Medical And Pharmacological Considerations In Implant Supported Prosthesis
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INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com
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Complications and loss of implants can be costly in terms of time, psyc and financial resources. Additionally it results in an edentulous space more difficult to restore than prior to implant placement. Therefore ability to reliably identify patients systemic conditions with greater potential to implant failure would be valuable.
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Medical considerations
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Evaluation of patient’s systemic statusA thorough systemic checkup includes1. complete medical and dental history 2. physical examination 3. laboratory investigation
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Medical historyA complete medical history must include1. any history of medication usage within preceding 6 months 2. any history of allergies 3. Medical history related to systems of body i.e. CVS, CNS, respiratory system, digestive system, endocrine system, hematopoetic system, bones and joints, malignancies, complete dental history along with a consent statement.
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Physical examinationIt includes1. complete extra oral and intra oral examination 2. palpation of submental, submandibular, parotid and cervical areas for lymphadenopathy 3. vital signs- blood pressure, pulse, temperature, respiration, weight and height www.indiandentalacademy.com
Laboratory evaluationIt should include 1. Complete blood cell count white blood cell (WBC) count red blood cell (RBC count) 2. Hemoglobin and Packed cell volume 3. Bleeding tests- platelet count, bleeding time, prothrombin time ( PT), partial thromboplastin time (PTT ) www.indiandentalacademy.com
WBC countNormal values- 5000 - 10000/ml Leucocytosis- infections, leukemic diseases, immune diseases, allergies Leucopenia- liver cirrhosis, anemia, viral infections RBC countNormal valuesmale- 4.5 - 5 million/ml females- 4 - 4.5 million/ml HemoglobinNormal valuesmale- 13.5 - 18 g/dl females- 12 - 16 g/dl Lesser values- anemia www.indiandentalacademy.com
Packed cell volumeNormal valuesmale- 40 - 45% females- 38 -42% Lesser values- anemia
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Bleeding testsPlatlet countNormal values- 2 - 4 lakhs / ml
Bleeding timeTime interval from oozing of blood from a blood vessel till the bleeding arrests. Normal values- 3 - 6 minutes
Clotting timeTime taken by the blood to clot after collecting from blood vessels. Normal values- 3 - 8 minute www.indiandentalacademy.com
Prothrombin timeTime taken for plasma to clot in presence of exogenously added tissue thromboplastin and calcium ions. Test to check the extrinsic pathway i.e. factor 5, 7, 10 Normal values- 12-14 seconds
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Partial thromboplastin timeTime taken for plasma to clot in presence of exogenously added factor 12. Test to check the intrinsic pathway i.e. factor 5, 8, 9,10, 11,12 Normal values- 26-32 seconds
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Diabetes mellitusDiabetes mellitus is related to absolute or relative insulin insufficiency. 2 types, Type-1 (IDDM) and Type – 2 (NIDDM) It is most common endocrine disorders and one of the leading causes of death. An implantologist will confirm diabetes by presence of glucose levels above 120mg/dl. www.indiandentalacademy.com
Currently number of diabetic patients has exceeded 150 million all over the world. Number of diabetic patients are expected to be doubled by year 2025.
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Prevalence in Indian population-
Rural population- 2.4% of adult population Urban population- 4 – 11.6% of adult population is diagnosed diabetic.
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ComplicationsDiabetic patients show 1. Decreased collagen synthesis- delayed wound healing 2. Impairment of leukocyte function 3. Increased susceptibility to infections 4. Increased incidence of perimplant diseases www.indiandentalacademy.com
5. Increased inflammatory tissue destruction as a result of exaggerated production of inflammatory mediators. 6. Increased alveolar bone loss , as reported by Fiorellini et al ( in 2000 ) that bone and mineral metabolism is altered in diabetics.
All potentially complicating factors during implant surgeries.
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Fiorellini et al (in 1990) in a study of 40 patients found lower success rates in diabetic patients, approximately 85%, but the authors concluded that this was still a reasonable treatment outcome potential. Most of the failures were in the first year after loading.
