Dental implants in the medically compromised patient Flashcards
Increasing numbers of medically compromised patients
require dental implant therapy due to —
Provide proper treatment planning based on the
knowledge of medical history.
extended life span.
Initial Consultation
(2)
Is there any relative or absolute contraindication for
dental implant surgery in this patient for medical
reasons?
Does the patient have any medical condition or take
any medications that jeopardizes the normal
osseointegration and healing of the implant surgery ?
Initial Consultation
Implant surgery is an —
— for appropriate control of the
disease process
Achieve favorable outcome in —
elective procedure
Medical consultation
long term
Controlled disease process vs Poorly controlled disease process
Pose surgical or
medical risk at the time
of the surgery
Potentially cause
failure of dental implant
to heal normally
Diabetes Mellitus
- Disorder of glucose metabolism
- Two major types
(2)
- Type I: Insulin-dependent
- Type II: Non-insulin-dependent (95%)
Diabetes Mellitus
- New cases: — are diagnosed per year
- Increases with age –
1.4 million
90% over 45 y/o
Diabetes Mellitus
- Its global prevalence was
estimated to be 2.8% in 2000
and is expected to rise to 4.4%
in 2030
- —% end stage renal disease
- Leading cause of —
- — leading cause of death
25
blindness
7th
Hyperglycemia has a negative effect on
bone metabolism
Diabetic osteopathy
REDUCE
(2)
INCREASE
(1)
IMPAIR
(3)
Bone mineral density
Bone mechanical properties
Risk of fracture
endochondral bone formation
intramembranous bone formation
microarchitectural quality
Hyperglycemia may lead to severe complications
(3)
Macro/micro angiopathy, neuropathy, increased risk of infections
Evidence Based Dentistry
- Current literatures support the use of dental implants in diabetic
patients with
- A comparable survival rates (85.5 to 100%) were reported on dental
implants placed in diabetic patients with
good metabolic glucose control
good/fair metabolic control.
Strict – control before and after
dental implant treatment
is highly recommended
glycemic
Preoperative Management
- Prepared by both
- Monitor
- Preoperative HbA1c value
- –% is ideal; –% is acceptable
- Others: (4)
dentist and endocrinologist
blood glucose levels
- current level and improvement
≤ 7, ≤ 8
co-morbidities, restoration of proper oral
hygiene, cessation of tobacco, treatment of
periodontitis
To reduce the potential risk of infections
- Consider (2)
antibiotics and antiseptic mouthwashes
- Antibiotics: (4)
- Antiseptic mouthwashes: (1)
- Reinforce
penicillin, amoxicillin, clindamycin or
metronidazole
Peridex (Chlorhexidine)
supportive therapy/maintenance systems
Uncontrolled DM
(2)
NO IMPLANTS
until it’s under controlled
Conventional solutions could
be good alternative options Removable dentures OR bridges as fixed prosthesis
Osteoporosis
- Definition
- Lead an increased risk of
- A total of – million U.S. adults age ≥ 50 are affected
Generalized reduction in bone density and alterations in the microstructure of bone
fractures
54
Evidence Based Dentistry
- The biologically plausible but still controversial
hypothesis
“the impaired bone metabolism can impair bone
healing and affect osseointegration”
- Not enough evidence to consider osteoporosis as an
absolute contraindication for implant placement
Preoperative Management
Need a careful evaluation of bone mineral density
DEXA/DXA (Bone densitometry) scan
skipped
Preoperative Management
- May increase risk of complications in
- Use of dental implants with
- Require longer healing period for
- — loading of the dental implants is not recommended
bone augmentation
modified, hydrophilic surfaces
osseointegration
Immediate
Head & Neck Cancer
- Account for — percent of all malignancies in the US
- Surgery and radiation therapy
- —% patients affected by head and neck cancer
have radiation therapy
6
60-80
Osteoradionecrosis (ORN)
- One serious complication of head & neck radiation
- Induce — rather than infection
(2)
- — or site with radiation ≥ — Rads/65Gy
vascular insufficiency
- Hypocellular, hypovascular and hypoxia
- Non healing wound and dead bone
Mandible, 6500
“Radiation dose — Gy significantly decreased
implant survival.”
