INDICATIONS AND CONTRAINDICATIONS OF IMPLANT SUPPORTED PROSTHESIS
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INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com
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INTRODUCTION The goal of modern dentistry is to restore the patients to normal contour, function, comfort, esthetics speech and health, regardless of the atrophy, disease or injury of the stomatognathic system. However the more teeth a patient is missing, the more arduous this goal becomes with traditional dentistry. As a result of continued research in treatment planning, implant designs, materials and techniques, predictable success of implants is now a reality for the rehabilitation for many challenging clinical situations. www.indiandentalacademy.com
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The increased need and use of implant related treatments results from the combined effect of a number of factors including, aging population tooth loss related to age anatomic consequences of edentulism poor performance of removable prostheses psycholoicgal aspects of tooth loss predictable long term results of implant supported prostheses advantages of implant supported prostheses www.indiandentalacademy.com
Research advances in dental implantology have led to the development of several different types of implants, and it is anticipated that continued research will lead to improved devices. At present, continued evaluation is necessary to determine that appropriate implant devices are available to meet the therapeutic demands of the different portions of the jawbones and the unique needs of patients. The medical evaluation remains of paramount importance in implant dentistry, perhaps more so than in other disciplines of dentistry. Implant treatment is primarily a surgical, prosthetic and maintenance discipline for a selected particular www.indiandentalacademy.com segment of the population.
Many patients who are partially or fully edentulous are better served with tissue integrated prostheses, rather than other classical forms of therapy. However not all patients can or should be considered for this procedure. The first step in the clinical protocol is a thorough medical and dental evaluation to screen out those patients who can be better served by an alternative treatment modality. Therefore a thorough understanding of the indications and contraindications of implant supported prostheses (intra oral implant) is mandatory for the success of the treatment. www.indiandentalacademy.com
INDICATIONS Generally any edentulous area can be an indication for dental implants. A decision has to be made whether it is a good idea based on the patients requirements and expectations, the amount of additional procedures required (bone grafting etc.), the doctor’s skill level and the long term prognosis. It is generally a good idea to assume that a toothless area can be considered a future implant site; however a thorough evaluation will help give better insight as to whether alternative, more conventional treatment options would bewww.indiandentalacademy.com a better choice in each individual situation.
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Some general indications for treatment are: Severe morphologic compromise of denture supporting areas that significantly undermine denture retention. Poor oral muscular coordination. Low tolerance of mucosal tissues. Parafunctional habits leading to recurrent soreness and instability of prostheses. Active or hyper active gag reflexes, elicited by a removable prosthesis. www.indiandentalacademy.com
• Psychological inability to wear a removable prosthesis even if adequate denture retention and stability is there. • Unfavorable number and location of potential abutments in a residual dentition. (Adjunctive location of optimally placed osseointegrated root analogues would allow for provision of a fixed prosthesis.) • Single tooth loss to avoid involving neighboring teeth as abutments.
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Dental implants may be broadly classified as: • ENDOSSEOUS • SUBPERIOSTEAL, • TRANSOSSEOUS These implant types are subdivided as follows: – Endosseous: – Root form. – Blade (plate) form. – Ramus frame. www.indiandentalacademy.com
Ramus frame
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– Subperiosteal: – Complete. – Unilateral. – Circumferential. – Transosseous: – Staple. – Single pin. – Multiple pin
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Indications for each implant type are specified below: • ENDOSSEOUS: root form, blade (plate) form: – Adequate bone to support the implant with width and height being the primary dimensions of concern. – Maxillary and mandibular arch locations. – Completely or partially edentulous patients.
• ENDOSSEOUS: ramus frame: – Adequate anterior bone to support the implant with width and height being the primary dimensions of concern. – Mandibular arch location. – Completely edentulous patients. www.indiandentalacademy.com
• SUBPERIOSTEAL: complete, unilateral, circumferential: – Atrophy of bone but with adequate bone to support the implant. – Maxillary and mandibular arch locations. – Completely and partially edentulous patients. – Stable bone for support.
