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.
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 ?
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
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
5
Q
Diabetes Mellitus
- Disorder of glucose metabolism
- Two major types
(2)
A
- Type I: Insulin-dependent
- Type II: Non-insulin-dependent (95%)
6
Q
Diabetes Mellitus
- New cases: _______ are diagnosed per year
A
1.4 million
7
Q
___% of the people with diabetes mellitus are over 45 years old
A
90%
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%
9
Q
___% of diabetics have end stage renal disease
A
25%
10
Q
What is the leading cause of blindness?
A
diabetes
11
Q
Diabetes is the __th leading case of death
A
7th
12
Q
Hyperglycemia has a negative effect on ________ metabolism
A
bone metabolism
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
14
Q
Hyperglycemia may lead to what severe complications
(3)
A
- Macro/micro angiopathy
- neuropathy
- increased risk of infections
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
16
Q
Strict _________ control before and after dental implant treatment is highly recommended
A
glycemic
17
Q
Preoperative Management for impant patients with diabetes should be prepared by both the…
A
dentist and endocriniologist
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
19
Q
What should the preoperative HbA1c value be for a implant patient with diabetes?
A
≤ 7% is ideal; ≤ 8% is acceptable
20
Q
To reduce the potential risk of infections consider… (2)
A
- antibiotics (penicillin, amoxicillin, clindamycin or metronidazole)
- antiseptic mouthwashes (Peridex/Chlorhexidine)
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)
22
Q
What is Osteoporosis?
A
- Generalized reduction in bone density and alterations in the microstructure of bone
- Lead an increased risk of fractures
23
Q
A total of ________________ U.S. adults age ≥ 50 are affected by osteoporosis
A
54 million
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
25
For preoperative management what can you use to make a careful evaluation of bone mineral density?
DEXA/DXA (Bone densitometry) scan
26
_____________ loading of the dental implants is not recommended
Immediate
27
What do you need to consider in patients with osteoporosis who want an implant?
- 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
28
Head & Neck Cancer account for ____ percent of all malignancies in the US
6%
29
__________% patients affected by head and neck cancer have radiation therapy
60-80
30
What are the early affects of irradiation due to head and neck cancer?
Salivary glands
skin
oral mucosa
31
What are the late affects of irradiation due to head and neck cancer?
Bone changes
demineralization
fibrosis
avascular necrosis
32
What is osteoradionecrosis (ORN)
- 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
33
Where is osteoradionecrosis most common?
- Mandible
- site with radiation ≥ 6500 Rads/65Gy
34
Radiation dose _____ Gy significantly decreased implant survival
≥ 55
35
Better implant survival rate in the mandible or maxilla?
mandible (93.3%)
| maxilla (78.9%)
36
An _________ implant failure risk (RR 2.74) in irradiated patients
increased
| Radiotherapy affect implant outcomes
37
In patients who are planned to undergoing radiotherapy, place the implants at least ______________ prior to or at least _______________ after irradiation treatment is recommended
3 weeks (21 days)
9 months
38
When an implant seeking patient has head and neck cancer what are the contraindications (2)?
- During irradiation treatment
- When patient has irradiation induced mucositis
39
What are the preoperative management options for patients with head and neck cancer who want implants?
- 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
What is MRONJ (Medication Related Osteonecrosis of the Jaws) ?
- Interfere with bone turnover at the dental implant interface
- Increase the risk of developing osteonecrosis of the jaws (ONJ)
41
Current evidence found the higher risk of ONJ for the following situation (3s)
- Intravenous BP
- Prolonged duration
- Posterior areas after implant placement
42
Cancer patients treated with intravenous BP are contraindicated for
implant placement
43
Oral BP are not considered a contraindication for what kind of patients...
In patients taking oral BP for ≤ 5 years
## Footnote
neither the short term (1-4 years) implant survival nor the risk of ONJ seem to be increased
44
What are the preoperative management options for patients with ONJ who want implants?
- A separate informed consent form discussing the risks
- Reduce the surgical trauma
- Antibiotic prophylaxis and antiseptic mouthwashes
- Drug Holiday: limited evidence
45
What is a "drug holiday" suggested as preoperative managment for some cases of ONJ before implants?
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
What are the Inherited bleeding disorders to consider?
(2)
- Von Willebrand Disease
- Hemophilia A and Hemophila B
| Not a contraindication for implant survival/success
47
What are the Medication associated bleeding disorders to consider?
