important for prosthodontics

1. Effect of systemic disease on
complete denture
Dr.mansi singh
PG Ist year
1

2. content
• Introduction
• Definition
• Medical history
• Debilitating disease
• Bone disease
• Cardiovascular disease
• Respiratory disease
• Oral and skin disease
• Neuromuscular
• Autoimmune disease
• Conclusion
• references
2

3. INTRODUCTION
• The prosthodontic procedures should not be
planned until the systemic status of the patient is
evaluated.
• Treatment planning is a consideration of all the
diagnostic findings, systemic and local which
influence the surgical preparations of the mouth,
impression making, maxilla-mandibular relation
records, occlusion, form and material in the teeth.
• So the dentist must not only be aware of the
systemic factors but also consider them in the
treatment plan.
3

4. • Some systemic diseases have a direct relation to
denture success even no local manifestation is
apparent.
• Many systemic diseases have a local
manifestation with no apparent systemic
symptoms and others have both local and
systemic reactions.
• In this we deals with systemic diseases and their
management during complete denture
4

5. 5
• Prosthodontics is the dental specialty pertaining to
the diagnosis, treatment planning, rehabilitation and
maintenance of the oral function, comfort, appearance and
health of patients with clinical conditions associated with
missing or deficient teeth and/or maxillofacial tissues
using biocompatible substitutes.
According to GPT
PROSTHODONTICS

6. DIAGNOSIS
According to HEART WELL
Diagnosis is the act or process of deciding the
nature of the diseased condition by examination
A careful investigation of facts to determine
the nature of a thing
The determination of the nature, location and
causes of a disease.
6

7. • According to BOUCHER
Diagnosis consists of planned observations to
determine and evaluate the existing conditions,
which lead to decision making based on the
conditions observed.
7
• According to GPT –
The determination of the nature of a disease.

8. 8
Treatment plan :-
According to SHELDON WINKLER
Treatment planning means developing a course
of action that encompasses the ramifications and
sequelae of treatment to serve the patient’s needs.
According to GPT
The sequence of procedures planned for the treatment
of a patient after diagnosis.

9. • In short, DIAGNOSIS & TREATMENT PLAN
can be summarized as:
• Recognizing the problem
• Formulating the plan
• Carrying out the necessary examination
• Finally, interpreting the result.
9

10. MEDICAL HISTORY:
• Patients today have a more complex health
history than ever before.
• More likely to involve the dentist in medicolegal
challenge.
• Therefore a complete medical history is an
extremely important part of the patient’s overall
diagnosis and treatment planning.
10

11. Systemic disease effect
11

12. Debilitating diseases
• Diabetes mellitus
• Tuberculosis
• anemia
12

13. Diabetes mellitus
• Definition-it is charectarised by impaired
metabolism of carbohydrate,fat,protein caused
by eighter lack of insulin seretion or decrease
sensitivity of the tissue to insulin
• 3rd leading cause of death after heart disease and
cancer in developing country
Etiology
1. decrease insulin secretion
2. Decrease glucoes utilization
3. Increase glucoes secretion
13

14. classificationn
melitus
14
TYPES I TYPES II
OTHER
SPECIFIC
CAUSES
GESTATIONA
L DIABETES
MELITUS
DIABETES MELITUS
TYPES IBTYPES IA

15. 15
TYPE 1 DIABETES
• Also known as Juvenile Onset Diabetes
• Found in 10%
• Insulin dependent diabetes
• Complete or near-total insulin deficiency
• Occurs <14 years old of age
• Underweight patient
• subtype1A-autoimmune destruction of B cell cause insulin
deficiency
• Subtype1b-insulin deficiency with ketosis but lack of
autoimmune marker

16. TYPE 2 DIABETES
• Most common
• 80%cases
• >40 years of age
• Also called non insulin dependent diabetes
• Normal or overweight
• Genetic factor
16

17. OTHER SPECIFIC TYPES OF DIABETES
17
Genetic defects of β cell function
characterized by mutation
Genetic defects in insulin action
Disease of exocrine pancreas
Endocrinopathies
Drug-or chemical-induced
Infections

18. GESTATIONAL DIABETES MELLITUS
(GDM)
• Aboutb 4% of pregnant women
• due to metabolic changes and revert back to
normal after pregnancy
• These women prone to develops DM later in life.
18

