This document discusses the implications of various systemic diseases in prosthodontics. It begins by introducing the topic and explaining the importance of oral health and prosthodontic treatment for patients with systemic illnesses. It then covers classifications of physical status and diseases. Specific conditions discussed in detail include cardiovascular diseases like angina and myocardial infarction, hypertension, bleeding disorders, bone diseases like osteoporosis and osteitis deformans, endocrine disorders like diabetes mellitus and thyroid disorders, and neurologic disorders. For each condition, considerations for dental treatment and prosthodontic management are provided.

1. IMPLICATIONS OF SYSTEMIC DISEASES
IN PROSTHODONTICS
1

2. CONTENTS
 INTRODUCTION
 CLASSIFICATION OF PHYSICALSTATUS
• CLASSIFICATION OF SYSTEMIC DISEASES
• CARDIOVASCULAR DISEASES
 ENDOCRINE DISORDERS
 BLEEDING DISORDERS
 BONE DISORDERS
 NEUROGENIC DISORDERS
 HEPATITIS
 CONTRAINDICATIONS
 EMERGENCY DRUGS
 SUMMARY
 REFERENCES
2

3. 1. INTRODUCTION
As the old adage goes , “Prevention is better than cure” and
hence the right to have overall good health is important. But as
the age advances, many biological changes take place in the
human body leading to diseases , which does impact the
systemic health.
In order to maintain good supply of nutrients ,oral health
needs to be looked after. Occurrence of many illnesses , will
hamper the oral health and so is the overall health. The role of
Prosthodontist becomes more vital so as to rehab the lost
structures of oral cavity and provide way for overall well –being
of the patient.
. 3

4. 4
CLASSIFICATION OF PHYSICAL STATUS OF PATIENT

5. CLASSIFICATION OF SURGICAL
AND PROSTHETIC
DENTAL TREATMENT BY MISCH
5

6. 6
CLASSIFICATION OF THE DISEASES BASED ON MODE OF OCCURENCE
CONGENITAL ACQUIRED INFECTIOUS
BLEEDING DISORDERS HYPERTENSION HEPATITIS
BONE DISORDERS DIABETES MELLITUS SUBACUTE BACTERIAL
ENDOCARDITIS
MYOCARDIAL
INFARCTION
ADRENAL GLAND
DISORDER
OTHERS
NEUROLOGIC AND PSYCHIATRIC CONDITIONS
CARCINOMAS OF ORAL CAVITY

7. 7
CARDIOVASCULAR DISEASES
ANGINA PECTORIS
• Defined as chest pain as a result of exertion and alleviated by rest
• Mechanism of angina
• supply to demand - mismatch
• hence the need to improve cardiac oxygen
MYOCARDIAL INFARCTION
• prolonged ischemia resulting from a deficiency in the coronary arterial
blood supply that causes injury to the myocardium
• Pain is more severe than angina pectoris.

8. iii.
DENTAL MANAGEMENT
ANGINA PECTORIS
• Follow stress reduction protocol
• If angina attack occurs during treatment, stop the dental treatment immediately.
• Patient needs to be in supine position
• Administer nitroglycerine (0.3-0.4 mg) sublingually
• Administer oxygen at 6L/ min
• Hospital assistance can be taken.
MYOCARDIAL INFARCTION :-
• No treatment to be performed for the first 6 months from the attack of MI
• Physician consent to be sought
• Follow stress reduction protocol
• Appointments should be of shorter duration
8

9. 9
STRESS REDUCTION
PROTOCOL
 minimize time in waiting
room
brief morning appointments
pre- medications as needed
pre-op , intra-op and post -
op vital signs

10. 10
DENTAL IMPLANT MANAGEMENT
RISK IMPRESSIONS IMPLANT PROCEDURES
MILD >12 MON + UNDER GENERAL
ANESTHESIA
MODERATE 6-12 MON + POSTPONE THE
TREATMENT
SEVERE <6 MON + POSTPONE THE
TREATMENT
AVOID EXCESSIVE AMOUNTS OF EPINEPHRINE BOTH IN LAAND RETRACTION
CORD
If highly suspected a MI
MONA: Morphine, Oxygen , NTG, Aspirin

