med comp implants Flashcards
questions of the initial consult for med comp pts
- 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 ?
implants elective or emergency
Implant surgery is an elective procedure
Medical consultation for appropriate control of the
disease process
Achieve favorable outcome in long term
Medically Compromised Patients can be classified how?
Controlled disease process vs Poorly controlled disease process
poorly controlled med comp pts issues with implants
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 type
- Type I: Insulin-dependent
- Type II: Non-insulin-dependent (95%)
systemic complications of DM
- 25% end stage renal disease
- Leading cause of blindness
- 7th leading cause of death
diabetic osteopathy
severe complications of hyperglycemia
Hyperglycemia may lead to severe complications:
Macro/micro angiopathy, neuropathy, increased risk of infections
Evidence Based Dentistry with DM and implants
- Current literatures support the use of dental implants in diabetic patients with 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.
- Strict glycemic control before and after dental implant treatment is highly recommended
DM preop management
- Prepared by both dentist and endocrinologist
- Monitor blood glucose levels
- current level and improvement
- Preoperative HbA1c value
- ≤ 7% is ideal; ≤ 8% is acceptable
- Others: co-morbidities, restoration of proper oral hygiene, cessation of tobacco, treatment of periodontitis
reducing infection risk in DM pts
- Consider antibiotics and antiseptic mouthwashes
- Antibiotics: penicillin, amoxicillin, clindamycin or
metronidazole - Antiseptic mouthwashes: Peridex (Chlorhexidine)
- Reinforce supportive therapy/maintenance systems
uncontrolled DM and implants
NO IMPLANTS until it’s under controlled
Conventional solutions could be good alternative options Removable dentures OR bridges as fixed prosthesis
Osteoporosis
Osteoporosis- Generalized reduction in bone density and alterations in the microstructure of bone
- Lead an increased risk of fractures
- A total of 54 million U.S. adults age ≥ 50 are affected
Evidence Based Dentistry and osteoporosis
- 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
preop with osteoporosis
Need a careful evaluation of bone mineral density
DEXA/DXA (Bone densitometry) scan
osteoporosis considerations
- May increase risk of?
- Use of dental implants with modified?
- Require longer healing period for?
- Immediate loading?
- 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
Head & Neck Cancer
Account for 6 percent of all malignancies in the US
- Surgery and radiation therapy
- 60-80% patients affected by head and neck cancer
have radiation therapy
Head & Neck Cancer Early Effect of Irradiation
Salivary glands, skin, oral mucosa (dry)
Head & Neck Cancer Late Effect of Irradiation
Bone changes: demineralization, fibrosis, avascular necrosis
HYPOCELLULAR, HYPOXIA, HYPOVASCULAR
all lead to osteoradionecrosis
Osteoradionecrosis (ORN)
site/dose?
- One serious complication of head & neck radiation
- Induce vascular insufficiency rather than infection
- Hypocellular, hypovascular and hypoxia
- Non healing wound and dead bone
- Mandible or site with radiation ≥ 6500 Rads/65Gy
Evidence Based Dentistry with radiation therapy
what doses sig decreasd survival?
which arch is better?
failure?
“Radiation dose ≥ 55 Gy significantly decreased implant survival.”
“Better implant survival rate in the mandible
(93.3%) than the maxilla (78.9%)
“An increased implant failure risk (RR 2.74) in
irradiated patients
Radiotherapy affect implant outcomes
when to place implants for irradiated pts
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
when are implants contraindicated with radiation
During irradiation treatment
When patient has irradiation induced mucositis
Preoperative Management of irradiated pts
prophylaxis?
controversial option? when?
immeadiate load?
- Antibiotic prophylaxis and strict surgical sepsis.
- Render Hyperbaric Oxygen Treatment (HBOT) when
the total irradiation dose is ≥ 50 Grays. Promote neo-angiognesis and Enhance bone healing - Avoid immediate loading and use implant supported
prosthesis without mucosal contact
MRONJ
Medication Related Osteonecrosis of the Jaws due to Bisphosphonates (BP) or Denosumab
Interfere with bone turnover at the dental implant interface
Increase the risk of developing osteonecrosis of the jaws (ONJ)
- Current evidence found the higher risk of ONJ for the following situations regarding BP
- Intravenous BP
- Prolonged duration (both oral and IV)
- Posterior areas after implant placement
Cancer patients treated with intravenous BP are?
Cancer patients treated with intravenous BP are contraindicated for implant placement
oral BP contraindication?
- 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.
- Explain in details the possible risk of complications is important
Preoperative Management of BP pt
- informed consent?
- Reduce the?
- antisepsis?
- Drug Holiday?