19. Diagnostic Criteria &
Management
19
Dent Clin N Am 50 (2006) 591–606

20. CLINICAL FEATURES
• Hyperglycemia
• Glycosuria
• Polydipsia
• Polyphasia
• Polyuria
• Dehydration
• Loss of weight
• Saliavary gland dysfunction
• Poor resistance to infections due to protein depletion
20

21. Oral manifestations and
complications
No specific oral lesions associated with diabetes. However, there are
number of problems by presence of hyperglycemia.
Periodontal problem
▫ Increased Ca+ and glucose lead to plaque formation.
▫ Increased collagen breakdown.
Increased risk of infection
▫ Reasons unknown, but macrophage metabolism altered with
inhibition of phagocytosis.
▫ Peripheral neuropathy and poor peripheral circulation
▫ Immunological deficiency
▫ High sugar medium
▫ Decrease production of Antibodies
▫ Candidal infection are more common and adding effects with
xerostomia
21

22. • Salivary glands
▫ Xerostomia is common, but reason is unclear.
▫ Tenderness, pain and burning sensation of tongue.
▫ May cause secondary enlargement of parotid glands with sialosis.
• Dental caries
▫ Increase caries prevalence in adult with diabetes. (xerostomia,
increase saliva glucose)
▫ Hyperglycemia state shows a positive association with dental
caries.
22

23. • Delayed healing of wounds
▫ Due to microangiopathy and ultilisation of protein for energy,
may retard the repair of tissues.
▫ Increase prevalence of dry socket.
• Miscellaneous conditions
▫ Pulpitis : degeneration of vascular.
▫ Neuropathies : may affect cranial nerves. (facial)
▫ Drug side-effects : lichenoid reaction may be associated with
sulphonylureas (chlopropamide)
▫ Ulcers
23

24. • GENERAL MANAGEMENTM
▫ Diet control
▫ Regular exercise
▫ Oral hypoglycaemic agents
▫ - Sulfonylurea – Tolbutamide, Gliclazide
▫ - Biguanides – Metformin
▫ - Alphaglucoside inhibitors –Acrabose
▫ Insulin therapy
24

25. Prosthetic management
• A proper medical history should be taken to know, which type of
diabetes is the individual is suffering from and accordingly plan the
treatment.
• The IDDM are more likely to develop glucose imbalance during
treatment then those with NIDDM
• Frequent evaluation of denture is necessary.
• Diabetic patients are prone to develop infections and vascular
complication so an antibiotic prophylaxis before dental surgery to
prevent subsequent infection is advised.
25
International Journal of Oral Health and Medical Research | ISSN 2395-7387 | JULY- AUGUST 2015 |
VOL 2 | ISSUE

26. • Glucose drinks should be available if patient complains
of symptoms of hypoglycemia.
• 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.
• The food table should be small.
• the patient should be given detailed instructions on
eating habits and oral hygiene.
26

27. Dental implant management:
• The implant dentist discover diabetes by the presence of
glucose levels above 120mg /dl.
• Implant dentistry is not contraindicated in most diabetic
patient, however their medial care should be as
controlled as possible.
• Specific questions should be asked to evaluate the diet,
insulin dosage, oral medication, method used to monitor
the blood glucose and recent glucose level
27

28. 28
RISK IMPRESSION IMPLANT PROCEDURE
MILD<=150 mg/dl + Sedation ,premedication, Diet and
insulin adjustment
MODEATE<=200
mg/dl
+ Sedation ,premedication ,Diet and
insulin adjustment, hospitalization
SEVERE
>250mg/dl
+ Postpone elective procedure
Dental implant management for Diabetes Mellitus

29. Tuberculosis
• Tuberculosis is an infectious disease that usually affects the lungs.
• it is the second biggest killer
• Caused by mycobacterium tuberculosis
• two kinds of tuberculosis infection:
• Latent the bacteria remain in the body in an inactive state.
They cause no symptoms and are not contagious, but they
can become active.
• Active the bacteria do cause symptoms and can be
transmitted to others.
•
29

30. SYMPTOM
30

31. Oral manifestation
• Oral TB lesions may be either
• primary - lesions are uncommon,seen younger
patients, and present as single painless ulcer with
regional lymph node enlargement and ulcers of long
duration
• secondary - lesions are common, often associated
with pulmonary disease, usually present as single,
indurated, irregular, painful ulcer covered by
inflammatory exudates in patients of any age group
but relatively more common in middle-aged and
elderly patients.
31

