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Implants > Dental implants in the medically compromised patient > Flashcards

Dental implants in the medically compromised patient Flashcards

1
Q

Increasing numbers of medically compromised patients require dental implant therapy due to —

A

extended life span.

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2
Q

What questions should you consider during the initial consultation?
(2)

A
  • 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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3
Q

What is important to remember during/before the initial consultation?

A
  • Implant surgery is an elective procedure
  • Medical consultation for appropriate control of the disease process
  • Achieve favorable outcome in long term
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4
Q

What are the characteristics of a patient with poorly controlled disease process when concerning impants?

A
  • Pose surgical or medical risk at the time of the surgery
  • Potentially cause failure of dental implant to heal normally
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5
Q

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

A
  • Type I: Insulin-dependent
  • Type II: Non-insulin-dependent (95%)
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6
Q

Diabetes Mellitus
- New cases: _______ are diagnosed per year

A

1.4 million

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7
Q

___% of the people with diabetes mellitus are over 45 years old

A

90%

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8
Q

Diabetes Mellitus’s global prevalence was estimated to be 2.8% in 2000 and is expected to rise to ____% in 2030

A

4.4%

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9
Q

___% of diabetics have end stage renal disease

A

25%

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10
Q

What is the leading cause of blindness?

A

diabetes

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11
Q

Diabetes is the __th leading case of death

A

7th

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12
Q

Hyperglycemia has a negative effect on ________ metabolism

A

bone metabolism

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13
Q

Diabetic osteopathy REDUCES (2), INCREASES (1), and IMPAIRS (3) what?

A

Reduces…
- Bone mineral density
- Bone mechanical properties

Increases…
- Risk of fracture

Impairs…
- endochondral bone formation
- intramembranous bone formation
- microarchitectural quality

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14
Q

Hyperglycemia may lead to what severe complications
(3)

A
  • Macro/micro angiopathy
  • neuropathy
  • increased risk of infections
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15
Q

Current literatures support the use of dental implants in diabetic patients with ____________________

A

good metabolic glucose control

A comparable survival rates (85.5 to 100%) were reported on dental implants placed in diabetic patients with good/fair metabolic control

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16
Q

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

A

glycemic

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17
Q

Preoperative Management for impant patients with diabetes should be prepared by both the…

A

dentist and endocriniologist

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18
Q

What preoperative managements do you need to consider before placing an implant in a patient with diabetes?

A
  • Monitor blood glucose levels
    — current level and improvement
  • Check HbA1c
  • co-morbidities, restoration of proper oral hygiene, cessation of tobacco, treatment of periodontitis
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19
Q

What should the preoperative HbA1c value be for a implant patient with diabetes?

A

≤ 7% is ideal; ≤ 8% is acceptable

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20
Q

To reduce the potential risk of infections consider… (2)

A
  • antibiotics (penicillin, amoxicillin, clindamycin or metronidazole)
  • antiseptic mouthwashes (Peridex/Chlorhexidine)
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21
Q

If a patient has uncontrolled DM what implants can you do?
(2)

A
  • 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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22
Q

What is Osteoporosis?

A
  • Generalized reduction in bone density and alterations in the microstructure of bone
  • Lead an increased risk of fractures
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23
Q

A total of ________________ U.S. adults age ≥ 50 are affected by osteoporosis

A

54 million

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24
Q

There is a biologically plausible but still controversial hypothesis “the impaired bone metabolism can impair bone healing and affect osseointegration”
- At this time there is not enough evidence to consider osteoporosis as an _____________________

A

absolute contraindication for implant placement

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25
Q

For preoperative management what can you use to make a careful evaluation of bone mineral density?

A

DEXA/DXA (Bone densitometry) scan

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26
Q

_____________ loading of the dental implants is not recommended

A

Immediate

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27
Q

What do you need to consider in patients with osteoporosis who want an implant?

A
  • May increase risk of complications in bone augmentation
  • Use of dental implants with modified, hydrophilic surfaces
  • Require longer healing period for osseointegration
  • Immediate loading of the dental implants is not recommended
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28
Q

Head & Neck Cancer account for ____ percent of all malignancies in the US

A

6%

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29
Q

__________% patients affected by head and neck cancer have radiation therapy

A

60-80

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30
Q

What are the early affects of irradiation due to head and neck cancer?

A

Salivary glands
skin
oral mucosa

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31
Q

What are the late affects of irradiation due to head and neck cancer?

A

Bone changes
demineralization
fibrosis
avascular necrosis

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32
Q

What is osteoradionecrosis (ORN)

A
  • One of the most serious complication of head & neck radiation
  • Induce vascular insufficiency rather than infection
    — Hypocellular, hypovascular and hypoxia
    — Non healing wound and dead bon
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33
Q

Where is osteoradionecrosis most common?