≥ 55
“Better implant survival rate in the
mandible
(93.3%) than the maxilla (78.9%)”
“An — implant failure risk (RR 2.74) in
irradiated patients”
increased
Radiotherapy affect implant outcomes
In patients who are planned to undergoing radiotherapy,
place the implants at least
3 weeks (21 days) prior to
or at least 9 months after irradiation treatment is
recommended
In patients who are planned to undergoing radiotherapy,
place the implants at least 3 weeks (21 days) prior to
or at least 9 months after irradiation treatment is
recommended
Contraindication:
(2)
During irradiation treatment
When patient has irradiation induced mucositis
Preoperative Management
Hyperbaric Oxygen Treatment (HBOT)
(3)
Promote neo-angiognesis
Enhance bone healing
Controversial opinion
- Antibiotic prophylaxis and strict surgical sepsis.
- Render Hyperbaric Oxygen Treatment (HBOT) when
the total irradiation dose is ≥ 50 Grays. - Avoid immediate loading and use implant supported
prosthesis without mucosal contact
MRONJ
Medication Related Osteonecrosis of the Jaws
Medication Related Osteonecrosis of the Jaws
Interfere with
Increase the risk of developing
bone turnover at the dental implant interface
osteonecrosis of the jaws (ONJ)
Evidence Based Dentistry
- Current evidence found the higher risk of ONJ for the
following situation
(3)
- Intravenous BP
- Prolonged duration
- Posterior areas after implant placement
Cancer patients treated with
intravenous BP are contraindicated
for
implant placement
Oral BP are not considered a contraindication
- In patients taking oral BP for ≤ 5 years, neither the
short term (1-4 years) implant survival nor the risk of
ONJ seem to be increased.
Preoperative Management
- A separate informed consent form discussing the risks
- Reduce the surgical trauma
- Antibiotic prophylaxis and antiseptic mouthwashes
- Drug Holiday: limited evidence
- Discontinue BP 2 months before and 3 months after surgery for ≥ 4
years in patients taking BP alone or associated with corticosteroids/
anti-angiogenic medication
- Inherited bleeding disorders
(2)
- Von Willebrand Disease
- Hemophilia A and Hemophila B
- Medication associated bleeding disorders
(2)
- Oral anticoagulants
- Antiplatelet Medication
Inherited bleeding disorder may
increase the risk of —
during implant surgery.
- Not a contraindication for
—
hemorrhage
implant survival/success
Preoperative Management
- Carefully plan any elective surgery and discuss with the patients’ physician /hematologist.
- Assessment and augmentation of the deficient
coagulation factor before surgery if necessary
- minimum level of —%
- Avoid
50
advanced implant surgical procedures (eg. direct sinus lift and bone graft harvest procedures)
Operative Management
- Use local anesthesia with
- Use appropriate — technique
- Use local hemostatic measures to achieve —
- Use
vasoconstrictor (slow injection
technique and fine needles)
suturing
hemostasis
anti-fibrinolytic agents (5% tranexamic
mouthwash) during surgery and up to 7 days post-
surgery
Nothing too crazy
Postoperative Management
- Reduce the risk of the infection
-Use
- Reduce the risk of postoperative bleeding
- Discuss the use of
topical antiseptics (chlorhexidine mouthwashes)
or antibiotics
non-steroidal anti-inflammatory
medications for pain management with the physician
The patients who are currently taking oral
anticoagulants or antiplatelet drugs are at
higher risk of — during implant surgery
hemorrhage
Anticoagulants and
Antiplatelet medication
Short half life
(12hrs)
- Examples: Pradaxa and Xarelto
- Stopped 1 day before the Implant procedure
Anticoagulants and
Antiplatelet medication
- Longer half life
(20-60hrs)
- Examples: Coumadin
- Risk at developing a thromboembolic episode
skipped
Medical interactions increase the anticoagulant
effect of Coumadin
- Antibiotics: (5)
- Analgesics: (1)
- Monitor (2)
amoxicillin, erythromycin,
metronidazole, clarithromycin, ciprofloxacin
NSAID
INR (2-3) and platelet count (>50,000/mm3)
Contraindication:
