Importance of taking medical history prior to implant placement/ dental crown & bridge courses

Importance of taking medical
history
prior to implant placement
INDIAN DENTAL ACADEMYINDIAN DENTAL ACADEMY
Leader in continuing Dental EducationLeader in continuing Dental Educationwww.indiandentalacademy.comwww.indiandentalacademy.com

INTRODUCTION
If one is thorough in the evaluation of anIf one is thorough in the evaluation of an
implant patient, complications and theimplant patient, complications and the
possibilities of failure will be minimized.possibilities of failure will be minimized.
It is important to determine if the patient canIt is important to determine if the patient can
successfully undergo implant therapy orsuccessfully undergo implant therapy or
whether existing medical or psychologicwhether existing medical or psychologic
conditions will contraindicate treatment.conditions will contraindicate treatment.
The most important step in the evaluationThe most important step in the evaluation
process is the health history. This will allowprocess is the health history. This will allow
assessment of the patient's existing systemicassessment of the patient's existing systemicwww.indiandentalacademy.comwww.indiandentalacademy.com

conditions.conditions.
Any positive responses are to be followed with specificAny positive responses are to be followed with specific
questions to elicit details of the past medical history.questions to elicit details of the past medical history.
Vital signs should be taken as part of the routineVital signs should be taken as part of the routine
screening process. These will establish a baseline forscreening process. These will establish a baseline for
each candidate. Pulse, blood pressure, respiration,each candidate. Pulse, blood pressure, respiration,
and temperature should be recorded. Any significantand temperature should be recorded. Any significant
variations from normal need to verified and resolved.variations from normal need to verified and resolved.
Along with the health history, vital signs, and properAlong with the health history, vital signs, and proper
medico consultations, routine chemistries, bloodmedico consultations, routine chemistries, blood
counts, and urinalysis should be performed prior tocounts, and urinalysis should be performed prior to
surgery. These offer suggestions of the presence ofsurgery. These offer suggestions of the presence of
some diseases. Any discrepancies should be notedsome diseases. Any discrepancies should be noted
and proper referrals made for evaluation andand proper referrals made for evaluation and
treatment.treatment.
www.indiandentalacademy.comwww.indiandentalacademy.com

The areas that should receive primary attentionThe areas that should receive primary attention
are the following:are the following:
Cardiovascular systemCardiovascular system
Respiratory systemRespiratory system
Gastrointestinal systemGastrointestinal system
Excretory systemExcretory system
Nervous systemNervous system
Endocrine systemEndocrine system
Vascular systemVascular system
Skin and mucous membraneSkin and mucous membrane

DISEASES OF THE CARDIOVASCULARDISEASES OF THE CARDIOVASCULAR
SYSTEMSYSTEM
Patients with a history of cardiac diseasePatients with a history of cardiac disease
includingincluding
Angina Myocardial infarction ArrhythmiasAngina Myocardial infarction Arrhythmias
Stress
Recurrent episodes
““Even placement of a single implant
could www.indiandentalacademy.comwww.indiandentalacademy.com

Coronary artery disease, are amenable toCoronary artery disease, are amenable to
surgical correction.surgical correction.
Patients are thenPatients are then susceptible to infections, or, or
complications of the graft site, or both.complications of the graft site, or both.
Rheumatic heart diseaseRheumatic heart disease
Mitral valve prolapseMitral valve prolapse
Prophylactic antibiotics /Prophylactic antibiotics /
consultation with theconsultation with the
patient's physician.patient's physician.
Attention!!

Careful consideration should be given to theCareful consideration should be given to the
this group of patients as usually they arethis group of patients as usually they are
indicated for some method of intravenousindicated for some method of intravenous
sedation for tranquilization to allay fears andsedation for tranquilization to allay fears and
emotional trauma with the reduction ofemotional trauma with the reduction of
intraoperative stress.intraoperative stress.

ANGINA PECTORIS
Angina pectoris may be may be manifested asAngina pectoris may be may be manifested as
almost any kind of pain or discomfort thatalmost any kind of pain or discomfort that
results from this disproportion between oxygenresults from this disproportion between oxygen
requirement and the oxygen supply of the heartrequirement and the oxygen supply of the heart
muscle.muscle.
Acute anginal attacks may occur as a result ofAcute anginal attacks may occur as a result of
thethe stress associated with dental services.associated with dental services.
They have been experienced when the patientThey have been experienced when the patient
was in the waiting room or sitting in the dentalwas in the waiting room or sitting in the dental
chair before treatment has begun.chair before treatment has begun.www.indiandentalacademy.comwww.indiandentalacademy.com

ANGINA PECTORIS
In a patient with known angina pectoris,
relatively short-acting antianginal drugs
such as sublingual isosorbide dinitrate
tablets are recommended prophylactically
in addition to any long-acting nitrate drugs.

CORONARY HEART DISEASE
Patients who are particularly stressful mayPatients who are particularly stressful may
benefit frombenefit from anxiolytic premedication beforebefore
treatment.treatment.
The rapid acting oralThe rapid acting oral benzodiazepines areare
particularly useful in this regard, and diazepamparticularly useful in this regard, and diazepam
is the most commonly used. It should be givenis the most commonly used. It should be given
in the waiting roomin the waiting room 1 hour to 45 minutes
before the dental procedure to minimize stressthe dental procedure to minimize stress
reactions occurring in the waiting room and inreactions occurring in the waiting room and in
the dental chair.the dental chair.