• TRANSOSSEOUS: staple, single pin, multiple pin: – Adequate anterior bone to support the implant with width and height being the primary dimensions of concern. – Anterior mandibular arch location. – Completely and partially edentulous patients. www.indiandentalacademy.com
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For long-term successful performance of all dental implant types the following general factors should be considered: Biomaterials. Biomechanics. Dental evaluation. Medical evaluation. Surgical requirements. Healing processes. Prosthodontics. Post insertion maintenance. www.indiandentalacademy.com
With regard to indications for a specific implant type, the bone available to support the implant is the primary factor after prosthodontic diagnosis and treatment plan. This bone is measured in width, height, length, anatomical contour, and density. These physiological and anatomical factors may be altered by either osteoplasty or augmentation of the bone. In addition, other factors affecting indications for implant type are the degree and location of the edentulism of the patient. www.indiandentalacademy.com
The AMERICAN SOCIETY OF ANESTHESIOLOGY has given a classification in which patients have been categorized according to presurgical risk. • CLASS 1: patient is physiologically normal, no medical diseases, lives a normal lifestyle. • CLASS 2: patient has some type of medical disorder but the disorder is controlled with various medications. Patient can thus engage in normal activity. • CLASS 3: patient who has multiple medical problems with impaired normal activity. • CLASS 4: advanced stage of disease, serious medical condition requiring immediate attention. • CLASS 5: patient usually is suffering from a fatal disease, is in the terminal end of the disease and will not survive the next 24 hours. www.indiandentalacademy.com
CONTRAINDICATIONS AND THEIR MANAGEMENT Systemic screening of a patient prior to implant or/biomaterial insertion is critical to a patient’s well being and success of the surgical procedure. It is no longer appropriate to limit the general contraindications to the malfunction of major organs and systems and not consider the devastating long term effects of an unhealthy lifestyle (smoking, inadequate diet etc.). However, modern standards of care should not systemically exclude patients with relative or marginal health conditions without exploring the possibilities of improving and stabilizing those conditions. Based on the classification of American Society of Anesthesiology, a number of absolute and relative contraindications have been ascertained. (Chanavaz M, 1999) www.indiandentalacademy.com
These conditions relate to health conditions that have the potential to jeopardize the patient’s overall health. Elective dental procedures are rarely indicated for these patients. However, some of the problems are self limiting or treatable, so elective surgery may be a realistic possibility in future. Thus even an absolute contraindication may become relative over a period of time. Treatments are proposed for optimizing some marginal health conditions and stabilizing unbalanced physiological function prior to surgery. Knowledge of the fundamentals of internal medicine is an important prerequisite for predictable implant and preprosthetic surgery. www.indiandentalacademy.com
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Standards of dental practice would suggest the following general contraindications for the above three categories of dental implants: Debilitating or uncontrolled disease. Pregnancy. Lack of adequate training of practitioner. Conditions, diseases, or treatment that severely compromise healing, e.g., including radiation therapy. Poor patient motivation. Psychiatric disorders that interfere with patient understanding and compliance with necessary procedures. Unrealistic patient expectations. Unattainable prosthodontic reconstruction. Inability of patient to manage oral hygiene. Patient hypersensitivity to specific components of the www.indiandentalacademy.com implant.
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DENTAL TREATMENTS CAN BE CLASSIFIED AS: TYPE 1: Examinations, radiographs, model impressions, oral hygiene, instruction, supragingival prophylaxis, simple restorative dentistry. TYPE 2: Scaling, root planning, endodontics, simple extractions, curettage, simple gingivectomy, advanced restorative procedures, simple implants. TYPE 3: Multiple extractions, gingivectomy, quadrant periosteal reflections, impacted extractions, apicectomy, plate form implants, multiple root forms, ridge augmentation, unilateral sius grafts, and unilateral subperiosteal implants. TYPE 4: Full arch implant (complete Subperiosteal implants, ramus frame implants, full arch endosteal implants), orthognathic surgery, autogenous bone augmentation, bilateral www.indiandentalacademy.com sinus graft.
ENDOCRINE DISORDERS • UNCONTROLLED DIABETES MELLITUS: This refers to confirmed severe diabetes which does not respond to treatment. The major symptoms are polyuria, polyphagia, polydypsia and weight loss. Diabetes patients are prone to develop infections and vascular complications. The healing process is affected by impaired vascular function, chemotaxis, impaired neutrophil function and an anaerobic milieu. Protein metabolism is decreased and healing of soft and hard tissue is delayed. Nerve regeneration is also altered and angiogenesis impaired. Such patients are pre-disposed to tissue degeneration and compromised healing with increased risk of infection. www.indiandentalacademy.com
The implant dentist will confirm or discover diabetes by the presence of glucose levels above 120 mg/dl. of these patients 90%have adult onset diabetes mellitus, which develops after age 40 and is common in adults over 55. About 80%of non-insulin dependent diabetes mellitus are overweight. All diabetic patients are subject to a greater incidence and severity of periodontal disease, dental caries due to xerostomia, candidiasis, burning mouth syndrome and lichenoid reactions. Approximately 75%of these patients suffer from periodontal disease and exhibit increased alveolar bone loss and inflammatory gingival changes. Tissue abrasions are more likely in denture wearers because the depletion in oxygen tension decreases the rate of epithelial growth and decreases tissue thickness. www.indiandentalacademy.com
DENTAL IMPLANT MANAGEMENT • The most serious complication for diabetic patients during dental procedure sis hypoglycemia, which usually occurs as a result of excessive insulin level, hypoglycemic drugs or inadequate food intake. Weakness, nervousness, tremor, palpitations and/or sweating are all signs of hypoglycemia. If the symptoms are not addressed, they may evolve from confusion and agitation to seizure, coma and even death. • The stress of surgery may provoke the release of counter regulatory hormones that will impair insulin regulation and may result in hyperglycemia and a catabolic state. A careful planning for post operative food and medication intake is needed to ensure the patient’s welfare. www.indiandentalacademy.com
Patients at low risk of complications related to diabetes are those who are asymptomatic and have good metabolic control. Their blood glucose levels are less than 150 mg/dl (average 100mg/dl).these patients may be treated with a normal protocol for all nonsurgical appointments(type1). For surgical procedures these patients need a little more care and attention. Need for a stress reduction protocol, diet evaluation before and after surgery and control of the risk of infection are all addressed. Sedative procedures and antibiotics are often used for implant or advanced surgical procedures (type 3 or 4). Insulin therapy is adjusted to half the dose in the morning of the surgery if oral intake is expected to be compromised. Oral medications can be discontinued for the day if the patient has taken morning dose on the day of the www.indiandentalacademy.com surgery.