11. 11
HYPERTENSION
• A CONDITION IN WHICH THE FORCE OF BLOOD AGAINST THE
ARTERY WALL IS TOO HIGH
• ESSENTIAL HPERTENSION- NO SECONDARY CAUSE
• SECONDARY HYPERTENSION - UNDERLYING SYSTEMIC
ETIOLOGY
BP CLASSIFICATION SBP mmHg DBP mmHg
NORMAL <120 <80
PREHYPERTENSION 120-139 80-89
HYPERTENSION -
STAGE 1
140-159 90-99
HYPERTENSION -
STAGE 2
>160 >100

12. 12
DENTAL MANAGEMENT
• MONITORING OF BLOOD PRESSURE IS MANDATORY
• FOLLOW STRESS REDUCTION PROTOCOL
• ADMINISTER DIAZEPAM 5- 10 MG ,NIGHT BEFORE PROCEDURE
• BRIEF AND MORNING APPOINTMENTS
• LOCAL ANAESTHESIA WITHOUT ADRENALINE TO BE GIVEN.
• ABSORBABLE SUTURES WITHOUT ADRENALINE TO BE USED.
• SHARP EDGES OF RPD SHOULD BE TRIMMED .
• CARE TO BE TAKEN WHILE FABRICATING COMPLETE DENTURE TO
AVOID CAUSING SOFT TISSUE ABRASION
• JUDICIOUS USE OF NSAID CAN BE HARMFUL IN LONG RUN

13. • Subacute Bacterial Endocarditis:
• DENTAL MANAGEMENT
• Oral prophylaxis to be performed prior to any soft tissue surgery
• Irrigation with Chlorhexidine 3-5 min before extraction lowers the risk of
SABE.
• Prophylaxis are recommended in high risk patients for procedures like
dental implant placement, sub gingival placement of antibiotic fibers or
strips.
• Prophylaxis not recommended for the placement of removable
prosthodontic appliances and making oral impressions.
• Antibiotic prophylaxis- 2g of amoxicillin orally, 60 min before the
procedure.
13

14. iv. Intramucosal inserts are also
contraindicated for many of these
patients because a slight bleeding
can occur on a routine basis for
several weeks during the initial
healing process.
v. Endosteal implants with an
adequate width of attached
gingiva are the implants of choice
for patients in this group need
implant supported prosthesis.
14

15.  Patients undergoing anticoagulant therapy
The main objective of this therapy is to reducethe occurrence of
thromboembolism .
It is usually recommended in all patients with
 thromboembolic risk
 in patients after angioplasty and stentplacement,
 bypass surgery
 prosthetic heart valve placement.
15

16.  Another strong recommendation is the avoidance of drugs
that may increase the bleeding tendency . Of particular
importance are:
Analgesics, because aspirin and other non-steroidal
antinflammatory agents significantly prolong the
bleeding time by preventing platelet aggregation and
thus increasing the activity of warfarin.
 Antibiotics, because some molecules such as
erythromycin, clarithromycin or metronidazole are able to
augment the anticoagulant effect of warfarin.
16

17. • The reduction of the preoperative warfarin dosage or the
discontinuation of the anticoagulant treatment 2 or 3 days
before the oral surgery procedure has been a widely used
strategy (Mulligan & Weitzel 1988).
 According to Scully et al. (2007), the placement of an implant in
patients undergoing OAT can be regarded with comparable or
even less surgical trauma than the extraction of three teeth,
provided that this procedure does not involve
 the harvesting of autogenous bone grafts,
 the raising of extensive flaps
 placing implant in sites where there is a risk during the
osteotomy preparation of extending outside the bony
envelope.
17
PROSTHODONTIC MANAGEMENT

