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PROSTHETIC CONSIDERATIONS IN
MEDICALLY COMPROMISED
PATIENTS
BY
DR. KRITI TREHAN
1st MDS
CONTENTS
 INTRODUCTION
 ARTHRITIS
 HYPERTENSION
 DIABETES MELLITUS
 CARDIOVASCULAR DISEASES
 BLEEDING DISORDERS
 BONE DISORDERS
 PSYCHIATRIC AND NEUROGENIC DISORDERS
 LIVER DISAESES
 HIV
 HEPATITIS
 SUMMARY
 REFERENCES
1. INTRODUCTION
 General health factors have a great impact on prosthetic
therapy in medically compromised patients.
 A detailed history including past health condition drugs and
medications taken by the patients should be recorded.
 All this information should be applied to access the risks
related to specific conditions identified in the evaluation.
 Certain conditions have direct bearing on management and
treatment of these patients.
CLASSIFICATION OF SURGICAL AND PROSTHETIC
DENTAL TREATMENT BY MISCH
SCREENING MEDICALLY COMPROMISED
PATIENTS
GOAL: To evaluate any source of infection that may compromise
successful dental or surgical therapy and restore optimal oral
health and function.
i. Full mouth intra-oral radiographs.
ii. Panoramic radiograph only if edentulous or not able to take
intraoral films .
iii. Thorough medical and dental history, including medications
documented on the dental chart.
iv. Physician consultation to corroborate medical history and
coordinate dental and medical care.
v. Recording vital signs ( BP, pulse, temperature,
respiration, weight and height).
vi. Lab investigations like CBC, BMP, CMP and bleeding
disorder tests.
vii. Initiate preventive therapy.
viii. Arrange treatment.
ix. Arrange follow-up.
RHEUMATOID ARTHRITIS
 Rheumatoid arthritis (RA) is a chronic inflammatory
disease characterized by synovial inflammation that
results in destruction of joint tissues.
 ETIOLOGY
 The cause of RA is not known, although its etiology appears
to be multifactorial and may involve infectious, genetic,
endocrine and immunological causes.
 It is believed to be caused due to sudden influx of T cells
into the affected joints and is followed by an increased
number of macrophages and fibroblasts, drawn by
the release of cytokines, particularly IL-1, and TNF-α.
 The characteristics of this
disease are bilateral chronic
inflammation of the synovium, a
condition known as synovitis.
 This inflammatory response
particularly affects small joints
of the upper and lower
extremities.
 In addition to the typical pattern
of inflammation, patients with
RA may experience systemic
manifestations such as fatigue,
loss of appetite, weakness and
vague musculoskeletal pain.
Nonsteroidal anti-inflammatory drugs are the current
mainstream "first-line"treatment.
Corticosteroids, another option, have both anti-
inflammatory and immunosuppressive effects.
Second-line" or disease-modifying antirheumatic drugs, or
DMARDs like gold, sulfasalazine,hydroxychloroquine.
Methotrexate has become a popular treatment choice
recently because of its immunosuppressive and anti-
inflammatory effects.
TREATMENT
 DENTAL MANAGEMENT
i. It is essential that the dentist keep himself or herself
updated as to the drugs the patient with RA is currently
receiving, their possible side effects and interactions with
other drugs.
ii. Oral hygiene procedures may become difficult because of
reduced manual dexterity. Such patients may have
particular difficulty in removing or inserting removable
partial dentures .
iii. Fixed solutions may be a more favourable treatment
modality with regard to reduced/impaired manual dexterity
iv. Advantages of implant placement in conjunction with fixed
prostheses were especially noted in patients suffering from
other systemic autoimmune diseases such as Sjo¨gren’s
syndrome.
v. Patients with severe RA who have had joints surgically
replaced with prosthetic joints may require prophylactic
antibiotic therapy before invasive procedures.
v. The temporomandibular joints can be 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.
a. Changes in occlusion:
 As the joint tissue are more susceptible to increased
loading, the prosthetic reconstructions should be aimed at
giving unloading appliances and improve the distribution of
occlusal force.
b. Jaw relation:
 There is a difficulty in recording an acceptable jaw
relationship because of the destruction of joint tissues.
 There is a large distance between the most returned and the
intercuspal position i.e., CR-CO.
 In such situations a muscularly relaxed and comfortable jaw
position should be chosen and tried in provisional
constructions before the permanent rehabilitation is
completed.
Osteoarthritis of temporomandibular joint
 Problem in complete denture construction, for
mandibular movements are painful.
 In extreme conditions surgery may be indicated.
 Special impression trays are often necessary because of
limited access from reduced ability to open the jaws.
 Jaw relation records are difficult to record and repeat,
and occlusal correction must be often made because of
subsequent changes in the joint.
HYPERTENSION
 Hypertension refers to blood pressure that is consistently
above 140 /90 mm Hg ( for more than 6 months).