A
  • Mandible
  • site with radiation ≥ 6500 Rads/65Gy
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34
Q

Radiation dose _____ Gy significantly decreased implant survival

35
Q

Better implant survival rate in the mandible or maxilla?

A

mandible (93.3%)

maxilla (78.9%)

36
Q

An _________ implant failure risk (RR 2.74) in irradiated patients

A

increased

Radiotherapy affect implant outcomes

37
Q

In patients who are planned to undergoing radiotherapy, place the implants at least ______________ prior to or at least _______________ after irradiation treatment is recommended

A

3 weeks (21 days)
9 months

38
Q

When an implant seeking patient has head and neck cancer what are the contraindications (2)?

A
  • During irradiation treatment
  • When patient has irradiation induced mucositis
39
Q

What are the preoperative management options for patients with head and neck cancer who want implants?

A
  • 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
40
Q

What is MRONJ (Medication Related Osteonecrosis of the Jaws) ?

A
  • Interfere with bone turnover at the dental implant interface
  • Increase the risk of developing osteonecrosis of the jaws (ONJ)
41
Q

Current evidence found the higher risk of ONJ for the following situation (3s)

A
  • Intravenous BP
  • Prolonged duration
  • Posterior areas after implant placement
42
Q

Cancer patients treated with intravenous BP are contraindicated for

A

implant placement

43
Q

Oral BP are not considered a contraindication for what kind of patients…

A

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

44
Q

What are the preoperative management options for patients with ONJ who want implants?

A
  • A separate informed consent form discussing the risks
  • Reduce the surgical trauma
  • Antibiotic prophylaxis and antiseptic mouthwashes
  • Drug Holiday: limited evidence
45
Q

What is a “drug holiday” suggested as preoperative managment for some cases of ONJ before implants?

A

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

46
Q

What are the Inherited bleeding disorders to consider?
(2)

A
  • Von Willebrand Disease
  • Hemophilia A and Hemophila B

Not a contraindication for implant survival/success

47
Q

What are the Medication associated bleeding disorders to consider?
(2)

Not a contraindication for implant survival/success

A
  • Oral anticoagulants
  • Antiplatelet Medication
48
Q

Inherited bleeding disorder may
increase the risk of _______ during implant surgery.

A

hemorrhage

49
Q

What are the preoperative management options for patients with bleeding disorders who want implants?

A
  • 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 50%
  • Avoid advanced implant surgical procedures (eg. direct sinus lift and bone graft harvest procedures)
50
Q

What is the minimum level of coagulation factor needed before doing elective surgery such as an implant?

A

at least 50%

51
Q

What are the options for operative managment for those patients with bleeding disorders?

A
  • Use local anesthesia with vasoconstrictor (slow injection technique and fine needles)
  • Use appropriate suturing technique
  • Use local hemostatic measures to achieve hemostasis
    — anti-fibrinolytic agents (5% tranexamic mouthwash)
52
Q

What are the preoperative management options for patients with bleeding disorders who want implants?

A
  • Reduce the risk of the infection
    — Use topical antiseptics (chlorhexidine mouthwashes) or antibiotics
  • Reduce the risk of postoperative bleeding
    — Discuss the use of non-steroidal anti-inflammatory medications for pain management with the physician
53
Q

The patients who are currently taking oral
anticoagulants or antiplatelet drugs are at
higher risk of _________ during implant surgery

A

hemorrhage

54
Q

Anticoagulants and Antiplatelet medication with a short half life (12 hrs) need to be stopped…

A
  • Stopped 1 day before the Implant procedure
  • Examples: Pradaxa and Xarelto
55
Q

Anticoagulants and Antiplatelet medication with a long half life (20-60 hrs) need to be stopped because…

A
  • Risk at developing a thromboembolic episode
  • Examples: Coumadin
56
Q

Medical interactions increase the anticoagulant effect of Coumadin such as…
- Antibiotics: (5)
- Analgesics: (1)

A
  • amoxicillin, erythromycin,
    metronidazole, clarithromycin, ciprofloxacin
  • NSAID
57
Q

What should you monitor as preoperative managament for patients on anticoagulants/antiplatelet medications?

A

Monitor INR (2-3) and platelet count (>50,000/mm3)

58
Q

Contraindication for a patient on anticoagulant or antiplatlet if they have a:
INR _________
Platelet count _______

A

> 3-3.5
< 50,000/mm3

59
Q

What are the options for operative managment for those patients on antiplatelet/anticoagulant medication?