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Morris et al (in 2000) studied over 650 patients with Type 2 diabetes and found only marginally more failures than with nondiabetic patients. The authors also found increased success with hydroxyapatite (HA)窶田oated implants and the use of chlorhexidine mouth rinses at the time of surgery. Kapur et al (in 2001) compared diabetics who had moderate levels of metabolic control and also concluded that implants could be used successfully in diabetic patients. The type of diabetes does not play any role in implant therapies. www.indiandentalacademy.com
This was substantiated by Olson et al (in 2000), who studied diabetics with implants over a 5-year period that the duration of diabetes had an effect on implant success. Greater failure rates were found in patients who had diabetes for longer time periods. However, no definitive length of time associated with a diagnosis of diabetes has been established as a guideline for treatment planning. Payam et al (in 2004) studied 782 diabetic patients and found implant success rate was 96.3% during the healing period and 94.1% one year after surgery. www.indiandentalacademy.com
Dental implant managementHigh blood sugar levels are definite contraindication for implant surgeries not the diabetic status of the patient. Diabetic patients are classified in 3 categoriesMild-
blood sugar level < 150 mg/dl
Moderate- blood sugar level < 200 mg/dl
Severe-
blood sugar level >200 mg/dl www.indiandentalacademy.com
All surgical procedures to be postponed
Protocol to be followed during implant surgeryStress reduction protocol Diet evaluation before and after surgery Control of risk of infection- aseptic techniques and proper antibiotic coverage Insulin doses are adjusted to the half of routine doses and oral hypoglycemic drugs are discontinued on the day of surgery. Use of corticosteroids must be avoided as it adversely effects blood glucose levels. www.indiandentalacademy.com
Most serious complication for diabetic patients during implant procedures is hypoglycemia. It occurs as a result of -excessive insulin levels or hypoglycemic drugs -inadequate food intake It is characterized by weakness, nervousness, tremors, palpitations, sweating and if not attended can lead to seizures, coma and death. Hypoglycemia is treated by by giving sugar or glucose orally and if not controlled IV dextrose solutions are given. www.indiandentalacademy.com
Cardiovascular diseases-
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HypertensionA patient is classified as hypertensive when resting systolic blood pressure is at or above 140 mm Hg or mean diastolic blood pressure at or above 90 mm Hg.
Patients with essential hypertension are susceptible to 3 times as much coronary diseases and 4 times as much cardiac failures. Apart from this most common complication that is seen during implant surgeries is excessive uncontrolled bleeding.
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Prevalence in Indian populationBetween the age of 20 â&#x20AC;&#x201C; 60 years 59.9 males and 69.9 females/ 1000 population in urban areas 35.5 males and 35.9 females/1000 population in rural areas.
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Dental implant management-
All surgical procedures to be postponed www.indiandentalacademy.com
Dental implant managementAnxiety greatly affects the blood pressure so a stress reduction protocol is indicated for hypertensive patients. NSAIDS are commonly used postoperatively after implant surgeries. Johnson et al ( in1994) and Anderson et al ( in 1993 ) have reported reduced efficacy of antihypertensive drugs when NASAIDS are used after implant surgeries. Therefore it is recommended that NSAIDS should be limited to short therapy or other analgesic agents should be used. www.indiandentalacademy.com
Angina pectorisIt is a symptomatic expression of temporary myocardial ischemia. Classical symptom is retrosternal pain which often develops during stress or physical exertion and radiates to shoulder, left arm, neck, palate or tongue.
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Prevalence in Indian populationOver the age of 30 years 65.4 males and 47.8 females/1000 population in urban areas 22.8 males and 17.3 females/1000 population in rural areas
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Dental implant management• Premedication to relieve
anxiety • Sedation preferred during surgeries • Supplemental oxygen • Treatment should be done with physician consent and after hospitalization
Surgical procedures contraindicated www.indiandentalacademy.com
Dental emergency kit should include nitroglycerine tablets or spray while treating a patient with history of angina. During anginal attack- All dental treatments should be stopped immediately - Nitroglycerine is administered sublingually and 100% oxygen is given at 6L/ min. - If the pain is not relieved in 8-10 minutes the www.indiandentalacademy.com patient should be shifted to hospital.