PROSTHODONTIC MANAGEMENT
i. Prosthodontic treatment approach in a hypertensive
patient should be planned meticulously.
ii. The blood pressure must be controlled before any
Type 3 or 4 dental treatments.
iii. The prescription of anxiolytic agents may prove
necessary in particularly anxious patients (5-10mg of
diazepam the night before and 1-2 hours before the
appointment) before dental treatment.
iv. An early morning appointment with minimum waiting
room time.
iv. LA with vasoconstrictor should be avoided or used in low doses
in patients with uncontrolled hypertension.
v. The sharp edges of the removable partial dentures should be
trimmed off and polished well.
vi. Fabricating a complete denture demands utmost care to avoid
causing soft tissue abrasion. Certain antihypertensive drugs are
associated with xerostomia which in turn hamper the retention
and stability of the complete dentures.
vii. In such patients artificial salivary lubricants should compensate
the effect of xerostomia for better post-therapy results .
viii. Due to higher concentrations of epinephrine in gingival
retraction cords used for prosthetics impressions and its rapid
uptake in circulation, the use of epinephrine for gingival
retraction in patients with cardiovascular disease should be
carefully administered.
ix. To minimize gingival bleeding, the margins of the preparation
should be kept supragingival.
x. During treatment, sudden changes in the body position
should be avoided, as they can cause orthostatic hypotension
as a side effect of the antihypertensives.
DIABETES MELLITUS
 Diabetes mellitus is a disease of glucose, fat & protein
metabolism resulting from impaired insulin secretion, varying
degree of insulin resistance or both.
 According to American diabetic association (ADA): Fasting
blood sugar (FBS) > 126 mg/dl or Post random blood sugar
(PRBS) > 200mg/dl.
 Symptoms like polyuria, polydypsia, polyphagia, weight loss
and visual disturbances are experienced by diabetic patients.
.
ORAL
MANIFESTATIONS
OF DIABETES
Xerostomi
a
Periodontitis
Increased
Caries
Risk
Burning
Sensation
Gingival
Inflammatio
n
Fungal
Infections
Poor
Wound
Healing
Alveolar
Bone
Resorption
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 breakfast and
medication before treatment.
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.
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.
 Impressions should be taken in mucostatic technique without
pressure.
 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 salivat- ion,
frequent sipping of water and use of sugarless gums may help
them to maintain salivary flow.
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.
 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 as much as
possible for ease of cleansing action.
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.
CARDIOVASCULAR DISEASES
 Cardiovascular diseases make up the most prevalent
category of systemic disease in almost all countries, and
increase in prevalence with age.
 Myocardial infacrtion isprolonged ischemia or lack of
oxygen resulting from a deficiency in the coronary arterial
blood supply that causes injury to the myocardium .
 Angina is a symptom of ischemic heart disease produced
when myocardial blood supply cannot be sufficiently
increased to meet the increased oxygen requirements that
result from coronary artery disease.
o Angina pectoris is a symptomatic expression of temporary
myocardial ischemia.
o The classical symptom of retrosternal pain often develops
during stress or physical exertion, radiates to the shoulders,
left arm, or mandible, or right arm, neck, palate, and tongue.
o Bacterial endocarditis is an infection of the heart valves or
the endothelial surfaces of the heart.
o Atherosclerosis is a progressive disease process that
involves the large- to medium-sized arteries.
o It can lead to ischemic lesions of the brain, heart or
extremities, and can result in thrombosis and infarction of
affected vessels, leading to death.
 GENERAL AND PROSTHODONTIC MANAGEMENT
 For patients with cardiovascular diseases short
appointments and a stress-reduction protocol are indicated,
including: -
 vital signs monitoring: (heart rate, blood pressure, etc);
 stress reduction protocol; - 2-5mg diazepam on the night,
before treatment and 1 hour prior to treatment;
 nitrous oxide+O2 or O2 (3 lit/min) via nasal canula;
 premedication with nitroglycerin if needed;
 Check whether the patient is using anticoagulants (including
aspirin ).
 Dental /prosthetic treatment should not be carried out without
consultation with their physician.
 Consider possible limitation of epinephrine for gingival
retraction.
 Patients with arteriosclerotic cerebral disease often have
reduced motor skills and may be absent – minded and
confused.
 They have difficulty coping with removable dentures , the
natural dentition should be remained if possible.
o Patients who take antidepressant drugs after a stroke may
suffer from several collateral effects . They might have
problems with stability and retention of their removable
prosthesis and should be made to use adhesive pastes.
IMPLANT MANAGEMENT
Angina pectoris:
i. The risk category for the typical angina patient is ASA
III and for recent or unstable angina is ASA IV.
ii. The vital signs have to be monitored during the procedure
and the patient is instructed to have nitroglycerine.
iii. The implant surgery is performed with nitrous oxide.
The use of vasoconstrictors is limited to 0.04 to
0.05mg epinephrine.
iv. Patient with moderate angina should be given
nitroglycerine sublingually just before advanced
operative or simple to moderate implant surgery.
v. Antianxiety sedation with supplemental oxygen are
also required.
v. Patients with severe angina are limited to
examination procedures and is an absolute
contraindication for elective dental surgery.