CORONARY HEART DISEASE
Ask specific questions?Ask specific questions?
Whether on anticoagulant therapy?Whether on anticoagulant therapy?
If on long-term anticoagulant therapy, specificIf on long-term anticoagulant therapy, specific
instructions particularly with regard to bleedinginstructions particularly with regard to bleeding
to be given by their physician.to be given by their physician.
Frequent periodic prothrombin timeFrequent periodic prothrombin time
determinations should be made by thedeterminations should be made by the
physician especially during inter-current illnessphysician especially during inter-current illness
and the patient should be cautioned concerningand the patient should be cautioned concerning
thethe possible risk of taking drugs such as
aspirin and broad spectrum antibiotics such
as tetracycline or ampicillin.www.indiandentalacademy.comwww.indiandentalacademy.com

Sudden withdrawal of anticoagulant drugs,of anticoagulant drugs,
(especially vitamin K preparations) may result(especially vitamin K preparations) may result
inin thrombosis or embolism, but the, but the
continuance of full dosage of the anticoagulantof full dosage of the anticoagulant
may cause profoundmay cause profound bleeding in somein some
patients. Anesthesia and procedures are wellpatients. Anesthesia and procedures are well
toleratedtolerated
Shorter appointments with less extensiveShorter appointments with less extensive
traumatic procedures should be scheduled.traumatic procedures should be scheduled.
Medical consultation is indicated because theseMedical consultation is indicated because these
patients probably have serious underlying heartpatients probably have serious underlying heart
disease and need careful monitoringdisease and need careful monitoringwww.indiandentalacademy.comwww.indiandentalacademy.com

ARTIFICIAL HEART VALVES
They areThey are subject to infection due todue to
bacteremia induced by dental treatment, andbacteremia induced by dental treatment, and
the patient should be giventhe patient should be given prophylactic
antibiotics.

RHEUMATIC HEART DISEASE AND
RHEUMATIC FEVER
 Rheumatic fever is believed to be a disease ofRheumatic fever is believed to be a disease of
altered immunologic reaction to group A beta-altered immunologic reaction to group A beta-
hemolytic streptococcal infection.hemolytic streptococcal infection.
 This abnormal reaction to streptococcalThis abnormal reaction to streptococcal
infection causes lesions in the nervous system,infection causes lesions in the nervous system,
the subcutaneous tissues, joints, and mostthe subcutaneous tissues, joints, and most
frequently, the heart.frequently, the heart.

INFECTIVE ENDOCARDITIS
• Endocarditis of dental origin are almost alwaysEndocarditis of dental origin are almost always
caused by bacteria of low virulence that slowlycaused by bacteria of low virulence that slowly
(subacutely) attack a previously damaged(subacutely) attack a previously damaged
endocardium, causing a subacute bacterialendocardium, causing a subacute bacterial
endocarditis.endocarditis.
• It has a marked predisposition for people withIt has a marked predisposition for people with
rheumatic or congenital cardiac or vascularrheumatic or congenital cardiac or vascular
defects.defects. www.indiandentalacademy.comwww.indiandentalacademy.com

INFECTIVE ENDOCARDITIS
Cardiac lesions predisposing to endocarditisCardiac lesions predisposing to endocarditis
includeinclude
Bicuspid aortic valve,Bicuspid aortic valve,
Leutic aortic valvular disease,Leutic aortic valvular disease,
Idiopathic hypertrophic sub aortic stenosisIdiopathic hypertrophic sub aortic stenosis
andand
Mitral valve prolapse.Mitral valve prolapse.

When one considers the extremely seriousWhen one considers the extremely serious
nature of this disease, it is apparent that everynature of this disease, it is apparent that every
known prophylactic measure should be taken toknown prophylactic measure should be taken to
preclude the possibility of transient bacteremiaspreclude the possibility of transient bacteremias
occurring in patients with known valvularoccurring in patients with known valvular
lesions.lesions.
Have the patient rinse with an antibacterialHave the patient rinse with an antibacterial
mouthwash such as chlorhexidine immediatelymouthwash such as chlorhexidine immediately
before dental treatment to help reduce thebefore dental treatment to help reduce the
number of oral microorganisms.number of oral microorganisms.

HYPERTENSION
Hypertension (high blood pressure) indicates aHypertension (high blood pressure) indicates a
disease entity in which the systolic or diastolicdisease entity in which the systolic or diastolic
pressure, or both, is elevated.pressure, or both, is elevated.
It is one of the major risk factors for coronary heartIt is one of the major risk factors for coronary heart
disease and the most important risk factor fordisease and the most important risk factor for
cerebrovascular disease.cerebrovascular disease.
Hypertensive patients may succumb to cerebralHypertensive patients may succumb to cerebral
hemorrhage, myocardial infarction, cardiachemorrhage, myocardial infarction, cardiac
decompensation, or renal failure.decompensation, or renal failure.www.indiandentalacademy.comwww.indiandentalacademy.com

All adult patients should have their bloodAll adult patients should have their blood
pressure taken on the first visit to thepressure taken on the first visit to the
dental office and at least once yearlydental office and at least once yearly
afterwards.afterwards.
Patients with known hypertension should havePatients with known hypertension should have
the pressure taken at each dental visit tothe pressure taken at each dental visit to
assure that there is no risk of harm from theassure that there is no risk of harm from the
stress of the dental procedure.stress of the dental procedure.

All patients on antihypertensive medicationAll patients on antihypertensive medication
should be carefully questioned to ascertain thatshould be carefully questioned to ascertain that
they have not discontinued the medication.they have not discontinued the medication.
If the blood pressure in a resting patient isIf the blood pressure in a resting patient is
persistently 160/95 or greater after being takenpersistently 160/95 or greater after being taken
two or three times during the same or ontwo or three times during the same or on
closely spaced dental visits the patient shouldclosely spaced dental visits the patient should
be referred to his or her physician for furtherbe referred to his or her physician for further
observation and decision making regardingobservation and decision making regarding
antihypertensive medication.antihypertensive medication.

An elevated blood pressure in a dental patientAn elevated blood pressure in a dental patient
requires careful consideration inrequires careful consideration in
Treatment planning,
Premedication,
Selection of an anesthetic, and
Determining the duration and the extent
of operative procedures.
Anything that results in an elevation of bloodAnything that results in an elevation of blood
pressure, causes nervousness, or creates apressure, causes nervousness, or creates a
stressful situation should be minimized instressful situation should be minimized in
hypertensive patients.hypertensive patients.

CARDIAC DYSRHYTHMIAS
Manifested by an abnormal pulse rate orManifested by an abnormal pulse rate or
rhythm and may vary in severity.rhythm and may vary in severity.
Patients who lose consciousness because ofPatients who lose consciousness because of
decreased cardiac output associated with adecreased cardiac output associated with a
decreased heart rate may often be helped bydecreased heart rate may often be helped by
direct vigorous thumping on the precordium.direct vigorous thumping on the precordium.

