Diagnosis and treatment planning in implants 1.

Diagnosis and treatment
planning in implants. – part 1
Medical evaluation of Implant patient.
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HISTORY
CLINCAL EXAMINATION
Diagnostic
imaging
Mounted study
casts.
Joint assessment
Surgeon/restortive dentist.
Treatment plan
Informed consent Medical
assessment
Psychological
assessment

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

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

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

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.

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

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

Vital signs
Blood pressure
Pulse
Temperature
Respiration.

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.

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.
Blood pressureBlood pressure

Two most common monometer systems
Mercury gravity
Aneroid gauges.
Mercury system is more accurate with
changing climates.
Blood pressureBlood 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.
Blood pressure

Relevance to implant patient.
Helps in diagnosing hypertensive
patients.

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.

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

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.
Pulse ratePulse 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.

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

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.

Pulse rhythm
In history of cardiovascular disease and
hypertension, pulse rhythm should be
always recorded.
2 types of abnormal pulse rhythm.
Regular
Irregular.

Which Increases during exercise indicates
Atrial fibrillation
• Hyperthyroidism.
• Mitral stenosis.
• Hypertensive heart disease.
Stress reduction protocols.
Implant may be contraindicated.
Regular irregularity.
Pulse rhythmPulse 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.

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.

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.

Temperature.
Thermometer was invented by Galileo.
First used clinically by Santorio of Padua in 17th
century.
Every degree of fever increases the pulse rate
by 5 and respiratory rate by 4 per minute.
Temperature Condition
Oral temperature of
99.50
or higher
febrile range (feverish).
96.8 0
to 99.40
F. Normal. Lowest in morning, highest in
late afternoon or evening.

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.
TemperatureTemperature

No elective
surgery,including implants
should be performed in
febrile patients.
increases the
patient's pulse
rate
HemorrhageEdemaInfection
Postoperative discomfort.
Elevated temperature
may
complicate
the healing
TemperatureTemperature

Low body temperature
Hypothyroidism.
Temperature.Temperature.

Respiration.
Should be noted while patients is at
rest.
Breaths per minute Condition
>20 requires investigation
16-20 normal
regular in rate and
rhythm.

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.
RespirationRespiration

 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.
Hyperventilation
RespirationRespiration

Laboratory Evaluation
Urinalysis.
Complete blood cell count
1. RBC count
2. WBC count
3. WBC differential.
4. Cellular morphology and
maturity.
5. Hemoglobin
determination.
6. Hematocrit.
7. Platelet count.
Bleeding tests.
1. Check the medical history
2. Review the physical examination.
3. Screen the clinical laboratory tests.
1. Platelet count.
2. Bleeding time
3. Partial thromboplatin time.(PTT)
4. 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

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.

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.

Complete blood cell count.
Completer blood count (CBC) consists of
several individual measurements on a single
sample of venous blood.
1. RBC count
2. WBC count
4. Cellular morphology and maturity.
5. Hemoglobin determination.
6. Hematocrit.
7. Platelet count.

Indications for CBC.
1. Suspected dyscrasia (WBC and RBC )
2. Glucocorticoid therapy within 1 year.
3. Chemotherapy.
4. Renal diseases.
5. Expected major blood loss during
surgery.
6. Bleeding disorders.
Complete blood
cell count.
Complete blood
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.
Complete blood
cell count.
Complete blood
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
Complete blood
cell count.
Complete blood
cell count.

Complete blood
cell count.
Complete blood
cell count.

Neutrophils
An increase indicates inflammation.
Helps in finding if infection around an implant is
affecting the patients overall health.
Absolute neutrophil
count (ANC)
management
2000. normal dental treatment
without antibiotic
prophylaxis
1000-2000 need antibiotic coverage.
Less than 1000 physician referral.
Complete blood
cell count.
Complete blood
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.
Complete blood
cell count.
Complete blood
cell count.

4. Cellular morphology and
maturity.
Complete blood
cell count.
Complete blood
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
Woman 12-16 g/dl.
Normal
10 g/dl : pre-operative
threshold
minimum baseline for
surgery
8 g/dl. Many patients can
undergo surgical
procedure safely
Complete blood
cell count.
Complete blood
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 %
of normal are
required before sedation
or general anesthesia.
Complete blood
cell count.
Complete blood
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
Complete blood
cell count.
Complete blood
cell count.