Myocardial infarction:
i. Patients with MIT in preceding 6 months can have
dental examination, but treatment has to postpone
for 6 months.
ii. Longer procedures should be segmented into
shorter appointments .
iii. Elective implant procedures should be postponed
for at least 12 months following MI.
iv. Hospitalization is an accepted modality for all
advanced surgical procedures regardless of time
elapsed after a MI.
 Subacute Bacterial Endocarditis:
i. The Endocarditis prophylaxis are recommended in high
risk patients for procedures like dental implant placement,
sub gingival placement of antibiotic fibers or strips.
ii. The Endocarditis prophylaxis not recommended for the
placement of removable prosthodontic appliances and
making oral impressions.
iii. Implants may be contraindicated for patients with a limited
oral hygiene potential and for those with history of stroke.
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.
 Patients undergoing anticoagulant therapy
 The main objective of this therapy is to reduce the
occurrence of thromboembolism .
 It is usually recommended in all patients with
 thromboembolic risk
 in patients after angioplasty and stent placement,
 bypass surgery
 prosthetic heart valve placement.
 The reduction of the perioperative 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.
 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.
(What influence do anticoagulants have on oral implant
therapy? A systematic review)
BLEEDING DISORDERS
 Bleeding disorders can be classified as coagulation factor
deficiencies, platelet disorders, vascular disorders or
fibrinolytic defects.
 Among the congenital coagulation defects, hemophilia A,
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.
 It is broadly divided into hemophilia A, B, and C, which
occur due to deficiency of factors VIII, IX, or XI (F VIII, F IX,
F XI) respectively
 The normal plasma concentration of factors is 50 to 100
IU/dL. When the plasma concentration falls below 1 IU/dL,
disease manifestations are severe; ranges between 2 and
4 IU/dL are moderate and a range between 6 and 40 IU/dL
is mild.
Prosthodontic rehablitation
 Removable 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
BONE DISEASES
1. Osteoporosis
 It shows a decrease in skeletal mass, increased
microstructural deterioration without alteration in the
chemical composition of bone.
 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.
 Dental implant management:
 Although 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.
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.
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.
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.
FIBROUS DYSPLASIA
 Fibrous dysplasia is a disorder in which fibrous connective
tissue replaces areas of normal bone in an unorganized
arrangement.
 It is found twice as often in women than it is in men.
 Oral manisfestations :
 Twice as commom in maxilla than mandible
 Monostotic fibrous dyplasia begins as a painless,
progressive lesion.
 Teeth may move as a consequence of progression.
 Predisposition to fracture.
 Slow healing and increased incidence of infection.
IMPLANT CONSIDERATION
 The implant placement is contraindicated in the regions of
this disorder because of lack of bone and increased
fibrous tissue which reduces rigid fixation of the implant.
 Excision of the fibrous dysplasia areas is usually the
treatment choice.
 After the condition is corrected long term, the area may
receive an implant.
KIDNEY DISEASES
Dental considerations :
 Do not use drugs toxic to the kidney i.e.
acetaminophen.
 Alter dosage form when using drugs eliminated by
the kidney i.e. penicillin (often reduced to 500 mg
two times per day versus four times per day)
 If patient on renal dialysis, dental treatment should
be done on the day following dialysis.
 If patient has kidney transplant,
immunosuppression protocol considerations must
be followed.
NEUROLOGIC AND PSYCHIATRIC
CONDITIONS
 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.
o In patients who have had cerebrovascular stroke, the
incidence and the risk of stroke after effects such as
dysphagia, hypoaesthesia, apraxia, reduction in muscle
tone, with a consequent reduced control of mouth and
tongue movements, are significantly high.
o Additionally, long-term denture wearers usually have a high
level of bone resorption, making the denture inadequate in
fit and function, so the old dentures should be replaced.
o In order to make the impression, the old denture may be
used as a tray.
o An additional silicone material with low viscosity should be
used as it is extremely manageable, tolerable and barely
irritable.
 The weakness of the muscles of mastication, such as the
buccinator muscle, alters the dynamics of eating, causing
food stagnation in the fornix area.
 In order to solve this problem, the outer surface of the
denture may be modified both to improve its retention (the
lower part) and to reduce the amount of food that remains
between the buccinator muscle and the prosthetic
modification.
 In those patients suffering from hemiplegia, we may have
difficulties even in inserting and removing the denture.
 Another problem which might occur is the presence
of facial asymmetry. In order to achieve facial
harmony, we may change the vestibular denture
flange and add some acrylic resin to expand it.
 Great care has to be taken in assessing the
midline, the aesthetic facial lines and the occlusal
plane.
CHRONIC OBSTRUCTIVE PULMONARY
DISEASES
 Two common forms of COPD are emphysema and
chronic bronchitis.