18. PROSTHETIC HEART VALVE
REPLACEMENT
PROBLEMS:-
• ENDOCARDITIS OF PROSTHETIC VALVE CAN OCCUR
FOLLOWING DENTAL TREATMENT
• PROLONGED BLEEDING CAN OCCUR FOR ANY INVASIVE
PROCEDURES.
• MANAGEMENT:-
1. ANTIBIOTIC PROPHYLAXIS IS MUST BEFORE STARTING THE
TREATMENT
2. PATIENTS ON OAT - SHOULD ADJUST THE DOSAGE AS PER
PHYSICIAN’S ADVICE
18

19. RHEUMATIC HEART DISEASE
• Rheumatic heart disease is a chronic condition resulting from rheumatic
fever which involves all the layers of the heart (i.e. pancarditis) and is
characterized by scarring and deformity of the heart valves.
• MITRAL VALVES are infected & then followed by all other valves.
• ETIOLOGY :-
• Group A beta-hemolytic streptococcus.
• Rheumatic fever
• DENTAL MANAGEMENT:-
• 1. Medical consultation.
• 2.Prophylactic antibiotic.
• 3. Mild tranquilizers (2-5 mgdiazepam).
• 4. Short dental appointment.
19

20. 20
ENDOCRINE DISORDERS
ADRENAL GLAND DISORDER:
• GENERAL MANAGEMENT
• It is preferable for the visits to be brief and in the morning
• non -invasive procedures can be performed normally
PROSTHODONTIC MANAGEMENT:-
• PHYSICIAN CONSENT IS MUST
• STEROID DOSE TO BE DOUBLED THE DAY BEFORE THE SURGERY
• MAINTENANCE DOSE TO BE RETURNED NORMALAFTER SURGERY
• JUDICIOS USE OF ANTIBIOTICS RECOMMENDED

21. THYROID DISORDERS:-
• BROADLY CLASSIFIED AS :-
HYPERTHYROIDISM - RESULTS IN CATABOLIC STATE WITH
TACHYCARDIA , DIARRHOEAAND HEAT INTOLERANCE.
• THYROID STORM - EXAGGERATED RESPONSE TO THE
STRESS CAUSED , LASTING FOR 24-48 HOURS
• LIFE THREATENING CONDITION.
• MANAGEMENT:-
• IF IN THYROID STORM - COOL DOWN THE PAIENT ,
INTRAVENOUS INFUSION OF GLUCOSE &IV FLUIDS ,
CORTICOSTEROIDS.
21

22. DIABETES MELLITUS
 Diabetes mellitus is a disease of glucose, fat & protein
metabolism resulting from impaired insulin secretion, varying
degree of insulin resistance or both.
22

23.  According to American diabetic association (ADA): Fasting
blood sugar (FBS) > 126 mg/dl or Post prandial blood
sugar (PRBS) > 180mg/dl.
 Symptoms like polyuria, polydypsia, polyphagia, weight loss
and visual disturbances are experienced by diabetic patients.
.
23

24. 24

25. ORAL
MANIFESTATIONS
OF DIABETES
Xerost
omi
a
Periodontitis
Increased
Caries
Risk
Burning
Sensation
Gingival
Inflammatio
n
Fungal
Infections
Poor
Wound
Healing
Alveolar
Bone
Resorption
25

26. PROSTHODONTIC MANAGEMENT
OF DIABETIC DENTAL
PATIENT
1. Medical History:
 It is important to take proper medical history of the patient’s
blood glucose levels, medication, dosage and timing of
medication taken.
 Make sure the patient had done their blood glucose level test
prior to the treatment.
2. Diet:
 It should be ensured that patient has had his/her breakfastand
medication before treatment.
26