Bleeding tests.
Bleeding disorders are one of the most
critical conditions encountered in surgery.
Ways to detect potential bleeding problems
are
1. Check the medical history
2. Review the physical examination.
3. Screen the clinical laboratory tests.
Over 90% of bleeding disorders can be
diagnosed on the basis of medical history
alone.
Urinalysis.
CBC
Bleeding tests.
Biochemical profiles
Urinalysis.
CBC
Bleeding tests.
Biochemical profiles

1. Medical history
History should include questions
covering 5 topics.
1. Bleeding problems in relatives.
Indicate
– inherited coagulation disorders.
– Hemophilia
– Christmas factor disease.
Bleeding testsBleeding tests

2. Spontaneous bleeding from the nose,
mouth, or other apertures.
3. Bleeding problems after operations,
tooth extractions, or trauma.
4. Use of medications that may cause
bleeding disorders.
– Anticoagulants
– Aspirin
– Long term antibiotics.

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.

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 petechia
bleeding gingiva
ecchymoses
Hemarthroses
hematomas
Acute or
chronic
leukemia.
Oral mucosa ulceration.
Hyperplasia of gingiva.
Petechiae or ecchymoses of skin or oral mucosa
Lymphadenopathy.

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.

Tests used to screen patients for
bleeding disorders.
I. Platelet count.
II. Bleeding time
III. Partial thromboplatin time.(PTT)
IV. Prothrombin time(PT)
 Additional tests
 Fibrinogen level.
 Thrombin clotting time (TCT)

Bleeding time.
Ivy bleeding time
Measures
 Coagulation pathways.
 Platelet function.
 Capillary activity.
Normal 2-8 minutes.

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

Normal PT
Abnormal PTT
Hemophilia
Abnormal PT
Normal PTT
Factor VII
deficiency
Abnormal PT
Abnormal PTT
Deficiency of
factors II,V,X or
fibrinogen.

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.

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.
&

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.

&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.

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.

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

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.

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.

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.

Biochemical profiles(Serum
chemistry).

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.

Serum glucose.
Normal range. 70-110 mg/ 100ml.
3.6-5.8 mmol/l
Serum glucose
Serum calcium
LDH
Creatinine.
Bilirubin
Serum glucose
Serum calcium
LDH
Creatinine.
Bilirubin

Is a relatively common finding.
Cause
diabetes mellitus.
Cushing’s disease.
Hyperglycemia.
Serum glucose
Serum calcium
LDH
Creatinine.
Bilirubin
Serum glucose
Serum calcium
LDH
Creatinine.
Bilirubin

Hypoglycemia.
It is unusual and can be due to varied
causes.
Addison’s disease.
Bacterial sepsis.
Excessive insulin administration.
Serum glucose
Serum calcium
LDH
Creatinine.
Bilirubin
Serum glucose
Serum calcium
LDH
Creatinine.
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.
Serum glucose
Serum calcium
LDH
Creatinine.
Bilirubin
Serum glucose
Serum calcium
LDH
Creatinine.
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.
Serum glucose
Serum calcium
Inorganic
phosphorous.
Alkaline
phosphatase.
LDH
Creatinine.
Bilirubin
Serum glucose
Serum calcium
Inorganic
phosphorous.
Alkaline
phosphatase.
LDH
Creatinine.
Bilirubin

Decreased calcium.
Seen in
Hypoproteinemic conditions
Renal disease.
Diet of potential implant patient may be
severely affected by the lack of denture
comfort and stability.
Serum glucose
Serum calcium
LDH
Creatinine.
Bilirubin
Serum glucose
Serum calcium
LDH
Creatinine.
Bilirubin

Inorganic phosphorus.
It maintains a ratio of 4 to 10 compared
with calcium ,and there is usually a
reciprocal relationship.
Serum glucose
Serum calcium
Inorganic
phosphorous.
LDH
Creatinine.
Bilirubin
Serum glucose
Serum calcium
Inorganic
phosphorous.
LDH
Creatinine.
Bilirubin