Patients at moderate risk show periodic manifestations of the disease but are in metabolic balance because few complications of diabetes are present. Their blood glucose levels are below 200mg/dl. Diet control, stress reduction protocol, aseptic techniques and antibiotics are more important for these individuals than for those in the low risk group. Most non-surgical procedures can follow a normal protocol (type 1). Oral or intravenous sedation should be considered for many surgical or restorative types 2 procedures. Corticosteroids, often used to decrease edema, swelling and pain may not be used in the diabetic patient because they adversely affect blood glucose levels. Medical consultation should precede moderate or advanced surgical procedures (type 3 or 4). Insulin dosage is often altered. Sedative techniques and hospitalization should be considered for advanced surgical procedures (type 4). www.indiandentalacademy.com
Patients at high risk report a history of frequent hypoglycemia and show multiple complications of diabetes. Their fasting blood sugar fluctuates widely, often exceeding 250 mg/dl. These patients can follow type 1 procedures only when a conscious effort is made to decrease stress. All other procedures whether non-surgical or surgical require medical consultation. Any treatment should be deferred until the medical condition is stabilized. www.indiandentalacademy.com
THYROID DISORDERS: • Second most common endocrine problem affecting approximately 1% of the population, particularly women. • Excessive production of Thyroxine ( hormone of the thyroid gland) results in hyperthyroidism. Symptoms of this disorder include increased pulse rate, nervousness, intolerance to heat, excessive sweating, weakness of muscles, diarrhea, increased appetite, increased metabolism and weight loss. excessive thyroxine may also cause atrial fibrillation, www.indiandentalacademy.com angina and congestive heart failure.
An insufficient production of thyroxine produces hypothyroidism. The related symptoms are a result of decreased metabolic rate. The patient complains of cold intolerance, weight gain and fatigue. Eventually hoarseness of voice and decreased mental activity occurs which may even lead to coma if left untreated. Thyroid function tests are used to confirm the diagnosis of hypothyroidism. DENTAL IMPLANT MANAGEMENT • Patients with hyperthyroidism are especially sensitive to epinephrine used in local anesthetics and gingival retraction cords. When exposed to such catecholamines is coupled with stress (often related to dental procedure) and tissue damage (dental implant surgery), an exacerbation of the symptoms of hyperthyroidism may occur. The result is termed thyrotoxicosis or thyroid storm and this is a life threatening condition. www.indiandentalacademy.com
• The hypothyroid patient is particularly sensitive to CNS depressant drugs, especially narcotics and sedatives drugs like diazepam and barbiturates. The risk of respiratory depression and/or cardiovascular depression must be considered. • Any patient with a thyroid disorder and a medical examination in the preceding 6 months who reports normal thyroid function and has no symptoms of the disease is at low risk and a normal protocol can be followed for all dental implant surgery and restorative appointments (type 1 – 4). www.indiandentalacademy.com
• The thyroid disorder patient who has no symptoms related to thyroid disorders, but has not had a physical or thyroid function test recently, is placed in the moderate risk category. The patient may follow a normal protocol for type 1 procedures. For any further treatment the physician needs to be consulted. • A symptomatic patient is at high risk regardless of when the last medical evaluation was performed. All treatment is deferred until a medical and laboratory evaluation confirms control of the disorder. www.indiandentalacademy.com
ADRENAL GLAND DISORDERS: • Epinephrine, nor epinephrine (adrenal medulla), glucocorticoids, mineralocorticoids and sex steroids (adrenal cortex) are the major hormones of the adrenal gland. • Addison’s disease corresponds to a decrease in adrenal function. • Cushing’syndrome results from hyper functioning of the gland.
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DENTAL IMPLANT MANAGENENT • Patients with a history of adrenal gland disease, whether hyperfunctioning or hypofunctioning, face similar problems related to dentistry and stress. The body is unable to produce increased levels of steroids during stressful situations and cardiovascular collapse may occur. Therefore for patients with known adrenal disorders the physician should be consulted before any implant related treatment. The nature of the disorder and the recommended treatment should then be evaluated. • Steroids act in three different ways that affect implant surgery. They decrease inflammation and are useful in decreasing swelling related pain. However, steroids also decrease protein synthesis, delay healing, also decrease leucocytes and thereby reduce the patient’s www.indiandentalacademy.com ability to fight infection.
SEVERE HORMONE DEFICIENCY: • This refers to patients with disorders affecting more than two different hormone families. The endocrine organs most often affected are the thyroid, parathyroid, pancreas, suprarenals prostrate and hypophysis.
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CARDIOVASCULAR DISEASES RECENT MYOCARDIAL INFARCTION(MI): MI is a prolonged ischemia or lack of oxygen that causes injury to the heart. The patient usually has severe chest pain in the sub sternal or left precordial area during an MI episode. It may radiate to the left arm or mandible. Cyanosis, cold sweat, weakness, nausea, vomiting and irregular and increased pulse rates are all signs of MI. The complications of MI include arrhythmias and congestive heart failure. Any history of MI indicates significant problems in the coronary vessels. Recent infarctions correspond to higher morbidity and www.indiandentalacademy.com death rates with even simple elective surgery.
