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Diagnosis and treatment planning in implants 1. /certified fixed orthodontic courses by Indian dental academy


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Diagnosis and treatment planning in implants 1. /certified fixed orthodontic courses by Indian dental academy

  1. 1. Diagnosis and treatment planning in implants. – part 1 INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. HISTORY CLINCAL EXAMINATION Diagnostic imaging Mounted study casts. Joint assessment Surgeon/restortive dentist. Psychological assessment Treatment plan Informed consent Medical assessment 2
  3. 3. 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 3
  4. 4. 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  4
  5. 5. 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 5
  6. 6. 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. 6
  7. 7. Medical A full and comprehensive review of a patients medical history should be undertaken. 7
  8. 8. HISTORY CLINCAL EXAMINATION Diagnostic imaging Mounted study casts. Joint assessment Surgeon/restortive dentist. Psychological assessment Treatment plan Informed consent Medical assessment 8
  9. 9. Medical assessment It comprises of  Vital signs  Laboratory evaluation  Systemic diseases 9
  10. 10. Vital signs Blood pressure Pulse Temperature Respiration. 10
  11. 11. 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.  11
  12. 12. Blood pressure Blood pressure There are two methods of determining blood pressure.  Direct  Indirect. 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. 12
  13. 13. Blood pressure Blood pressure Two most common monometer systems  Mercury gravity  Aneroid gauges. Mercury system is more accurate with changing climates. 13
  14. 14. 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. 14
  15. 15. Relevance to implant patient. Helps in diagnosing hypertensive patients. 15
  16. 16. 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.  16
  17. 17. 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 17
  18. 18. Pulse rate Pulse 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. 18
  19. 19. Pulse rate Pulse 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. 19
  20. 20. Pulse rate Pulse 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  20
  21. 21. Pulse rate Pulse 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. 21
  22. 22. Pulse rhythm In history of cardiovascular disease and hypertension, pulse rhythm should be always recorded. 2 types of abnormal pulse rhythm.  Regular  Irregular. 22
  23. 23. Pulse rhythm Pulse rhythm Regular irregularity. Which Increases during exercise indicates Atrial fibrillation • Hyperthyroidism. • Mitral stenosis. • Hypertensive heart disease. Stress reduction protocols. Implant may be contraindicated. 23
  24. 24. Pulse rhythm Pulse 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. 24
  25. 25. Pulse rhythm Pulse 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. 25
  26. 26. 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.  26
  27. 27. 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. 27
  28. 28. 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.  28
  29. 29. 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. 29
  30. 30. Temperature. Temperature. Low body temperature Hypothyroidism. 30
  31. 31. Respiration. Should be noted while patients is at rest. Breaths per minute Condition >20 requires investigation 16-20 normal regular in rate and rhythm. 31
  32. 32. 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. 32
  33. 33. 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. 33
  34. 34. 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 34
  35. 35. 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. 35
  36. 36. 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- Examination of blood is a more reliable test for patients glucose metabolism. Deficiencies or irregularities in Metabolism  Renal disease  Liver function  Suspected infection.  36
  37. 37. 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. 37
  38. 38. Complete blood Complete blood cell count. cell 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. 38
  39. 39. Complete blood Complete blood cell count. cell count. 1. RBC count. RBC’s are responsible for the transport of oxygen and carbon dioxide throughout the body and for control of the blood pH. No of RBC’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. 39
  40. 40. Complete blood Complete blood cell count. cell 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 40
  41. 41. Complete blood Complete blood cell count. cell count. 3. WBC differential. 41
  42. 42. Complete blood Complete blood cell count. cell 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. 42
  43. 43. Complete blood Complete blood cell count. cell 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. 43
  44. 44. Complete blood Complete blood cell count. cell count. 4. Cellular morphology and maturity. 44
  45. 45. Complete blood Complete blood cell count. cell 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 45
  46. 46. Complete blood Complete blood cell count. cell 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. 46
  47. 47. Complete blood Complete blood cell count. cell count. 7. Platelet count. per /ml 2,00,000-3,00,000 Normal below 80,000 A clinical symptoms occur 20,000 Spontaneous bleeding 47
  48. 48. Urinalysis. Urinalysis. CBC CBC Bleeding tests. Bleeding tests. Biochemical profiles Biochemical 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. 48
  49. 49. Bleeding tests Bleeding tests 1. Medical history History should include questions covering 5 topics. Bleeding problems in relatives. Indicate – inherited coagulation disorders. – Hemophilia – Christmas factor disease. 1. 49
  50. 50. Bleeding tests Bleeding 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. 50
  51. 51. Bleeding tests Bleeding 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. 51
  52. 52. Bleeding tests Bleeding 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. 52