32. • Oral TB may occur at any location on the oral
mucosa, but the tongue is most commonly
affected.
• Other sites include the palate, lips, buccal
mucosa, gingiva, palatine tonsil, and floor of the
mouth.
• Salivary glands, tonsils, and uvula are also
frequently involved.
• The oral lesions may be present in a variety of
forms, such as ulcers, nodules, tuberculomas,
and periapical granulomas
32

33. Precautions for Dental Health
Care Professional
• Maintenance of proper hand hygiene
• personal protective equipment (eye shields, face
masks, headcaps, gloves and surgical gowns)
• proper sterilization procedures should be followed.
• Standard surgical face masks do not protect against
TB transmission; dental healthcare personnel
should use particulate face masks.
• Masks should be changed at regular intervals, inter-
appointments (between patients) and intra-
appointments (during patient treatment) if it
becomes wet.
33

34. • Spread by aerosolized droplets  high risk to
dentist
• Past history of T.B. physician’s consultation 
if culture positive  only emergency treatment
provided
• Minimal use of high speed handpieces
• Operating air should be vented out ( HEPA-
filtered)recirculation is necessary,with high
volume suction are indicated for carrying out
any procedure to minimize aerosol generation.
• Oral lesions may make use of prosthesis difficult
34

35. ANEMIA
Anemia is the most common hematologic disorder
It is defined as
• the reduction in the-- oxygen carrying capacity
of blood
• decrease in the number of erythrocytes or
• the abnormality of hemoglobin
There are a number of different types of anemia,
the most common being iron deficiency anemia
& relative bone marrow failure
35

36. SYMPTOM
 fatigue
anxiety
Sleeplessness
shortness of breath abdominal pain
bone pain
tingling of extremeties
muscular weakness
headaches
nausea
The general signs of anemia include
jaundice, pallor, spooning or crackling of
nails, hepatomegaly, splenomegaly &
lymphadenopathy
36

37. Oral manifestation
• Generalised stomatitis
• Mucosal pallor
• Atrophy of filliform papillae of tongue
• Glossitis
• Altered taste sensation
• Angular stomatitis
• Gingivitis
• Candidial infection
• Plumber vinson syndrome
37

38. • The abnormal bleeding in anemic patients, due to
hemorrhage causes difficulty in placement of sub
periosteal implants.
• The increased edema increases the risk of postoperative
infection. This may affect long-term maintenance of the
implant or abutment teeth.
• The minimum baseline recommended is 10mg/dl
especially for implant surgery. In majority of anemic
patients, implant procedures are not contraindicated.
However preoperative and postoperative antibiotics
should be administered
38

39. Bone disease
39

40. Osteoporosis
• Osteoporosis is a systemic disease in the elderly.
• Osteoporosis shows a decrease in the skeletal
mass without alteration in the chemical
composition of bone.
• The most common disease of bone metabolism
the dentist will encounter.
40

41. • Oral bone loss related to osteoporosis may be
expressed in both dentate & edentulous patients
• The advanced demineralization & consequent
increase in bone loss of completely edentulous
may become a vicious circle
• The denture is less secure & the patient may not
be able to follow the diet needed to maintain
proper calcium absorption levels
• Although osteoporosis is a significant factor in
for bone volume & density, it is not a
contraindication for dental prosthesis
41

42. 42
Osteoporosis is common in aging individuals, especially
post menopausal women when the estrogenic blood
level is low.
In elderly men and women, osteoporosis is caused by a
variety of factors such as calcium loss, calcium
deficiency, hormonal deficiency, change in protein
nutrition and decreased physical activity.
Progressive loss of alveolar bone may be a
manifestation of osteoporosis

43. Prosthetic management
• Designing complete denture requires special
consideration for these patients to preserve the
underlying tissue structure as much as possible.
• Prosthodontist are in a strategic position to
intercept early evidence of osteoporosis and educate
the geriatric patient towards good nutrition
• Estrogen therapy can retard severe bone
demineralization caused by osteoporosis in women.
Adequate dietary calcium intake is essential.
Recommended calcium intake of 800 mg / day for
average person and 1500 mg for the
postmenopausal women
43

44. Dental implant management
• osteoporosis is significant factor for bone
volume and density, it is not a contraindication
for dental implants
• The bone density does affect the treatment plan,
surgical approach, length of healing and
loading.
• Implant designs should be greater in width and
coated with hydroxyapetite to increase bone
contact and density.
44

