PROSTHODONTIC CONSIDERATIONS OF SYSTEMIC DISEASES

PROSTHODONTIC CONSIDERATIONS OF
SYSTEMIC DISEASES
DR.SWETHA.S
PG STUDENT

TABLE OF CONTENTS
 INTRODUCTION
 IMPORTANCE OF MEDICAL HISTORY
 PROSTHODONTIC CONSIDERATIONS OF
DIABETES MELLITUS
CARDIOVASCULAR DISORDERS
HEMATOLOGICAL DISORDERS
RESPIRATORY DISORDERS
NEUROLOGICAL DISORDERS
RENAL DISORDERS
SKIN DISORDERS
OSSEOUS DISORDERS
RADIATION THERAPY
 CONCLUSION
 REFERENCES

INTRODUCTION
 Dentist must be aware of each patient’s general health, especially conditions that might influence the
choice of treatment, or that can be aggravated by a clinical intervention. The initial evaluation starts by
observing the patient’s behavior in the office.
 Evaluating the patient for proper diagnosis, prognosis and appropriate treatment plan is the first step in
a denture treatment.
 General health of the individual has an impact for prosthodontic management.

PHYSICAL CLASSIFICATION- TRANSLATED FOR DENTAL TREATMENT-
ASA

Patients today have a more complex health history than ever before.
More likely to involve the dentist in medicolegal challenge.
Can influence the prognosis
Therefore a complete medical history is an extremely important part of the
patient’s overall diagnosis and treatment planning.
It is the management of patients in whom the dental treatment may need
modification according to their medical condition.
IMPORTANCE

MEDICAL HISTORY
General and accurate information of medical issues to be noted.
The following classification may be helpful:
 1. Conditions affecting the treatment methodology (e.g., any disorders
that necessitate the use of antibiotic premedication, any use of steroids
or anticoagulants, and any previous allergic responses to medication or
dental materials).

2. Conditions affecting the treatment plan (e.g., previous radiation therapy,
hemorrhagic disorders, extremes of age, and terminal illness).
 These can be expected to modify the patient's response to dental treatment
and may affect the prognosis.

3. Systemic conditions with oral manifestations.
(Eg- periodontitis may be modified by diabetes, menopause, pregnancy, or the
use of anticonvulsant drugs ;
Drugs causing reduced salivary flow
Gerd cause erosion)
certain drugs may generate side effects that mimic temporomandibular
disorders (TMDs) or reduce salivary flow.

4. Possible risk factors to the dentist and auxiliary personnel
(e.g., patients who are suspected or confirmed carriers of hepatitis B,
acquired immunodeficiency syndrome, or syphilis).

DIABETES MELLITUS
 Hypo-function or lack of function of the beta cells of the islets of
Langerhans in the pancreas, leading to high blood glucose levels and
excretion of sugar in the urine.
 Apart from the obvious impact of impaired glucose metabolism, diabetes
mellitus & chronic hyperglycemia are associated with important ophthalmic
renal, cardiovascular, Cerebrovascular & peripheral neurological disorders.

TYPES OF DIABETES MELLITUS
1. Primary
a. Type 1 or Insulin Dependent DM (IDDM)
b. Type 2 or non-insulin Dependent DM (NIDDM)
 2. Other specific types of Diabetes
a. Pancreatic Disease
b. Excess Endogenous production of hormonal antagonists to insulin
c. Medication (Corticosteroids, thiazide diuretics, phenytoin)
d. Associated with genetic syndromes.
 3. Gestational Diabetes

 According to American diabetic association (ADA):
 Fasting blood sugar (FBS) > 126 mg/dl or
 Post random blood sugar (PRBS) > 200mg/dl
 Impaired fasting glucose (IFG) when FBS is between 100 - 125 mg/dl.
 Impaired glucose tolerance (IGT)140 – 199 mg/dl
 This distinction is important because individuals with IFG & IGT are at increased risk
of developing atherosclerotic disease even though if they don't develop diabetes.

ORAL MANIFESTATIONS OF DIABETES MELLITUS
 Xerostomia
 Gingival Inflammation
 Increased Caries Risk
 Burning Sensation
 Periodontitis
 Fungal Infections
 Poor Wound Healing
 Alveolar Bone Resorption
 Oral candidiasis

KEY DENTAL TREATMENT CONSIDERATIONS FOR DIABETIC PATIENTS
1) Medical history :
 Take history and assess glycemic control at initial appt.
 Glucose levels
 Frequency of hypoglycemic episodes
 Medication, dosage and times.
2) Establishing the levels of glycemic control early in the treatment
process:
 Patients recent glycated Hb values

3) Stress Reduction :
 Endogenous production of epinephrine and cortisol increase during stressful situations.
 Profound anesthesia reduces pain and minimizes endogenous epinephrine release.
 Conscious sedation should be considered for extremely anxious patient.
4) Oral hygiene instructions, frequent prophylaxis & monitoring of periodontal health,
as there is increased risk of periodontal disease.
5)Treatment: The use of antibiotics in case of infection and Diet Modification.

PROSTHODONTIC MODIFICATIONS
 Mucostatic technique.
 Wax spacer to cover complete tissue in special trays,
use of rubber base material for border molding should be
considered.
 Broad area of tissue coverage, decrease buccolingual
width of teeth, setting of the teeth above the ridge, using
semi-anatomic or cusp-less teeth, avoidance of incline
planes, centralizing the occlusal contacts to increase
stability of dentures and providing adequate inter-
occlusal distance should be considered.
 Frequent massaging the oral tissues and follow ups
needed.

 If patient is provided removable partial denture (RPD), then restoration and
maintenance of good oral hygiene by any restorative procedures or root
planning and scaling must be accomplished first.
 As diabetic patients are more prone to develop periodontal diseases,
therefore in certain cases splinting of periodontally compromised teeth is also
a good option.

FOR FPD
 Finish-line of the preparation should be placed supragingival and to provide chamfer finish-
line or radial shoulder on the facial aspect of prepared tooth as it is better than shoulder
because shoulder can concentrate stresses on weakened tooth/ teeth.
 A narrow occlusal table, group function or mutually protected occlusal scheme is better
choice for periodontally compromised teeth.
 In certain cases procedures like crown lengthening, periodontal surgery and orthodontic
extrusion of tooth will further improve the quality of fixed prosthesis in diabetic patients.

DIABETES AND IMPLANT
 Implant dentistry is not contraindicated in most diabetics.
 Implant supported prosthesis are not advised for patients whose blood sugar level remains
uncontrollable but if conditions are favorable, then this type of prosthesis can be planned.
 The critical dependence on bone metabolism for implant survival may be a vulnerability for
patients with diabetes.
 Need for a stress reduction protocol, prophylactic antibodies, diet evaluation before after
surgery and control of the risk of infection are all addressed.
 Corticosteroids, often used to decrease edema, swelling and pain may not be used in the
diabetic’s patient.
 Delay in implant integration were identified for patients with HbA1c levels over 8.0%.