Myocardial infarctionMyocardial infarction ( MI ) is prolonged ischemia that causes irreversible injury to cardiac muscles. Approximately 18-20% of patients with recent history of MI will have recurrent MI attack, with a high mortality rate of 40-70%. If surgery is done within 3 months of MI, risk of recurrent attack is 30%, if within 3-6 months, it is 15%. After 12 months the incidence of recurrence is less than 5%.
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Dental implant managementPremedication to relieve anxiety Sedation preferred during surgeries Supplemental oxygen Treatment should be done with physician consent and after hospitalization Surgical procedures contraindicated
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Subacute bacterial endocarditis and valvular heart diseasesBacterial endocarditis is an infection of heart valves or endothelial surfaces of heart. Dental procedures causing transient bacterimia are major cause of bacterial endocarditis, so a implantologist should identify the patient at risk and implement prophylactic procedure.
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Prevalence in Indian populationComprises of 3% of total deaths due to cardiovascular diseases In 1998 total no. of deaths in India due to RHD – 86000 Chances of RHD after streptococcal infection – 3% www.indiandentalacademy.com
Incidence of bacterial endocarditis Surgical procedures contraindicated
Surgical procedures under proper antibiotic coverage
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Dental implant managementIn patients of high risk of bacterial endocarditis implant therapy is contraindicated, especially those with limited oral hygiene or history of stroke. Patients in other category can undergo implant treatment with adequate antibiotic prophylaxis.
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Antibiotic prophylaxis to prevent endocarditis ď Ž
Tab 4-3
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AnemiaIt is defined as a reduction in oxygen carrying capacity of blood as result of decrease in number of erythrocytes or abnormality of hemoglobin. Normal values of hemoglobin areMales - 13.5 - 18 g/dl Females - 12 - 16 g/dl A patient is diagnosed as anemic when hemoglobin values are below 10 g/dl. www.indiandentalacademy.com
ComplicationsBone maturation and development are impaired, so bone needed to support implant is significantly affected. Prolonged and excessive bleeding . Increased postoperative edema and discomfort. Increased risk of postoperative infection. www.indiandentalacademy.com
PrecautionsMinimum base line recommended for surgeries is 10g/dl. For majority of patients implant procedures are not contraindicated. Pre and post operative antibiotics Aspirin should be avoided to relieve post operative inflammation. www.indiandentalacademy.com
Osteoporosis and estrogen statusOsteoporosis is age related disorder of bone characterized by a decrease in bone mass, increased micro architectural deterioration and susceptibility to fractures. Past the age of 60 almost 1/3 of the population has this disorder and occurs in twice as many women as man.
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Role of estrogenEstrogen, a female sex hormone is secreted in large quantities from ovaries and small quantities from adrenal cortex (pregnancy - placenta ). Estrogen plays a major role in bone metabolism by increasing osteoblastic activity. In menopause which results due to atrophy of ovaries, either estrogen is not secreted or becomes very scanty. www.indiandentalacademy.com
Osteoporosis in malesTestosteron also induces osteoblastic activity like estrogen but the incidence of osteoporosis in males is almost half in comparison to females . It is because of â&#x20AC;&#x201C; Effect of testosteron in osteoblastic activity is not as pronounced as that of estrogen. Secretion of testosteron reduces slowly as the age advances. www.indiandentalacademy.com
Bone metabolism is impaired with emphasis on resorption, cortical plates become thinner, trabecular bone pattern more discrete and advanced demineralization occurs, thus as reported by Jeffcoat et al ( in 2000 ) this patient group exhibit reduced alveolar bone mass and density. Theoretically, osseous integration may be more difficult to achieve.