45. FIBROUS DYSPLASIA
• Fibrous dysplasia is a disorder in which fibrous
connective tissue replaces areas of normal bone
• Etiology-mutation in GNAS1,that codes Gprotein
which stimulate production of c-amp
• C-amp causes
hyperfunction of affected endocrine organ,
hyperthyroidism, precocious puberty,Growth
harmone and cortisol overproduction
Melanocytes prolification cause large,irregular
margin café-au-lait spot
Effect on diffrentiationof osteoblast cause fibrous
dysplasia
• The condition in maxilla is twice as common as in
mandible
45

46. Clinical features
Four disease patern are recognised
1. Monostotic form-70-80%,mostly affecting
ribs,femur,tibia,craniofacial form,pain or patholaogical
fracture
2. Polyostotic form-20-30%,mostly skull and facial bone,
Most of bone+café-au-lait=jaffe’s type
most of bone+café-au-lait+endocrine
disturbances=albright syndrome
3. Craiofacial form
4. cherubism-special type of
accurs only in children
46

47. • The facial plate usually expands, the teeth may
move as a consequence of this progression
• Roots of the teeth may be displaced but external
resorption is rare
• Radiographically the appearance of fibrous dysplasia is
a noted increase in trabeculation which presents a
“mottled appearance”
• A ground glass appearance may also be noted
• The polyostotic fibrous dysplasia may affect one or
virtually all bones
47

48. • 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
48
International Journal of Oral Health and Medical Research |

49. PAGET’S DISEASE
• Also called as Osteitis deformans
• It is a slowly progressing chronic disease where
osteoblasts and osteoclasts are involved with
predominance of its osteoclastic activity.
• The jaws are affected in 20% of the cases .The
• Jaws are affected in approximately 20% of the
cases
• The maxilla is more often involved than the
mandible, there is increased tooth mobility
49

50. • Edentulous patients are often unable to wear
their prosthesis without discomfort
• Radiographs reveal a cotton or wool appearance
to bone
• Bony enlargements may often be palpated
intraorally
• Spontaneous fractures are relatively common
because the increase in osseous vascularity is
significant
50

51. Prosthodontic implication
• The remakes and adjustment of dentures are
needed due to continual enlarging and changing
of supporting structure especially of the
maxillary tuberosity.
• Oral implants are contraindicated in the regions,
affected by this disorders.
51

52. CARDIOVASCULAR DISEASES
 Includes ischemic heart disease(anginas),
arterial hypertension, arrhythmias, myocardial
infarction & chronic heart failure,SABE
 Consultation with patients cardiologist is
indicated
 Surgical procedure of any nature may be
contraindicated
 Short appointments with pre- medication
52

53. • DEFINITION— it is defined as persistent high
blood pressure.
• CLINICALY—when systolic pressure remain
elevated above 150mm hg and diastolic pressure
remain elevated above 80mm hg it is considered
as HYPERTENTION.
53
HYPERTENSION

54. 54
Dent Clin N Am 50 (2006) 547–562 Dental Management of Patients
with Hypertension.Bruce Bavitz
Adult classification:
Classification Systolic BP Diastolic BP
Normal <120 < 80
Prehypertension 120–139 or 80–89
Stage I hypertension 140–159 or 90–99
Stage II hypertension <=160 or <=100

55. TYPES
Primary hypertension Secondary hypertension
Elevation of BP without any
underlying disease.
Also called as essential hypertention.
Elevation of BP due to some
underlying disorder(CVS,endocrine
,renal,neurogenic and pregnancy)
55

56. 56
Oral MANIFESTATION OF CARDIOVASCULAR DISEASE AND THERE
TREATMENT
Drug Oral adverse side effects
• Diuretics Dry mouth, lichenoid reaction
• Beta blockers Dry mouth, taste changes, lichenoid reaction
• ACE inhibitors Loss of taste, dry mouth, ulceration, angioedema
• Calcium channel blockers Gingival enlargement, dry mouth,
altered taste
• Alpha blockers Dry mouth
• Direct-acting vasodilators Facial flushing, possible increased risk
of gingival bleeding and infection
• Central-acting agents Dry mouth, taste changes, parotid pain
• Angiotensin 2 antagonists Dry mouth, angioedema, sinusitis, taste lossDent Clin N Am 50 (2006) 547–562 Dental Management of Patients with Hypertension.Bruce Bavitz

57. • frequent prescribed drugs cause, Xerostomia is
the first
•
• Which cause frequent candida infections,
increased periodontal diseases, caries &
bacterial infection caused by loss of protection
by saliva
• Xerostomia also decreases the valve seal of soft
tissue – borne removable prosthesis & increases
the risk of abrasions & sore spot.
• Extra oral manifestation--sialadenosis
57