• Approximately 18 – 20% of patients with a recent history of MI will have complications of recurrent MI, with a high mortality rate of 40 – 70%. • If surgery is done within 3 months of MI, the risk of another MI is 30%. • If within 3 – 6 months, it is 15%. • After 12 months the incidence of recurrent MI stabilizes at about 5%.
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DENTAL IMPLANT MANAGEMENT: • Contemporary cardiology, including non-surgical intervention procedures has greatly improved the care and treatment of patients suffering from MI. this has led to a much reduced use of patent anti-coagulants on a permanent basis, while the cardio-vaso protectors, beta-blockers, hypotensive drugs and mild anti-coagulants are used extensively. A stable condition for these patients is usually reached 6 – 12 months after initial care and treatment. However, it is important to avoid any surgical stress which could trigger uncontrolled vasoconstriction with tachycardia and arrhythmia, until the patient is stabilized for at least 6 – 12 months. Further more, if anti-coagulants are prescribed, their interruption in the early stages of the disease may also prove extremely risky. www.indiandentalacademy.com
• The dental evaluation should include the dates of all episodes of MI, especially the latest, and any complications. Medical consultation should preclude any extensive restorative or surgical procedure. • Patients with a MI in the preceding 6 months may have dental examinations (type 1) without any special protocol. Any treatment should be postponed for 6 months. • Patients who experienced MI 6 – 12 months preceding consultation may have examination, non-surgical procedures and simple emergency surgical procedures performed after medical consultation. Longer procedures should be segmented into several shorter appointments whenever possible. Stress reduction protocol is always indicated. Elective implant procedures should be postponed for at least 12 months following MI. • Elective hospitalization is an accepted modality for all advanced surgical procedures, regardless of the time elapsed after a MI; (itwww.indiandentalacademy.com is mandatory if general anesthesia is
CONGESTIVE HEART FAILURE(CHF): • CHF is a chronic heart condition in which the heart is failing as a pump. Symptoms include, abnormal tiredness, shortness of breath, wheezing, edema of legs and ankle, frequent urination, nocturnal dyspnea, weight gain, orthopnea, pulmonary edema etc.
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SUB ACUTE BACTERIAL ENDOCARDITIS/VALVULAR HEART DISEASE Bacterial endocarditis is an infection of the heart valves or endothelial surfaces of the heart. It is the result of growth of bacteria on damaged/altered cardiac surfaces. The microorganisms most often associated with endocarditis following dental treatment are ÎŹ-hemolytic streptococcus viridans and less frequently staphylococci and anaerobes. The disorder is serious with a mortality rate of 10%. Dental procedures causing transient bacteremia are a major cause of bacterial endocarditis. As a result the implant dentist should identify the patient at risk and implement prophylactic procedures. www.indiandentalacademy.com
• The risk of bacterial endocarditis increases with the amount of intra oral soft tissue trauma. • A correlation exists between the incidence of endocarditis and the number of teeth extracted or the degree of a pre existing inflammatory disease in the mouth. A 6 times higher incidence of bacteremia is found in patients with severe periodontal disease. • Endocarditis has also been reported to occur in an edentulous patient with denture sores.
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VALVULAR PROSTHESES: • The onset of bacteremia in patients fitted with valvular prostheses constitutes a major threat to the longevity of the cardiac valve. The oral cavity has been traditionally recognized as the principal gateway to such infections. It is therefore important to avoid dental surgery or invasive periodontal procedures in until a stable condition is achieved, usually 15 – 18 months after cardiac surgery. According to the type of valve the patient may be on potent anti-coagulants (for metallic valves) and mild plasma volume elevators (for porcine valves). Any planned procedure must take into consideration the occurrence of the surgical stress, anti-coagulant imbalance and infection risk. www.indiandentalacademy.com
DENTAL IMPLANT MANAGEMENT: • The implant dentist must be familiar with the antibiotic regimens for heart conditions requiring prophylaxis. A similar regimen is required for any person requiring antibiotic coverage. • In some patients implant therapy is contraindicated because of high risk for endocarditis like, patients with previous history of endocarditis, prosthetic heart valve, surgical systemic pulmonary shunt, rheumatic valvular defect, congenital heart disease, acquired valvular disease, intravascular prostheses and coarctation of aorta. Edentulous patients restored with implants must contend with transient bacteremia from chewing, brushing or peri-implant disease. www.indiandentalacademy.com
As a result implant may be contraindicated in patients with limited oral hygiene potential and those with a history of stroke. In addition intramucosal inserts may be contraindicated for many of these patients because a slight bleeding can occur on a routine basis for several weeks during the initial healing process. Endosseous implants with an adequate width of attached gingival are the implants of choice for patients in this group who need implant supported prostheses. www.indiandentalacademy.com
