joint prosthesis because those bacteremias associated with acute infections can and do cause late implant infections. www.indiandentalacademy.com

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Prosthetic Prostheticjoints joints

Dental procedures with higher risk of bacteremia.

Dental extractions.

2. Surgical placement of implants 3. Periodontal surgery.

4. Prophylactic cleaning of teeth and implants.

1.

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Prosthetic Prostheticjoints joints

Antibiotic prophylaxis

Recommended for patients with higher risk for hematogenous infections undergoing dental procedures with a higher bacteremic incidence.

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Radiation therapy.

Approximately 3% of all malignancies occur in head and neck region. 90% of which are squamous cell carcinoma.

Treatment reginmens   

Surgery.

Radiotherapy.

Chemotherapy.

Surgery and radiotherapy are the most effective and therefore most used.

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Early stage disease are treated with single modality therapy In more advanced cancers combination therapies are needed and outcome is less favorable.

Microscopic disease

50-55 Gy

Macroscopic disease with high riskof recurrance

65-70 Gy

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49 Gy

Significant injury to the endothelium of the blood vessels in mandible.

> 60 Gy

ability of osseous structures to recover from an operative insult independently is minimal.

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Osteoradionecrosis Osteoradionecrosis is a condition characterized by the development of non vital areas of osseous tissue in irradiated bone after injury.

Treatment 

 

Disease should be best prevented whenever possible.

Segmental resection and extensive reconstruction.

It is extremely costly both in time and resources. www.indiandentalacademy.com

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Potential implant patient.

The fields irradiated and the dosages received by the tissues in that area must be analyzed to determine areas of the jaws at risk.

If areas receiving radiation doses of 60 Gy must be violated surgically,preoperative hyperbaric oxygen therapy(HBO) can reduce the risk of Osteoradionecrosis. www.indiandentalacademy.com

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Chemotherapy Drugs used as chemotherapeutic agents have the capability to disrupt normal cellular events leading to replication.

Oral mucosal ulcerations are common and often complicate therapy by secondary infection. www.indiandentalacademy.com

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ď Ź ď Ź

Granulocyte-stimulating factor Granulocyte-macrophage colony-stimulating factor

Can be used in patients exhibiting severe neutropenia.

The clinician managing the oral needs of the patients with cancer must weigh the risks of infection and failure inpatients undergoing or likely to require chemotherapy against the benefits of dental rehabilitation. www.indiandentalacademy.com

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ď ŹHISTORY ď ŹCLINCAL

EXAMINATION

Diagnostic imaging

Mounted study casts.

Joint assessment Surgeon/restortive dentist.

Psychological assessment

Treatment plan Informed consent www.indiandentalacademy.com

Medical assessment 191

Psychological assesment

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Attitute.

It is important to assess the patients attitude in relation to Reasons for treatment.  Any psychological problems.  Realism, regarding timing. 

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Reasons for treatment.

Good candidates for treatment.

Those with Funcitonal dificulties(poor mastication)  Poor esthetics 

Poor candidates.

Existing work has failed  Those trying to gain “lost youth” 

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Psychological problems.

Patients with problems of Psychogenic origin may become convinced that provision of a stable dental occlusion will cure their problems.

Kiyak et al (1990) reported a correlation between high scores of neuroticism and less satisfaction with treatment results.

Such patients should not be denied treatment but require more supportive therapy www.indiandentalacademy.com

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Realism, regarding timing.

Usually there is a time gap between the placement of fixture and their use for supporting a prosthesis.

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ď ŹHISTORY ď ŹCLINCAL

EXAMINATION

Diagnostic imaging

Mounted study casts.

Joint assessment Surgeon/restortive dentist.

Psychological assessment

Treatment plan Informed consent www.indiandentalacademy.com

Medical assessment 197

ď Ź ď Ź

www.indiandentalacademy.com Leader in continuing dental education

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