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However, established systemic osteoporosis does not imply that a jaw bone is unsuitable for osseous integration, nor is it an absolute contraindication to implant therapy. Dao et al (in 95) and Becker et al ( in 2000) in studying the association between premenopausal and postmenopausal women and implant failure, did not find a higher failure rate for implants placed in women older than 50 as compared with women younger than 50 or between women and men older than 50. www.indiandentalacademy.com
August et al (in 2001) examined jaw differences in pre- and postmenopausal women and found more failures in postmenopausal women with maxillary implants, but not mandibular implants. The authors found that postmenopausal women not taking hormone replacements had the highest failure rates. They reasoned that because osteoporosis affects trabecular bone more than cortical bone and the maxilla has more trabecular bone content than the mandible, the maxilla is more susceptible to the effects of systemic osteoporosis. www.indiandentalacademy.com
Minsk and Polson ( in 2000 ) studied postmenopausal women undergoing hormone replacement therapy and found that the combination of osteoporosis and smoking did result in more implant failures. Osteoporosis has been shown to result in loss of periodontal attachment in natural tooth, but a similar loss of peri-implant tissue has not been established.
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Dental implant managementFor patients with extreme osteoporosis, it may be wise to be cautious with maxillary implant treatment planning . Reduced bone density does effect the treatment planning surgical approach, length of healing, necessitates need of progressive bone loading and hydroxyapatite coating on implants. Daily calcium uptake up to 1500 mg/day pre and post surgically. www.indiandentalacademy.com
Cancer and cancer treatmentsPatients who have undergone tumor resection in the oral region are some of the most difficult patients to restore with conventional prosthetic treatment modalities and these are the patients who could benefit most from the placement of endosteal dental implants. However, there are concerns about the ability of irradiated tissue to support osseous integration and the effects of systemic chemotherapy on bone quality. www.indiandentalacademy.com
Prevalence in Indian population-
Oral cancer comprises of 50 - 70 % of all cancers diagnosed in Indian population as compared to 2 â&#x20AC;&#x201C; 3 % in USA or UK. 16.4 males and 8.8 females/ 1000 population.
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Radiation treatmentThe oral effects of radiation treatment include xerostomia, mucositis, hypovascularity, fibrosis, hypoxia, and most seriously osteoradionecrosis, all potential hindrances to implant treatment success. August et al (in 98) in a retrospective study, concluded that past tumoricidal radiation is no longer an absolute contraindication to implant placement, but a reduced success rate usually reported around 70% is seen. www.indiandentalacademy.com
To counteract the effects of radiation on bone growth and remodeling, Granstorm et al ( in 1993) and Larsen et al (in 1998) have suggested the use of hyperbaric oxygen therapy to improve osseous integration. HBO increases the blood to tissue oxygen gradient and improves the healing capacity of irradiated tissue by stimulating capillary growth and osteogenesis. Treatment consists of breathing 100% pressurized oxygen for approximately 90 minutes for about 20 sessions presurgery and 10 sessions postsurgery. www.indiandentalacademy.com
Albrektsson et al (in 1995) suggest that without HBO therapy, implant surgery should be delayed for 12 months after radiation. Weischer et al (in 2001) reported on a retrospective study that include follow-up of irradiated patients for 9 years and concluded that irradiation does not significantly affect osseous integration after HBO therapy though they concluded that soft tissue support should be avoided if possible, or at least minimized, due to the complications associated with poorer soft tissue healing. www.indiandentalacademy.com
ChemotherapyChemotherapy cancer treatment causes malnutrition of osseous tissue, xerostomia, and mucosal inflammation. While implant integration during active chemotherapy cannot be supported by available data, Steiner et al ( in 1998) reported on success in 1 patient who started chemotherapy 1 month after having implants placed. www.indiandentalacademy.com
Kovacs (in 2002) reported on patients who had previously received courses of 3 common chemotherapeutic agents, but no radiotherapy prior to implant placement. The author concluded that there was no clinically significant detriment to the success of implants in the mandible over the study length, which averaged 3 years per patient.
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ParafunctionParafunctional habits (clenching and bruxism) have been identified as concerns in implant treatment planning due to the increased pressure on the implants, resulting in possible metal fatigue and fracture and possible surrounding bone loss. Overload caused by either improper prosthesis design or parafunctional habits is considered one of the primary causes of late stage implant failures. www.indiandentalacademy.com
However, Engel et al, ( in 2001 ) in a study of 379 patients who had worn implant retained restorations for many years, found that increased occlusal wear, usually an indicator of the severity of a bruxism parafunction, had no effect on implant integration and did not result in an increased loss of bone around implants.
