systemic disease and their effect on prosthodontic treatment and role of prosthodontist in managing them

1. Prosthodontic failures in patients with
systemic disorders
A. Langer
Journal of Oral Rehabilitation, 1979 january, volume 6, pages 13-19
AJAY. Y

2. INTRODUCTION
• When a patient wishes to be treated for dentures, a careful examination and anamnesis have to be
made.
• In the course of the anamnesis a detailed medical and dental history has to be taken to diagnose any
systemic disease.
• The patient might suffer from, such as metabolic, hormonal, autoimmune, neurological, mental or
emotional disorders.

3. • No attempt should be made to treat or re-treat a patient suffering from denture problems related to
systemic disorders, unless the offending clinical symptoms are relieved by specific therapy of the
primary disease.
• Various systemic diseases play a pivotal role in deciding treatment options in dentistry.
• Prosthodontic procedures need to be carefully judged and planned according to the systemic
status of the patient.

4. NEUROLOGICAL DISORDERS

5. NEUROLOGICAL DISORDERS
• Manipulation with removable dentures, particularly with the complete ones, is based on a very
complex pattern of neuromuscular coordination.
• Instrumental for the activation of the dentures is the integrated action of the primary (chewing) and
secondary (tongue, lips and cheeks) muscles of the orofacial organ, which all take part in the actions
of speech articulation, mastication and swallowing.

6. • A typical neurologic disorder that has a disabling effect on the denture wearer is Parkinson's
disease (paralysis agitans).
• The tremulous muscle motion and lessened muscular power, render the use of dentures very
difficult.

7. • Furthermore, the anticholinergic agents used for symptomatic treatment of Parkinson's disease, and
especially the recent and widely used L-dopa (L-dihydroxyphenylalanine), have a side effect of
severe xerostomy.
(Davidson & Macleod, 1971; Harrison, 1974).

8. • Denture wearers suffering from myasthenia gravis may be mistakenly referred to a prosthodontist
for new dentures because of chewing difficulties, characterized by lessening power of mastication.
• In most cases the disease affects the facial and pharyngeal muscles as well, and its first
manifestations are often in swallowing difficulties (dysphagia).

9. • Unless the disease is diagnosed before the beginning of prosthodontic treatment and the patient
referred to a neurologist, a dangerous situation may occur during clinical procedures (impression
taking) and the final result may be most embarrassing for the operator and disappointing for the
patient.

10. • Progressive bulbar palsy occurs generally in the fifth and sixth decades of life and is characterized
by weakness of facial muscles, loss of power of masticatory muscles, difficulty in chewing,
swallowing and phonation.
• Fasciculations and jerky twitchings of the tongue and face leads to disabled mastication, especially
an inability to speak articulately.
• The effect is more obvious in the mandibular denture, since its retention and functioning depend
on tongue adaptation and pattern of manipulation.
Shafer, Hine & Levy, 1974

11. Metabolic and autoimmune
disorders

12. METABOLIC AND AUTOIMMUNE DISORDERS
• Diabetes mellitus is known to produce a tenderness of the mucosa, rendering it prone to
infections, and notably to Candida alba , dryness of the oral mucosa and glossodynia .
• The patients will complain of a burning sensation beneath the dentures, which they usually attribute
to the dentures and futilely try to relieve the symptoms by making new ones.
Pindborg, 1970.

13. • The IDDM are more likely to develop glucose imbalance during treatment than those with
NIDDM.
• The operator should use an impression technique that will produce maximum physiologic
compatibility of the denture base with supporting structure.
• Careful occlusal correction should be accomplished to remove all interferences.
• Diabetic patients are prone to develop infections and vascular complication so an antibiotic
prophylaxis before dental surgery to prevent subsequent infection is advised.

14. • A common complaint among postmenopausal women is a burning sensation of the mucosa,
mainly of the tongue (glossopyrosis) and of the palate in the region of the incisive papilla.
• The patients tend to put the blame on the denture material, their faulty construction or the dentist
himself, as the symptoms often appear concurrently with the transition to complete dentures..

15. • If the disease is recognized early on in the treatment, it is advisable to explain the problem to the
patient and be very careful in promising improvement by replacing the dentures with new ones
made of different materials and by more sophisticated techniques though in some cases cast-metal
bases (e.g. cobalt-chromium) can bring some relief.

16. • Another disorder, occurring predominantly in the menopausal and post-menopausal women is
Sjogren's Syndrome.
• Symptoms -keratoconjunctivitis sicca , xerostomy and sometimes rheumatoid arthritis, lupus
erythematosis or scleroderma. This disorder is of obscure aetiology, though there are strong
indications as to its autoimmune character.
(Robbins & Angell, 1971).