CARDIAC DYSRHYTHMIAS
Similar symptoms associated with rapidSimilar symptoms associated with rapid
heartbeats may sometimes respond toheartbeats may sometimes respond to vagal
stimulation, such as, such as carotid sinus massage.massage.
This is done by first massaging the rightThis is done by first massaging the right
carotid sinus for 10 to 20 seconds. If this iscarotid sinus for 10 to 20 seconds. If this is
ineffective, the left carotid sinus is massaged.ineffective, the left carotid sinus is massaged.
Both carotid sinuses should not be
massaged simultaneously.www.indiandentalacademy.comwww.indiandentalacademy.com

Emergency measures other than the above relyEmergency measures other than the above rely
onon
The administration of drugs or
Cardioversion (electric shock),
both of which must be carefully monitored withboth of which must be carefully monitored with
an electrocardiogram.an electrocardiogram.

Electromagnetic radiation in the dental officein the dental office
interfering with cardiac pacemakers has beeninterfering with cardiac pacemakers has been
the subject of some concern.the subject of some concern.
Should the pacemaker accidentallyShould the pacemaker accidentally shut off, all, all
possiblepossible electric sources of interferenceof interference
shouldshould be switched off and cardiopulmonaryoff and cardiopulmonary
resuscitation should be begun if indicated.resuscitation should be begun if indicated.
Artificial respiration should cause the heart toArtificial respiration should cause the heart to
resume its normal rhythm and the pacemakerresume its normal rhythm and the pacemaker
to resume its normal function.to resume its normal function.

DISEASES OF THE RESPIRATORY SYSTEM
Several diseases of the respiratory systemSeveral diseases of the respiratory system
interfere with the ability to function in normalinterfere with the ability to function in normal
daily activities and therefore change the normaldaily activities and therefore change the normal
physiology of the body.physiology of the body.
Chronic bronchitis, pulmonary embolism,Chronic bronchitis, pulmonary embolism,
emphysema, and lung tumors may severelyemphysema, and lung tumors may severely
interfere with the normal healing mechanismsinterfere with the normal healing mechanisms
of the body. These pathologic processes mayof the body. These pathologic processes may
create a potentially high risk for this patientcreate a potentially high risk for this patient
intraoperatively or may entirely contraindicateintraoperatively or may entirely contraindicate
surgery.surgery. www.indiandentalacademy.comwww.indiandentalacademy.com

DISEASES OF THE RESPIRATORY SYSTEM
These pathologic processes may create aThese pathologic processes may create a
potentially high risk for this patientpotentially high risk for this patient
intraoperatively or may entirely contraindicateintraoperatively or may entirely contraindicate
surgery.surgery.

SINUSITIS / SINUS PROBLEMS
Pain in the maxillary molars and premolars thatPain in the maxillary molars and premolars that
is unexplained by local lesions may be causedis unexplained by local lesions may be caused
by maxillary sinusitis.by maxillary sinusitis.
Sinus problems can indicate the presence of anSinus problems can indicate the presence of an
allergy.allergy.
The patient may experience some respiratoryThe patient may experience some respiratory
distress when placed in a supine position.distress when placed in a supine position.
Distress may also be present if rubber dam isDistress may also be present if rubber dam is
used.used. www.indiandentalacademy.comwww.indiandentalacademy.com

SINUSITIS / SINUS PROBLEMS
Specific treatment modifications includeSpecific treatment modifications include
postponing treatment until the patient is able topostponing treatment until the patient is able to
breathe more comfortably, limiting the degreebreathe more comfortably, limiting the degree
of recline in the dental chair.of recline in the dental chair.

ASTHMA
Patients using beta adrenergic inhalers shouldPatients using beta adrenergic inhalers should
be reminded tobe reminded to bring the inhaler with them towith them to
the dental office.the dental office.
The dentist shouldThe dentist should avoid inhalation
anesthetics oror analgesics in asthmaticin asthmatic
patients due to the possibility of stimulating anpatients due to the possibility of stimulating an
acute asthmatic attackacute asthmatic attack

CHRONIC OBSTRUCTIVE PULMONARY DISEASES
Considering the alterations in blood gases in theseConsidering the alterations in blood gases in these
patients, their tolerance to long treatment sessions ispatients, their tolerance to long treatment sessions is
low.low.
This should be taken into consideration when planningThis should be taken into consideration when planning
dental therapy.dental therapy.
The patient's tolerance to partial airway obstructingThe patient's tolerance to partial airway obstructing
devices, such as a rubber dam, should be evaluateddevices, such as a rubber dam, should be evaluated
carefully, and before obstructing the oral airway, thecarefully, and before obstructing the oral airway, the
dentist should ascertain that the nasal passages aredentist should ascertain that the nasal passages are
capable of supplying the patient's respiratory needs.capable of supplying the patient's respiratory needs.
Inhalation analgesics or anesthetics should be givenInhalation analgesics or anesthetics should be given
only when absolutely necessary and in conjunctiononly when absolutely necessary and in conjunction
with an anesthesiologist.with an anesthesiologist.www.indiandentalacademy.comwww.indiandentalacademy.com

PULMONARY TUBERCULOSIS
Primarily spread by aerosolized dropletsPrimarily spread by aerosolized droplets
Infected patients pose a risk to the dentist &Infected patients pose a risk to the dentist &
dental office.dental office.
Fomites may not pose a risk of spread of theFomites may not pose a risk of spread of the
disease.disease.
Patients with a past history of active TB shouldPatients with a past history of active TB should
be evaluated by contacting patient's physicianbe evaluated by contacting patient's physician
to ensure that a course adequate treatment andto ensure that a course adequate treatment and
follow-up has been achieved. This is especiallyfollow-up has been achieved. This is especially
important if the patient presently has symptomsimportant if the patient presently has symptoms
consistent with tuberculosis.consistent with tuberculosis.