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Rather than regarding excessive occlusal forces in patients with parafunctional habits as absolute contraindications, many authors have recommended attempting to mitigate these forces. Methods suggested include Educating patients about habits and paying diligent attention to occlusal contact design, ( Mc coy in 2002 ) Placing increased number of implants ( Balsi et al in 1996 ), www.indiandentalacademy.com
Avoiding the use of cantilevers Using bruxism appliance therapy ( Perel in 1994 ) Increasing time intervals during the prosthetic restoration stages to provide more opportunity for progressive loading techniques, ( Misch 1999 ) Using acrylic resin teeth in the prosthesis ( Gracis in 1994 )
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CorticosteroidsSteroids act in 4 different ways that affect implant surgery- decrease inflammation and related post operative pain and swelling - inhibit protein synthesis and so delays wound healing - inhibits leucocytic functions thus increased chances of infections - causes adrenal suppression www.indiandentalacademy.com
Cranin ( in 1995) concluded long-term use of corticosteroids generates a systemic loss of bone mass. Fujimoto et al (1998 ) studied Osseo integrated implants in rabbits and found that systemic corticosteroids had less effect on the integration of titanium implants in the mandible than in other skeletal bones. Steiner et al ( in 2000) concluded that prolonged use of corticosteroids is not a contraindication to the placement of implants. www.indiandentalacademy.com
Dental implant managementOn basis of severity of adrenal suppression patients are classified in â&#x20AC;&#x201C; 1. Mild â&#x20AC;&#x201C;steroid therapy ended 1 year prior to surgery 2. Moderate - were on steroid therapy in preceding year to surgery 3. Severe- on steroid therapy at the time of surgery www.indiandentalacademy.com
Protocol to be followed in these patients is as followsOn the day of surgery- prednisone up to 60 mg Second day of surgery- dose is reduced to half Third and consecutive days- dose is slowly reduced down
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This regimen is necessary because due to steroidal gland suppression, body is unable to produce additional natural steroids which are essential to fight stressful conditions like implant surgery. Antibiotic follow-up by amoxycillin or clindamycin for 3-5 days
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HyperparathyroidismAdvanced stages of hyperparathyroidism show bony lesions in form of altered trabecular pattern and ground glass appearance of involved area. Implants are contraindicated if bony lesions are present in the region of implant placement.
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Fibrous dysplasiaA disorder where fibrous connective tissue replaces areas of normal bone. Implants are contraindicated in the region of disorder as lack of bone and increased fibrous tissue decreases rigid fixation of the implant.
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Pagets diseaseIt is a chronic bone disease characterized by increased osseous vascularity and osteoclastic activity in bone. Radiographically characterized by cotton wool appearance of bony lesion. Implants are contraindicated in the region of disorder. www.indiandentalacademy.com
Other diseasesThere have been case reports of the successful placement of implants in patients with a wide variety of systemic conditions that could potentially affect biologic functions, particularly healing mechanisms. These diseases include scleroderma, Sjogrenâ&#x20AC;&#x2122;s syndrome, HIV infection, multiple myeloma, chronic leukemia, pemphigus vulgaris, and hypohidrotic ectodermal dysplasia.