 Patients with COPD may have a combination of
chronic cough, sputum production and shortness of
breath.
Dental implant management
 Patients with difficulty breathing only on significant
exertion and normal lab blood gases are at minimal
risk and may follow all restorative or surgical
procedures with normal protocols.
 Dental management of COPD patients may require
repositioning the patient from the normal supine
position.
 Supplemental oxygen should be administered
throughout the dental procedures.
 Patients with difficulty in breathing on exertion in
general are at a moderate risk .
 For type 2 procedures these patients need a hospital
setting.
 If the patient is on bronchodilators , no epinephrine or
vasoconstrictors should be added to the anesthetics or
gingival retraction cord.
 Adrenal supression should be evaluated for any patient
on corticosteroid therapy within the past year.
 Patients at high risk are those with previously
unrecognized COPD, acute exacerbation or dyspnea
at rest.
 In these patients elective moderate procedures or
prosthetic procedures are contraindicated.
LIVER DISEASES
 Cirhossis is the 3rd leading cause of death in young
men between the ages of 35 and 54years
 It occurs as a result of injury to the liver with
resultant loss of liver cells and progressive scarring.
 Major cause is alcoholic liver disease.
Dental implant management
 Patient with no abnormal lab values for CMP, CBC, PTT
and PT are at low risk.
 A normal protocol is indicated for all procedures (type 1
to type 4 ).
 Patients with an elevated PT of less than 1.5 times the
control value, or bilirubin slightly affected are at a
moderate risk.
 These patients should be refered to their physician and
use of sedatives and tranquilizers may need their
clearance.
 Strict attention to homeostasis is indicated.
 Moderate to advanced surgical procedures may
require hospitalization(Type 3 and 4 ).
 Elective dental procedures such as implants are
contraindicated in patients at high risk.(PT of more
than 1.5 times the control value).
Dental implant management HIV positive patients with AIDS:
a) The distinction should be made between asymptomatic HIV
positive patient and AIDS patient with varying degrees of
immunosupression with reduced T lymphocytes.
b) The change from health to disease or from asymptomatic HIV
positive phase to AIDS is indicated by decreasing T cell
lymphocyte counts and the onset of opportunistic infections.
c) The individuals whose HIV- positive status is identified soon
after infection, general dental care can often be provided for
many years without particular concern regarding the patient
overall health status along with rigid infection control
guidelines.
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.
 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.
SUMMARY
 Various systemic diseases play a pivotal role in deciding
treatment options in dentistry.
 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 prosthodontist must not only be aware of the
systemic factors but also consider them in the treatment
plan.
REFERENCES
 Misch CE : Contemporary Implant Dentistry,St Louis, MO,
CV Mosby, 1993,3; 421-461.
 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.
 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 Case Report.
J.Med.Sci 2007;7(6):1065-67.
THANK YOU

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Prosthetic considerations in medically compromised patients

  • 1. PROSTHETIC CONSIDERATIONS IN MEDICALLY COMPROMISED PATIENTS BY DR. KRITI TREHAN 1st MDS
  • 2. CONTENTS  INTRODUCTION  ARTHRITIS  HYPERTENSION  DIABETES MELLITUS  CARDIOVASCULAR DISEASES  BLEEDING DISORDERS  BONE DISORDERS  PSYCHIATRIC AND NEUROGENIC DISORDERS  LIVER DISAESES  HIV  HEPATITIS  SUMMARY  REFERENCES
  • 3. 1. INTRODUCTION  General health factors have a great impact on prosthetic therapy in medically compromised patients.  A detailed history including past health condition drugs and medications taken by the patients should be recorded.  All this information should be applied to access the risks related to specific conditions identified in the evaluation.  Certain conditions have direct bearing on management and treatment of these patients.
  • 4.
  • 5. CLASSIFICATION OF SURGICAL AND PROSTHETIC DENTAL TREATMENT BY MISCH
  • 6. SCREENING MEDICALLY COMPROMISED PATIENTS GOAL: To evaluate any source of infection that may compromise successful dental or surgical therapy and restore optimal oral health and function. i. Full mouth intra-oral radiographs. ii. Panoramic radiograph only if edentulous or not able to take intraoral films . iii. Thorough medical and dental history, including medications documented on the dental chart. iv. Physician consultation to corroborate medical history and coordinate dental and medical care.
  • 7. v. Recording vital signs ( BP, pulse, temperature, respiration, weight and height). vi. Lab investigations like CBC, BMP, CMP and bleeding disorder tests. vii. Initiate preventive therapy. viii. Arrange treatment. ix. Arrange follow-up.
  • 8. RHEUMATOID ARTHRITIS  Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by synovial inflammation that results in destruction of joint tissues.  ETIOLOGY  The cause of RA is not known, although its etiology appears to be multifactorial and may involve infectious, genetic, endocrine and immunological causes.  It is believed to be caused due to sudden influx of T cells into the affected joints and is followed by an increased number of macrophages and fibroblasts, drawn by the release of cytokines, particularly IL-1, and TNF-α.