(2)
| Not a contraindication for implant survival/success
- Oral anticoagulants
- Antiplatelet Medication
48
Inherited bleeding disorder may
increase the risk of _______ during implant surgery.
hemorrhage
49
What are the preoperative management options for patients with bleeding disorders who want implants?
- 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
What is the minimum level of coagulation factor needed before doing elective surgery such as an implant?
at least 50%
51
What are the options for operative managment for those patients with bleeding disorders?
- 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
What are the preoperative management options for patients with bleeding disorders who want implants?
- 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
The patients who are currently taking oral
anticoagulants or antiplatelet drugs are at
higher risk of _________ during implant surgery
hemorrhage
54
Anticoagulants and Antiplatelet medication with a short half life (12 hrs) need to be stopped...
- Stopped 1 day before the Implant procedure
- Examples: Pradaxa and Xarelto
55
Anticoagulants and Antiplatelet medication with a long half life (20-60 hrs) need to be stopped because...
- Risk at developing a thromboembolic episode
- Examples: Coumadin
56
Medical interactions increase the anticoagulant effect of Coumadin such as...
- Antibiotics: (5)
- Analgesics: (1)
- amoxicillin, erythromycin,
metronidazole, clarithromycin, ciprofloxacin
- NSAID
57
What should you monitor as preoperative managament for patients on anticoagulants/antiplatelet medications?
Monitor INR (2-3) and platelet count (>50,000/mm3)
58
Contraindication for a patient on anticoagulant or antiplatlet if they have a:
INR _________
Platelet count _______
> 3-3.5
< 50,000/mm3
59
What are the options for operative managment for those patients on antiplatelet/anticoagulant medication?
- Use local hemostatic measures during implant surgery
--- Same concept as bleeding orders
--- Anti-fibrinolytic agents, gelfoam, fibrin glu
60
Immunodeficiency Disorders most common to see for implants
(3)
HIV Infection
Organ Transplant
Crohn’s disease
61
For 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
62
What labs should you check for an HIV-positive patient?
- CD4 Cell count
- Absolute neutrophil count (ANC)
- Platelet count
63
Measuring the number of CD4 T lymphocytes allows for what in an HIV-positive patient?
- Indicator of the immune system function
- The strongest predictor of HIV progression
64
CD4 count
Normal range
500-1200 cells/mm3
65
CD4 count
Risk of infection
Opportunistic infection (candida)
≤ 400 cells/mm3
66
CD4 count
HIV+ progresses to stage 3 infection
(AIDS)
≤ 200 cells/mm3
67
An absolute neutrophil count
- Measure the number of neutrophil _________ present in the blood
granulocytes
68
Risk Category ANC (absolute neutrophil count)
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
69
Successful dental implant therapy has been reported in patients receiving organ transplantation (mainly liver and kidney) with _______________________?
long-term cyclosporin therapy
70
What is crones disease?
Characterized by the presence of several antibody‐antigen complexes, leading to autoimmune inflammatory processes in many parts of the body
71
Can patients with crohn's disease get implants?
- 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
Immuno-incompetence is not an contraindication, but what do you need to check/consider before an implant?
- Appropriate medical consultation
- Assess the degree of immuno-compromise
- Reduce risk of infections by rendering antibiotic prophylaxis/antiseptic mouthwashes
73
What type fo immuno-incompetent patients cannot get a dental implant?
- Significant immunosuppression cases
- Eg. Total White Blood Cell count <1,500-3,000/mcL (Normal: 3,500-10,500/mcL)
74
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
75
Long Term Effects of Corticosteroids Reduce...
bone density
epithelial fragility
immunosuppression
76
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.
77
What are the preoperative management options for immunocompromised patients who want implants?
- 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
Cardiovascular Diseases to consider when placing implants?
(3)
- Coronary Artery Disease (Angina, Myocardial Infarction)
- Cardiovascular Surgery (cardiac bypass surgery or cardiac stent placement)
- Hypertension
79
No evidence that cardiac disorders are contraindicated for implants. But what other issues do you need to consider?
- The occurrence of bleeding (Hypertension)
- Cardiac ischemia (Coronary artery disease)
80
What are the preoperative management options for patients with cardiovascular disorders who want implants?
- 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
Only Emergency procedures if MI is within ___ months
2 months
82
What factors affect the outcome of implants in patients with neuropsychiatric disorders?
- Poor oral hygiene
- Oral parafunctions
- Harmful habits
- Behavioral problems
83
What are the preoperative management options for patients with neuropsychiatric disorders who want implants?
- Appropriate patient selection
--- Properly understanding
--- Accepting the proposed treatment
- Medical consultation
- Oral hygiene reinforcemen