HYPERTENSION: A patient is classified as hypertensive when the mean value after three or more blood pressure readings taken at three or more medical visits reveals a resting arterial systolic blood pressure at or above 140mm Hg and/or mean diastolic blood pressure at or above 90mm Hg. Hypertension is usually asymptomatic and is the major risk factor for coronary heart disease and cerebro-vascular accidents leading to cardiovascular morbidity and mortality for people more than 50 years of age. www.indiandentalacademy.com
In hypertensive patients 90% have essential or idiopathic hypertension. The medical history should focus on predisposing factors such as excessive alcohol intake, history of renal disease, stroke, other cardiovascular diseases, diabetes, obesity and smoking. Essential hypertension is treated with medications, many of which have an impact on implant therapy because of their numerous side effects. These include orthostatic hypotension, dehydration, sedation, and xerostomia, gingival hyperplasia around teeth and implants and depression. The side effects may alter treatment or require special precautions. www.indiandentalacademy.com
DENTAL IMPLANT MANAGEMENT: • Anxiety greatly affects the blood pressure. Therefore a stress reducing protocol is indicated for the hypertensive patient. Premedication may be indicated before the procedure. Monitoring of the blood pressure is recommended for all patients, especially if the patient is diagnosed with hypertension. Patients in the normal and high normal (140-159/90-99 mmHg) range with no other systemic disease may follow regular treatment and can tolerate all non-surgical and single implant surgical type 1 and type 2 procedures. • However, patients in the range of 180-209/110119mm Hg (stage 3) or 210/120mm Hg or greater (stage 4) can follow only emergent non-stressful procedures therapy (type 1) and should be immediately referred to a physician. www.indiandentalacademy.com
ANGINA PECTORIS:
Angina pectoris or chest pain or cramp of the cardiac muscle is a form of coronary heart disease. The classical symptom of retrosternal pain often develops during stress or physical exertion, radiates to the shoulder, left arm or mandible, or right arm, neck, palate, tongue, these symptoms are relieved by rest. www.indiandentalacademy.com
DENTAL IMPLANT MANAGEMENT The major concern of the dentist is the precipitation and/or management of the actual attack. Precipitating factors can be exertion, cold, heat, large meals, humidity, psychological stress and dental related stress. All these factors cause catecholamines release which in turn increases heart rate, blood pressure and myocardial oxygen demand. However, the physician must be consulted before any surgical procedures in a patient with history of angina. www.indiandentalacademy.com
BONE DISEASES OSTEOPOROSIS The most common disease of bone metabolism the implant dentist will encounter is osteoporosis, an age related disorder characterized by a decrease in bone mass, increased microarchitectural deterioration and susceptibility to fractures. This condition is common in post menopausal women. The osteoporotic changes in the jaws are similar to other bones in the body. The structure of the bone is normal, however, due to the uncoupling of the bone resorption/formation process with emphasis on resorption, the cortical plates become thinner, the trabecular bone pattern more discrete and advanced demineralization occurs. Oral bone loss related to osteoporosis may be expressed in both dentate and edentulous patients. Recent advances in radiology such as DXA can measure as little as 1 mg of bone mass change and can therefore www.indiandentalacademy.com predict high risk cases.
DENTAL IMPLANT MANAGENENT • The bone density affects the treatment plan, surgical approach, length of healing and the nature of progressive loading. Implant designs should be greater in width and coated with hydroxyapatite to increase bone contact and density.
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• VITAMIN D DISORDERS: • Vitamin D is synthesized by the body in several steps involving the skin, liver, kidney and intestine. Its deficiency leads to osteomalacia in adults. Oral symptoms include a decrease in trabecular bone, indistinct lamina dura and an increase in chronic periodontal disease. • HYPERPARATHYROIDISM: • Oral changes occur with the advanced state of this disease. Loss of lamina dura, loosening of teeth, altered trabecular bony pattern are some of the features of this disorder. It has been noted that when skeletal depletion occurs as a result of stimulation by the parathyroid gland, alveolar bone may be affected www.indiandentalacademy.com before that of the rib.
• FIBROUS DYSPLASIA: • A disorder in which fibrous connective tissue replaces areas of normal bone. It is found twice more commonly in women than men and may affect a single bone or multiple bones, twice more commonly in the maxilla than mandible. Implant dentistry is contraindicated in the regions of this disorder. • PAGET’S DISEASE: • A slowly progressive chronic bone disorder where both osteoblasts and osteoclasts are involved, but osteoblastic activity is more predominant. The maxilla is more often involved than the mandible. Oral implants are contraindicated in the regions affected by www.indiandentalacademy.com this disorder.
• MULTIPLE MYELOMA: • Plasma cell neoplasm originating in the bone marrow. Usually seen in patients between 40 – 70 years of age. Pathologic fractures may occur. Paresthesia, swelling, tooth mobility and gingival enlargements are also seen. Implants are contraindicated in these patients.