Elevated phosphorous.
1. Chronic glomerular disease
(common ).
2. Hypoparathyroidism. Decrease calcium
and normal renal function.
3. Hyperthyroidism
4. Increases growth hormone.
5. Cushing’s syndrome.
Serum glucose
Serum calcium
Inorganic
phosphorous.
LDH
Creatinine.
Bilirubin
Serum glucose
Serum calcium
Inorganic
phosphorous.
LDH
Creatinine.
Bilirubin

Decreased phosphorus.
Hyperparathyroidism. With associated
hypercalcemia.
In chronic user’s of aluminium
hydroxide antacids.
Serum glucose
Serum calcium
Inorganic
phosphorous.
LDH
Creatinine.
Bilirubin
Serum glucose
Serum calcium
Inorganic
phosphorous.
LDH
Creatinine.
Bilirubin

Its level helps in determining
hepatobiliary and bone diseases.
Normal : 40-125 U/L
Serum glucose
Serum calcium
Alkaline
phosphatase.
LDH
Creatinine.
Bilirubin
Serum glucose
Serum calcium
Alkaline
phosphatase.
LDH
Creatinine.
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.
Serum glucose
Serum calcium
LDH
Creatinine.
Bilirubin
Serum glucose
Serum calcium
LDH
Creatinine.
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.
Serum glucose
Serum calcium
LDH
Creatinine.
Bilirubin
Serum glucose
Serum calcium
LDH
Creatinine.
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.
Serum glucose
Serum calcium
LDH
Creatinine.
Bilirubin
Serum glucose
Serum calcium
LDH
Creatinine.
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.
Serum glucose
Serum calcium
LDH
Creatinine.
Bilirubin
Serum glucose
Serum calcium
LDH
Creatinine.
Bilirubin

Systemic disease and oral
implants.

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

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.

Cardiovsascular diseases.
Hypertension.
Angina pectoris.
Myocardial infarction.
Congestive heart failure.
Sub acute bacterial endocarditis.

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.

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
HypertensionHypertension

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.

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

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.

Implant management.
Stress reducing protocol
As anxiety greatly affects blood
pressure.
Flurazepam 30mg or diazepam 5 to
10mg in the evening to help the patient
sleep quietly night before the
operation.
An early appointment.as medication
may still be effective in elderly.

Risk Systolic
mm hg
Diastolic
mm hg
Type
1
Type 2 Type 3 Type4
High
normal
130-
139
85-89 + + Sedatio
n
sedatio
n
Hyperte
nsion
Stage 1
140-
159
90-99 + Sedatio
n
Sedatio
n
Sedatio
n
Stage 2 160-
179
100-109 + Sedatio
n
Postpone all
elective
procedures.
Stage 3 180-
209
110-119 Refer andpostmpone all elective
procedure.
Stage 4 >210 >120 Refer and postpone all elective
procedures.
Type 1.
Examination.
Radiographs.
Study model
impressions.
Oral hygiene
instructions.
Supragingival
prophylaxis.
Simple restorative
dentistry.
Type 2
Scaling and root
planning.
Endodontics
Simple
extractions
Curettage
Simple
Gingivectomy.
Advanced
restorative
procedures.
Simple implants.
Type 3
Multiple extractions
Gingivectomy
Quadrant peroseal
reflections
Impacted
extractions
Apicoectomy
Plate form implants
Ridge
augmentation.
Unilateral sinus
graft.
Unilateral
subperiosteal
implants.
Type 4
Full arch implants
Orthognathic surgery
Autogenous bone
augmentation
Bilateral sinus graft.

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.
Angina pectorisAngina pectoris

Risk factors for Angina
 Smoking
 Hypertension
 High cholesterol
 Obesity
 Diabetes.
Angina is classified as
 Mild.
 moderate.
 Severe.

Precipitating factors.
Exertion.
Cold.
Heat.
Large meals.
Humidity.
Psychological stress.
Dental related stress.

Risk Type 1 Type 2 Type3 Type 4
Mild One or
less
/month
+ + Sedation
supplemental oxygen
Moderat
e
One or
less/wee
k
+ Sedation
premedicate
nitrates
supplemental
oxygen
Premedicat
e
Sedation
Outpatient
hospitilizati
on
Severe Daily/mo
re
Unstable
+ Physicia
n
Elective procedures
contraindicated.
Mild
Type 3 and 4
Appointments should be as short as possible.
Concentrations of vasoconstrictor greater than
1/100000 avoided
Moderate
Type 2 and 3: vasoconstrictor is contraindicated.
Antianxiety sedation with supplemental oxygen
Type 4 may require a hospital setting.