INR
Platelet count
> 3-3.5
<50,000/mm3
Operative Management
- Use local hemostatic measures during implant surgery
(3)
- Same concept as bleeding orders
- Anti-fibrinolytic agents, gelfoam, fibrin glue
Immunodeficiency
Disorders
(3)
HIV Infection
Organ Transplant
Crohn’s disease
HIV-Positive Patients
- Dental implant treatment can be rendered only when
(2)
- The CD4 cell count rates are high
- The patient is on antiretroviral treatment
HIV Pos
- Check the following lab values
(3)
- CD4 ell count
- Absolute neutrophil count (ANC)
- Platelet count
Laboratory Investigations CD4 Count
Measure the number of CD4 T lymphocytes
Indicator of the
The strongest predictor of
immune system function
HIV progression
CD4 count
Normal range
500-1200 cells/mm3
CD4 count
Risk of infection
Opportunistic infection (candida)
≤ 400 cells/mm3
CD4 count
HIV+ progresses to stage 3 infection
(AIDS)
≤ 200 cells/mm3
Laboratory Investigations Absolute Neutrophil Count
Measure the number of neutrophil — present in the blood
granulocytes
Risk Category ANC
1 (Normal ):
2 (Mild risk of infection):
3 (Moderate risk of infection):
4 (Severe risk of infection):
More than 1500/mm³
From 1000 to 1500/mm³
From 500 to 1000/mm³
Less than 500/mm³
Organ Transplant Patients
- An accepted treatment for
- Successful dental implant therapy has been reported
in patients receiving organ transplantation (mainly liver
and kidney) with long-term
end-stage organ failure
cyclosporin therapy
Crohn’s Disease Patients
(2)
- Characterized by the presence of several antibody‐
antigen complexes, leading to autoimmune
inflammatory processes in many parts of the body - A relative contraindication for dental implant treatment
skipped
Recommendations
-Immuno-incompetence is not an contraindication
(3)
- Appropriate medical consultation
- Assess the degree of immuno-compromise
- Reduce risk of infections by rendering antibiotic
prophylaxis/antiseptic mouthwashes
NOT suitable to place dental implants
(2)
- Significant immunosuppression cases
- Eg. Total White Blood Cell count <1,500-3,000/mcL
(Normal: 3,500-10,500/mcL)
Long Term Effects of Corticosteroids
- Exerts a negative
feedback control on the
HPA axis
- Suppress corticotropin
releasing hormone(CRH) then
corticotropin(ACTH) secretion
- Adrenal atropy and loss of
cortisol secretory capability
Long Term Effects of Corticosteroids
- Reduce
- increase (2)
bone density,
epithelial fragility
and immunosuppression
- Adrenal Crisis
Does dental Implant failure rate and/or surgical
morbidity increase in patients under systemic
corticosteroids?
NO
No evidence in literature that have been demonstrated it.
Preoperative Management
- Surgery is a potent activator of the
- — is a critical reason for elevation of cortisol levels
- Access the need of operative corticosteroid coverage
- For dental implant surgery,
HPA axis
Pain
take regular steroid dose
prior to the surgical procedure “No need to double
the dose of steroids”
Cardiovascular Disease
(3)
Coronary Artery Disease (Angina, Myocardial Infarction)
Cardiovascular Surgery (Cardiac Bypass surgery
or cardiac stent placement)
Hypertension
Evidence Based Dentistry
- No evidence that cardiac disorders are contraindicated
- Consider other issues
(2)
- The occurrence of bleeding (Hypertension)
- Cardiac ischemia (Coronary artery disease)
skipped
Preoperative Management
- Review changes in medical history
- Medical consult
- Stress reduction protocol
(5)
- Supplemental oxygen
- Sedation
- Effective local anesthesia with aspiration
(limit epinephrine use) - Minimize duration of appointment
- Position semi-supine
Only Emergency procedures if MI is within
2 months
Evidence Based Dentistry
- Implant therapy can be successful
- Factors affect the outcome
(4)
- Poor oral hygiene
- Oral parafunctions
- Harmful habits
- Behavioral problems
Preoperative Management
- Appropriate patient selection
(2)
- Medical consultation
- Oral hygiene reinforcement
- Properly understanding
- Accepting the proposed treatment