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TobaccoPatients who smoke have an increased risk for occurrence and severity of periodontal disease. Also, the deleterious effect of smoking on wound healing after tooth extraction is well documented. Therefore, the negative effect of tobacco use on implant success should be expected, and indeed this is established by several studies. Various cohort and clinical trials done in last decade consistently rate smoking as a primary patient centered risk factor for implant loss. www.indiandentalacademy.com
Local and systemic effects of smokingCigarette smoke has various effects on implants either locally and systemically. Local effects are regulated by cytotoxic and vasoconstrictive substances within smoke such as nicotine. Systemically it adversely affects the immunologic response and results in a disturbance of peripheral and oral neutrophill function. It also causes direct vasoconstriction, and limited production of antibodies. Krall ( in 1991) reported association of smoking with decreased calcium absorption. www.indiandentalacademy.com
Specifically, rather than affecting the process of integration, the negative effect of smoking seems to occur after second-stage surgery. Gorman et al ( in 1996) in a study of patients receiving over 2000 implants, found significantly more failures in smokers after second-stage surgery. Success in smokers was increased by use of presurgical antibiotics and HA-coated implants. www.indiandentalacademy.com
Hass et al ( in 1998 ) reported that smoking has been associated with an increased incidence of peri-implantitis. After implant uncovering, smokers tend to have faster rates of peri-implant bone loss, especially in the first year, compared with nonsmokers or patients who have stopped smoking.
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Lambert et al (in 2000) conducted a longitudinal study to assess the influence of smoking in a group of patients with over 2900 endosteal dental implants. The results showed more failures after the second stage of surgery. The authors theorized that the effect of tobacco on healing after implant placement is different from that after tooth extraction because implant wounds are closed, and the intimate adaptation of the implant to the bone tissue does not allow the same magnitude of interference in healing by the vasoconstrictive nature of nicotine www.indiandentalacademy.com
In general, smoking appears to have a greater impact for maxillary implants than for mandibular implants. De Bruyn and Collaert ( in 1996) in a retrospective study of over 200 implants, found that prior to loading, there was a difference in success rates in smokers between maxillary and mandibular implants. Maxillary success rates were adversely affected, but those in the mandible were not. Haas et al ( in 1998) found peri-implantitis significantly worse in the maxilla in smokers than in nonsmokers. www.indiandentalacademy.com
Kan et al ( in 2000 ) in a study of 60 implant patients reported the reduced success of implants placed into grafted maxillary sinuses, regardless of the amount smoked In addition, smoking is known to reduce systemic bone density, and correspondingly, there is an increased incidence of poorer bone quality. Bain and Moy ( in 1996) found that the prevalence of Type IV bone was twice as high among heavy smokers as compared with nonsmokers or even light smokers. www.indiandentalacademy.com
Lemon et al (in 1997) also reported smokers have significantly higher levels of Type IV bone Schwartz-Arad et al (2002) studied the complications of smoking in patients with implants and found a greater incidence of post operative complications in smokers. Levin et al ( in 2004) in their study including 145 onlay bone grafts and sinus lift surgeries concluded that chances of graft rejection and other surgical complications were almost double in smokers when compared to non smokers. www.indiandentalacademy.com
The protocol suggested by Bain ( in 2000 ) should be followed, which advises patients to cease smoking for a minimum of 1 week prior to and at least 8 weeks after implant surgery.
1. 2. 3.
Apart from this according to Misch sufficient healing time should be provided progressive bone loading antibiotic prophylaxis should be implemented. www.indiandentalacademy.com
The oral burn syndromeCullen ( in 1998) reported on the deleterious effects to soft tissues around implants after the ingestion of hot foods and liquids. He termed this effect the oral burn syndrome. Similar to the known harmful effect of overheating bone during the placement of implants. Cullen theorized that the amount of metal in implants hastens the transfer of heat to supporting tissue and that this is a significant factor of implant complications.
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Alcoholism and implantsBone metabolism is affected by alcohol consumption because1. It inhibits osteoblastic proliferation. 2. Resorption rate is accelerated by increased osteoclastic activity.
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Weyant et al ( in 1994) after a 5 year study of implant patients reported that abuse of alcohol was a risk factor for poor implant healing and eventual failure. Samuel et al ( in 2004) found that percentage of direct bone to implant contact is significantly less in alcoholic population than the nonalcoholic one. Karina et al ( in 2004) reported that in their animal study there was significant delay in reparative bone formation after implant placement. www.indiandentalacademy.com
The cluster phenomenonWhile none of the conditions discussed above are absolute contraindications to implant therapy, a combination of risk factors might be. Ekfeldt et al ( in 2001 ) studied a group of implant patients who had multiple implant failures, in the hope of identifying patients at risk before treatment.