POSSIBLE EFFECTS OF DIABETES ON IMPLANT HEALING

EMERGENCY MANAGEMENT
 Most common is hypoglycemia.
 Signs & symptoms
Mild
• Anxiety
• Tachycardia
• Sweating
Severe
• Confusion
• Seizures
• Coma

MANAGEMENT OF HYPOGLYCEMIA
• Terminate all dental procedures
• Alert the patient
• 15 gm carbohydrate( 6 oz orange juice, 4 oz cola, 3-4 teaspoons sugar)
• In case of uncooperative patient, Glucagon 1 mg s.c, i.m. followed by oral
glucose supplement or 25-50 ml of 50% dextrose solution (D50) i.v
Signs and symptoms of hypoglycemia should reduce in 10- 15 min.

XEROSTOMIA
Salivary substitutes contains
Sodium carboxymethyl cellulose* 0.5% aqueous solution
Use as a rinse as frequently as needed.
Commercial Salivary Substitute:
Commercial oral moisturizing gels (OTC) includes
 OralBalance.
 XERO-Lube
 Salivart
 Moi-Stir Orex
 Optimoist

Saliva Stimulants:
The use of sugar free gum, lemon drops or mints are conservative methods to temporarily
stimulate salivary flow in patients with medication xerostomia or with salivary gland dysfunction

PROSTHODONTIC CONSIDERATIONS IN CARDIOVASCULAR
DISEASES
 Hypertension
 Ischemic heart disease
 Cardiac arrhythmias
 Heart failure
 Infective endocarditis
 Cardiac pacemakers

1.HYPERTENSION:
Persistent high blood pressure - Systolic Bp › 150mm Hg
Diastolic Bp › 90mm Hg
 History
 Duration of hypertension,
 Medication and
 Patient compliance with regard to antihypertensives,
 Other associated co-morbid conditions,
 Current oral disease,
 Past dental treatment including its outcome, complications during treatment and post-
treatment medication.

AUSCULTATION
 The most preferred method is auscultation, with the
patient seated calmly for at least 5-10 minutes with
arm at the level of the heart, and feet on the floor and
rather than lying down on a table.
 Activities like exercise, smoking and caffeine should be
avoided at least 30 minutes prior to measuring of
blood pressure, to avoid artificially high readings.

 Particular attention should be given for accurate measurement of blood
pressure in pregnant women, since pregnancy may alter the patient BP values
with more than 10% of pregnant women having clinically relevant
hypertension.
 BP monitoring is also necessary in diabetic patients, patients with
autonomous dysfunction, and elderly patients in whom orthostatic
hypotension is a huge problem.

ORAL MANIFESTATIONS OF ANTIHYPERTENSIVES
 Xerostomia.
 This hyposalivation was related to the sustained increase in both systolic as well as
diastolic blood pressure and also in patients who were under antihypertensive
medication especially with diuretics.
 The unstipulated salivary flow will be reduced.
Xerostomia decay, difficulty in chewing, swallowing and speaking,
candidiasis and oral burning syndrome

Lichen planus like lesions or lichenoid reactions.
 Characterised as acanthosis, basal cell degeneration, hyperparakeratosis,
numerous chronic inflammatory cell infiltrates throughout the connective
tissue especially the plasma cells and histiocytes.
Gingival hyperplasia
 Pain, gingival bleeding, and difficulty in mastication.
Increased periodontitis

GENERAL PROTOCOL FOR DENTAL MANAGEMENT OF
HYPERTENSIVES
 A well-controlled hypertensive patients does not pose a risk in clinical practice.
 Instructed to take his or her medication as usual on the day of dental treatment.
 Prior to such treatment, the patient blood pressure should be recorded.
 Preferable for brief morning visits.
 Anxiolytic agents may be used in particularly anxious patients (5-10 mg of diazepam
the night before and 1-2 hours before the appointment) before dental treatment, or
alternatively sedation with nitrous oxide may be considered.

 In the case of emergency dental visits, treatment should be conservative, with
the use of analgesics and antibiotics.
 NSAIDs should not be prescribed for longer than this five-day period.
 Patients with cardiovascular disease are at a greater risk of massive
endogenous adrenalin release secondary to deficient local anesthesia than of
reaction to the small amount of vasoconstrictor used in local anesthetics.
 Nevertheless, vasoconstrictor use should be limited, taking care not to exceed
0.04 mg of adrenaline.

VARIOUS DRUG INETRACTIONS
 Most antihypertensive drugs have drug interactions with LA (local anaesthetic)
and analgesics.
 LA toxicity may be increased by interaction of LA with nonselective beta-
blockers.
 The cardiovascular effects of epinephrine used during dental procedures may
be potentiated by the use of medications such as nonselective beta-blockers
(propranolol and nadolol).

 Most frequent cardiovascular drugs & their related manifestations are :
 ACE inhibitors : - Erythema Multiforme, Xerostomia, Loss Of Taste, Pharyngitis, Burning
Sensation & Ulcers.
 B- blockers : Xerostomia, Paresthesia.
 Calcium antagonists (nifedipine) : Gingival Hyperplasia.
 Diuretics : Xerostomia, Parotid Gland Hypertrophy.
 Nitrates : Alterations Of The Denture Base Materials.
 Ibuprofen, indomethacin or naproxen - lowering their antihypertensive action.

2. ISCHEMIC HEART DISEASE
 Reduction (partial or total) in coronary blood flow.
 In 90% of all cases, this occurs following thrombus
formation secondary to an atheroma plaque that occludes
the arterial lumen, though other factors such as cold,
physical exercise or stress can act as coadjuvant factors or
(less frequently) trigger the event themselves.
 In turn, sudden death may also occur, generally as a result
of arrhythmias.

DENTAL MANAGEMENT AND PRECAUTIONS
 A minimum safety period of 6 months has been established before any oral surgical
procedure can be carried out.
 After this safety period, the treatment decision should be established on the basis of
the situation and medical condition of each individual patient.
 If nitrates are used, the patient should bring them to each visit to the dental clinic, in
case chest pain develops.
 In the case of very anxious patients, premedication can be administered to lessen
anxiety and stress (5-10 mg of diazepam the night before and 1-2 hours before
treatment).

 Depending on the patient, blood pressure and pulsioxymetric monitoring may
be required before and during dental treatment.
 If the patient is receiving antiplatelet medication, excessive local bleeding is to
be controlled.
 The local hemostatic measures that can be used comprise bone wax, sutures,
gelatin of animal origin, regenerated oxidized cellulose, collagen, platelet rich
plasma, thrombin, fibrin sealants, electric or laser scalpels, antifibrinolytic
agents such as tranexamic acid.

3. CARDIAC ARRHYTHMIAS
An abnormality in rate, regularity, or site of origin of the cardiac impulse.
Dental management:
1. Anxiolytics can be used to lessen stress and anxiety.
2. Although modern pacemakers are more resistant to electromagnetic interferences, caution is
required when using electrical devices (e.g., ultrasound and electric scalpels).
3. If arrhythmia develops during dental treatment, the procedure should be suspended, oxygen
is to be provided, and the patient vital signs are to be assessed.
4. Sublingual nitrites are to be administered in the event of chest pain.
5. The patient should be placed in the Trendelenburg position, with vagal maneuvering where
necessary ( massage in the carotid pulse region, etc.).