17. • Lack of salivary lubrication, due to degenerative changes and consequently dysfunction of the
salivary glands, causes a burning sensation in the emaciated mucosa and difficulties in chewing
and swallowing with dentures.
• The typical complaint, as in other cases of xerostomy, is that of a feeling of food sticking to the
dentures and underneath their bases.

19. THYROID DISORDERS
• The most common thyroid disorder patient seen in dentistry is one with known and treated thyroid
disease.
• So these types of patients without any symptom can be considered as low risk and a normal
protocol can be followed for implant surgery and prosthodontic appointments.

20. • The patients with thyroid disorder who has no symptoms but had recently thyroid function test is
considered as moderate risk category. These patients may follow a normal protocol in addition
with stress reduction.
• The use of epinephrine and CNS depressant drugs should be limited- in moderate to advanced
implant procedures and surgery.
• The patients with symptoms are considered at high risk. Such patients should have only
examination procedures performed and all other treatment is defaced until the medical and
laboratory evaluation confirms controls of disorder.

21. PULMONARY DISEASES

22. PULMONARY DISEASES
• Patient with difficulty in breathing upon exertion and using bronchodilator therapy should undergo
medical examination.
• The use of epinephrine or vasoconstrictors in anesthetics or gingival retraction cord is not advised.
• In patients with high risk like acute exacerbation and history of CO2 retention, the moderate and
advanced surgical or prosthetic procedures are contraindicated.
• The use of epinephrine, narcotics, sedatives and tranquilizers should be discussed with physician.

23. LIVER DISEASES

24. LIVER DISEASES
Cirrhosis
• In these cases the two most commonly affected is synthesis of clotting factors and ability to
detoxify drugs.
• Dental Implant Management : Non-surgical and simple surgical procedures may follow normal
protocol. Use of sedatives and tranquilizers need physician clearance.
• Strict attention to hemostasis is indicated.
• Moderate to advanced surgical procedure requires hospitalization.

25. BONE DISEASES

26. BONE DISEASES
Fibrous dysplasia:
• The implant placement is contraindicated in these disorders because of lack of bone and
increased fibrous tissue, as it reduces rigid fixation of the implant.
• After the excision of the fibrous dysplasia area, they may receive implant.

27. • Osteoporosis is the commonest metabolic bone disease. Its onset is earlier and progress more
rapid in females, appearing most frequently soon after menopause.
• This disease often leaves the alveolar bone devoid of its cortical layer and the residual ridges are
sharp and covered with spicules as a result of uneven resorption.
• The osteoporosis is most evident in the spine and pelvis. Hence prosthodontists should pay
attention to persistent backache history, resulting from vertebral collapse.
(Langar, 1976).

28. • If the disease is properly diagnosed, the patient should be referred to a specialist to adjust his
dietary habits by balancing his vitamin and calcium intake.
• In addition, the denture bases should be lined with soft reline material, extending over the entire
support area and carefully balanced.
Combe & Grant, 1973

29. • In a patient affected by osteoporosis and polyarthritis, Eder et al. reported a peri-implant bone
resorption of 1.38 mm at four years, slightly greater than expected in a healthy subject.
Eder et al.

30. • Rheumatoid arthritis: The temporomandibular joints are frequently affected in this disease.
The problem encountered in the prosthodontic rehabilitation of patients with Rheumatoid
arthritis of TMJ are:
• a. Changes in occlusion.
• b. Jaw relation

31. a. Changes in occlusion:
• As the joint tissue are more susceptible to increased loading, the prosthetic reconstruction should be
aimed at giving unloading appliances and improve the distribution of occlusal force.
• The removable denture in the lower jaw was not only beneficial for chewing but also for unloading
the diseased joints.
• Treatment should be primarily focused on antirheumatic medications as the prosthetic procedures
do not cure the joint disease and are therefore secondary.

32. 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.
• Since the disease commonly occurs between acute and chronic stages. The irreversible treatment
like fixed prosthesis should not be given until the disease is cured.

33. CARDIAC DISEASES

34. CARDIAC DISEASES
Angina pectoris:
• Patients with mild angina may undergo non surgical dental procedures.
• The vital sign has to be monitored during the procedure and the patient is instructed to have
nitroglycerine. The implant surgery is performed with nitrous oxide or oral reduction.
• The use of vasoconstrictors is limited to 0.04 to 0.05 mg epinephrine. Patient with moderate angina
should be given nitroglycerine sublingually just before advanced operative or simple to moderate
implant surgery.