Although an actively infected patient is thoughtAlthough an actively infected patient is thought
to be noninfectious after 2 to 3 weeks of antito be noninfectious after 2 to 3 weeks of anti
tuberculosis drug treatment elective dentaltuberculosis drug treatment elective dental
treatment should be prudently deferred untiltreatment should be prudently deferred until
sputum cultures are negative usually in 3sputum cultures are negative usually in 3
months.months.
To avoid aerosolization as much as possible,To avoid aerosolization as much as possible,
use a rubber dam and minimalize use ofuse a rubber dam and minimalize use of
ultrasonic scalers and the high-speed handultrasonic scalers and the high-speed hand
piece. The operatory air should be vented topiece. The operatory air should be vented to
the outside.the outside. www.indiandentalacademy.comwww.indiandentalacademy.com

DISEASES OF THE GASTROINTESTINAL SYSTEM
Nervous stomach with vomiting, hypersecretions,Nervous stomach with vomiting, hypersecretions,
xerostomia, and hyperacidity all contribute to changesxerostomia, and hyperacidity all contribute to changes
in the pH of the saliva, which willin the pH of the saliva, which will interfere with healing
of the mucous membranes.
Various ulcers of the GI tract are sometimes indicativeVarious ulcers of the GI tract are sometimes indicative
of the patient'sof the patient's life stresses and strains.
This may be revealing with regard to the overallThis may be revealing with regard to the overall
treatment, as this patient maytreatment, as this patient may manifest his or her
emotional states in the form of bruxism, clenching, orin the form of bruxism, clenching, or
various tongue habits which may, in turn, contribute tovarious tongue habits which may, in turn, contribute to
eccentric forces being applied to the implant that willeccentric forces being applied to the implant that will
lead to its failure.lead to its failure. www.indiandentalacademy.comwww.indiandentalacademy.com

Diarrhea, constipation, and colitis are significantDiarrhea, constipation, and colitis are significant
factors in the ability to properly digest food andfactors in the ability to properly digest food and
maintain emotional stability.stability.
The liver has many functions like storage, filtration,The liver has many functions like storage, filtration,
and formation (on demand) of blood cells;and formation (on demand) of blood cells;
carbohydrate metabolism, production of prothrombincarbohydrate metabolism, production of prothrombin
and other coagulation factors, synthesis of plasmaand other coagulation factors, synthesis of plasma
proteins & when impaired,proteins & when impaired, may influence the normal
healing mechanisms.
In recent years eating disorders—anorexia, bulimia,In recent years eating disorders—anorexia, bulimia,
etc.—have been recognized as being detrimental toetc.—have been recognized as being detrimental to
the oral structures. These patients should be carefullythe oral structures. These patients should be carefully
evaluated prior to implant therapy. In addition,evaluated prior to implant therapy. In addition,
consultation with the treating professional staff isconsultation with the treating professional staff is
strongly recommended.strongly recommended.

DISEASES OF THE KIDNEY AND URINARY TRACT
The kidneys are responsible for filtering the blood,The kidneys are responsible for filtering the blood,
among other functions. They excrete the wasteamong other functions. They excrete the waste
products of body metabolism.products of body metabolism.
Disease states as nephritis, glomerulonephritis,Disease states as nephritis, glomerulonephritis,
chronic urinary tract infections, and tumors of thechronic urinary tract infections, and tumors of the
kidney will all cause disturbances of normal kidneykidney will all cause disturbances of normal kidney
function, and thus afunction, and thus a change in the normal composition
of the blood.of the blood.
SinceSince kidney transplants are becoming a moreare becoming a more
common procedure, consultation with the patient'scommon procedure, consultation with the patient's
physician should be sought prior to initiating anyphysician should be sought prior to initiating any
implant procedure on an organ transplant patient.implant procedure on an organ transplant patient.

KIDNEY DYSFUNCTION
Treatment modifications includingTreatment modifications including antibiotic
prophylaxis may be appropriate for severalmay be appropriate for several
chronic forms of renal disease.chronic forms of renal disease.
CHRONIC RENAL DISEASE
Important to minimize possible sources ofImportant to minimize possible sources of
infection.infection.
Avoid drugs metabolized by kidneys such asAvoid drugs metabolized by kidneys such as
tetracycline, streptomycin. Good oral hygienetetracycline, streptomycin. Good oral hygiene
very important.very important. www.indiandentalacademy.comwww.indiandentalacademy.com

HEMODIALYSIS
Same as chronic renal failure, plusSame as chronic renal failure, plus careful
scheduling of appointments to avoid bleedingto avoid bleeding
following use of heparinfollowing use of heparin (appointment day after
dialysis preferred).
Use antibiotic premedication to preventUse antibiotic premedication to prevent
endarteritis of the shunt.endarteritis of the shunt.
RENAL TRANSPLANT
Minimize sources of infection, avoidMinimize sources of infection, avoid
nephrotoxic drugs in cases of renal transplant,nephrotoxic drugs in cases of renal transplant,
Screen for HBsAg.Screen for HBsAg.
Same antibiotic coverage as in prevention ofSame antibiotic coverage as in prevention of
bacterial endocarditis.bacterial endocarditis.www.indiandentalacademy.comwww.indiandentalacademy.com

DISEASES OF THE NERVOUS SYSTEM
Epileptics are subject to convulsive disordersEpileptics are subject to convulsive disorders
followed by states of unconsciousness.followed by states of unconsciousness.
The forces that can be exerted during theseThe forces that can be exerted during these
seizures can be traumatic to implants.seizures can be traumatic to implants.
Doctors often must modify the treatment (forDoctors often must modify the treatment (for
example, use stress reduction techniques) forexample, use stress reduction techniques) for
patients with known seizure disorders.patients with known seizure disorders.
In addition, many of these patients are treatedIn addition, many of these patients are treated
with phenytoin (Dilantin), an anticonvulsant.with phenytoin (Dilantin), an anticonvulsant.
One of the effects of phenytoin is gingivalOne of the effects of phenytoin is gingival
hypertrophy,hypertrophy,

The epileptic patient who has implants may beThe epileptic patient who has implants may be
subject to gingival hypertrophy around thesubject to gingival hypertrophy around the
abutment neck and should be warned of thisabutment neck and should be warned of this
possibility because subsequent surgicalpossibility because subsequent surgical
corrections may be necessary.corrections may be necessary.
Other neurologic disorders, such as trigeminalOther neurologic disorders, such as trigeminal
neuralgia, Bell's palsy, glossopharyngealneuralgia, Bell's palsy, glossopharyngeal
neuralgias, or existing paresthesia, should beneuralgias, or existing paresthesia, should be
noted on the patient's medical historynoted on the patient's medical history
preoperatively.preoperatively.