58. • Management of such patients includes saliva
substitutes, salivary stimulants, frequent
glasses of water throughout the day, strict
control of diet to decrease cariogenicity &
avoidance of alcohol & tobacco products
58

59. Prosthetic Management
• Communicate with the patient’s physician.
• Prevent hemorrhage in pt. taking anti-coagulant
therapy.
• Reduce patient’s stress and anxiety.
• Morning appointment.
• Short wait in waiting room.
• Reassurance & peaceful environment.
59

60. • Avoid surgical procedures if possible.
• If not, perform it under proper antibiotics coverage.
• Postpone procedures for at least 6 months if not
very necessary.
• Do not treat patient with coronary bypass until at
least 2 weeks after operation.
• Always ready with emergency kit & services for an
immediate control.
60

61. ANGINA PECTORIS
• Angina pectoris or chest pain is a form of
coronary heart disease.
• Occasionally the myocardium needs more
oxygen laden blood than it receives .
• It is a symptomatic expression of transient
myocardial ischemia.
61

62. • CAUSES
mainly arthosclerosis of coronary vassels
 Anemia
 Hypotenion
 Emboli
 Aquired arthritis
• The classical symptom of retrosternal pain
often develops during stress or physical
exertion, radiates to the shoulders, left arm, or
mandible, or right arm, or neck, palate &
tongue
62

63. Precipitating factors:
63
• Physical activity
• Hot, humid environment
• Cold whether
• Large meals
• Emotional stress
• Caffeine ingestion
• Fever, anemia, thyrotoxicosis
• Cigarette smoking
• Smog
• High altitudes
• Second – hand smoke

64. Dental therapy considerations:
• Avoid overstressing the patient
• Supplemental oxygen via nasal canula or nasal hood
during the treatment – 3-5 L/min
• Pain control during therapy – appropriate use of
local anesthesia – smaller dose with maximum
effect – slow administration
• Vasodepressor administration should be minimized
in increased risk patients
• Psycho sedation – N2O – O2 is preferable
• Monitoring vital signs
• Nitroglycerine premedication 5 min before
treatment
64

65. Acute myocardial infarction
It is a clinical syndrome caused by a deficient
coronary arterial blood supply to a region of
myocardium that results in cellular death and
necrosis
Predisposing factors:
• Atherosclerosis and coronary artery disease
• Coronary thrombosis, occlusion and spasm
• Other risk factors are-
• Males
• 5th and 6th decades of life
• Undue stress
65

66. • Symptoms and Signs
• Pain – severe to intolerable,Prolonged, 30
min,Crushing, choking, Retrosternal,Radiates – left
arm, hand, epigastrium, shoulders, neck, jaw
• Nausea and vomiting
• Weakness
• Dizziness
• Palpitations
• Cold perspiration
• Restlessness
• Acute distress
• Skin – cool, pale, moist
• Heart rate – bradycardia to tachycardia; PVC
(premature ventricular contractions) common
66

67. Dental therapy considerations:
• Avoid overstressing the patient
• Supplemental oxygen via nasal cannula or nasal hood
during the treatment – 3-5 L/min and 5 – 7 L/min
• Pain control during therapy – appropriate use of local
anesthesia – smaller dose with maximum effect – slow
administration
• Vasodepressor administration is a relative
contraindication
• Psychosedation – N2O – O2 is preferable
• It is strongly recommended that elective dental care is
avoided until at least 6months after MI
• Medical consultation and anticoagulation and
antiplatelet therapy need not be altered
• Inferior alveolar NB and Posterior superior alveolar NB
– risk of hemorrhage – should be avoided
67

68. SABACUTE BACTERIA
ENDOCARDITIS
• Bacterial endocarditis is an infection of the
heart valves or the endothelial surfaces of the
heart
• It is result of the bacterial growth on the
damaged/altered cardiac surfaces
• The microorganisms most often associated with
endocarditis following dental treatment are
alpha-hemolytic streptococcus viridans & less
frequently staphylococci & anaerobes
68

69. 69

70. Dukes Criteria
• Definitive Endocarditis if,
• - Two major or,
• - One major and three minor or,
• - five minor
• Possible Endocarditis if,
• - One major and one minor or,
• - Three minor
70