27. 3. Scheduling of the Patient’s Visit:
 Diabetic patients should be scheduled preferably in the
morning.
4. In RPD:
 All components of RPD must be designed appropriately such
that prosthesis is tissue friendly.
 Proper oral hygiene and denture hygiene or maintenance
instructions should be given to the patients.
27

28. 5. In CD:
 Denture border and tissue surfaces of the dentures should be
smooth without any sharp nodules or over extensions to
prevent tissue damage.
 Primary Impressions should be taken in mucostatic
technique without pressure & secondary impressions to be
taken in selective pressure technique
 Concept of neutral zone technique can be employed to reduce
the bone resorption .
 Proper oral hygiene instructions can be given to patients to
avoid fungal infections.
 As there is decrease denture retention due to less salivation ,
frequent sipping of water and use of sugarless gums may help
them to maintain salivary flow. 28

29. 6. In FPD:
 It is better to keep the finish line supragingival to avoid
damaging soft tissue.
 The chamfer margin is a better option as it applies less
force or stress on weakened tooth.
 Ante's law should be obeyed as the diabetic patient more
prone for periodontal infection.
 Proper flossing should be done to maintain the oral hygiene.
29

30.  During tooth preparation, care should be taken to avoid
trauma to the soft tissue as diabetes patients have poor
wound healing.
Hygienic pontic should be preferred .
Multiple abutments to be selected.
Regular follow up is a must .
30

31. 31
PROSTHODONTIC MANAGEMENT :-

32. 7. In Implant or Implant Supported Dentures:
 As this condition is commonly associated with impaired wound
healing, any surgical procedure like pre-prosthetic surgery or
dental implant placement should be performed only when the
diabetes is in well controlled state.
 Antimicrobial cover using penicillin, amoxicillin, clindamycin or
metronidazole should be provided before and after the implant
surgery.
 These patients should also quit smoking, optimize oral hygiene
measures and use antiseptic mouthrinses to prevent the
occurrence of periodontal and peri-implantitis.
 Patient should maintain their sugar level even after the surgical
placement of implants.
32

33. BLEEDING DISORDERS
 Bleeding disorders can be classified as coagulation factor
deficiencies, platelet disorders, vascular disorders or fibrinolytic
defects.
 Among the congenital coagulation defects, hemophiliaA,
hemophilia B (Christmas disease) and von Willebrand’s disease
are the most common.
 Hemophilia comprises a group of hereditary bleeding
disorders caused due to the deficiency of one or more
clotting factors.
33

34.  It is broadly divided into hemophilia A, B, and C, which occur due
to deficieny of factors VIII, IX, or XI (F VIII, F IX, F XI) respectively.
Prosthodontic rehablitatio
• Removeable prosthodontic procedures do not usually involve a
considerable risk of bleeding.
 Trauma should be minimized by careful post-insertion
adjustments. Oral tissue should be handled delicately during the
various clinical stages of prosthesis fabrication to reduce the risk
of ecchymosis
34

35. BONE DISEASES
• 1.Osteoporosis
• Osteoporosis is defined by the WHOas bone mineral density
(BMD)greater than 2.5 standard deviations below that of the
young adult BMD.
• Osteoporosis is common in aging individuals, especially
post menopausal women when the estrogenic blood level
is low.
• Residual ridge resorption of the jaws is also more rapid in
increasing age group, depleted bone being prone to the
injurious impact of mechanical forces
35

36. 36
Prosthodontic management
.Management
1. Mucostatic and Open mouth impression techniques,
2. Use of acrylic - or semi-anatomic teeth rather than porcelain ones,
3. Narrowing the occlusal table and/or decreasing number of
posterior teeth,
4. Periods of extended tissue rest (by keeping dentures out of the
mouth for 10–12 h daily),
5. Optional use of soft liners and shorter recall intervals to facilitate
early intervention could be incorporated.