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.

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.

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
Angina pectoris*Angina pectoris*

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.

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

Complications of MI
 Arrhythmias
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 Risk of another MI
3 months 30%
3-6 months 15%
12 months 5%
Myocardial
infarction*
Myocardial
infarction*

Risk Type 1 Type
2
Type 3 Type 4
Mild >12
months
+ + Physicia
n
Physician
hospitaliza
tion if
anesthesia
required.
Modera
te
6-12
months
+ Postpone all elective
procedures.
Severe < 6months + Postpone all elective
procedures.
Myocardial
infarction
Myocardial
infarction

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.

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.

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.
Congestive heart
failure*
Congestive heart
failure*

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%.

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.
SABESABE

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.
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,
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.
SABE*SABE*

Antibiotic regimens
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.
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.
SABE*SABE*

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.

Symptoms are:
Polyuria
Polydypsia
Polyphagia
Weight loss.
Diabetics are more prone to
Delayed soft and hard tissue healing
Altered nerve regeneration.
Infections
Vascular complications.
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.
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.

Implant protocol.
Most serious complication during implant
procedure is hypoglycemia.
It can be due to
 Excessive insulin level
 Hypoglycemic drugs
 Inadequate food intake.

Symptoms
Weakness
Nervousness
Tremor
Palpitations
sweating
Can be treated
with sugar inform
of candy or orange
juice.
Confusion
Agittion
Seizure
Coma
death

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.
Diabetes mellitus*
Diabetes mellitus*

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

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 0-
3+
ketonria 0
+ + Sedation
Premedica
tion
Diet/insulin
Adjustmen
t.
Physician
Diet/insulin
Adjustmen
t.
Physician
Hospitaliza
tion.
Severe Uncontroll
ed> 250
mg/dl glyc
3+
Ketonuria
0
+ Postpone all elective procedures

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.

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.
ThyroidThyroid

Hypothyroidism
Symptoms are related to decrease in
metabolic rate.
Cold intolerance
Fatigue
Weight gain
Hoarseness
Decreased mental activity
Coma.
ThyroidThyroid

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
ThyroidThyroid

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

Risk Type
1
Type 2 Type
3
Typ
e 4
Mild Med exam <
6 months
normal fct
last 6 months
+ + + +
Moderat
e
No symptom
no med exam
no Fct test
+ Decreas
e
epinephr
ine
steroids
CNS
depress
ants
Physician
consultation.
Severe Symptoms + Postpone all elective
procedures.

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.

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.
Addisons's disease
Adrenal gland disorderAdrenal 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.

Hyper function of adrenal cortex.
Symptoms
Bruise easily
Poor wound healing
Experience osteoporosis
Increased risk of infection.
Cushing's syndrome.
Characteristic
symptoms
Moon
facies
Trunc
al
obesity
or
“buffalo
hump”
Muscl
e
wasting
hirsuti
sm

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.

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.

Risk Type
1
Type 2 Type 3 Type 4
Mild Equiv.
Prednisone
alternate
day >1 year
+ Surgery on day
of steroids
Sedation and antibiotics
Steroids
< 60mg prednisone
day1
dose X/2 day 2
maintenance dose day
3
Modera
te
Equiv
prednisone
>20 mg or
> 7 days in
past year.
+ 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
Severe. Euiv.
Prednisone
5mg/day
+ Elective procedures contraindicated

Hematologic disorders.
Erythrocytic disorders.
Polycythemia
Anemia
Leukocytic disorders.

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.

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 oxygen-
carrying capacity of the blood and results from
a decrease in the number of erythrocytes or
abnormality of hemoglobin.

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.
AnemiaAnemia

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
AnemiaAnemia

Chronic anemia.
Shortness of breath.
Abdominal pain
Bone pain
Tingling of extremities
Muscular weakness
Headaches
Fainting
Change of heart rhythm
nausea
AnemiaAnemia

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.
AnemiaAnemia

Other complications.
Abnormal bleeding.-decreased field of
vision.
Increased edema and discomfort
postoperatively.
Increased risk of postoperative infection
and its consequences.
AnemiaAnemia

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.
AnemiaAnemia

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.
AnemiaAnemia

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.