4. HEART FAILURE
 The incapacity of the heart to function properly, pumping insufficient blood
towards the tissues and leading to fluid accumulation within the lungs, liver
and peripheral tissues

DENTAL MANAGEMENT
 Dental treatment is to be limited to patients who are in stable condition.
 The patient should be placed in the semi-supine position in a chair, with control of
body movements (which should be slow), in order to avoid orthostatic hypotension.
 In patients administered digitalis agents (digoxin, methyldigoxin), the vasoconstrictor
dose is to be limited to two anesthetic carpules, since this drug combination can
favor the appearance of arrhythmias.

 Aspirin (acetylsalicylic acid) can lead to sodium and fluid retention, and therefore
should not be prescribed in patients with heart failure.
 In the event of an emergency and after contacting the emergency service, the patient
should be placed seated with the legs lowered, and receiving nasal oxygen at a rate
of 4-6 liters/minute.
 Sublingual nitroglycerin tablets are indicated (0.4-0.8 mg), and the dose may be
repeated every 5 or 10 minutes if blood pressure is maintained.

5. INFECTIVE ENDOCARDITIS
 Endocarditis usually develops in individuals with underlying structural cardiac
defects who develop bacteremia with organisms likely to cause endocarditis.
 Blood-borne bacteria may lodge on damaged or abnormal heart valves or on the
endocardium or the endothelium near anatomic defects, resulting in bacterial
endocarditis or endarteritis.
 Streptococcus viridans (α-hemolytic streptococci) is the most common cause of
endocarditis following dental or oral procedures.

BACTERIAL ENDOCARDITIS
Damage to the endocardium
Adherence of platelet and fibrin to subendothelial layer
Devolopment of non bacterial thrombotic vegetation
bacteria
Adherence of microorganism to the vegetation and its multiplication
Local and systemic consequences of bacterial endocarditis

DENTAL MANAGEMENT
 Individuals who are at risk for developing bacterial endocarditis should establish and
maintain the best possible oral health to reduce potential sources of bacterial
seeding.
 In general, antimicrobial prophylaxis is recommended for procedures associated with
significant bleeding from hard or soft tissues, periodontal surgery, scaling, and
implant surgery.
 Antimicrobial prophylaxis to be administered within 2 h following the procedure.

6. CARDIAC PACEMAKERS
 Automated Implantable Cardioverter Defibrillators (AICDs) or Implantable Cardioverter
Defibrillators (ICDs) have been in use .
 An ICD is a small battery powered electrical impulse generator that is implanted in patients who are at a
risk of sudden cardiac death due to ventricular fibrillation and ventricular tachycardia.
 Diathermy is best avoided in patients with pacemakers. If diathermy must be used, bipolar diathermy is
preferred.
 If unipolar diathermy must be used, the ground pad should be placed so that the pacemaker or its leads
do not lie within the electric field (between the ground pad and the instrument).
 Thus, it is commonly recommended that if diathermy is to be used, ICD devices should be programmed
off immediately prior to surgery and on again postoperatively.

DENTAL MANAGEMENT
 All patients who have any type of implantable cardiac devices
should provide the details of manufacturer’s identification
card like manufacturer of the device, model number, serial
number, date of implantation, and mode of operation to their
oral health provider.
 Care should be taken not to place electrical cords over
patient’s chest.
 Unshielded pacemakers should be covered with a lead apron.
 Dentists should be aware of symptoms of pacemaker
malfunction such as difficulty in breathing, light headedness,
dizziness, change in pulse rate, prolonged coughing, swelling
in chest and arm, and chest pain.
 In such conditions, cardiologist should be consulted
immediately.

8. STROKE
 Dental management:
 Blood pressure and pain should be monitored and maintained during the entire intervention.
 Six hours after bleeding, when blood clots are built up, heparin systemic treatment can be resumed.
 If the patient shows symptoms of stroke, he should get oxygen therapy immediately and should be
referred to a hospital as soon as possible
Cerebral haemorrhage or cerebral ischemia is a serious neurological accident, often fatal, due to a
sudden interruption of the oxygenated blood supply to the brain.

PROSTHODONTIC CARE
 Fabricating a complete denture demands utmost care to avoid causing soft tissue
abrasion.
 Certain antihypertensive drugs are associated with xerostomia which in turn hamper
the retention and stability of the complete dentures .
 For denture wearers, denture adhesives and artificial saliva may aid in the retention
of the prostheses. In such patients artificial salivary lubricants should compensate the
effect of xerostomia for better post-therapy results.
 The sharp edges of the removable partial dentures should be trimmed off.
Removable partial denture should be polished well and preferably should be
fabricated with flexible material.

 Gingival retraction cord contains approximately 71micro gram of racemic
epinephrine per inch of cord. Epinephrine is readily absorbed through gingival
epithelium
 About 64% to 94% of applied epinephrine is absorbed into the cardiovascular
system.
Use of epinephrine for gingival retraction, and its use is contraindicated in
individuals with a history of cardiovascular disease.
EPINEPHRINE SYNDROME

HEMATOLOGICAL DISORDERS
 Blood disorders affect the soft and hard tissues of the oral cavity.
 The patient should be asked for any history of significant and prolonged bleeding after dental
extraction or bleeding from gingivae.
 If a patient is taking anticoagulant drugs, it will be important to consult his or her physician
before any major surgical procedure. In addition, a number of medications may interfere with
hemostasis and prolong bleeding.

Cellular defects:
(1) a) RBC (erythrocytes)
Increased : Polycythemia
Decreased : Anaemia
1. Pernicious anaemia
2. Aplastic anaemia
3. Thalassemia
4. Sickle cell anaemia
5. Erythroblastosis fetalis.
6. Iron deficiency anaemia
b) WBC (Leukocytes) –
Increased –
Physiological - leucocytosis
Pathological-
1. Leukemia
2. Infectious mononucleosis
Decreased –
1. Leucopenia
2. Agranulocytosis
3. Neutropenia
c) Thrombocytes
increased – Thrombocytopenic purpura
Decreased – Thrombocytopenic purpura

LAB INVESTIGATIONS
 When a bleeding disorder is suspected, laboratory investigations, including blood counts and
clotting studies, should be carried out.
 Preoperative laboratory tests of the hemostatic system are:
 CBC
 Bleeding time to determine platelet function (normal range: 2–7 minutes)
 Activated partial thromboplastin time to evaluate the intrinsic coagulation pathway (normal
range: 25 ± 10 seconds)
 International normalized ratio to measure the extrinsic pathway.
 platelet count to quantify platelet function (normal range: 150,000–450,000/µl).

ORAL MANIFESTATIONS OF ANEMIA
 POLYCYTHEMIA:
Erythema of oral mucosa, glossitis, gingivitis, gingival bleeds spontaneously but no
tendency to ulcerate.
 PERNICIOUS ANEMIA:
Glossitis, beefy red tongue, hunter’s glossitis (The papilla undergoes atrophy with
loss of papillae become smooth or bold glossitis with glossopyrossis and
glossodynia), xerostomia, apthous ulcer like ulcers.
 THALASSEMIA:
Excessive overgrowth of maxilla (affects occlusion and esthetics), excessive lacrimation and
nasal stiffiness, palor oral mucosa, rodent facies, chipmunk facies.