71. Major criteria
• Positive blood culture
▫ Typical organism from two cultures
▫ Persistent positive blood cultures taken >
12 hours apart
▫ Three or more positive cultures taken over
more than 1 hour.
• Endocardial involvement
▫ Positive echocardiographic findings of
vegetations
▫ New valvular regurgitation
71

72. Minor crietaria
• Predisposition: Predisposing valvular or cardiac
abnormality
• Intravenous drug misuse
• Pyrexia ≥38°C (≥100.4°F)
• Embolic phenomenon
• Vasculitic/ immunologic phenomenon
• Blood cultures suggestive: -organism grown but
not achieving major criteria
• Suggestive echocardiographic findings
72

73. SITUATION OF
THE PATIENT
AGENT REGIMEN
STANDARD
PROPHYLAXIS
AMOXICILLIN ADULTS: 2.0 G, 1 HR BEFORE PROCEDURE
UNABLE TO TAKE
ORAL MEDICATONS
AMPICILLIN ADULTS: 2.0 G, IM OR IV
ALLERGIC TO
PENICILLIN
CLINDAMYCIN
CEPHALEXIN OR CETRADOXIL
ARITHROMYCIN OR
CLARITHROMYCIN
ADULTS: 600 MG 1 HR BEFORE THE
PROCEDURE
ADULTS: 2.0 G, 1HR BEFORE THE
PROCEDURE
ADULTS: 500 MG, 1 HR BEFORE PROCEDURE
ALLERGIC TO
PENICILLIN &
UNABLE TO TAKE
ORAL MEDICATION
CLINDAMYCIN
CEFAZOLIN
ADULTS: 600 MG IV WITHIN 30 MIN BEFORE
PROCEDURE
ADULTS: 1.0 G IM OR IV WITHIN 30 MIN
BEFORE PROCEDURE
73
ANTIBIOTIC REGIMEN FOR CARDIAC CONDITIONS REQUIRING
PROPHYLAXIS

74. Respiratory disease
74

75. CHRONIC OBSTRUCTIVE
PULMONARY DISEASES
• The two common forms of COPD are:
▫ Emphysema
▫ Chronic bronchitis
• COPD is the second most common cause of
death after cardiovascular disease
• Respiratory failure is usually precipitated by
pulmonary infection & leads to death
75

76. Prosthodontic considration
• Elective moderate procedures or advanced
surgical or prosthodontic procedures are
usually contraindicated
• However, if surgery or a prosthetic procedure is
required, they should be performed in a hospital
setup
• The use of epinephrine should be limited
• Drugs that depress the respiratory function,
such as sedatives, tranquilizers should be
discussed with the physician
76

77. Disease of skin and oral mucosa
• Oral sub mucous fibrosis
• Leukoplakia
• Pemphigus
• Lichen planus
• Hyperkeratosis
• Recurrent apthous ulcer
• Candidiasis
• Moniliasis
• Stomatitis venenata
• scleroderma
77

78. Oral submucous fibrosis
• An insidious chronic disease affecting any part
of the oral cavity & sometimes pharynx
• occasionally preceded by &/or associated with
vesicle formation.
• It is always associated with juxta epithelial
inflamatory reaction followed by fibro-elastic
changes of lamina propria, with epithelial atrophy
leading to stiffness of oral mucosa & causing
trismus & inability to eat.
78

79. Etiology
• Chronic irritation- chillies, tobacco, lime,
arecanut
• Nutritional deficiency
• Defective iron metabolism
• Bacterial infections
• Collagen disorders
• Immunological disorders
• Genetic susceptibility
• Altered salivary composition
79

80. Management
• Restriction of habit
• Medicinal therapy –
• Supportive treatment
• Steroids – local , systemic
• Hyaluronidase
• Vitamine E
• Oral physiotherapy- Mouth opening,
Ballooning of mouth, Forceful mouth
opening with mouth gag
80
Surgical treatment
Indications – marked trismus, neoplastic change
Surgical treatments –conventional, laser,
cryosurgery

81. Prosthodontic considerations
• Difficulty in impression making  due to
restricted mouth opening
• Solution – use of sectional impression trays
81
Journal of Prosthodontics 2010: 19; 299-302

82. • Difficulty during border molding d/t
restricted movement of tongue
• Difficulty in insertion & removal of
dentures
• Solution – use of sectional dentures
82
Journal of Prosthodontics 2010: 19; 299-302