  • 9.  The characteristics of this disease are bilateral chronic inflammation of the synovium, a condition known as synovitis.  This inflammatory response particularly affects small joints of the upper and lower extremities.  In addition to the typical pattern of inflammation, patients with RA may experience systemic manifestations such as fatigue, loss of appetite, weakness and vague musculoskeletal pain.
  • 10. Nonsteroidal anti-inflammatory drugs are the current mainstream "first-line"treatment. Corticosteroids, another option, have both anti- inflammatory and immunosuppressive effects. Second-line" or disease-modifying antirheumatic drugs, or DMARDs like gold, sulfasalazine,hydroxychloroquine. Methotrexate has become a popular treatment choice recently because of its immunosuppressive and anti- inflammatory effects. TREATMENT
  • 11.  DENTAL MANAGEMENT i. It is essential that the dentist keep himself or herself updated as to the drugs the patient with RA is currently receiving, their possible side effects and interactions with other drugs. ii. Oral hygiene procedures may become difficult because of reduced manual dexterity. Such patients may have particular difficulty in removing or inserting removable partial dentures . iii. Fixed solutions may be a more favourable treatment modality with regard to reduced/impaired manual dexterity
  • 12. iv. Advantages of implant placement in conjunction with fixed prostheses were especially noted in patients suffering from other systemic autoimmune diseases such as Sjo¨gren’s syndrome. v. Patients with severe RA who have had joints surgically replaced with prosthetic joints may require prophylactic antibiotic therapy before invasive procedures. v. The temporomandibular joints can be 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.
  • 13. a. Changes in occlusion:  As the joint tissue are more susceptible to increased loading, the prosthetic reconstructions should be aimed at giving unloading appliances and improve the distribution of occlusal force. b. Jaw relation:  There is a difficulty in recording an acceptable jaw relationship because of the destruction of joint tissues.  There is a large distance between the most returned and the intercuspal position i.e., CR-CO.  In such situations a muscularly relaxed and comfortable jaw position should be chosen and tried in provisional constructions before the permanent rehabilitation is completed.
  • 14. Osteoarthritis of temporomandibular joint  Problem in complete denture construction, for mandibular movements are painful.  In extreme conditions surgery may be indicated.  Special impression trays are often necessary because of limited access from reduced ability to open the jaws.  Jaw relation records are difficult to record and repeat, and occlusal correction must be often made because of subsequent changes in the joint.
  • 15. HYPERTENSION  Hypertension refers to blood pressure that is consistently above 140 /90 mm Hg ( for more than 6 months).
  • 16. PROSTHODONTIC MANAGEMENT i. Prosthodontic treatment approach in a hypertensive patient should be planned meticulously. ii. The blood pressure must be controlled before any Type 3 or 4 dental treatments. iii. The prescription of anxiolytic agents may prove necessary in particularly anxious patients (5-10mg of diazepam the night before and 1-2 hours before the appointment) before dental treatment. iv. An early morning appointment with minimum waiting room time.
  • 17. iv. LA with vasoconstrictor should be avoided or used in low doses in patients with uncontrolled hypertension. v. The sharp edges of the removable partial dentures should be trimmed off and polished well. vi. Fabricating a complete denture demands utmost care to avoid causing soft tissue abrasion. Certain antihypertensive drugs are associated with xerostomia which in turn hamper the retention and stability of the complete dentures. vii. In such patients artificial salivary lubricants should compensate the effect of xerostomia for better post-therapy results .
  • 18. viii. Due to higher concentrations of epinephrine in gingival retraction cords used for prosthetics impressions and its rapid uptake in circulation, the use of epinephrine for gingival retraction in patients with cardiovascular disease should be carefully administered. ix. To minimize gingival bleeding, the margins of the preparation should be kept supragingival. x. During treatment, sudden changes in the body position should be avoided, as they can cause orthostatic hypotension as a side effect of the antihypertensives.
  • 19. DIABETES MELLITUS  Diabetes mellitus is a disease of glucose, fat & protein metabolism resulting from impaired insulin secretion, varying degree of insulin resistance or both.
  • 20.  According to American diabetic association (ADA): Fasting blood sugar (FBS) > 126 mg/dl or Post random blood sugar (PRBS) > 200mg/dl.  Symptoms like polyuria, polydypsia, polyphagia, weight loss and visual disturbances are experienced by diabetic patients. .
  • 22. 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 breakfast and medication before treatment.
  • 23. 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.
  • 24. 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.  Impressions should be taken in mucostatic technique without pressure.  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 salivat- ion, frequent sipping of water and use of sugarless gums may help them to maintain salivary flow.
  • 25. 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.
  • 26.  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 as much as possible for ease of cleansing action.
  • 27. 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.