 SICKLE CELL ANEMIA:
Pallor buccal mucosa, gingival enlargement, orofacial pain, paresthesia of mental nerve, delayed eruption,
enamel hypoplasia, osteomyelitis, mongoloid facies, asymptomatic pulpal necrosis, hypercementosis,
osteoporosis, step ladder defect in alveolar bone (mandible) and severe malocclusion are the main oral
manifestations.
 IRON DEFICIENCY ANEMIA :
Mucosal pallor, atrophic mucosa, angular cheilitis, glossitis, migratory glossitis, cheilosis, candida infection,
dehydration and ulceration due to atropy of mucosa.
 PLUMMER VINSON SYNDROME:
Atropic glossitis, angular cheilitis, hyperkeratotic lesion, Dysphagia (due to esophageal webs),
pharyngoesophageal ulcerations.

 Increasing factor VIII levels, replacing factor VIII and inhibiting fibrinolysis .
 Desmopressin (DDAVP) is used to achieve a transient increase in factor VIII level through the
release of endogenous factor VIII in patients with hemophilia A and von Willebrand’s disease
 DDAVP may be combined with antifibrinolytic agents to increase its effectiveness.
 Options for factor VIII replacement are factor VIII concentrates, fresh frozen plasma and
cryoprecipitate.
 Highly purified forms of factor VIII concentrates, manufactured using recombinant or
monoclonal antibody purification techniques, are preferred because of their greater viral
safety.
Hemophilia A, B and von Willebrand disease are the most common

PATIENT ON ANTICOAGULANT THERAPY
 Anticoagulant treatment is very common in cardiac patients.
 For a healthy person without anticoagulant treatment, the International Normalized
Ratio (INR) = 1. Anticoagulant treatment usually targets to an INR between 2.0–3.0.
 In certain high-risk situations (e.g. a mechanical mitral valve prosthesis), higher INR
values 2.5–3.5 (–4.0) may be required.
 If INR values are greater than 3.0, physician referral is suggested.
 It is important to consider the risk of reducing the level of anticoagulation in patients
on warfarin due to the risk of a thromboembolic event.

 The risk of bleeding in patients on oral anticoagulants undergoing dental surgery may be
minimized by:
a. The use of oxidized cellulose (Surgicel) or collagen sponges and sutures.
b. 5% tranexamic acid mouthwashes used four times a day for two days.
 Patients taking warfarin should not be prescribed non-selective NSAIDs and COX-2 inhibitors
as analgesia following dental surgery.

ORAL MANIFESTATIONS
 Platelet deficiencies can cause ecchymosis in oral mucosa and promote spontaneous
gingival bleeding.
 These disorders may be present alone or in conjunction with gingival hyperplasia in
cases of leukemia.
 Hemosiderin and other blood degradation products can cause brown deposits on
the surface of teeth due to chronic bleeding.
 People with hemophilia may have multiple bleeding events over their lifetime. The
frequency of bleeding depends on the severity of hemophilia. Hemarthrosis of the
temporomandibular joint is uncommon

PROSTHODONTIC CARE
 These procedures do not usually involve a considerable risk of bleeding.
 Trauma should be minimized by careful post-insertion adjustments.
 Oral tissue should be handled delicately during the various clinical stages of
prosthesis fabrication to reduce the risk of ecchymosis.
 Careful adjustment of prostheses is needed to reduce trauma to soft tissue

 The United Kingdom Haemophilia Centre Doctors' Organisation
(UKHCDO) Dental Working Party
• Augmentation of the coagulation factor before surgery (and before nerve block).
• Pre- and post-operative use of antifibrinolytic agents (oral tranexamic acid and/or 5%
tranexamic mouthwash). These should be continued up to seven days post-surgery
• Use local anaesthesia with vasoconstrictor, which should be performed with the slow injection
technique and with fine gauge needles
• Use appropriate suturing technique

• Avoid sinus lift and bone grafts
• In order to reduce the risk of local infection and inflammation the clinician is
recommended to use topical antiseptics (chlorhexidine or povidone iodine), or
antibiotics if the infection is considered to require more than topical measures
• Several medications commonly used by dental practitioners (like
metronidazole, erythromycin, clarithromycin) may increase the anticoagulant
effect of warfarin.

RESPIRATORY DISORDERS
 The respiratory system is basically responsible for O2 and CO2 exchange
between the blood and the external environment.
 This gas exchange takes place passively across partial pressure gradients
within the terminal respiratory units (alveolar spaces).
 Any defects or changes in conditions of the respiratory tract including
the trachea, bronchi, bronchioles, alveoli, pleurae, pleural cavity, and the
nerves and muscles of respiration.

ASTHMA
A chronic disease characterised by obstruction of repeated episodes of respiratory tract due to
hyperresponsiveness to inhaled antigen

Spread by aerosolized droplets high risk to dentist
Minimal use of high speed handpieces
Operating air should be vented out .
Oral lesions may make use of prosthesis difficult
• It is an infectious granulomatous disease caused mycobacterium tuberculosis or rarely
mycobacterium bovis.
TUBERCULOSIS:

PROSTHODONTIC CONSIDERATIONS
 Consultation with physician can determine the infective status of patient
 Patients on anti TB therapy can be safely treated after the second week of the antibiotic treatment •
 Emergency situations in the infective period should be managed by palliative treatment ( antibiotic
analgesic)
 Dental personnel should be aware that cold sterilization or chemical sterilization solutions are ineffective
for TB
 Patients pulmonary capacity should be evaluated before any sedation or narcotic administration
Acetaminophen can interact with hepatotoxic effect of rifampin
 Aspirin or cephalosporine may cause ototoxicity when combined with sterptomycine
 Clearance of diazepam is accelerated by rifampin

COVID-19
 It is an enveloped RNA beta coronavirus related to the Severe Acute Respiratory Syndrome
(SARS) virus, and the virus has been shown to use the angiotensin-converting enzyme 2
(ACE2) receptor for cell entry.
 Direct person-to-person transmission occurs through close contact, mainly through
respiratory droplets that are released when the infected person coughs, sneezes, or talks.
 These droplets may also land on surfaces, where the virus remains viable. Infection can also
occur if a person touches an infected surface and then touches his or her eyes, nose, or
mouth.
 The median incubation period is 5.1 days (range 2–14 days).

SYMPTOMS
 As per WHO surveillance guidelines
 Fever
 Cough
 Fatigue
 Shortness of breath
 Expectoration
 Myalgia
 Rhinorrhea,
 Sore throat,
 Diarrhea
 Loss of smell (anosmia) or loss of taste (ageusia) preceding the onset of respiratory symptoms has also been
reported

 The challenge to Prosthodontist is going to be much more because of factors
such as high concentration of copious saliva in trays & dentures, exposure to
blood during pre prosthetic surgeries and implant placement and exposure to
aerosols during tooth preparation for crown and bridge.

 In the light of given pandemic & its source of spread and transmission, it becomes the moral
duty of the prosthodontist to defer all elective treatment procedures like Crowns, Bridges,
Veneers, Inlays, Onlays, which involve the generation of aerosols and handle only urgent and
basic procedures.
 In certain situations where the clinician has to proceed with an aerosol generating procedure
complete personal protective equipment (PPE suit, face shield, double gloves, N95 mask,
shoe cover) should be donned by the prosthodontist as well as the assistant.
 The prosthodontists are instructed to use PPE while using the trimmers and buff along with a
high vacuum suction to ensure that the ﬂints or fragments are sucked out completely.

