Dental implants in the medically compromised patient Flashcards by sophie rosen

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.

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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 ?

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Initial Consultation
Implant surgery is an —
— for appropriate control of the
disease process
Achieve favorable outcome in —

elective procedure
Medical consultation
long term

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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

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Diabetes Mellitus
- Disorder of glucose metabolism
- Two major types
(2)

Type I: Insulin-dependent
Type II: Non-insulin-dependent (95%)

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Diabetes Mellitus
- New cases: — are diagnosed per year
- Increases with age –

1.4 million
90% over 45 y/o

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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

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Hyperglycemia has a negative effect on

bone metabolism

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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

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Hyperglycemia may lead to severe complications
(3)

Macro/micro angiopathy, neuropathy, increased risk of infections

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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.

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Strict – control before and after
dental implant treatment
is highly recommended

glycemic

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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

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To reduce the potential risk of infections
- Consider (2)

antibiotics and antiseptic mouthwashes

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Antibiotics: (4)
Antiseptic mouthwashes: (1)
Reinforce

penicillin, amoxicillin, clindamycin or
metronidazole

Peridex (Chlorhexidine)

supportive therapy/maintenance systems

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Uncontrolled DM
(2)

NO IMPLANTS
until it’s under controlled
Conventional solutions could
be good alternative options Removable dentures OR bridges as fixed prosthesis

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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

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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

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Preoperative Management
Need a careful evaluation of bone mineral density

DEXA/DXA (Bone densitometry) scan

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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

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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

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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

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“Radiation dose — Gy significantly decreased
implant survival.”

≥ 55

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“Better implant survival rate in the

mandible
(93.3%) than the maxilla (78.9%)”

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“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