- 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
common bleeding dx seen
Inherited bleeding disorders:
- Von Willebrand Disease
- Hemophilia A and Hemophila B
Medication associated bleeding disorders:
- Oral anticoagulants
- Antiplatelet Medication
inherited bleeding and implants
- Inherited bleeding disorder may increase the risk of hemorrhage during implant surgery.
- Not a contraindication for implant survival/success
preop managment of bleeding pts
- Carefully plan?
- Assessment and augmentation of? level?
- Avoid?
- 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)
operative managment of bleeding pts
- LA?
- sutures?
- local measure?
- anti-fibrinolytic agents?
- Use local anesthesia with vasoconstrictor (slow injection
technique and fine needles) - Use appropriate suturing technique
- Use local hemostatic measures to achieve hemostasis
- Use anti-fibrinolytic agents (5% tranexamic
mouthwash) during surgery and up to 7 days post-
surgery
postop bleeding pt managment
- Reduce the risk of? how?
- postoperative bleeding?
- Discuss the use of what with the physician?
- 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
Anticoagulants and Antiplatelet medication
The patients who are currently taking oral anticoagulants or antiplatelet drugs are at higher risk of hemorrhage during implant surgery
warfarin, pradaxa, xarelto, plavix
short half life anticoag
examples/when stopped?
- Short half life (12hrs)
- Examples: Pradaxa and Xarelto
- Stopped 1 day before the Implant procedure
long half life anticoag
example/risk of?
- Longer half life (20-60hrs)
- Examples: Coumadin
- Risk at developing a thromboembolic episode if stopped
can we decide to stop anticoags
no must be MD
Preoperative Management of anticoag pts
- Medical interactions?
- Monitor what?
Preoperative Management
- Medical interactions increase the anticoagulant effect of Coumadin- Antibiotics: amoxicillin, erythromycin, metronidazole, clarithromycin, ciprofloxacin
- Analgesics: NSAID
- Monitor INR (2-3) and platelet count (>50,000/mm3)
Contraindications with anticoag pts
INR
Platelet count
INR >3-3.5
Platelet count <50,000/mm3
Operative Management anti coag pts
- Use local hemostatic measures during implant surgery
- Same concept as bleeding orders
- Anti-fibrinolytic agents, gelfoam, fibrin glue
common immuno def disorders seen
HIV
Chrons
organ transplant
HIV-Positive Patients
- Dental implant treatment can be rendered only when:
- Check the following lab values:
**Dental implant treatment can be rendered only when: **
- The CD4 cell count rates are high
- The patient is on antiretroviral treatment
**Check the following lab values: **
- CD4 cell count
- Absolute neutrophil count (ANC)
- Platelet count
CD4 count table
- Measure the number of CD4 T lymphocytes
- Indicator of the immune system function
- The strongest predictor of HIV progression
Absolute Neutrophil Count
Measure the number of neutrophil granulocytes present in the blood
Organ Transplant Patients
- An accepted treatment for end-stage organ failure
- Successful dental implant therapy has been reported
in patients receiving organ transplantation (mainly liver
and kidney) with long-term cyclosporin therapy
Crohn’s Disease Patients
- 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
“Crohn’s disease showed a significant effect on early implant failure and resulted in increased, however not significant, implant loss.”
is immunocompetence an absolute contra
-Immuno-incompetence is not an contraindication
- Appropriate medical consultation
- Assess the degree of immuno-compromise
- Reduce risk of infections by rendering antibiotic prophylaxis/antiseptic mouthwashes
when is it not ok to place implants in immunocompromised pts
- NOT suitable to place dental implants
- 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 (exogenous)
- 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
- Reduce bone density, increase 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.
preop managment of corticosteroid pts
- Surgery is a potent activator of?
- Pain is a critical reason for elevation of?
- Access the need of?
- For dental implant surgery, steroid dose?
- 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”
CVD and implant contraindication
- No evidence that cardiac disorders are contraindicated
Consider other issues: - The occurrence of bleeding (Hypertension)
- Cardiac ischemia (Coronary artery disease)
Preoperative Management CVD implant pts
- Review changes in?
- consult?
- Stress reduction?
- O2?
- Sedation?
-LA?
- Minimize duration?
- Position?
Preoperative Management
- 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
if pt has MI within 2 months what can be done
only emergency procedures
Evidence Based Dentistry for implants in pts with Neuropsychiatric disorders
what can affect outcome?
- Implant therapy can be successful
**Factors affect the outcome: ** - Poor oral hygiene
- Oral parafunctions
- Harmful habits
- Behavioral problems
Preoperative Management of neuropsych pts
- Appropriate patient selection
- Properly understanding
- Accepting the proposed treatment
- Medical consultation
- Oral hygiene reinforcement