DISEASES OF THE ENDOCRINE SYSTEM
The eight endocrine glands in the body areThe eight endocrine glands in the body are
responsible for numerous functions dealing withresponsible for numerous functions dealing with
growth, sexual development, metabolism, andgrowth, sexual development, metabolism, and
reproduction.reproduction.
States such as gigantism, dwarfism andStates such as gigantism, dwarfism and
acromegaly all demonstrate abnormal growthacromegaly all demonstrate abnormal growth
with subsequent abnormally large or smallwith subsequent abnormally large or small
maxillofacial skeletal size which could influencemaxillofacial skeletal size which could influence
implant intervention.implant intervention.

THYROID DISEASE
The clinical presence of thyroid dysfunction - eitherThe clinical presence of thyroid dysfunction - either
hyperthyroidism or hypothyroidism—should prompthyperthyroidism or hypothyroidism—should prompt
the doctor to use caution in the administration ofthe doctor to use caution in the administration of
certain drug groups for example,certain drug groups for example,
epinephrine to hyperthyroid patients andepinephrine to hyperthyroid patients and
CNS depressants to hypothyroid patientsCNS depressants to hypothyroid patients
In most instances however, the patient already hasIn most instances however, the patient already has
seen a physician and undergone treatment for theirseen a physician and undergone treatment for their
thyroid disorder by the time they seek dentalthyroid disorder by the time they seek dental
treatment. In this case the patient is in a euthyroidtreatment. In this case the patient is in a euthyroid
state (normal blood levels of thyroid hormone)state (normal blood levels of thyroid hormone)
because of surgical intervention, irradiation, or drugbecause of surgical intervention, irradiation, or drug
therapy.therapy. www.indiandentalacademy.comwww.indiandentalacademy.com

Myxedema and cretinism are also states whichMyxedema and cretinism are also states which
lead to retarded dental development, either inlead to retarded dental development, either in
pattern of eruption or with malformation of thepattern of eruption or with malformation of the
structures.structures.

PARATHYROID HORMONE
The parathyroid glands are responsibleThe parathyroid glands are responsible
primarily for calcium and phosphorusprimarily for calcium and phosphorus
metabolism. Ninety-nine percent of bodymetabolism. Ninety-nine percent of body
calcium is found in the organic matrix of bonecalcium is found in the organic matrix of bone
and teeth.and teeth.
Calcium is essential for numerous functions inCalcium is essential for numerous functions in
the body.the body.
The formation of bone and teeth as well as itsThe formation of bone and teeth as well as its
role in the coagulation of blood are among therole in the coagulation of blood are among the
more important actions of calcium.more important actions of calcium.

PARATHYROID HORMONE
Therefore, any abnormal calcium activity in theTherefore, any abnormal calcium activity in the
body requires complete review beforebody requires complete review before
placement of dental implants.placement of dental implants.

DIABETES
Pancreas secretes insulin.Pancreas secretes insulin.
The most common disease associated with theThe most common disease associated with the
pancreas is diabetes—the inability of the body topancreas is diabetes—the inability of the body to
metabolize carbohydrates.metabolize carbohydrates.
Diabetics are prone to periodontal disease: they haveDiabetics are prone to periodontal disease: they have
a decrease in local as well as general resistance toa decrease in local as well as general resistance to
The selection of the diabetic patient to receiveThe selection of the diabetic patient to receive
implants must be carefully considered. Consultationimplants must be carefully considered. Consultation
with the patient's physician should also be sought.with the patient's physician should also be sought.www.indiandentalacademy.comwww.indiandentalacademy.com

DIABETES
Patients should be informed of the potential forPatients should be informed of the potential for
complications or failure related to theircomplications or failure related to their
preexisting disease.preexisting disease.
Care should be taken to avoid fatiguing patient.Care should be taken to avoid fatiguing patient.
The greatest concerns during dental treatmentThe greatest concerns during dental treatment
relate to the possible effects of dental care onrelate to the possible effects of dental care on
subsequent eating and development ofsubsequent eating and development of
hypoglycemia (low blood sugar).hypoglycemia (low blood sugar).www.indiandentalacademy.comwww.indiandentalacademy.com

Patients leaving a dental office with residualPatients leaving a dental office with residual
soft tissue anesthesia, especially in thesoft tissue anesthesia, especially in the
mandible, usually defer eating until sensationmandible, usually defer eating until sensation
returns, a period of possibly many hours.returns, a period of possibly many hours.
Diabetic patients may have to modify theirDiabetic patients may have to modify their
insulin doses if they do not maintain normalinsulin doses if they do not maintain normal
eating habits.eating habits.
Complications of diabetes includeComplications of diabetes include
hypoglycemia, and loss of conciousness due tohypoglycemia, and loss of conciousness due to
hyperglycemia (extremely rare in a dentalhyperglycemia (extremely rare in a dental
office).office).

Well controlled type 2 diabetic patients mayWell controlled type 2 diabetic patients may
have a slight increase in early implant failure.have a slight increase in early implant failure.
Uncontrolled diabetes is totally contraindicatedUncontrolled diabetes is totally contraindicated
for implant therapy.for implant therapy.
Neither type 1 nor type 2 diabetes, whenNeither type 1 nor type 2 diabetes, when
controlled, are contraindications for implantcontrolled, are contraindications for implant
placement.placement.
Antibiotic therapy at the time of implant surgeryAntibiotic therapy at the time of implant surgery
should be considered.should be considered.www.indiandentalacademy.comwww.indiandentalacademy.com

DISEASES OF THE BLOOD
ANEMIA
Anemia is a relatively common adult ailment,Anemia is a relatively common adult ailment,
especially among young adult women (iron-deficiencyespecially among young adult women (iron-deficiency
anemia).anemia).
The doctor must determine the type of anemiaThe doctor must determine the type of anemia
present.present.
In addition, congenital or idiopathicIn addition, congenital or idiopathic
methemoglobinemia is a relative contraindication tomethemoglobinemia is a relative contraindication to
the administration of the amide local anestheticthe administration of the amide local anesthetic
prilocaine.prilocaine.
The patient with anemia should be treated with care,The patient with anemia should be treated with care,
as even an elective surgical procedure can cause aas even an elective surgical procedure can cause a
sudden drop in the blood count.sudden drop in the blood count.