37. 2. Osteitis deformans :
 It is a slowly progressing
chronic disease where
osteoblasts and osteoclasts
are involved with
predominance of its
osteoblastic activity.
 Characterized by excessive,
uncoordinated phases of
resorption and deposition of
osseous tissue in single /
multiple bones.
 The jaws are affected in
20% of the cases .The
maxilla is more often
involved than mandible.
37

38. ORAL MANIFESTATIONS
 Pain with bilaterally symmetrical swelling of the involved
bone.
 Leontiasis ossea - facial bone involvement
 Headache, blindness, deafness.
 Difficulty in wearing old dentures.
 Diastema, loosening of teeth, malocclusion may be seen.
 Necrosis of gingiva over the underlying bone may occur
due to excessive internal pressure.
 Pathologic fractures also may occur as bone becomes very
weak.
38

39. MANAGEMENT
 Prosthodontists treating patients with this disease
must be aware of complaints of pain with sudden onset
accompained by swelling.
 Oral implants are contraindicated in the regions affected
by this disorder .
 The remakes and adjustment of dentures are needed
due to continual enlarging and changing of supporting
structure especially of the maxillary tuberosity.
39

40. NEUROLOGIC DISORDERS
 The neurologic conditions like parkinson’s disease, stroke,
and seizures require thorough history and list of
medications. A consultation with physician is helpful in
treating these patients.
Prosthodontic considerations :
 The patient with lack of salivary control should be
positioned in a semi reclined position to avoid pooling of
salvia, airway obstruction, and aspiration.
 When dentist is providing replacement complete denture,
duplication technique should be used in order to retain the
learned muscle control of familiar denture.
40

41. PARKINSON’S DISEASE
• Parkinson’s disease is a neurological disorder characterized
by tremors, rigidity, bradykinesia and postural instability.
• Oral hygiene is poor.
• Edentulism risk is high
• DENTAL MANAGEMENT:-
• Tremor and rigidity may cause problems with patient ability to
cooperate.
• Should be seen at a time of day when their medication
produce their maximum effect. •
• Upright sitting position to prevent orthostatic hypotension
• Positioned in a semi reclined position to avoid pooling of
salvia, airway obstruction, and aspiration
41

42. 42

43. 43
RPD
• Denture retention, stability and support are compromised due to
tremors, rigidity of the orofacial musculatures and drooling of saliva.
• Impressions should be recorded with quick setting impression
materials
• Neutral zone technique, flange technique and selective grinding of
the occlusion .
• Moisture based denture adhesives or artificial salivary substitutes
can be prescribed .
• Overdentures can provide better masticatory efficiency
• When dentist is providing replacement complete denture, duplication
technique should be used in order to retain the learned muscle
control of familiar denture
PROSTHODONTIC MANAGEMENT

44. 44
IMPLANT SURGERY
• LA containing epinephrine is used cautiously, because if
agonises with levodopa or entacapone, shoots up BP and heart
rate .
• Epinephrine of less than 0.05 milligram appears to be safe.
• Dentist should be careful when prescribing erythromycin and
ampicillin, as they are known to interfere with biliary excretion

45. BELL’S PALSY
• DEFINITION
• Acute onset of non suppurative
inflammation of the facial nerve above the
stylomastoid foramen, producing a
unilateral LMN FACIAL PALSY.
• SYMPTOMS:
• Corner of mouth droops.
• Forehead is unforrowed
• Eye on the paralysed side rolls upward –
BELL’S PHENOMENON
• Saliva may dribble from the corner of the
mouth
• Heaviness or numbness of the face
45

46. PROSTHODONTIC MANAGEMENT
• Neutral Zone Impression Technique
• Lingualised Teeth Arrangement
• Intermediate Dentures To Stabilise Jaw
Movements
• Liquid Dentures
• Supporting Prosthesis For Speech
• Face Lift Device
• Extended Buccal Flange Technique
• Dentures with detachable buccal/cheek
plumper/cheek lifting appliance 46