35. Myocardial infarction:
• Patients with MIT in preceding 6 months can have dental examination, but treatment has to
postpone if possible for 6 months. Longer procedures should be segmented into shorter
appointments .
• Elective implant procedures should be postponed for at least 12 months following MI.
• Hospitalization is an accepted modality for all advanced surgical procedures regardless of time
elapsed after MI.

36. Subacute Bacterial Endocarditis:
• The Endocarditis prophylaxis are recommended for procedures like dental implant placement, sub
gingival placement of antibiotic fibers or strips.
• The Endocarditis prophylaxis is not recommended for the placement of removable prosthodontic
appliances and making impressions.

37. Congestive cardiac failure:
• The patients with chronic heart failure may be at risk for acute exacerbation during dental
procedure.
• If during a dental procedure a patient experiences acute dyspnea, certain actions must be taken -
administer oxygen and ask the patient to sit upright.
• Medication prescribed for Congestive heart failure, are classified as three D’s –digitalis, diuretics
and dilators.
• Digitalis increases the heart’s pumping action, diuretics eliminate salt and water, vasodilator dilate
the blood vessels so that pressure decreases and blood can flow more readily.

38. Hypertension:
• A stress reducing protocol is indicated for anxiety patients by giving diazepam 5 to 10mg, night
before a procedure.
• Most of the patients undergoing anti hypertensive therapy use NSAID concomitantly , these drugs
have shown to reduce the action of hypertensive agents.
• So it is recommended that NSAIDs be limited to short therapy and other analgesics be used.

39. SALIVARY DYSFUNCTION

40. SALIVARY DYSFUNCTION
• This leads to xerostomia or dry mouth.
• Complaints of xerostomia necessitates the search for an underlying systemic disease. Many
systemic disease cause salivary dysfunction, the most prominent is Sjogren’s syndrome.
• The drugs like antidepressants , antihypertensive, antihistamines and diuretics also result in
xerostomia.
• So a complete and detailed medical history of patient should be taken because of vast etiology of
salivary dysfunction.

41. HEMATOLOGIC DISEASES

42. HEMATOLOGIC DISEASES
Anemia:
• Anemia is the most common hematologic disorder resulting from decreased production of
erythrocytes.
Dental implant consideration:
• Bone maturation and development are often impaired in the long term anemic patient. There is a
reduction in 25% to 40% trabecular pattern. Therefor the character of the bone needed to support
the implant is significantly reduced.
• The time needed for a proper interface formation is longer in anemic patients.

43. CONCLUSION
• The above discussion shows the importance of systemic status of an individual. It also shows the
impact of drugs taken for the diseases on the outcome of treatment.
• The successful management of patient begins right from the medical history to the treatment plan in
which much consideration has to be given to the systemic status of individual.
• The practitioner neglecting the systemic status in the history will step into more serious
complication at the cost of individual life.

44. REFERENCES
• The Hypertensive Dental Patients: 6. JADA 1997 vol 128, Aug: 1109 – M. Glick.
• Systemic Diseases of Concern to Prosthodontist -Niyati Singh ,International Journal of Oral Health
and Medical Research | ISSN 2395-7387 | July- august 2015 | vol 2 | issue 2.
• Contemporary implant dentistry – Carl E. Misch .
• Dental implants in patients affected by systemic diseases. 2014 Oct;217(8):425-30. doi.2014.911,
Donos N, Calciolari E.
• Value of Medical diagnostic screening tests for dental patients – JADA 1970 vol 80 Jan: 133 –
William Sabers

45. • Hussain M, Yazdanie N, Askari J. Management of diabetes mellitus patients in prosthodontics. J Pak
Dent Assoc. 2010 Jan;19(1):46-8.
• Suresh S, Asopa V. Prosthodontic management of complete edentulous patients with neuromuscular
disorders-Case reports. Journal of Advanced Oral Research. 2011 Apr 15;2(1):67-72.
• Singhal S, Chand P, Singh BP, Singh SV, Rao J, Shankar R, Kumar S. The effect of osteoporosis on
residual ridge resorption and masticatory performance in denture wearers. Gerodontology. 2012
Jun;29(2):e1059-66.
• Hussain S, Jayesh R, Nayar S, Aruna U, Abraham AM. Prosthodontic management of a completely
Edentulous patient with Bell's Palsy. Indian Journal of multidisciplinary dentistry. 2011 Nov 1;2(1).

46. Prosthodontic failures in patients with
systemic disorders
A. Langer
Journal of Oral Rehabilitation, 1979, volume 6, pages 13-19
AJAY