A
  • Use local hemostatic measures during implant surgery
    — Same concept as bleeding orders
    — Anti-fibrinolytic agents, gelfoam, fibrin glu
60
Q

Immunodeficiency Disorders most common to see for implants
(3)

A

HIV Infection
Organ Transplant
Crohn’s disease

61
Q

For HIV-Positive Patients, dental implant treatment can be rendered only when… (2)

A
  • The CD4 cell count rates are high
  • The patient is on antiretroviral treatment
62
Q

What labs should you check for an HIV-positive patient?

A
  • CD4 Cell count
  • Absolute neutrophil count (ANC)
  • Platelet count
63
Q

Measuring the number of CD4 T lymphocytes allows for what in an HIV-positive patient?

A
  • Indicator of the immune system function
  • The strongest predictor of HIV progression
64
Q

CD4 count
Normal range

A

500-1200 cells/mm3

65
Q

CD4 count
Risk of infection
Opportunistic infection (candida)

A

≤ 400 cells/mm3

66
Q

CD4 count
HIV+ progresses to stage 3 infection
(AIDS)

A

≤ 200 cells/mm3

67
Q

An absolute neutrophil count
- Measure the number of neutrophil _________ present in the blood

A

granulocytes

68
Q

Risk Category ANC (absolute neutrophil count)
1 (Normal ):
2 (Mild risk of infection):
3 (Moderate risk of infection):
4 (Severe risk of infection):

A

More than 1500/mm³
From 1000 to 1500/mm³
From 500 to 1000/mm³
Less than 500/mm³

69
Q

Successful dental implant therapy has been reported in patients receiving organ transplantation (mainly liver and kidney) with _______________________?

A

long-term cyclosporin therapy

70
Q

What is crones disease?

A

Characterized by the presence of several antibody‐antigen complexes, leading to autoimmune inflammatory processes in many parts of the body

71
Q

Can patients with crohn’s disease get implants?

A
  • A relative contraindication for dental implant treatment
  • “Crohn’s disease showed a significant effect on early implant failure and resulted in increased, however not significant, implant loss.”
72
Q

Immuno-incompetence is not an contraindication, but what do you need to check/consider before an implant?

A
  • Appropriate medical consultation
  • Assess the degree of immuno-compromise
  • Reduce risk of infections by rendering antibiotic prophylaxis/antiseptic mouthwashes
73
Q

What type fo immuno-incompetent patients cannot get a dental implant?

A
  • Significant immunosuppression cases
  • Eg. Total White Blood Cell count <1,500-3,000/mcL (Normal: 3,500-10,500/mcL)
74
Q

Long Term Effects of Corticosteroids
- Exerts a negative feedback control on the…

A

HPA axis
- Suppress corticotropin releasing hormone (CRH) then corticotropin (ACTH) secretion
- Adrenal atropy and loss of cortisol secretory capability

75
Q

Long Term Effects of Corticosteroids Reduce…

A

bone density
epithelial fragility
immunosuppression

76
Q

Does dental Implant failure rate and/or surgical morbidity increase in patients under systemic corticosteroids?

A

NO
No evidence in literature that have been demonstrated it.

77
Q

What are the preoperative management options for immunocompromised patients who want implants?

A
  • Surgery is a potent activator of the HPA axis
  • Pain is a critical reason for elevation of cortisol levels
  • Access the need of operative corticosteroid coverage
    — For dental implant surgery, take regular steroid dose prior to the surgical procedure “No need to double the dose of steroids”
78
Q

Cardiovascular Diseases to consider when placing implants?
(3)

A
  • Coronary Artery Disease (Angina, Myocardial Infarction)
  • Cardiovascular Surgery (cardiac bypass surgery or cardiac stent placement)
  • Hypertension
79
Q

No evidence that cardiac disorders are contraindicated for implants. But what other issues do you need to consider?

A
  • The occurrence of bleeding (Hypertension)
  • Cardiac ischemia (Coronary artery disease)
80
Q

What are the preoperative management options for patients with cardiovascular disorders who want implants?

A
  • Review changes in medical history
  • Medical consult
  • Stress reduction protocol
    — Supplemental oxygen
    — Sedation
    —Effective local anesthesia with aspiration (limit epinephrine use)
    — Minimize duration of appointment
    — Position semi-supine
81
Q

Only Emergency procedures if MI is within ___ months

82
Q

What factors affect the outcome of implants in patients with neuropsychiatric disorders?

A
  • Poor oral hygiene
  • Oral parafunctions
  • Harmful habits
  • Behavioral problems
83
Q

What are the preoperative management options for patients with neuropsychiatric disorders who want implants?

A
  • Appropriate patient selection
    — Properly understanding
    — Accepting the proposed treatment
  • Medical consultation
  • Oral hygiene reinforcemen

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