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• SEVERE RENAL DISORDER: • Etiology may be repetitive kidney infections (nephritis), malignant or voluminous benign tumors (or multiple cystic kidneys), uncontrolled diabetes, and/or complications arising from kidney stones. Damage to the nephrons may lead to bone destruction via calciuria and loss of production of 1,25-DHCC. In fact the lack of reabsorption of calcium together with the malfunction of PTH could rapidly lead to metabolic osteopenia and retention of plasma endotoxins with major infection risks. Excessive use of common analgesics may also contribute to kidney failure. www.indiandentalacademy.com
• HEAVY SMOKING HABITS: • Smoking more than 20 cigarettes a day is an absolute contraindication. The deleterious effects of tobacco use (smoking or chewing) have been well documented over the last decade. A definite correlation has been established between smoking and poorer levels of periodontal conditions. Tobacco smoke decreases PMNs activity leading to reduced phagocytic activity. Smoking is also associated with decreased calcium absorption. A reduced mineral content in the bone of aging smokers and to a greater degree in post menopausal women. www.indiandentalacademy.com
• DENTAL IMPLANT MANAGEMENT • When incision line opening after surgery occurs, smokers will delay the secondary healing, contaminate a bone graft and contribute to early bone loss during initial healing. Therefore a cautious approach is recommended. Doctors must inform their patients that smoking will have a detrimental effect on their treatment and therefore should advise them to start a cessation program for successful prognosis of the treatment. Excessive smoking remains an absolute contraindication for the long term success of dental implant systems. www.indiandentalacademy.com
• CHRONIC OR SEVERE ALCOHOLISM: • This problem frequently leads to liver disorder, cirrhosis and medullary aplasia with a cascade of possible complications like platelet disorder, distress infarction, aneurysm and risk of insidious hemorrhage. Such patients often present retarded healing aggravated by malnutrition, psychological disorder, inadequate hygiene and major infection risk. Alcoholics frequently suffer from osteopenia. • DRUG ADDICTION: • Most patients with drug addictions have a low resistance to disease, predisposition to infection, malnutrition, psychological disorders and inadequate hygiene. www.indiandentalacademy.com
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COPD. CIRRHOSIS. PREGNANCY: Implant surgery procedures are contraindicated for the pregnant patient. The radiographs or medications that may be needed for implant therapy and the increased stress are all reasons the elective implant surgical procedure should be postponed till after childbirth. Periodontal disease is often exacerbated during pregnancy. All elective dental care with the exception of dental prophylaxis should be deferred until after childbirth. www.indiandentalacademy.com
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HEMATOLOGIC DISEASES: Polycythemia. Anemia. Leucocytic disorders. RADIATION THERAPY IN PROGRESS: Disruption of defense mechanisms, compromised Endosseous vascular system, inhibition of osteoinduction and localized loss of osseous vitality are the main insults to the body while the patient undergoes radiation therapy. With regard to bone, the osteogenic potential of the periosteum is most severely affected. All these conditions can severely limit the prognosis for reconstructive dental procedures. Such patients may be subject to osteoradionecrosis and should be treated with caution www.indiandentalacademy.com only after the dentist consults the radiotherapist.
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Aids and seropositive patients Prolonged use of corticosteroids Disorders of phosphocalcic metabolism Bucco-pharyngeal tumors Chemotherapy in progress Hepato-pancreatic disorder Multiple endocrine disorder Psychological disorders, psychoses Unhealthy lifestyle Lack of understanding and motivation Unrealistic treatment plan Blood dyscrasias Regular intake of corticosteroids or immunosuppressive drugs www.indiandentalacademy.com
• PATIENT’S CURRENT CONDITION: • Before beginning any implant restorations in the partially edentulous case, the dentist must thoroughly evaluate the patient’s current dental condition. Frequently the patients present with overerupted and/or tipped teeth and inadequate vertical dimensions, all of which lead to an unacceptable occlusal plane. Treatment can be complicated by the degree of malocclusion, severe caries, periapical lesions (any infection, abscess, cysts) or periodontal disease. These conditions require treatment before or in conjunction with implant therapy to maximize long term success by eliminating inflammatory disease and unfavorable excessive occlusal forces. • Existing residual bone, proximity of the adjacent teeth and the opposing dentition must be evaluated. (The optimal dimensions of the available bone for root form implant placementwww.indiandentalacademy.com are: 5mm in width, 13-15mm in height and 5mm in length.)
SUMMARY Systemic diseases have a broad effect. They may be categorized as mild, moderate and severe. Implant therapy also offers a broad range of treatments. Patients with mild diseases may follow any type of treatment. A stress reduction protocol is suggested for advanced treatment. Patients with moderate disease usually require more monitoring. Hospital assistance is usually required for the more advanced procedures. Several diseases generally contraindicate implant therapy. www.indiandentalacademy.com
REVIEW OF LITERATURE • In 1984, Mc Elroy TH, did a study on oral considerations of infection in patients undergoing chemotherapy for cancer. He concluded that because of the various factors associated with the disease process and its treatment, the patient receiving chemotherapy for cancer was highly susceptible to infection, and infection accounts for approximately 70% of patient fatalities. When potential sources of infection were considered in the patient receiving chemotherapy for cancer, the mouth provided ideal conditions for microbial growth, particularly in the debilitated patient, and was a portal of entry for contamination of the lungs, the digestive tract, and the circulatory system. These patients were more susceptible to oral infection because of alteration of oral flora towards greater pathogenicity and impairment of host-defense mechanisms. Oral/dental management of the patient receiving chemotherapy for cancer will enhance the general health and comfort of the patient and will prevent or reduce oral complications including mucositis and local and systemic infection. www.indiandentalacademy.com
In 1992, Karr RA, Kramer DC, Toth BB, did a study on implants and chemotherapy complications. He concluded that the cancer patient receiving chemotherapy often suffers severe oral complications related to the administration of antineoplastic drugs. Cancer patients who also have transmucosal or endosseous dental implants pose special problems for medical oncologists and dentists, both when planning for chemotherapy and when providing supportive care during the course of treatment. The relationship between dental implants and cancer chemotherapy was described and complications experienced by implant patients treated with chemotherapy at The University of Texas M.D. Anderson Cancer Center were reviewed. Recommendations on various aspects of management involving implant evaluation and the removal or retention of dental implants were evaluated. www.indiandentalacademy.com
• In 1994, Wicks RA, did a study on a systematic approach to definitive planning for osseointegrated implants. He said that thoughtful design selection is crucial for the perpetual success of any dental implant restoration. He reviewed treatment considerations specific to the postsurgical presentation of the implant patient and said that deviations from the originally planned design may be necessary at that stage. • In 1995, Steiner M, Windchy A, Gould AR, Kushner GM, Weber R, conducted a study on the effects of chemotherapy on patients with dental implants. Endosseous implant placement is generally considered to be contra-indicated in patients undergoing chemotherapy for the treatment of cancer. He presented a case where a patient was diagnosed with cancer and began chemotherapy four weeks after endosseous implants were placed. The impact of chemotherapeutic agents on endosseous implant acceptance as wellwww.indiandentalacademy.com as upon oral tissue was examined.