83. Vesciculo-bullous lesions
• Vesciculo-bullous lesions which may have intra
oral manifestations are –
▫ Pemphigus
▫ Pemphigoid
▫ Erythema multiformae
• Management –
▫ Topical / systemic steroids
▫ Immuno-suppresive therapy
83

84. • Prosthodontic consideration –
▫ Difficulty in wearing removable prosthesis
▫ Increased chances of trauma due to prosthesis
84

85. Candida associated lesion
[denture stomatitis]
[chronic atrophic candidiasis]
• Site – usually under CD & RPD
• Appearance patchy distribution often
associated with speckled curd like white lesion
• Symptoms  soreness & dryness of mouth
• Signs  palatal tissue  bright red, edematous
& granular
85

86. • Red patches  erythematous or speckled
sharply outlined & restricted to the tissue
actually in contact with the denture
• Multiple pinpoint foci of hyperemia involving
maxilla
86

87. Treatment
• Removal of the cause
• Replacement of denture or relining or applying
mycostatin
• Denture – cleaned thoroughly & regularly &
should be left out of the mouth at night in
hypochlorite solution
• Anti-fungal treatment
87

88. Angular chelitis
[perleche,angular cheilosis]
Causes
• Micro-organisms – mainly candida albicans
• Mechanical factors – over closure of jaws
- edentulous patient
- prosthesis with decreased vertical dimension
• Nutritional deficiency
• Atopic/ seborrhoic dermatitis
• Hypersalivation
88

89. Clinical features
• Dry & burning sensation at corners of mouth
• Rough triangular area of edema & erythema
• Wrinkled & maserated epithelium,deep fissures
appear ulcerated  do not bleed
89

90. Management
• Removal of cause
• Nutritional supplement
• Antifungal treatment –Miconazole
• Restore correct vertical dimension
90

91. Autoimmune disorder
91

92. HIV AIDS
• Acquired immuno deficiency
syndrome
• Epidemic disease
• Associated with wide range of oral
lesions like
 Oral candidiasis
 Oral hairy luekoplakia
 Kaposis sarcoma
 NUG & NUP
 Recurrent aphthous ulcerations
92

93. • Many of the dental treatments are
contraindicated in HIV patients
• The treatment plan depends on the overall
systemic health of the patient
• Precautions for prevention of transmission
93

94. 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 is
• a. Changes in occlusion
• b. Jaw relation
94

95. Changes in occlusion:
• As the joint tissue are more susceptible to increased
loading, the prosthetic reconstruction’s 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.
95

96. 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 cure.
96

97. NEUROMUSCULARL
DISORDERS:
a) Bells palsy
b) Parkinson’s disease
c) epilepsy
d) Myasthemia gravis
Added Problems:
 Denture retention
 Maxillo-mandibular relation
records
 Supporting musculature
97

98. 98
BELL’S PALSY
JPD vol35, Issue 2, February 1976, Pages 192-201.Prosthetic support for unilateral
facial paralysis. Larsen & carter
Bell's palsy is a disorder of the nerve that controls movement of the
muscles in the face.
Damage to this nerve causes weakness or paralysis of these
muscles.
Cause: Not clear. May be due to Herpes zoster infection ,trauma but
most of cases is idiopathic
The face will feel stiff or pulled to one side, and may look different.
Other symptoms can include:
•Difficulty eating and drinking; food falls out of one side of the mouth
•Drooling due to lack of control over the muscles of the face
•Drooping of the face, such as the eyelid or corner of the mouth
•Hard to close one eye

99. 99
•Problems smiling, grimacing, or making facial
expressions
•Twitching or weakness of the muscles in the face
•Dry eye or mouth
•Loss of sense of taste
•Sound that is louder in one ear (hyperacusis)

100. 100
•Prosthodontics considerations :
•Proper training on insertion & removal of dentures.
•Non- anatomic teeth.
•Heat strength metal reinforced denture bases
•Upright positions with head supported for making impressions.
•Repeated JR’s.
•Record neutral zone
•Denture hygiene instructions.
•Regular follow-up.
Prosthodontic management of complete edentulous patients with neuromuscular disorders
- Case reports. JADR Jan 2011 : 2(1); 67-72.