  • 28. CARDIOVASCULAR DISEASES  Cardiovascular diseases make up the most prevalent category of systemic disease in almost all countries, and increase in prevalence with age.  Myocardial infacrtion isprolonged ischemia or lack of oxygen resulting from a deficiency in the coronary arterial blood supply that causes injury to the myocardium .  Angina is a symptom of ischemic heart disease produced when myocardial blood supply cannot be sufficiently increased to meet the increased oxygen requirements that result from coronary artery disease.
  • 29. o Angina pectoris is a symptomatic expression of temporary myocardial ischemia. o The classical symptom of retrosternal pain often develops during stress or physical exertion, radiates to the shoulders, left arm, or mandible, or right arm, neck, palate, and tongue. o Bacterial endocarditis is an infection of the heart valves or the endothelial surfaces of the heart. o Atherosclerosis is a progressive disease process that involves the large- to medium-sized arteries. o It can lead to ischemic lesions of the brain, heart or extremities, and can result in thrombosis and infarction of affected vessels, leading to death.
  • 30.  GENERAL AND PROSTHODONTIC MANAGEMENT  For patients with cardiovascular diseases short appointments and a stress-reduction protocol are indicated, including: -  vital signs monitoring: (heart rate, blood pressure, etc);  stress reduction protocol; - 2-5mg diazepam on the night, before treatment and 1 hour prior to treatment;  nitrous oxide+O2 or O2 (3 lit/min) via nasal canula;  premedication with nitroglycerin if needed;
  • 31.  Check whether the patient is using anticoagulants (including aspirin ).  Dental /prosthetic treatment should not be carried out without consultation with their physician.  Consider possible limitation of epinephrine for gingival retraction.  Patients with arteriosclerotic cerebral disease often have reduced motor skills and may be absent – minded and confused.  They have difficulty coping with removable dentures , the natural dentition should be remained if possible.
  • 32. o Patients who take antidepressant drugs after a stroke may suffer from several collateral effects . They might have problems with stability and retention of their removable prosthesis and should be made to use adhesive pastes. IMPLANT MANAGEMENT Angina pectoris: i. The risk category for the typical angina patient is ASA III and for recent or unstable angina is ASA IV. ii. The vital signs have to be monitored during the procedure and the patient is instructed to have nitroglycerine.
  • 33. iii. The implant surgery is performed with nitrous oxide. The use of vasoconstrictors is limited to 0.04 to 0.05mg epinephrine. iv. Patient with moderate angina should be given nitroglycerine sublingually just before advanced operative or simple to moderate implant surgery. v. Antianxiety sedation with supplemental oxygen are also required. v. Patients with severe angina are limited to examination procedures and is an absolute contraindication for elective dental surgery.
  • 34. Myocardial infarction: i. Patients with MIT in preceding 6 months can have dental examination, but treatment has to postpone for 6 months. ii. Longer procedures should be segmented into shorter appointments . iii. Elective implant procedures should be postponed for at least 12 months following MI. iv. Hospitalization is an accepted modality for all advanced surgical procedures regardless of time elapsed after a MI.
  • 35.  Subacute Bacterial Endocarditis: i. The Endocarditis prophylaxis are recommended in high risk patients for procedures like dental implant placement, sub gingival placement of antibiotic fibers or strips. ii. The Endocarditis prophylaxis not recommended for the placement of removable prosthodontic appliances and making oral impressions. iii. Implants may be contraindicated for patients with a limited oral hygiene potential and for those with history of stroke.
  • 36. 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.
  • 37.  Patients undergoing anticoagulant therapy  The main objective of this therapy is to reduce the occurrence of thromboembolism .  It is usually recommended in all patients with  thromboembolic risk  in patients after angioplasty and stent placement,  bypass surgery  prosthetic heart valve placement.
  • 38.  The reduction of the perioperative 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.
  • 39.  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. (What influence do anticoagulants have on oral implant therapy? A systematic review)
  • 40. BLEEDING DISORDERS  Bleeding disorders can be classified as coagulation factor deficiencies, platelet disorders, vascular disorders or fibrinolytic defects.  Among the congenital coagulation defects, hemophilia A, 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.
  • 41.  It is broadly divided into hemophilia A, B, and C, which occur due to deficiency of factors VIII, IX, or XI (F VIII, F IX, F XI) respectively  The normal plasma concentration of factors is 50 to 100 IU/dL. When the plasma concentration falls below 1 IU/dL, disease manifestations are severe; ranges between 2 and 4 IU/dL are moderate and a range between 6 and 40 IU/dL is mild. Prosthodontic rehablitation  Removable 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
  • 42. BONE DISEASES 1. Osteoporosis  It shows a decrease in skeletal mass, increased microstructural deterioration without alteration in the chemical composition of bone.  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.
  • 43.  Adequate dietary calcium intake is essential. Recommended calcium intake of 800 mg / day for average person and 1500 mg for the postmenopausal women.  Dental implant management:  Although 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. 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.
  • 45. 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.
  • 46. 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.