STANDARD & SUGGESTED DENTAL OFFICE PROTOCOLS
1. Initial tele-screening of dental patients to identify suspected COVID-19 carriers
2. Considering every patient as a potential asymptomatic COVID-19 carrier.
3. Considering recently recovered patients as potential virus carriers for at least 30 days
after the recovery conﬁrmation by a laboratory test.
4. Meticulous screening of even asymptomatic patients is important. Patients should be
requested to ﬁll out detailed questionnaire regarding COVID-19
5. Maintenance of proper record, address, contact details are of paramount importance.
Since the incubation period of SARS-CoV-2 may extend over 2 weeks, a positive response
any of the above queries mandates deferring the appointment for at least 2 weeks.

6. Those patients who seem ﬁt for appointment scheduling should be advised to wear surgical
face mask and preferably come alone or with a single attendant at the time of their dental visit.
7. Dental ofﬁce and the waiting area should be well ventilated at all times along with spaced out
seating of patients.
8. Patients should be instructed to arrive on time for their appointments.
9. Remove magazines, reading materials, toys and other objects.
10. Schedule appointments to minimize possible contact with other patients in the waiting room.

11. Use of contact less thermal screen and pulse oximeter device should be considered even if
the patient answers no to the COVID symptoms questions
12. An oxygen saturation of below 90% is a good marker for some form of oxidative distress in
the body.
13. Patients should be instructed for hand sanitization and proper hand washing as soon as
he/she enters the clinic.
14. The prosthodontist in his clinic should ensure that entire team is well versed with the
universal precautions

PROSTHODONTIC EMERGENCIES
 This urgent care is needed so that the patient can carry on with his usual activities without
impairment in oral function or appearance.
Some of such situations are:
•Dental trauma due to denture fracture
•Repair of broken dentures
•The need for temporary or immediate dentures
•Final crown/bridge repair or cementation if the temporary restoration is lost or broken.
•Problems with implants or implant prosthesis
•Ulceration due to sharp edges of tooth or prosthesis

STERLIZATION PROTOCOL
Alginate – 0.5 % Sodium Hypochlorite or iodophors or
2% Gluteradehyde
Zinc-oxide eugenol impression paste – 2%
Gluteraldehyde or Chlorine compounds
Elastomeric impression materials – 2% Gluteraldehyde
or Cidex
Prefer disposable trays
Metal trays to be autoclaved
Plastic trays/Bite rim 2% Gluteraldehyde solution for 10 mins
Dental casts & die can be immersed in Sodium Hypochlorite for 10
min
Soaking of denture in 3% Hydrogen Peroxide for 30 mins
Soaking in 0.2% Chlorhexidine gluconate for 10 mins (More potent
than Sodium hypochlorite)
100% Vinegar (acetic acid) for 6-8 hours

 A mandatory pre procedural mouth rinse is also advocated to reduce the microbial load of the
oral cavity for each and every patient visiting the clinic for any emergency or urgency
consultation. Routine mouth rinse using chlorhexidine might not be useful.
 Since the virus is susceptible to oxidation a mouth rinse of 1% hydrogen peroxide or 0.2%
povidine iodine will prove helpful.
 Patients should also be covered with a full length drape with their hands tucked in and a head
cap and goggles and the immediate extra oral area may be wiped with
 Betadine solution or a disposable disinfectant face wipe before commencing the procedure

 The patient is advised to safely keep the dislodged crown,
 FPD or implant prosthesis in a box with butadiene solution.
 Patient is also advised to send a picture of the dislodged prosthesis via email or whatsApp.
 If it is urgent & patient is healthy, appointment is ﬁxed.
 The prosthesis is cleaned any residual cement, disinfected again in the operatory and tried in patients’
mouth. If the ﬁt is satisfactory, the prostheses is re-cemented and due instructions is provided to the
patient.

 In case of ill ﬁtting prosthesis, the patient provide with a temporary prosthesis which can be
fabricated chair side or sent to the lab as deemed necessary
 Slow speed micromotors with contra angle hand-pieces to be given preference.
 High vacuum extra oral suctions used in conjunction with high speed saliva ejectors, should
be mandatory to minimize aerosol dissemination.

METHODS TO REDUCE VIRAL LOAD IN OPERATORY
 High Efficiency Particulate Air (HEPA) filters and Negative ion
generators have also shown promise in reducing the viral load in the
air of the operatory.
 HEPA filters help in removal of particulates from the air of the size as
small as 0.3 microns quite efficiently from the surrounding air
especially in closed rooms.
 Negative ion generators also can come in handy in the current
scenario which tend to fill the air with millions of negative ions in the
air of the room and have an effect on the lipid layer of the virus akin to
that by the soap that is it breaks down the lipid layer of the virus and
thus helps in reduction of the viral load.
 After every splatter related /aerosol generating treatment strict
fumigation is to be done.

OSSEOUS DISORDERS
 Osteoporosis
 Osteoarthritis of TMJ
 Rhenumatoid arthritis of TMJ
 Fibrous dysplasia
 Ostetis deformans

Osteoporosis is a decrease in the skeletal mass without alteration in the
chemical composition of bone, affects micro-architecture of the bone
thus increasing the bone turn over and bone fragility
o Common in aging individuals, especially post menopausal women when
the estrogenic blood level is low.
o Caused by a variety of factors such as calcium loss, calcium deficiency,
hormonal deficiency, change in protein nutrition and decreased physical
activity.
o Progressive loss of alveolar bone may be a manifestation of osteoporosis.
OSTEOPOROSIS:

MANAGEMENT:
 Designing complete denture requires special consideration for these patients
to preserve the underlying tissue structure as much as possible.
 Estrogen therapy can retard severe bone demineralization caused by
osteoporosis in women.
 Adequate dietary calcium intake is essential.

DENTAL IMPLANT MANAGEMENT:
 Although osteoporosis is significant factor for bone volume and density, it is not a
contraindication for dental implants .
 Success rate of dental implants in osteoporosis patients is comparable to healthy
patients. Dental implants can be placed and managed with predictable prognosis in
osteoporosis patients under oral Bisphosphonates.
The bone density does affect the treatment plan, surgical approach, length of
healing and loading.
Implant designs should be modified.


Painful mandibular movements difficulty in construction of dentures.
Special impression trays accommodate reduced mouth opening.
Difficulty in recording jaw relations.
Occlusal corrections have to be made often.
 It is characterized by breakdown of the articular cartilage, architectural changes in bone,
and degeneration of the synovial tissues causing pain and/or dysfunction in functional
movements of the jaw.
 Characterised by pain, clicking, deviation on opening.
OSTEOARTHRITIS OF TMJ

Non-surgical modalities such as
• Control of contributory factors,
• Pharmacological interventions as well as
• Physiotherapy.
• Cold or warm packs applied to the joint,
• Occlusal appliances,
Surgical treatment options include
• Intra-articular injections,
• Arthrocentesis (lavage of the joint) as well as attempts at repair or
replacement of portions of the TMJ.