Leukopenia
Reduction of WBC below 5000/mm3.
Can be due to
Certain infections (infectious hepatitis)
Bone marrow damage (radiation therapy)
Nutritional deficiency.
Blood diseases.
WBC disordersWBC 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.

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.

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.

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.
COPDCOPD

Risk Type 1 Type 2 Type 3 Type 4
Mild + + + +
Moderat
e
+ PHYSICIAN PHYSICIAN/MODE
RATE
TREATMENT.
severe + POSTPONE
(HOSPITALI
ZATION)
ELECTIVE
PROCEDURES
CONTRAINDICATE
D.
•Difficulty breathing
only on significant
exertion
•Normal laboratory
blood gases
•Difficulty breathing upon exertion
•Those on chrnic bronchodilator therapy.
•those who have used corticosteroids.
•Procedure should be
performed in hospital
setting
•No vasoconstrictor to be
added to anesthetics or
gingival cord if patient is on
bronchodilators
•Previously unrecognized COPD
•Acute exacerbation of respiratory
infection
•Patients with dyspnea at rest
•Those with history of CO2 retention

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.

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

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.

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.

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-
40 years.
30 % more
than woman
At 80 years 27 % loss. 40 % loss
OsteoporosisOsteoporosis

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.

Recommended calcium intake 800
mg/day.
Average intake in United states 450 to
550 mg.
Postmenopausal woman 1,500 mg is
required.

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.

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.

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.

Oral findings
Decrease in trabecular bone
Indistinct lamina dura.
Increase in chronic periodontal disease.
Treatment is similar to osteoporatic
patient.
Implants are not contraindicated.
OsteomalaciaOsteomalacia

Hyperparathyroidism.
Mild Asymptomatic
Moderate Renal colic.
Severe Disturbances in
 Bone- alveolar bone
depletion.
 Renal
 Gastric

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.
Hyperparathyroidism.Hyperparathyroidism.

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.

•Increase in trabeculation
Radiographically seen as the
mottled appearance.
•Facial plate usually expands
moving the teeth along with
it.
Fibrous dysplasiaFibrous 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.
Fibrous dysplasiaFibrous dysplasia

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.

Cotton or wool
appearance
radiographically.
Paget’s diseasePaget’s disease

There is no specific treatment.
Patients are predisposed to
development of osteosarcoma.
Oral implants are contraindicated in the
regions affected.
Paget’s diseasePaget’s disease

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

Punched
out lesions
radiograph
ically.
•There is no treatment and condition is usually
fatal 2 to 3 years after onset.
•Implants are usually contraindicated.
Multiple MyelomaMultiple Myeloma

Use of tobacco.
There is established relationship
between smoking and…
1. ..Periodontal attachment loss.
2. ..Bone loss.
3. ..decreased resistance to
1. Inflammation.
2. Infection.
4. ..Impaired wound healing.
5. ..Reduced mineral content in bone in
1. aging smokers
2. Postmenopausal female smokers.

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.
TobaccoTobacco

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.

Procedures which can be carried out.
Caries control
Emergency procedures.
Dental prophylaxis.
Drugs approved
Lidocaine
Penicillin
Erythromycin
Acetaminophen.
PregnancyPregnancy

Drugs usually contraindicated.
Aspirin
Epinephrine(Vasoconstrictor)
Narcotics analgesics (cause respiratory
depression)
Always contraindicated.
Diazepam
Nitrous oxide
Tetracycline.
PregnancyPregnancy

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.

Dental procedures with
higher risk of bacteremia.
1. Dental extractions.
2. Surgical placement of implants
3. Periodontal surgery.
4. Prophylactic cleaning of teeth and
implants.
Prosthetic jointsProsthetic joints

Antibiotic prophylaxis
Recommended for patients with higher risk
for hematogenous infections undergoing
dental procedures with a higher bacteremic
incidence.
Prosthetic jointsProsthetic joints

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.

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

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.

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.

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.

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.

 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.

Psychological assesment

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

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”

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

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

Diagnosis and treatment planning in implants 1.

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