  • 47. FIBROUS DYSPLASIA  Fibrous dysplasia is a disorder in which fibrous connective tissue replaces areas of normal bone in an unorganized arrangement.  It is found twice as often in women than it is in men.  Oral manisfestations :  Twice as commom in maxilla than mandible  Monostotic fibrous dyplasia begins as a painless, progressive lesion.  Teeth may move as a consequence of progression.  Predisposition to fracture.  Slow healing and increased incidence of infection.
  • 48. IMPLANT CONSIDERATION  The implant placement is contraindicated in the regions of this disorder because of lack of bone and increased fibrous tissue which reduces rigid fixation of the implant.  Excision of the fibrous dysplasia areas is usually the treatment choice.  After the condition is corrected long term, the area may receive an implant.
  • 50. Dental considerations :  Do not use drugs toxic to the kidney i.e. acetaminophen.  Alter dosage form when using drugs eliminated by the kidney i.e. penicillin (often reduced to 500 mg two times per day versus four times per day)  If patient on renal dialysis, dental treatment should be done on the day following dialysis.  If patient has kidney transplant, immunosuppression protocol considerations must be followed.
  • 51. NEUROLOGIC AND PSYCHIATRIC CONDITIONS  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.
  • 52. o In patients who have had cerebrovascular stroke, the incidence and the risk of stroke after effects such as dysphagia, hypoaesthesia, apraxia, reduction in muscle tone, with a consequent reduced control of mouth and tongue movements, are significantly high. o Additionally, long-term denture wearers usually have a high level of bone resorption, making the denture inadequate in fit and function, so the old dentures should be replaced. o In order to make the impression, the old denture may be used as a tray.
  • 53. o An additional silicone material with low viscosity should be used as it is extremely manageable, tolerable and barely irritable.  The weakness of the muscles of mastication, such as the buccinator muscle, alters the dynamics of eating, causing food stagnation in the fornix area.  In order to solve this problem, the outer surface of the denture may be modified both to improve its retention (the lower part) and to reduce the amount of food that remains between the buccinator muscle and the prosthetic modification.  In those patients suffering from hemiplegia, we may have difficulties even in inserting and removing the denture.
  • 54.  Another problem which might occur is the presence of facial asymmetry. In order to achieve facial harmony, we may change the vestibular denture flange and add some acrylic resin to expand it.  Great care has to be taken in assessing the midline, the aesthetic facial lines and the occlusal plane.
  • 55. CHRONIC OBSTRUCTIVE PULMONARY DISEASES  Two common forms of COPD are emphysema and chronic bronchitis.  Patients with COPD may have a combination of chronic cough, sputum production and shortness of breath. Dental implant management  Patients with difficulty breathing only on significant exertion and normal lab blood gases are at minimal risk and may follow all restorative or surgical procedures with normal protocols.
  • 56.  Dental management of COPD patients may require repositioning the patient from the normal supine position.  Supplemental oxygen should be administered throughout the dental procedures.  Patients with difficulty in breathing on exertion in general are at a moderate risk .  For type 2 procedures these patients need a hospital setting.
  • 57.  If the patient is on bronchodilators , no epinephrine or vasoconstrictors should be added to the anesthetics or gingival retraction cord.  Adrenal supression should be evaluated for any patient on corticosteroid therapy within the past year.  Patients at high risk are those with previously unrecognized COPD, acute exacerbation or dyspnea at rest.  In these patients elective moderate procedures or prosthetic procedures are contraindicated.
  • 58. LIVER DISEASES  Cirhossis is the 3rd leading cause of death in young men between the ages of 35 and 54years  It occurs as a result of injury to the liver with resultant loss of liver cells and progressive scarring.  Major cause is alcoholic liver disease.
  • 59. Dental implant management  Patient with no abnormal lab values for CMP, CBC, PTT and PT are at low risk.  A normal protocol is indicated for all procedures (type 1 to type 4 ).  Patients with an elevated PT of less than 1.5 times the control value, or bilirubin slightly affected are at a moderate risk.  These patients should be refered to their physician and use of sedatives and tranquilizers may need their clearance.
  • 60.  Strict attention to homeostasis is indicated.  Moderate to advanced surgical procedures may require hospitalization(Type 3 and 4 ).  Elective dental procedures such as implants are contraindicated in patients at high risk.(PT of more than 1.5 times the control value).
  • 61. Dental implant management HIV positive patients with AIDS: a) The distinction should be made between asymptomatic HIV positive patient and AIDS patient with varying degrees of immunosupression with reduced T lymphocytes. b) The change from health to disease or from asymptomatic HIV positive phase to AIDS is indicated by decreasing T cell lymphocyte counts and the onset of opportunistic infections. c) The individuals whose HIV- positive status is identified soon after infection, general dental care can often be provided for many years without particular concern regarding the patient overall health status along with rigid infection control guidelines.
  • 62. 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.
  • 63.  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.
  • 64. SUMMARY  Various systemic diseases play a pivotal role in deciding treatment options in dentistry.  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 prosthodontist must not only be aware of the systemic factors but also consider them in the treatment plan.