RHEUMATOID ARTHRITIS
 Chronic inflammatory disease characterized by synovial inflammation that destroys the
articular cartilage and underlying bone, and causes erosions
ETIOLOGY:
 The cause of RA is not known
 Due to sudden influx of T cells into the affected joints and is followed by an increased number of
macrophages and fibroblasts, drawn by the release of cytokines, particularly IL-1, and TNF-α.
CHARACTERISTICS:
 Synovitis
 Affects small joints of the upper and lower extremities.
 fatigue, loss of appetite, weakness and vague musculoskeletal pain.

GEN MANAGEMENT:
NSAIDS- first line
Second-line" or disease-modifying antirheumatic drugs, or DMARDs like gold, sulfasalazine,
hydroxychloroquine, methotrexate.
DENTAL MANAGEMENT:
 Oral hygiene procedures may become difficult because of reduced manual dexterity.
 Such patients may have particular difficulty in removing or inserting removable partial dentures .
 Implant in conjunction with fixed prostheses can be utilised as option.

DIFFICULTIES WITH RA
a. Changes in occlusion:
As the joint tissue are more susceptible to increased loading, the prosthetic reconstructions
should be aimed at giving unloading appliances and improve the distribution of occlusal force.
b. Jaw relation:
There is a difficulty in recording an acceptable jaw relationship because of the destruction of
joint tissues.
There is a large distance between the most returned and the intercuspal position i.e., CR-CO.
In such situations a muscularly relaxed and comfortable jaw position should be chosen and
tried in provisional constructions before the permanent rehabilitation is completed.

 Many reports have revealed that surgical correction of rheumatoid-associated TMJ
disease and the resulting dentofacial deformity can successfully be treated by a
surgical TMJ reconstruction with mandibular advancement surgery with or without
maxillary orthognathic surgery and genioplasty.
 Sato et al also demonstrated that occlusal reconstruction using a prosthetic
approach might be of considerable value for inducing the desirable remodeling of the
condylar heads.

FIBROUS DYSPLASIA
ORAL MANIFESTATIONS :
Twice as common in maxilla than mandible
Monostotic fibrous dyplasia begins as a painless, progressive lesion.
Teeth may move as a consequence of progression.
Predisposition to fracture.
Slow healing and increased incidence of infection.
Non-neoplastic, self-limited intracortical fibroosseous lesion, fibrous connective
tissue replaces areas of normal bone in an unorganized arrangement.

IMPLANT CONSIDERATION :
 The implant placement is contraindicated in the regions of this disorder because of lack of
bone and increased fibrous tissue which reduces rigid fixation of the implant.
 Excision of the fibrous dysplasia areas is usually the treatment choice.
 After the condition is corrected long term, the area may receive an implant.

OSTEITIS DEFORMANS
It is a slowly progressing chronic disease characterized by excessive, uncoordinated phases
of resorption and deposition of osseous tissue in single / multiple bones.
May present with pathologic fracture
The jaws are affected in 20% of the cases .
The maxilla is more often involved than mandible

ORAL MANIFESTATIONS:
Pain with bilaterally symmetrical swelling of the involved bone.
Leontiasis ossea - facial bone involvement
Headache, blindness, deafness.
Difficulty in wearing old dentures.
Diastema, loosening of teeth, malocclusion may be seen.
Necrosis of gingiva over the underlying bone may occur due to excessive internal pressure.
Pathologic fractures also may occur as bone becomes very weak.

MANAGEMENT
The remakes and adjustment of dentures are needed due to continual enlarging and changing
of supporting structure especially of the maxillary tuberosity.
Oral implants are contraindicated in the regions affected by this disorder .

NEUROLOGICAL DISORDERS
 The neurologic conditions like parkinson’s disease, stroke, and seizures require thorough
history and list of medications.
 Reduction in muscle tone, with a consequent reduced control of mouth and tongue
movements, are significantly high.
 A consultation with physician is helpful in treating these patients.

HOUSE-BRACKMANN FACIAL NERVE GRADING SYSTEM
Grade I - Normal
Normal facial function in all areas
Grade II - Slight Dysfunction
Gross: slight weakness noticeable on close inspection; may have very slight synkinesis
At rest: normal symmetry and tone
Motion: forehead - moderate to good function; eye - complete closure with minimum effort; mouth - slight
asymmetry.
Grade III - Moderate Dysfunction
Gross: obvious but not disfiguring difference between two sides; noticeable but not severe synkinesis,
contracture, and/or hemi-facial spasm.
Motion: forehead - slight to moderate movement; eye - complete closure with effort; mouth - slightly weak with
maximum effort.

Grade IV - Moderate Severe Dysfunction
Gross: obvious weakness and/or disfiguring asymmetry
Motion: forehead - none; eye - incomplete closure; mouth - asymmetric with maximum effort.
Grade V - Severe Dysfunction
Gross: only barely perceptible motion
At rest: asymmetry
Motion: forehead - none; eye - incomplete closure; mouth - slight movement
Grade VI - Total Paralysis
No movement

• Bell’s palsy is a rapid unilateral facial nerve paresis
(weakness) or paralysis (complete loss of movement) of
unknown cause.
• The myriad treatment options for Bell’s palsy include
• Medical therapy (steroids and antivirals, alone and in
combination),
• Surgical decompression,and
• Complementary and alternative therapies (acupuncture)
BELL’S PALSY

 Prosthodontic considerations :
•The most difficult step is jaw due to non-repeatability of the path of closure and bite position on the
bite plane.
•Non- anatomic teeth.
•Heat strength metal reinforced denture bases .
•Denture hygiene instructions.
Proper training on insertion & removal of dentures.
•Regular follow-up.

PARKINSON’S DISEASE (SHAKING PALSY)
Dr. James Parkinson in 1817.
 It is a progressive neurogenerative disorder effecting muscle
control, movement, balance and many other nonmotor
functions.
 Occurs mostly above 50 yr. of age.
 Cause – destruction of dopamine producing brain cells which
control muscular movement.
 “Pill-rolling” movement between thumb and fingers is the
typical feature of Parkinson’s disease

ORAL MANIFESTATIONS
 “Mask like” appearance due to the reduced movements of facial muscles. Other symptoms
include lip pursing and tongue thrusting.
 More time to consume food due to reduced tongue movement, slow chewing movement and
dysphagia
 Drooling of saliva
 Xerostomia due to anticholinergics

PROSTHODONTIC CONSIDERATIONS :
 Morning short appointments
 An intraoral rubber bite block or extra oral ratchet type prop should be used to keep
the mouth of the patient open for the convenience of the procedure.
 When dentist is providing replacement complete denture, duplication technique
should be used in order to retain the learned muscle control of familiar denture.
 Quick setting impression materials should be used.

 Metal denture bases or high impact denture base resins are preferred
 Monoplane occlusion to be preferred
 The weakness of the muscles of mastication, such as the buccinator muscle,
alters the dynamics of eating, causing food stagnation in the fornix area.
 Denture cleansers to be given

FIXED PROSTHODONTICS
 The use of rubber dam and suction aids is compulsory especially when there is
drooling of saliva
 Supra gingival or equigingival margin of the preparations are preferred.
 Resin fused to metal or gold bridges should be used in the patients with bruxism.
The retainers and the pontic of the prosthesis should be designed for being self
cleansing.
 Fixed partial dentures should be cemented using resin cements as it reduces
miroleakage.
.