In 1998, Blanchaert RH, conducted a study on implants in the medically challenged people. He said, proper patient selection and careful technique will always be the marks of quality implant dentistry providers and described the implications for therapy, of existing systemic disease or systemic therapies. All health care delivery provided by dental practitioners must take into account, always and foremost, the patient. Careful patient evaluation is critical. Patients' physicians may not fully appreciate the physiologic ramifications of the complex and sometimes lengthy appointments required in performing implant procedures. The final decisions regarding the prescription of therapy rests with the dentist. Through increased knowledge of the pathophysiology of diabetes mellitus, disorders of bone metabolism, radiotherapy, and chemotherapy, improved patient selection and perioperative management can benefit the dental implant www.indiandentalacademy.com team.
In 1999, Crews KM, Cobb GW, Seago D, Williams N, conducted a study on tobacco and dental implants. Dental implants are the ideal standard of care for many oral health care providers. They concluded, tobacco use is an impediment to the success of this sophisticated procedure. Dentists who are trained to help their patients stop using tobacco are in position to improve their success rates with dental implants. A suggested protocol for tobacco cessation in the implant practice, if utilized, could raise the standard of health care in the dental office. www.indiandentalacademy.com
In 2000, Lambert PM, Morris HF, Ochi S, did a study on the influence of smoking on a 3-year clinical success of osseointegrated implants. Health risks associated with smoking have been exhaustively documented and include increased incidence of periodontal disease, greater risk of osteitis following oral surgery, and compromised wound healing due to hypoxia. Information related directly to dental implants, although limited, points to higher rates of implant failures among smokers than non-smokers. They studied long-term clinical outcomes of osseointegrated dental implants placed in smokers and non-smokers in a longitudinal clinical study of endosseous dental implants smokers than non-smokers. They suggested that increased implant failures in smokers were not only the result of poor healing or osseointegration, but also of exposure of peri-implant tissues to tobacco smoke. Data also suggest that detrimental effects may be reduced by: 1) cessation of smoking; 2) the use of preoperative antibiotics; and 3) the use of HA-coated implants. www.indiandentalacademy.com
In 2002, Abdulwassie H, Dhanrajani PJ conducted a clinical study on diabetes mellitus and dental implants. They concluded, Diabetes mellitus is no longer considered to be a contraindication for implant-supported prostheses, provided that the patient's blood sugar was under control, and that there was motivation for oral hygiene procedures. They presented the experiences of treating diabetic patients using implants with good success rates. www.indiandentalacademy.com
In 2002, Sugerman PB, Barber MT, did a study on oral and systemic considerations in patients selection for endosseous dental implants. He reviewed and discusses patient selection for endosseous dental implants and the effect of systemic and local pathology on the success rate of dental implants. Endosseous dental implants may be preferable to conventional dentures in patients with compromised supporting bone or mucosa, xerostomia, allergy to denture materials, severe gag reflex, susceptibility to candidiasis, diseases affecting orofacial motor function or in patients who demand optimal bite force, esthetics, and phonetics. Conventional dentures or fixed partial prostheses may be preferable to endosseous dental implants in growing and epileptic patients and patients at risk of oral carcinoma, anaphylaxis, severe hemorrhage, steroid crisis, endocarditis, osteoradionecrosis, myocardial infarction, or peri-implantitis. He outlined a systematic approach to dental implant patient selection and recommended a centralized reporting of dental implant outcome. www.indiandentalacademy.com
In 2002, Farzad P, Andersson L, Nyberg J, did a study on dental implant treatment in diabetic patients. The purpose of their study was to investigate how many diabetic patients and types of cases that were treated with dental implants in their clinic and to assess the outcome of such treatment. Medical records from 782 patients were examined in patients treated by the Branemark method for partial or total edentulism with implant supported bridges. From these records, 25 patients (3.2%) with diabetes before implant treatment (136 implants) were identified and further studied with respect to age, gender, type of diabetes, treated jaw, degree of edentulism, bone graft, implant survival, periimplant inflammation, bleeding on probing, and radiographic bone loss. Furthermore, the patients' opinion about the outcome of the treatment was registered. The implant success rate was 96.3% during the healing period and 94.1% 1 year after surgery.www.indiandentalacademy.com