  • 65. REFERENCES  Misch CE : Contemporary Implant Dentistry,St Louis, MO, CV Mosby, 1993,3; 421-461.  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.
  • 66.  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 Case Report. J.Med.Sci 2007;7(6):1065-67.

Editor's Notes

  1. The key to successful prosthetic management and rehablitation of medically compromised patient is accomplished by and the typical systemic disorders reported in a population of people over 65 are arthritis (44%), hypertension(31%),cardiovascular disease (25%), diabetes (7%) and other health problems (87%)(Mac Entee ,1994).
  2. It was designed to estimate the medical risk presented by a patient reciveing general anesthesia for a surgical procedure.
  3. This cytokine release and subsequent migration of cells is thought to be responsible for the chronic inflammation, and characteristic destructive changes in rheumatoid joints.
  4. (after extremities) it often leads to the deterioration and eventual destruction of articular cartilage and juxta-articular bone, as well as to an inflammatory process surrounding tendons, all of which result in deformities of the affected joints.
  5. ii. So Replacement therapy for adrenally suppressed people may be necessary to prevent cardiovascular collapse, as their response to surgical stress may include a precipitous drop in blood pressure.
  6. The problem of soreness of the oral mucosa in conjunction with removable mucosa-supported prostheses and dry-mouth sensation is well known and may constitute a particular problem for (elderly) patients that could be avoided or reduced by exclusive implant support of dentures.(Payne et al. 1997).
  7. The removable denture in the lower jaw is not only beneficial for chewing but also for unloading the diseased joints.
  8. History should cover specific aspects like the duration of hypertension, medication and patient compliance with regard to antihypertensives, other associated co-morbid conditions, current oral disease, past dental treatment including its outcome, complications during treatment
  9. preferably should be fabricated with flexible material.
  10. . Hyposalivation was also found as one of the clinical manifestations in hypertensive patients which related to the sustained increase in both systolic as well as diastolic blood. Many antihypertensive drugs like ACEIs, thiazide diuretics, loop diuretics, calcium channel blockers and clonidine are associated with xerostomia. Patients taking diuretics show hyposalivation.
  11. •HbA1C is evaluated to check overall glycemic control for a period of 3 months.It is very important to evaluate proper medical history and assess glucose level at the initial appointments in all the patients older than 45 years of age
  12. Since endogenous cortisol level is higher during morning time which in turn increases blood glucose level.
  13. STRESS OF SURGERY MAY PROVOKE COUNTERREGULATORY HORMONES AND IMPAIRS INSULIN FUNCTION CAUSING HYPERGLYCEMIA THUS Stress reduction protocol for patients IS RECOMMENDED PATIENTS with HbA1C 7 GLUCOSE LEVEL LESS THAN 150 need sedation and antiobiotics for type 3 or 4 treatments.
  14. The end result of mi is cellular death and necrosis. angina is caused due to discrepancy between mycardial oxygen demand and the amount of oxygen being delivered through the coronry arteries. Stress and anxiety related to dental visit may precipitate angina attack
  15. It is the result of the growth of bacteria on damaged or altered cardiac surfaces. The microorganism most often associated is alpha hemolytic streptococcus viridans. Dental procedures causing tranisent bacterimia are a major cause of bacterial endocarditis.
  16. these patients are difficult to treat and protracted and complex treatment should be avoided
  17. High risk patients : artificial prosthetic valves prophylaxis 2g amox 60mins before orally h/o bacterail endocarditis 2g ampicillin iv or im 30mins before (patients who cant take oral medications) Unrepaired Cynatic congenital heart disease allergc to penicillin 600mg clindamycin
  18. With implant surgery becoming the standard of care to replace missing teeth and with more and more dental practices increasing their exposure to oral surgery, the dental professional must be fully prepared for the management of such patients and the potential complications
  19. Hemophilia A is an X-linked recessive hereditary disorder and most common of the three .
  20. Normal PTNo type of dental treatment is done in the following scenario: a) If bleeding time greater than 10 minutes b) If platelet count less than 60,000 c) If PTT greater than 45 seconds d) If PT greater than 22 seconds e) If INR greater than 3.5
  21. It is, therefore, recommended to thoroughly evaluate the jawbone quality prior implant and modify treatment planning if indicated
  22. The tissue is hypocellular so healing is imapired
  23. Depending on the severity of disease, orthopnea may result.The patient can be placed in the most recumbent position so that the breathing is comfortable.
  24. Bovine collagen, topical thrombin, or additionla sutures are indicated for homeostasis. ELECTIVE IMPLANT THERAPY CONTRAINDICATED IN PATIENTS WITH SYMPTOMS OF ACTIVE ALCOHOLISM. Fresh frozen plasma to correct the pt value Platlet transfusion for even scaling procedures
  25. Any left granulomatous or cystic tissue would affect the osseointegration process by increasing the failure risk.
  26. However it is meaningful to avoid such a surgery in active acute or active chronic hepatitis