101. 101
Dr. James Parkinson in 1817.
Parkinson's disease is a disorder of
the brain that leads to shaking
(tremors) and difficulty with walking,
movement, and coordination.
Occurs mostly above 50 yr. of age.
Cause – destruction of dopamine
producing brain cells which control
muscular movement.
Parkinson’s disease (shaking palsy)

102. • SYMPTOMS
• Automatic movements (such as blinking) slow or
stop
• Constipation
• Difficulty swallowing & Drooling
• Impaired balance and walking
• Lack of expression in the face (mask-
like appearance)
• Muscle aches and pains
• Movement problems.
• Abnormalities in oral behavior such as
purposeless chewing, grinding & sucking
movements make dental treatment especially
difficult
102

103. 103
Gen Dent. 2008 May-Jun;56(4):e12-6.Complete denture prosthodontics for a patient with Parkinson's disease
using the neutral zone concept: a clinical report. Makzoume JE
Prosthodontic management :
 patient with Parkinson's disease is reassurance
before treatment treatment.
If xerostomia is also present, then use of salivary
substitutes recommended.
Use neutral zone technique
When dental treatment is finished, the patient should
be warned to take care when changing from a supine
to standing position, sine levodopa has a significant
orthostatic hypotensive effect

104. MYASTHENIA GRAVIS
• Myasthenia gravis is a disease characterized by easy
fatigability of striated muscle secondary to a disorder at
the neuromuscular junction
• The chief complaint of the patients with myasthenia
gravis is muscle weakness following exercise
• The facial muscles are commonly involved giving the
patient an immobile, expressionless appearance
• There is difficulty in chewing, the patient’s masticatory
muscles may become so tired that that the mouth
remains open after eating
104

105. Dental cosiderations:
 dentist must be aware that a respiratory
crisis may develop from the disease itself or
from overmedication
Therefore the dental treatment must be
performed in the hospital where
endotracheal intubation can be performed
The airway must be kept clear, use of a
rubber dam & suction to avoid aspiration
must be considered
105

106. Epilepsy
• It is a condition in which a person has recurrent
episode of seizures
• Seizure – Paroxysmal event due to
abnormal,excessive,hyper synchronous
discharge from CNS neurons
• It is generally controlled but not cure
106

107. Classification
107
Partial seizure
Primary
generalised
Absence ( Petit Mal)
Tonic- clonic ( Grand Mal )
tonic
atonic
Myoclonic
Simple partial
Complex partial
Partial seizure with
secondary generalization

108. In dental office
• Most comman cause of any type of seizure
Seizure in an epileptic paitent.
Hypoglycemia
Hypoxia sec. to syncope
Local anesthetic over dose
108

109. Phase wise management
• Prodomal phase—terminate dental procedure
• Ictal phase—paitent supine with leg elevated
asses and BLS if needed airways,breathing
Carry the person away from danger
diazepam(i/v)
definative care,protect from injury
giving o2,monitor vital sign
Post ictal phase—same as avobe ,assure paitent recovery
and discharge paitent
109

110. Conclusion:
• All the facts must be known before they can be
correlated in such a way that decision can be
made. Only then can treatment plans be
developed to best serve the needs of each
individual patient.
• For the patient to be happier the dentist should
not only require the skills of complete denture
construction but also the skills to treat a
patient’s aspirations & expectations.
110

111. References
• William R. Laney: Diagnosis and treatment in
prosthodontics, 2nd edition
• Boucher’s: Prosthodontic treatment for edentulous
patients, 10th &12th edn.
• Winkler: Essentials of complete denture
prosthdontics, 2nd edn.
• Rahn & Heartwell: Textbook of complete denture,
5th edn.
111

112. • Sheldon Winkler – Essentials of complete
denture prosthodontics.
• Bernard levin – impressions for complete
denture.
• Fenn- Clinical denture prosthetics, 3rd edn.
• S.I. bhalajhi – orthodontics art &science, 3rd
edition.
• JADR Vol II:Issue I: Jan, 2011.Prosthodontic
management of complete edentulous patients
with neuromuscular disorders - Case reports.
Dr. Suresh s. & Dr. Vipul asopa
112

113. 113
•The dental clinics of North America, Jan 1996;40(1)
•The Dental Clinics of North America, Apr 1977;21(2)
•Radiographic examination of edentulous mouths, JPD
1990;64:180-182.
•Arthur Grieder : Psychological aspects of prosthodontics, JPD
1973;30:736-744
•Wical K.E. & Swoope C.C. : Studies of residual ridge
resorption. Part I Use of panoramic radiographs for
evaluation and classification of mandibular resorption. JPD
1974;32:7-12
•James R. Hupp : Ischemic Heart Diseases & Their
Management. Dent Clin N Am 2006 :50 (4); 483–491
•Bruce Bavitz : Dental Management Of Patients With

114. 114