Of all 38 bridges, one was lost. Few complications occurred and all patients, except for one, were satisfied with the treatment. Today, diabetic patients are being treated successfully for all types of edentulism, including bone-grafting treatment. Diabetics that undergo dental implant treatment do not encounter a higher failure rate than the normal population, if the diabetics' plasma glucose level is normal or close to normal as assessed by personal interviews. www.indiandentalacademy.com
In 2002, Attard NJ, Zarb GA, conducted a study on medically treated hypothyroid patients. Their purpose was to investigate the success outcomes of implants and prosthodontic treatment placed in patients with a previous history of hypothyroidism that was being controlled with medications. Twenty-seven female patients with a medically confirmed history of primary hypothyroid disease who were on replacement medications at the time of implant surgery were selected as the study group. Additional factors studied were medical history, medications, smoking habits, and bone quality and quantity. They suggested that medically controlled hypothyroid female patients treated with dental implants are not at higher risk of implant failure when compared with matched controls, and that a history of controlled hypothyroidism does not appear to be a contraindication for implant therapy with endosseous implants. www.indiandentalacademy.com
In 2003, Beikler T, Flemmig TF, conducted a study on implants in the medically compromised patients. Dental clinicians are confronted with an increasing number of medically compromised patients who require implant surgery for their oral rehabilitation. However, there are only few guidelines on dental implant therapy in this patient category and thus numerous issues regarding pre- and post-operative management remain unclear to the dental clinician. They presented the current knowledge regarding the influence of the most common systemic and local diseases on the outcome of dental implant therapy, e.g., abnormalities in bone metabolism, diabetes mellitus, xerostomia, and ectodermal dysplasias. Specific pathophysiologic aspects of the above-mentioned diseases as well as their potential implications for implant success were critically appraised. In line with these implications, guidelines for pre- and post-operative management that may assist in the successful implantsupported rehabilitation of this patient category were proposed. www.indiandentalacademy.com
In 2004, Penarrocha M, Palomar M, Sanchis JM, Guarinos J, Balaguer J, conducted a radiologic study of marginal bone loss around 108 dental implants and its relationship to smoking, implant location, and morphology. The concluded, conventional periapical films and digital radiographs were more accurate than orthopantomography in the assessment of peri-implant bone loss. Smoking and implant location in the maxilla were associated with increased peri-implant marginal bone resorption. www.indiandentalacademy.com
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REFERENCES Contemporary implant dentistry-Carl E. Misch Dental implants, the art and science-Charles A. Babbush Practical implant dentistry- Arun K. Garg The branemark system of oral reconstruction- Richard A. Rasmussen Sugerman PB, Barber MT, Patient selection for endosseous dental implants: oral and systemic considerations, Int J Oral Maxillofac Implants. 2002 Mar-Apr;17(2):191-201. Chanavaz M, Patient screening and medical evaluation for implant and preprosthetic surgery, J Oral Implantol. 1998;24(4):222-9. Beikler T, Flemmig TF, Implants in the medically compromised patient, Crit Rev Oral Biol Med. 2003;14(4):305-16. Chanavaz M, Screening and medical evaluation of adults: contraindications for invasive dental procedures, J Indiana Dent Assoc. 1999 Fall;78(3):10-7. www.indiandentalacademy.com
• Blanchaert RH, Implants in the medically challenged patient, Dent Clin North Am. 1998 Jan;42(1):35-45. • Karr RA, Kramer DC, Toth BB, Dental implants and chemotherapy complications, J Prosthet Dent. 1992 May;67(5):683-7. • Wicks RA, A systematic approach to definitive planning for osseointegrated implant prostheses, J Prosthodont. 1994 Dec;3(4):237-42. • McElroy TH, Infection in the patient receiving chemotherapy for cancer: oral considerations, J Am Dent Assoc. 1984 Sep;109(3):454-6. • Farzad P, Andersson L, Nyberg J, Dental implant treatment in diabetic patients, Implant Dent. 2002;11(3):262-7. • Crews KM, Cobb GW, Seago D, Williams N, Tobacco and dental implants, Gen Dent. 1999 Sep-Oct;47(5):484-8. • Lambert PM, Morris HF, Ochi S, The influence of smoking on 3-year clinical success of osseointegrated dental implants, Ann Periodontol. 2000 Dec;5(1):79-89. www.indiandentalacademy.com
• Steiner M, Windchy A, Gould AR, Kushner GM, Weber R, Effects of chemotherapy in patients with dental implants, J Oral Implantol. 1995;21(2):142-7. • Abdulwassie H, Dhanrajani PJ, Diabetes mellitus and dental implants: a clinical study, Implant Dent. 2002;11(1):83-6. • Attard NJ, Zarb GA, A study of dental implants in medically treated hypothyroid patients, Clin Implant Dent Relat Res. 2002;4(4):220-31. • Penarrocha M, Palomar M, Sanchis JM, Guarinos J, Balaguer J, Radiologic study of marginal bone loss around 108 dental implants and its relationship to smoking, implant location, and morphology, Int J Oral Maxillofac Implants. 2004 Nov-Dec;19(6):861-7.
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