  53. 53. Bleeding tests Bleeding 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. 53
  54. 54. Bleeding tests Bleeding 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) 54
  55. 55. Bleeding tests Bleeding tests Bleeding time. Ivy bleeding time  Measures  Coagulation pathways.  Platelet function.  Capillary activity.  Normal 2-8 minutes. 55
  56. 56. Bleeding tests Bleeding 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 56
  57. 57. Bleeding tests Bleeding 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. 57
  58. 58. Bleeding tests Bleeding 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. 58
  59. 59. Bleeding tests Bleeding tests Patients on Aspirin: Tests to be obtained. 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. & 59
  60. 60. Bleeding tests Bleeding 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. 60
  61. 61. Bleeding tests Bleeding 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. 61
  62. 62. Bleeding tests Bleeding 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. 62
  63. 63. Bleeding tests Bleeding tests In light of such controversial is advisable to consult with the physicians administering the medication regarding the need and amount of reduction and sequencing. 63
  64. 64. Bleeding tests Bleeding 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. 64
  65. 65. Bleeding tests Bleeding 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. 65
  66. 66. Bleeding tests Bleeding 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. 66
  67. 67. Biochemical profiles(Serum chemistry). 67
  68. 68. 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. 68
  69. 69. Serum glucose Serum 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 69
  70. 70. Serum glucose Serum 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. 70
  71. 71. Serum glucose Serum 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. 71
  72. 72. Serum glucose Serum glucose Serum calcium Serum 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. 72
  73. 73. Serum glucose Serum glucose Serum calcium Serum 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. 73
  74. 74. Serum glucose Serum glucose Serum calcium Serum calcium Inorganic phosphorous. Inorganic phosphorous. Alkaline phosphatase. Alkaline phosphatase. LDH LDH Creatinine. Creatinine. Bilirubin Bilirubin Decreased calcium. Seen in  Hypoproteinemic  Renal conditions disease. Diet of potential implant patient may be severely affected by the lack of denture comfort and stability. 74
  75. 75. 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. 75
  76. 76. 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. Cushing’s syndrome. 76
  77. 77. 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 user’s of aluminium hydroxide antacids. 77
  78. 78. 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 78
  79. 79. Serum glucose Serum glucose Serum calcium Serum calcium Inorganic phosphorous. Inorganic phosphorous. Alkaline phosphatase. Alkaline 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. 79
  80. 80. 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.  80
  81. 81. 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. 81
  82. 82. 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 µmol/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. 82
  83. 83. Systemic disease and oral implants. 83
  84. 84. 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 –stage hypertensive cardiovascular disease or insulin dependent diabetes with impaired normal activity 84
  85. 85. 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. 85
  86. 86. Cardiovsascular diseases. Hypertension. Angina pectoris. Myocardial infarction. Congestive heart failure. Sub acute bacterial endocarditis. 86
  87. 87. 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. 87
  88. 88. 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 88
  89. 89. 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.  89
  90. 90. 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. 90
  91. 91. Hypertension Hypertension Mild hypertension  Single diuretics drugs are used.  Fewest complications that can modify implant treatment. Combination drugs indicate a more severe hypertension. Patients taking additional drugs like clonidine exhibit severe hypertension and need medical consultation. 91
  92. 92. 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 medication may still be effective in elderly. 92
  93. 93. Type 3 Risk Systolic Diastolic Type Type 2 1.Type 3 Type4 Type Type 2 mm hg mm hg Multiple extractions 1 Scaling and root GingivectomyExamination. planning. sedatio High 13085-89 + + Sedatio Type 4 Radiographs. Quadrant peroseal normal 139 n n reflections Endodontics Study Sedatio Sedatio Hyperte 14090-99 Impacted arch implants + Full Sedatiomodel Simple nsion 159 n impressions. 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 Ridge Bilateral sinus Gingivectomy. graft. 179 n Supragingival elective augmentation.prophylaxis. procedures. Unilateral sinus Simple Advanced restorative Stage 3 180110-119 graft. Refer andpostmpone all elective restorative dentistry. 209 procedure. procedures. Unilateral subperiosteal postpone all elective Stage 4 >210 >120 Refer and Simple implants. implants. procedures. 93
  94. 94. Angina pectoris Angina 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. 94
  95. 95. Angina pectoris Angina pectoris Risk factors for Angina Smoking  Hypertension  High cholesterol  Obesity  Diabetes.  Angina is classified as Mild.  moderate.  Severe.  95
  96. 96. Angina pectoris Angina pectoris Precipitating factors. Exertion. Cold. Heat. Large meals. Humidity. Psychological stress. Dental related stress. 96
  97. 97. Risk Mild Type 1 Type 2 Type3 Type 4 One or + Sedation Moderate + less supplemental oxygen /month Type 2 and 3: vasoconstrictor is contraindicated. Moderat Antianxiety sedation with supplemental oxygen One orMild + Sedation Premedicat e less/wee e Type 4 may require a premedicate hospital setting. Type 3 and 4nitrates k Sedation supplemental Appointments 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 97