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They concluded that while no one risk factor was critical, a combination of several factors such as diabetes, osteoporosis, ongoing medications, parafunctional jaw movements, and heavy smoking habits could provide a contraindication. The authors termed the occurrence of implant failures due to combination of many risk factors as ‘‘cluster phenomenon.’’
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Pharmacological considerations-
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Management of postoperative painAfter surgery pain and inflammation commonly occur, and multiple strategies both pharmacological and behavioral are essential to optimize patient comfort.
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Non opiod analgesics (NSAIDS)Arachidonic acid ( a product released in response to tissue injury ) in presence of cyclooxygenase produces a variety of biologically active factors as prostaglandins, prostacyclins, thromboxane and leucotrines. These factors along with bradykinin and histamin play a major role in initiation of inflammation. NSAIDS primarily inhibits synthesis of prostaglandins from arachidonic acid. www.indiandentalacademy.com
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NSAIDS are also used before or immediately following surgery to diminish postoperative inflammation. Agents most commonly studied are acetaminophen and ibuprofen. Aspirin can significantly alter normal hemostasis it is not used for prophylactic therapy. www.indiandentalacademy.com
Jeffcoat et al ( in 1999 ) studied the use of a 3-month course of NSAIDs for patients receiving dental implants and reported that 100 mg of flurbiprofen taken twice daily resulted in less bone loss in the immediate postloading period. The higher level of bone was maintained for the first year after initial surgery.
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Prostaglandin E2 is stimulus for bone resorption, NSAIDS which inhibit prostaglandinE2 synthesis may play a major role in implant dentistry. Investigations are under way of newer NSAIDS as flurbiprofen for use as adjunctive therapy to slow bone loss and to enhance osseointegration.
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Opiod analgesicsThere are no analgesic agents more efffective than opioids in releiving severe acute pain. Most commonly used opioids are morphine ( 10 mg IM ) and codeine (60 mg PO ).
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Management of patient with severe and moderate pain-
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Management of post operative swellingNSAIDS may be used pre operatively and postoperatively to limit postoperative swelling but these are not very effective in managing postoperative swelling. Effectiveness of glucocorticoids is well established in managing postoperative inflammation. Skjelbred and loken ( in 1998) have reported when corticosteroids were injected 3 hrs prior to oral surgeries, swelling was reduced to 47% than without use of steroids. www.indiandentalacademy.com
Factors to be considered before steroid therapyChosen steroid should have minimal mineralocorticoid effect. Should be administered before surgery, allowing ample time for drug distribution. Should be given preferbly in morning when cortisol is naturally released by the body. Post operative regimen should not exceed 3 days. Should always be administered along with antibiotic coverage. www.indiandentalacademy.com
Corticosteroid regimen for managing postoperative swelling-
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Antimicrobial agentsAntibiotics are used not only to treat existing infections but also used to prevent infection following surgeries. Routine surgical prophylaxis by antibiotics is controversial. It may be effective in some cases, but rapid emergence of antibiotic resistant bacterial strains makes it questionable to use them frequently. Leviner et al (in 1994 ) reported development of resistant streptococcus viridans after administration of prophylactic antibiotics. They concluded that it can compromise long term success of implants. www.indiandentalacademy.com
Nevertheless antibiotic prophylaxis is indicated in following conditionsImmunocompromised status of the patient Patients at the risk of developing bacterial endocarditis When lengthy surgical procedures are expected
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Suggested antibiotics for implant related infections-
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Two way approach to select antibiotics to treat implant related infections-
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Antibiotic prophylaxis to prevent endocarditis-
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Seative anxiolyticsUse of anxiolytics is a valuable adjunct during meticulous surgeries required for implant placement. Benzodiagepines are drug of choice as anxiolytics because of their greater therapeutic index. These act by inhibiting benzodiazapine receptors which potentiate generalized depressant effect of GABA. www.indiandentalacademy.com
BENZODIAZEPINES- DOSES
Diazepam- 10-20 mg PO Lorazepam- 2-4 mg PO Triazolam- 0.25-0.5 mg PO
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References
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