47. HEPATITIS B
 In dentistry, viral hepatitis B is considered to be
dangerous due to cross infection risk after sharp injuries.
 The main reason that chronic viral hepatitis may be of interest
for the outcome of the implant restoration may be when the
bone quality and quantity is altered.
 It is important factor before placing immediately an implant
in the socket, post-extraction, to have a thorough cleaning
of the cavity.
47

48.  Post-surgery the patient advised to rinse the mouth
with 0.12% chlorexidine antiseptic solution for a
week.
 hepatitis B carriers were not considered to be a
group of relative or absolute contraindication for
implantology.
48

49. 49
ABSOLUTE CONTRAINDICATIONS RELATIVE CONTRAINDICATIONS
1. RECENT MI 1. CONNECTIVE TISSUE DISEASE
2. CEREBROVASCULAR ACCIDENT 2. AUTOIMMUNE DISEASES
3. VALVULAR PROSTHESIS SURGERY 3.HIV
4.HAEMOPHILIA 4.SMOKING
5.IMMUNOSUPPRESSION- ORGAN
TRANSPLANT
5. PREGNANCY
6.FIBROUS DYSPLASIA 6. OSTEOPOROSIS
7.PAGET’S DISEASE 7.VITAMIN D- DISORDERS
8. OSTEORADIONECROSIS 8. PSYCHOLOGICAL DISORDERS
CONTRAINDICATIONS

50. 50
SL .
NO.
DRUG INDICATIONS DOSAGE AND ROUTE
1. Epinephrine
1:1000
ANAPHYLAXIS 0.3 ML IM
2.
3. Salbutamol
inhaler
ASTHMA 2-3 PUFFS over one in 2 min
7. Diazepam {5 mg/
ml}
SEIZURE 10 mg IV over 2 min.
8. Ammonia SYNCOPE to be inhaled.
9. Naloxone (0.4
mg/ml}
opioid antidote 0.2-0.4mg IV over 2- 3 min

51. SUMMARY
Although the dental treatments will require a
little modification, the informed dentist will
recognize the need for more information on
the identification and management of
chronic diseases in this age group.
Increased knowledge and concern for the
patient should allow better treatment
planning and effective patient care
management.
51

52. REFERENCES
 Misch CE : Contemporary Implant Dentistry,St Louis, MO,
CV Mosby, 1993,3; 421-461
• MALIK NA : Textbook of OMFS , SG DAMLE , 4 TH
EDITION, 2016:43-9;1048
 E Budtz-Jørgensen :Prosthodontics for the elderly:
diagnosis and treatment, pg 75-86.
 Bornstein MM, Cionca N, Mombelli A. Systemic conditions
and treatments as risks for implant therapy. Int J Oral
Maxillofac Implants 2009;24:12–27.
 Diz P,Scully C, Sanz M. Dental implants in the medically
compromised patient. J Dent 2013;41:195–206.
52

53.  Krennmair G, Seemann R, Piehslinger E. Dental implants in
patients with rheumatoid arthritis: clinical outcome and peri- implant
findings. J Clin Periodontol 2010; 37: 928–936.
 Kansal G, Goyal D. Prosthodontic Management Of Patients With
Diabetes Mellitus. J Adv Med Dent Scie Res 2013;1(1):38-44.
 Gupta A, Epstein J B, Cabay R J. Bleeding disorders of importance
in dental care and related patient management. J Can Dent
Assoc2007; 73: 77–83.
 Elsubeihi E, Zarb G. Implant Prosthodontics in Medically Challenged
Patients: The University of Toronto Experience• J Can Dent Assoc
2002; 68(2):103-8
 Kafas P,Andreopoulos I , Kafas G. The Success of Implant Surgery
Influenced by Hepatitis B Condition? A CaseReport. J.Med.Sci
2007;7(6):1065-67.
 Kumar P, Singh SV, Aggarwal H, Alvi HA. Call for detection of
osteoporosis in India-can a dentist help? Indian J Endocrinol
Metabol 2014;18: 871.
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54. THANK YOU
54