  98. 98. Angina pectoris Angina 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. 98
  99. 99. Angina pectoris Angina 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. 99
  100. 100. Angina pectoris* Angina pectoris* Side effects of nitroglycerin Decrease in blood pressure –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 –analgesics may be needed. Tolerance to drug can occur and so 2 tablets may be needed 100
  101. 101. 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. 101
  102. 102. 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 may radiate to left arm or mandible.  Pain is similar to angina pectoris but more severe. 102
  103. 103. Myocardial Myocardial infarction* infarction* Complications of MI 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% 103
  104. 104. 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 Type 4 104
  105. 105. 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. 105
  106. 106. 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. 106
  107. 107. Congestive heart Congestive heart failure* failure* Diuretics.(furosemide) eliminate excess salt and water. Dilators. Expands the blood vessels so that pressure decreases. Calcium channel blockers.  Gingival hyperplasia around teeth implants,or superstructure bars of overdentures, especially with nifedipine. 107
  108. 108. 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. Alpha-hemolytic streptococcus viridans  Sometimes staphylococci and anaerobes.  Mortality rate is about 10%. 108
  109. 109. 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.  109
  110. 110. 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. 110
  111. 111. 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, 111
  112. 112. 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. 112
  113. 113. SABE* SABE* Antibiotic regimens 113
  114. 114. 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. 114
  115. 115. 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. 115
  116. 116. 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.  116
  117. 117. 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. 117
  118. 118. Diabetes mellitus* Diabetes 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. 118
  119. 119. Diabetes mellitus* Diabetes 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. 119
  120. 120. Diabetes mellitus* Diabetes mellitus* Implant protocol. Most serious complication during implant procedure is hypoglycemia. It can be due to Excessive insulin level  Hypoglycemic drugs  Inadequate food intake.  120
  121. 121. Diabetes mellitus* Diabetes mellitus* Symptoms Weakness Nervousness Tremor Palpitations sweating Can be treated with sugar inform of candy or orange juice. Confusion Agittion Seizure Coma death 121
  122. 122. Diabetes mellitus* Diabetes 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. 122
  123. 123. 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. 123
  124. 124. 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 Diet/insulin Adjustmen t. Physician Hospitaliza tion. 124
  125. 125. 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. 125
  126. 126. 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. 126
  127. 127. Thyroid Thyroid Hypothyroidism Symptoms are related to decrease in metabolic rate.  Cold intolerance  Fatigue  Weight gain  Hoarseness  Decreased mental activity  Coma. 127
  128. 128. 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. 128
  129. 129. 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. 129
  130. 130. 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 procedures. 130
  131. 131. 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. 131
  132. 132. Adrenal gland disorder Adrenal gland 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. 132
  133. 133. Adrenal gland disorder Adrenal gland 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. 133
  134. 134. Adrenal gland disorder Adrenal gland disorder Cushing's syndrome. Characteristic symptoms Hyper function of adrenal cortex. Symptoms  Bruise easily  Poor wound healing  Experience osteoporosis  Increased risk of infection. Moon facies Trunc al obesity or “buffalo hump” Muscl e wasting hirsuti sm 134
  135. 135. Adrenal gland disorder Adrenal gland 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. 135
  136. 136. Adrenal gland disorder Adrenal gland disorder Steroids in implant surgery patient.  Decrease inflammation,swelling and related pain.  Also decrease protein synthesis and delay healing.  Decrease leukocytes and therefore reduce ability to fight infection. Therefore antibiotics are always prescribed whenever steroids are given to patients for surgery. 136
  137. 137. 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 137
  138. 138. Hematologic disorders. Erythrocytic disorders.  Polycythemia  Anemia Leukocytic disorders. 138
  139. 139. 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. 139
  140. 140. 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. 140
  141. 141. 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.  141
  142. 142. 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  142
  143. 143. Anemia Anemia Chronic anemia. Shortness of breath. Abdominal pain Bone pain Tingling of extremities Muscular weakness Headaches Fainting Change of heart rhythm nausea 143
  144. 144. 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 – it indicates 25-40% loss in trabecular pattern. Decreased bone density affects Initial implant placement  Initial amount of lamellar bone formation at interface.  144
  145. 145. Anemia Anemia Other complications. Abnormal bleeding.-decreased field of vision. Increased edema and discomfort postoperatively. Increased risk of postoperative infection and its consequences. 145
  146. 146. 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. 146
  147. 147. 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. 147
  148. 148. 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. 148