ANEMIA
General anesthesia should be avoided in patients withGeneral anesthesia should be avoided in patients with
sickle cell trait and those withsickle cell trait and those with sickle cell anemiasickle cell anemia;;
when used, it is imperative to avoid episodes ofwhen used, it is imperative to avoid episodes of
hypoxia because of the cerebral or myocardialhypoxia because of the cerebral or myocardial
thrombosis which might result.thrombosis which might result.
A patient withA patient with chronic anemiachronic anemia has poor healing afterhas poor healing after
dental procedures.dental procedures.
There are two major problems in the dentalThere are two major problems in the dental
management of patients withmanagement of patients with aplastic anemiaaplastic anemia
infection and bleeding.infection and bleeding.
Local infections and bacteremias originating in theLocal infections and bacteremias originating in the
oral region can have a fatal course.oral region can have a fatal course.www.indiandentalacademy.comwww.indiandentalacademy.com

Gingival bleeding can be reduced by using systemicGingival bleeding can be reduced by using systemic
antifibrinolytic agents, such as aminocaproic acid orantifibrinolytic agents, such as aminocaproic acid or
tranexamic acid, and local hemostatic measures.tranexamic acid, and local hemostatic measures.
Oral rinses with chlorhexidine 0.2% in an aqueousOral rinses with chlorhexidine 0.2% in an aqueous
solution will reduce the amount of plaque and thesolution will reduce the amount of plaque and the
number of microorganisms in the oral cavity.number of microorganisms in the oral cavity.
However, intramuscular injections and nerve blockHowever, intramuscular injections and nerve block
anesthesias are to be avoided because of theanesthesias are to be avoided because of the
thrombocytopenia and bleeding tendency.thrombocytopenia and bleeding tendency.
Intraligamentary anesthesia can be used safely inIntraligamentary anesthesia can be used safely in
these cases.these cases.

LEUKEMIASLEUKEMIAS
A marked increase in leukocytes andA marked increase in leukocytes and
hyperplasia of the tissues that form white bloodhyperplasia of the tissues that form white blood
cells is termed leukemia.cells is termed leukemia.
Any form of acute leukemia wouldAny form of acute leukemia would
contraindicate dental implants.contraindicate dental implants.
Continuous bleeding with ulcerative stomatitisContinuous bleeding with ulcerative stomatitis
is a frequent finding. The chronic leukemias areis a frequent finding. The chronic leukemias are
usually not as violent, but the oral symptomsusually not as violent, but the oral symptoms
are similar.are similar. www.indiandentalacademy.comwww.indiandentalacademy.com

HEMOPHILIAHEMOPHILIA
Classic hemophilia is found only in males and isClassic hemophilia is found only in males and is
characterized by a deficiency of plasma factor VIII.characterized by a deficiency of plasma factor VIII.
These patients have prolonged bleeding following theThese patients have prolonged bleeding following the
most minute trauma or surgical procedure.most minute trauma or surgical procedure.
The doctor must thoroughly evaluate hemophilia andThe doctor must thoroughly evaluate hemophilia and
other bleeding disorders before beginning anyother bleeding disorders before beginning any
procedure, especially those in which bleeding mayprocedure, especially those in which bleeding may
occur.occur.
The use of aspirin(anti platelet action) and otherThe use of aspirin(anti platelet action) and other
nonsteroidal anti-inflammatory drugs for pain controlnonsteroidal anti-inflammatory drugs for pain control
are contraindicated in patients with bleeding disordersare contraindicated in patients with bleeding disorders
owing to their inhibition of platelet function andowing to their inhibition of platelet function and
potentiation of bleeding episodes.potentiation of bleeding episodes.www.indiandentalacademy.comwww.indiandentalacademy.com

HEMOPHILIAHEMOPHILIA
Intramuscular injections should also be avoidedIntramuscular injections should also be avoided
because of the risk of hematoma formation.because of the risk of hematoma formation.
The doctor is advised to avoid (whenever possible) theThe doctor is advised to avoid (whenever possible) the
administration of regional nerve blocks in which theadministration of regional nerve blocks in which the
risk of positive blood aspiration is great.risk of positive blood aspiration is great.
In most instances, alternative techniques for painIn most instances, alternative techniques for pain
control should be considered.control should be considered.
Usually these patients are not considered forUsually these patients are not considered for
dental implants.dental implants.

PURPURASPURPURAS
Purpuras are characterized by hemorrhage intoPurpuras are characterized by hemorrhage into
the skin and mucous membranes.the skin and mucous membranes.
These patients will have prolonged orThese patients will have prolonged or
spontaneous bleeding and should not bespontaneous bleeding and should not be
considered for dental implants.considered for dental implants.
Topical treatment to stop gingival bleedingTopical treatment to stop gingival bleeding
should always include removing obvious localshould always include removing obvious local
irritants and direct pressure.irritants and direct pressure.
The use of absorbable gelatin or collagenThe use of absorbable gelatin or collagen
sponges, topical thrombin, or the placement ofsponges, topical thrombin, or the placement of
microfibrillar collagen.microfibrillar collagen.

PURPURASPURPURAS
A group of drugs, anticoagulants, are used toA group of drugs, anticoagulants, are used to
"thin out the blood.""thin out the blood."
Heparin, given only intravenously, will cause anHeparin, given only intravenously, will cause an
increase in the coagulation time.increase in the coagulation time.
Warfarin sodium (Coumarin) prolongs theWarfarin sodium (Coumarin) prolongs the
prothrombin time and can be administeredprothrombin time and can be administered
orally as well as intravenously.orally as well as intravenously.

Both of these drugs will cause hemorrhage,Both of these drugs will cause hemorrhage,
and patients taking them are poor implantand patients taking them are poor implant
candidates. If these patients can be regulatedcandidates. If these patients can be regulated
to a more normal level for favorableto a more normal level for favorable
intraoperative and postoperative safety, theyintraoperative and postoperative safety, they
may be acceptable candidates. Consultationmay be acceptable candidates. Consultation
and teamwork with the attending physician orand teamwork with the attending physician or
hematologist are advisablehematologist are advisable