IMPLANT PROCEDURES:
 The use of implant supported prosthesis has greatly improved the general as well as
oral health of the patient; masticatory ability of the patient is also improved with the
use of such prosthesis.
 Use of magnetic attachments in the mandibular over dentures is very helpful to the
patient as it is easy to insert and remove for the patient.

EPILEPSY
 Epilepsy is a disease that involves seizures which are characterized by an
alteration of perception, behavior and mental activities, as well as by
involuntary muscle contractions, temporary loss of consciousness and chronic
changes in neurological functions that result from abnormal electrical activity
in the brain

DENTAL MANAGEMENT
 In order to prevent such seizures, three fundamental principles should guide
the dentist during his or her interaction with the patient in a clinical
environment:
1) Knowledge of the patient’s previous seizure episodes and medication,
2) Knowledge of the conditions that provoke epileptic seizures, in order to avoid
such conditions, and
3) Dentist should be able to recognize the early signs of a seizure, take
precautions before it occurs, and provide the patient with supportive care if it
does occur

 During seizures, injuries such as soft tissue damage, tongue injuries, fractures
within the maxillofacial region, temporomandibular joint subluxations, tooth
fractures, subluxation or avulsion frequently occur.
 For these patients, therefore, a combination of prophylactic anti-epilepsy
drugs, in tandem with vitamin D and calcium supplements, is recommended

 Metal temporary crowns or implant-supported-bridges are more practical than
amalgam or porcelain restorations because of the risk of damage during seizures
 A rubber dam must be used in light of the risk of seizure during restorative treatment
 This is because there is a risk of the inhalation of and damage to the prosthesis if it
falls out of its normal position during seizure
 It is also proposed that a good denture and oral hygiene and a good fit of the
dentures decrease the risk of phenytoin induced gingival hyperplasia

HIV
 HIV is a lentivirus that causes AIDS, a condition in humans in which the immune system begins to fail,
leading to life-threatening opportunistic infections.
 Infection with HIV occurs by the transfer of blood, semen, vaginal fluid, pre-ejaculate, or breast milk.

 General Measures:
1. Create safe and empathetic environment.
2. Maintain confidentiality of patients’ information.
3. Use standard precautions.
4. Provide unbiased treatment.
5. Advise regular dental visits.
6. Identify and manage oral manifestations of HIV/AIDS.

MEASURES IN PARTICULAR TO PROSTHODONTICS:.
• Evaluation of periodontal status of existing dentition during construction of removable and fixed
dentures.
• Evaluation and management of xerostomia.
• Increased maintenance of dentures for prevention of candidiasis.
• Evaluation of temporomandibular joint disorders.
• Precautions during pre-prosthetic and implant surgeries.

 Use of protective barriers like disposable gloves, mask, eye protection or face shield, and gown during
routine patient care carried out by health care workers.
 SP encompasses precautions in the handling of sharps, blood; all body fluids, secretions and excretions;
and avoidance of contamination of non-intact skin and mucous membrane.
 Needle stick injury when working with a known case of infection should be reported to HIV centres
at the earliest.
 The provision of post exposure prophylaxis, including antiretroviral therapy, should follow thorough
risk assessment and counselling tailored to the need of the injured

 The materials should be first thoroughly rinsed under running water to remove gross contaminants like
saliva, blood and food debris and superficial microorganisms from the surface.
 To remove the microorganisms form the body of the prosthesis, spraying or immersion technique of
disinfection may be followed.
 Ultraviolet light may also be used for this purpose.
 Heat stable items like face bows, pliers, and metal impression trays should be heat sterilized rather
than disinfected. Impression should be disinfected in the same manner before submitting to the
laboratory.
 Alternative impression materials like autoclavable impression materials may also be used.

IMPLANT THERAPY IN HIV
 Implant therapy is not contraindicated in HIV/AIDS and can be successfully carried out with careful
and thorough evaluation and treatment planning.
 If the patients are immunologically stable with low viral loads, there is no need of modification of
implant therapy in patients with HIV infection.
 Careful attention should be given to rule out peri-implantitis and HIV associated oral lesions with
regular follow up. Thus a high compliance level of the patients is principally required.
 Implant Site Evaluation
 Osteopenia and osteoporosis are common side effects related to HAART therapy.

 The investigators conducted a 6 month follow up study to evaluate clinical and radiographic outcome
of endosseous oral implants placement in HIV-positive individuals under Protease inhibitors (PI) and
non-PI based HAART.
 There was no evidence of infection, bone loss or implant mobility and the implant success rate was
100 % for both groups.
 Beikler and Flemming recommended basic guidelines to be followed prior to placing implants like
diagnosis and treatment of cause of xerostomia, elimination of bacterial and fungal infections and
follow up at shorter intervals.

HEPATITIS VIRUS
 Hepatitis B virus (HBV) is transmitted through percutaneous (i.e., puncture through the skin)
or mucosal (i.e., direct contact with mucous membranes) exposure to infectious blood or body
fluids.
 HBV is highly infectious, can be transmitted in the absence of visible blood, and remains
viable on environmental surfaces for at least seven days.
 Persons with chronic infection (e.g., those with persistent hepatitis B surface antigen [HBsAg]
in the serum for at least 6 months following acute infection) serve as the main reservoir for
HBV transmission

 If surgery is required, it is advisable to:
Check the prothrombin time. If it is greater than 35, an injection of vitamin K
will usually correct the problem. This should be discussed with the patient’s
physician.
Monitor the bleeding time to check platelet function. If it is not less than 20
minutes, the patient may require platelet replacement before surgery. This
should also be discussed with the patient’s physician.

May have oral manifestations E.g. Pemphigus & lichen planus
Oral mucosa is very painful
Topical anesthesia and antibiotics to be used.
Constant use of dentures is contraindicated their use is primarily for mental
comfort
Any malignant lesions should be eradicated by surgery/ chemotherapy/ radiation
therapy.
Unless the radiation site is healed, denture should not be fabricated.
DISEASES OF SKIN

OTHER LESIONS TO BE CONSIDERED:
 Vesiculobullous lesions:
1. Pemphigus
2. Pemphigoid
3. Erythema multiformae
 Candida associated lesions
 Herpes
 HIV associated lesions
 Angular cheilitis

ORAL CANDIDIASIS
OPPOURTUNISTIC INFECTION BY C.ALBICANS
TYPES
• Pseudomembranous
• Erythematous
• Hyperplastic
• Angular cheilitis
• Median rhomboid glossitis

• Denture-wearing patients:
• Clean the denture and avoid wearing it overnight. Soak the denture in a dilute
solution of bleach (1 tsp for 8 oz of water) or in chlorhexidine gluconate 0.12% and
rinse thoroughly before reinsertion in the mouth. .
• Steroid inhaler users: Brush and rinse the palate after each inhalation.
• Topical treatment is usually required for at least 2 weeks to eradicate the infection,
although patients might feel symptom resolution 3–4 days usage.