  149. 149. WBC disorders WBC 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. 149
  150. 150. WBC disorders WBC 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. 150
  151. 151. WBC disorders WBC 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. 151
  152. 152. 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. 152
  153. 153. 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. 153
  154. 154. Risk •Previously Mild •Acute Type 1 Type 2 unrecognized COPD + + Type 3 Type 4 + + exacerbation of respiratory infection breathing PHYSICIAN PHYSICIAN/MODE •Difficulty + Moderat •Patientssignificant only on with dyspnea at rest e RATE exertion TREATMENT. •Those with history of CO2 retention •Normal laboratory blood gases severe + POSTPONE•Procedure should be ELECTIVE (HOSPITALIperformed in hospital PROCEDURES •Difficulty breathing upon exertion •Those on chrnic bronchodilator therapy. CONTRAINDICATE ZATION) setting •those who have used corticosteroids. •No vasoconstrictor to be D. added to anesthetics or gingival cord if patient is on bronchodilators 154
  155. 155. 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. 155
  156. 156. 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 156
  157. 157. 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.  157
  158. 158. 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. 158
  159. 159. 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, 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. 40 % loss 159
  160. 160. 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.  160
  161. 161. Osteoporosis Osteoporosis Recommended calcium intake 800 mg/day. Average intake in United states 450 to 550 mg. Postmenopausal woman 1,500 mg is required. 161
  162. 162. 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. 162
  163. 163. 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. 163
  164. 164. 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. 164
  165. 165. 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. 165
  166. 166. Hyperparathyroidism. Mild Asymptomatic Moderate Renal colic. Severe Disturbances in Bone- alveolar bone depletion.  Renal  Gastric  166
  167. 167. 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. 167
  168. 168. 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. 168
  169. 169. Fibrous dysplasia Fibrous dysplasia •Increase in trabeculation Radiographically seen as the mottled appearance. •Facial plate usually expands moving the teeth along with it. 169
  170. 170. Fibrous dysplasia Fibrous dysplasia Implant dentistry is contraindicated in the regions of this disorder. Lack of bone and increased firous tissue  Decreases rigid fixation.  Susceptible to local infection processes. Excision of fibrous dysplasia is treatment of choice. Excised area may receive implant in long term. 170
  171. 171. 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.  171
  172. 172. Paget’s disease Paget’s disease Cotton or wool appearance radiographically. 172
  173. 173. Paget’s disease Paget’s disease There is no specific treatment. Patients are predisposed to development of osteosarcoma. Oral implants are contraindicated in the regions affected. 173
  174. 174. 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  174
  175. 175. Multiple Myeloma Multiple Myeloma Punched out lesions radiograph ically. •There is no treatment and condition is usually fatal 2 to 3 years after onset. •Implants are usually contraindicated. 175
  176. 176. Use of tobacco. There is established relationship between smoking and… 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. 176
  177. 177. 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. 177
  178. 178. 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. 178
  179. 179. Pregnancy Pregnancy Procedures which can be carried out.  Caries control  Emergency procedures.  Dental prophylaxis. Drugs approved  Lidocaine  Penicillin  Erythromycin  Acetaminophen. 179
  180. 180. Pregnancy Pregnancy Drugs usually contraindicated.  Aspirin  Epinephrine(Vasoconstrictor)  Narcotics analgesics (cause respiratory depression) Always contraindicated.  Diazepam  Nitrous oxide  Tetracycline. 180
  181. 181. 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 – 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. 181
  182. 182. Prosthetic joints Prosthetic 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. 182
  183. 183. Prosthetic joints Prosthetic joints Antibiotic prophylaxis Recommended for patients with higher risk for hematogenous infections undergoing dental procedures with a higher bacteremic incidence. 183
  184. 184. 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. 184
  185. 185. 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 185
  186. 186. 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. 186
  187. 187. 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.  187
  188. 188. 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. 188
  189. 189. 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. 189
  190. 190. 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. 190
  191. 191. HISTORY CLINCAL EXAMINATION Diagnostic imaging Mounted study casts. Joint assessment Surgeon/restortive dentist. Psychological assessment Treatment plan Informed consent Medical assessment 191
  192. 192. Psychological assesment 192
  193. 193. Attitute. It is important to assess the patients attitude in relation to  Reasons for treatment.  Any psychological problems.  Realism, regarding timing. 193
  194. 194. 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” 194
  195. 195. 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 195
  196. 196. Realism, regarding timing. Usually there is a time gap between the placement of fixture and their use for supporting a prosthesis. 196
  197. 197. HISTORY CLINCAL EXAMINATION Diagnostic imaging Mounted study casts. Joint assessment Surgeon/restortive dentist. Psychological assessment Treatment plan Informed consent Medical assessment 197
  198. 198.  Leader in continuing dental education  198