DISEASES OF THE SKIN AND MUCOUS
MEMBRANES (DERMATOLOGIC)
Pathologic states as lichen planus, erythemaPathologic states as lichen planus, erythema
multifomie, lupus erythematosus, and pemphigus allmultifomie, lupus erythematosus, and pemphigus all
affect the mucous membranes and skin.affect the mucous membranes and skin.
This group has also been categorized as collagen orThis group has also been categorized as collagen or
connective tissue defects.connective tissue defects.
Patients with these disorders will often be very ill andPatients with these disorders will often be very ill and
will not even present for dental treatment. However,will not even present for dental treatment. However,
many of these patients will have subacute or mildmany of these patients will have subacute or mild
cases of these diseases and will seek treatment.cases of these diseases and will seek treatment.
In general, this category of patients is a poor group forIn general, this category of patients is a poor group for
implant restoration, as the physiologic healingimplant restoration, as the physiologic healing
mechanism is impaired.mechanism is impaired.www.indiandentalacademy.comwww.indiandentalacademy.com

MALIGNANT DISEASE
Many patients with malignancies are treated byMany patients with malignancies are treated by
radiation therapy or antimetabolites or both.radiation therapy or antimetabolites or both.
Patients who have had, or are receiving,Patients who have had, or are receiving,
radiation therapy to the head and neck regionradiation therapy to the head and neck region
have a change in the normal physiologichave a change in the normal physiologic
processes of the mucous membranes andprocesses of the mucous membranes and
bone.bone.
The vascular supply to regions either primarilyThe vascular supply to regions either primarily
or secondarily irradiated has been impaired.or secondarily irradiated has been impaired.www.indiandentalacademy.comwww.indiandentalacademy.com

MALIGNANT DISEASE
When an elective procedure, such as anWhen an elective procedure, such as an
implant insertion, is carried out, the additionalimplant insertion, is carried out, the additional
interruption of the tissues may be sufficient tointerruption of the tissues may be sufficient to
cause further impaired vascular supply with acause further impaired vascular supply with a
resultant failure or even radiationresultant failure or even radiation
osteonecrosis.osteonecrosis.
However, recent reports have demonstratedHowever, recent reports have demonstrated
favorable two-stage osteointegratedfavorable two-stage osteointegrated
reconstruction in selected cases.reconstruction in selected cases.

CHEMOTHERAPEUTIC AGENTS
These affect the overall physiologicThese affect the overall physiologic
composition of the body, with a resultantcomposition of the body, with a resultant
decrease in its ability to protect itself againstdecrease in its ability to protect itself against
Implant reconstruction is usuallyImplant reconstruction is usually
contraindicated for patients who have been orcontraindicated for patients who have been or
are being so treated.are being so treated.
However, consultation with the oncologistHowever, consultation with the oncologist
should be sought to determine the return to ashould be sought to determine the return to a
physiologic normal baseline.physiologic normal baseline.

Hepatitis A (infectious) Hepatitis CHepatitis A (infectious) Hepatitis C
Hepatitis B (serum) Liver diseaseHepatitis B (serum) Liver disease
Yellow jaundice Blood transfusionYellow jaundice Blood transfusion
Drug addictionDrug addiction
These diseases or problems either areThese diseases or problems either are
transmissible (AIDS and hepatitis A and B) ortransmissible (AIDS and hepatitis A and B) or
can indicate hepatic dysfunction.can indicate hepatic dysfunction.
A history of blood transfusion or past or presentA history of blood transfusion or past or present
history of drug addiction should alert the doctorhistory of drug addiction should alert the doctor
to a probable increase in the risk of hepaticto a probable increase in the risk of hepatic
dysfunction or AIDS.dysfunction or AIDS.www.indiandentalacademy.comwww.indiandentalacademy.com

Hepatitis BHepatitis B
Hazard to dentist and staff (all of whom shouldHazard to dentist and staff (all of whom should
have received hepatitis B vaccine).have received hepatitis B vaccine).
Avoid all but emergency care.Avoid all but emergency care.
Caution in care of instruments.Caution in care of instruments.
Avoid treatment if cuts or abrasions onAvoid treatment if cuts or abrasions on
clinician's hands.clinician's hands.
Consider double-gloving.Consider double-gloving.
Frequency of condition makes necessaryFrequency of condition makes necessary
extreme care with instruments for ALL patients.extreme care with instruments for ALL patients.

ACQUIRED IMMUNODEFICIENCY SYNDROMEACQUIRED IMMUNODEFICIENCY SYNDROME
Patients who have tested positive for human-Patients who have tested positive for human-
immunodeficiency virus (HIV) areimmunodeficiency virus (HIV) are
representative of every area of the population.representative of every area of the population.
The usual barrier techniques should beThe usual barrier techniques should be
employed to minimize the risk of cross infectionemployed to minimize the risk of cross infection
to both the patient and staff members.to both the patient and staff members.

SYNCOPE
Do you feel very nervous about having dentistryDo you feel very nervous about having dentistry
treatment?treatment?
Have you ever had a bad experience in the dentistryHave you ever had a bad experience in the dentistry
office?office?
These type of relevant questions need to be asked toThese type of relevant questions need to be asked to
the patient.the patient.
An affirmative response to either or both questionsAn affirmative response to either or both questions
should lead to a thorough dialogue history and toshould lead to a thorough dialogue history and to
possible treatment modifications aimed at decreasingpossible treatment modifications aimed at decreasing
the patient's dental fears.the patient's dental fears.
Once anxiety is recognized it should be managedOnce anxiety is recognized it should be managed
combined with the positioning of patients in supinecombined with the positioning of patients in supine
should be considered.should be considered.
Psychosedation is one of the methods to reducePsychosedation is one of the methods to reduce
stress.stress.
Drugs like nitrous oxide and oxygen are also helpful.Drugs like nitrous oxide and oxygen are also helpful.www.indiandentalacademy.comwww.indiandentalacademy.com

PREGNANCY
Avoid drugs that can have detrimental effectsAvoid drugs that can have detrimental effects
on the fetus or whose effects are not yeton the fetus or whose effects are not yet
determined.determined.
Good oral hygiene essential.Good oral hygiene essential.
Best time for treatment is second trimester.Best time for treatment is second trimester.
Avoid treatment in first trimester.Avoid treatment in first trimester.
Avoid prolonged stay in supine position in theAvoid prolonged stay in supine position in the
third trimester.third trimester.
It is always better to avoid implant placement inIt is always better to avoid implant placement in
a pregnant lady, it is advisable to wait anda pregnant lady, it is advisable to wait and
postpone the procedure until delivery.postpone the procedure until delivery.www.indiandentalacademy.comwww.indiandentalacademy.com

EMOTIONAL DISTURBANCES
Be supportive.Be supportive.
Conservative therapy usually indicated.Conservative therapy usually indicated.
Avoid anesthetics containing epinephrine, whenAvoid anesthetics containing epinephrine, when
indicated. These candidates are again poor forindicated. These candidates are again poor for
implant placement.implant placement.