• Clotrimazole (10 mg oral troches): Dissolve 1 troche in oral cavity 5 times a day.
• Nystatin oral suspension (100 000 U/mL): rinse 5 cc q.i.d. for 2 minutes and
expectorate.
• Topical - clotrimazole: 1% cream or nystatin: 100 000 U/g cream or ointment
• Denture-wearing patients: Apply a thin layer to the tissue side of the denture and the
infected oral mucosa after meals.

RADIOTHERAPHY
 Radiotherapy is increasingly being used as an adjunctive form of treatment in the management of head
and neck cancer.
TYPES OF RADIATIONS USED:
 Electromagnetic radiations (photons, x-rays, gamma rays) and
 Particulate radiations (electrons, neutrons and protons).
TYPES OF RADIATION THERAPIES:
1. Conventional radiotherapy
2. Intensity modulated radiation therapy
3. Brachy therapy.

COMPLICATIONS OF RADIOTHERAPY:
 Erythema, mucositis, ulcers, fungal infections,
 Xerostomia,
 Caries from decreased salivary flow and ph changes,
 Infection in the jaws or the potential for osteoradionecrosis from infection or trauma to
irradiated bone

Various physical methods to reduce side effects are:
 Protective shielding, proper positioning and the use of multiple fields.
 By modifying dose and fractionalisation
A Prosthodontist can help by the fabrication of radiation stents which can protect normal tissues
from radiation injury.

PROSTHETIC DEVICES USED:
 Stents
 Shields
 Positioners
 Carriers
 Splints

 The main purpose of these prostheses is to hold the radiation source securely in the same
place during the entire period of treatment.
 It should be easy to load and unload.
 The exact location and the number of sources are determined by the radiotherapist and are
marked on the dental model.
 They are of two types;
Preloaded Carriers
After Loaded Carrier

1. Radioactive source (cesium132 or iridium 192).
Direct implantation of the radioactive source in the tumor useful in; Lesion of the tongue and anterior floor
of the mouth, palatal tumors
Preloaded (RS position within prosthesis prior to carrier insertion) medical staffs receives some
exposure.
After loading technique, isotopes are threaded into the hollow tubing after the carrier is in predesigned
location reduces the radiation exposure to medical staff.
Used to position the source and also determine the proper depth of insertion.

PERIORAL CONE POSITIONING STENTS
 This type of stent is commonly used when boosting the dose to the trauma site.
 It holds the cone in the repeatable and the exact position as desired by the
radiotherapist, thus minimizing the chances of the movement of the cone during a
particular treatment session.
 The actual cone or cylinder of the same diameter as the cones is used to form an
acrylic resin ring of 5 to 6 cms long.
 Tin foil is wrapped around the cone as a separator from acrylic resin.

 Cone is centered over the lesion.
Cone is centered over the lesion.

RADIATION PROTECTION/ SHIELDING STENTS
 They are used to shield the vital structures which are adjacent to radiation therapy sites from
excess dosage of radiation
 The therapy beam scatters electrons from the high-Z metals used in the dental alloys,
resulting in a local dose enhancement, which leads to excess dose in the surrounding tissues,
thus causing mucositis.
 Low melting alloys like Cerroband, Pb-Bi-Sn, and Lipowitz are used as shielding materials.
 Cerrobend alloy is preferred because of its low melting temperature and it effectively prevents
the transmission of the electron beam.

POSITION MAINTAINING STENTS
 It is used to precisely position structures which are to be treated in fixed and
repeatable positions for multiple treatment sessions.
 They are used to position movable structures like tongue, soft palate etc.

TONGUE DEPRESSING STENTS
 It is a custom made device which positions the mandible,
depresses the tongue and spares the parotid gland
during radiotherapy of head and neck tumours.
 An interocclusal stent is prepared for the dentate patient,
that extends lingually from both the alveolar ridges, with a
flat plate of acrylic resin which serves to depress the
tongue.
 A hole is made in the anterior segment in which the tip of
the tongue is placed in order to establish a reproducible
position.

DOSIMETER POSITIONING STENTS
 Dosimeter is a device which is used to calculate the amount of doses required for a lesion.
 These stents are designed with a series of slots for holding lithium fluoride capsules.
 The lithium fluoride capsule is wrapped in a 0.1 inch tinfoil which is wrapped with acrylic resin
casing and is allowed to cure.

TISSUE RECONTOURING STENTS
 These stents are effective when treating skin lesions which are associated with lips when the
beam is adjusted for midlines.
 Low doses are delivered at the corners of the mouth because of the curvature of the lips.
 A stent can be made to flatten the lip and the corner of the mouth, thereby placing the entire
lip in the same plane.

TISSUE BOLUS COMPENSATORS/ BALLOON BOLUS
SUPPORTING STENTS
TING STENTS
 These prostheses help in the treatment of superficial lesions of the face with irregular
contours.
 BOLUS is a tissue equivalent material which is placed directly onto or into the irregularities,
that helps in converting irregular tissue contours into flat surfaces which are perpendicular
to the central axis of the ionizing beam, to thereby more accurately aid in the homogenous
distribution of the radiation.

DENTAL IMPLANTS AND RADIOTHERAPY
• The incidence of ORN of the mandible varies from 5% to 15%, and the
incidence of ORN of the maxilla is much lower.
• An irradiated bone has a greater risk of implant failure than a nonirradiated
bone.
• 5-year survival rate in the ORN group was only 48.3%.
• Histomorphological BIC had no significant difference between 15Gy control
side and 15Gy radiation side. 30Gy radiation side showed a significantly lower
BIC.

 Implant placement before radiotherapy is still a valuable treatment modality
considering bony site with poor healing capacity after irradiation.
 It would be recommended submerging the implant until tumor therapy (including
radiotherapy) is complete, as well as using a longer healing period for nonirradiationa
cases.

• For the tissue damage after radiotherapy, HBO can improve the implant survival rate and
achieve the ideal efficacy
• BMP could enhance the generation and repair of bones after radiotherapy
• In a recent study, combined adenovirus-mediated human BMP-2 gene-modified bone marrow stromal
cells with allograft enhanced the defect healing and improved the strength of implant fixation with
osseointegration in a 3-mm bone defect around a titanium alloy implant.
 The OPG is a 14-mer bone cell mitogen that increases bone formation and trabecular bone density
and stimulates fracture healing.
 Animal experiments showed that OPG could induce the transformation of cartilage callus into bone
callus at the fracture site, promote the differentiation and maturation of the bone cells around
implants, and accelerate the process of osseointegration

CONCLUSION
 There is a significant link between one’s oral health and overall health.
 Prosthodontist should know about the systemic status of the individual before
treatment planning.
 Neglecting the systemic status in the history can lead to serious complications
which may cost the life of an individual.
“A CLEAN MOUTH NEEDS A CLEAN BODY AND VICE VERSA”

REFERENCES:
 Essentials of Complete Denture Prosthodontics- Sheldon Winkler.
 Contemporary dental implant prosthetics- carl misch
 Rosenstiel,Land,Fugimoto
Contemporary Fixed Prosthodontics 3rd edi. The mosby co.
 Shillingburg H.T etal.
Fundamentals of fixed Prosthodontics.3r edi.quintessence pub.co
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