SYSTEMIC DRUGSSYSTEMIC DRUGS
Phenytoin , cyclosporine, calcium channel
blockers ( immuno suppressant)( immuno suppressant)
Stress on plaque control.Stress on plaque control.
Corticosteroids
May require steroid supplement before stressfulMay require steroid supplement before stressful
procedure;procedure;
possible prophylactic antibiotics.possible prophylactic antibiotics.

Anticoagulants
Have anticoagulant level reduced untilHave anticoagulant level reduced until
prothrombin time is not more thanprothrombin time is not more than
approximately 1.5-2 times control.approximately 1.5-2 times control.
May require reduction in warfarin dosage.May require reduction in warfarin dosage.
Avoid use of salicylates, quinolone antibiotics,Avoid use of salicylates, quinolone antibiotics,
and tetracycline.and tetracycline.

Aspirin
Stop all salicylates at least 7 days before surgery.Stop all salicylates at least 7 days before surgery.
Tricyclic antidepressants
Possible exaggerated response to epinephrine.Possible exaggerated response to epinephrine.
Use anesthetic without epinephrine.Use anesthetic without epinephrine.
Oral contraceptives
Increased emphasis on plaque control must beIncreased emphasis on plaque control must be
placed.placed.
If antibiotics are prescribed, warn patient thatIf antibiotics are prescribed, warn patient that
contraceptive effectiveness may be reduced.contraceptive effectiveness may be reduced.www.indiandentalacademy.comwww.indiandentalacademy.com

Quinolone antibiotics
Caution the patient if he is using anti-Caution the patient if he is using anti-
coagulants.coagulants.
Avoid diagnostic testing (e.g., glucose, alkalineAvoid diagnostic testing (e.g., glucose, alkaline
phosphatase).phosphatase).
Caution patient regarding photosensitivity ifCaution patient regarding photosensitivity if
also taking tetracyclines.also taking tetracyclines.

Bell’s palsy
Careful retraction of cheek during oral hygieneCareful retraction of cheek during oral hygiene
becomes very essential.becomes very essential.
Other conditions:
Alcoholism
Increased bleeding time, increased side effectsIncreased bleeding time, increased side effects
of other drugs. Conservative care is indicated.of other drugs. Conservative care is indicated.
Smokers
Postsurgical healing of smokers is poor, andPostsurgical healing of smokers is poor, and
there is some evidence that osseointegration isthere is some evidence that osseointegration is
decreased. Peri-implantitis is more common.decreased. Peri-implantitis is more common.www.indiandentalacademy.comwww.indiandentalacademy.com

Uncontrolled orUncontrolled or poorly controlled diabetes is ais a
contraindication for implant placement.contraindication for implant placement.
Osteoporosis
Osteoporosis does not appear to influence implantOsteoporosis does not appear to influence implant
success rates. Implant placement may actually besuccess rates. Implant placement may actually be
beneficial, because bone density increases nearbeneficial, because bone density increases near
loaded implants.loaded implants.
Age
Increasing age, per se. is not a factor for reducedIncreasing age, per se. is not a factor for reduced
success of dental implants. Although it is oftensuccess of dental implants. Although it is often
associated with systemic diseases.associated with systemic diseases.
Young patients should not receive implants until theirYoung patients should not receive implants until their
growth is complete, because the ankylosed implantgrowth is complete, because the ankylosed implant
will not follow the growth progression.will not follow the growth progression.www.indiandentalacademy.comwww.indiandentalacademy.com

Psychological conditions
Quality of life should be improved, particularlyQuality of life should be improved, particularly
for edentulous cases.for edentulous cases.
But high expectations must be toned downBut high expectations must be toned down
because of possible disappointment.because of possible disappointment.
Immunocompromised
There is no evidence that these conditions areThere is no evidence that these conditions are
contraindications to dental implants.contraindications to dental implants.

Thus absolute contraindications are:
Uncontrolled diabetes mellitusUncontrolled diabetes mellitus
Long-term immunosuppressant drug therapyLong-term immunosuppressant drug therapy
Diseases of connective tissueDiseases of connective tissue
(e.g.,disseminated lupus erythematosus)(e.g.,disseminated lupus erythematosus)
Blood dyscrasias and coagulopathies (e.g.,Blood dyscrasias and coagulopathies (e.g.,
leukemia, hemophilia)leukemia, hemophilia)
Regional malignancy (e.g., oral, perioral)Regional malignancy (e.g., oral, perioral)
Metastatic diseaseMetastatic disease
Previous radiation to the jaws that might lead toPrevious radiation to the jaws that might lead to
postsurgical osteoradionecrosispostsurgical osteoradionecrosis
Alcohol or drug addictionAlcohol or drug addiction
Severe psychologic disordersSevere psychologic disorderswww.indiandentalacademy.comwww.indiandentalacademy.com

In addition, there are many relativeIn addition, there are many relative
contraindications to treatment. If these arecontraindications to treatment. If these are
managed properly, however, a patient maymanaged properly, however, a patient may
undergo implant surgery with very goodundergo implant surgery with very good
chances for success.chances for success.
Consultations with a patient's physician may beConsultations with a patient's physician may be
required so that patient acceptability is clarifiedrequired so that patient acceptability is clarified
and the requisite details of surveillance andand the requisite details of surveillance and
support therapy are instituted throughout andsupport therapy are instituted throughout and
after the procedure.after the procedure.

Conclusion
Thus success in implant therapy includesThus success in implant therapy includes
careful and critical evaluation of the patient ascareful and critical evaluation of the patient as
well as his systemic condition. Properwell as his systemic condition. Proper
measures must be taken to prevent anymeasures must be taken to prevent any
complications which might arise in the dentalcomplications which might arise in the dental
office and this can be accomplished by an inoffice and this can be accomplished by an in
depth history taking. Medical history recordingdepth history taking. Medical history recording
is also very essential to rule out patients whois also very essential to rule out patients who
are not good candidates for implant placement.are not good candidates for implant placement.

Importance of taking medical history prior to implant placement/ dental crown & bridge courses

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