Diagnosis and treatment planning /fixed orthodontic courses by IDA

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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats. Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics, Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call 0091-9248678078


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Diagnosis and treatment planning in implants. – part 1 :

Diagnosis and treatment planning in implants. – part 1 INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com

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www.indiandentalacademy.com 2 HISTORY CLINCAL EXAMINATION Diagnostic imaging Mounted study casts. Joint assessment Surgeon/restortive dentist. Treatment plan Informed consent Medical assessment Psychological assessment


www.indiandentalacademy.com 3 History. It is designed to provide an accurate profile of how the patient’s quality of life is being affected by tooth loss. It consists of 3 elements Dental Social/personal medical


www.indiandentalacademy.com 4 Dental It should include identification of all current problme’s from the patients perspective. Functional Unstable or loose denture Inability to masticate efficiently Pain TMJ disorders Difficulties with speech Gagging Ulceration and soreness of mucosa

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www.indiandentalacademy.com 5 Psychological and social. Loss of self esteem and confidence Feelings of guilt and insecurity Poor interpersonal relationships Social avoidance Lack of motivation. Aesthetic Loss of labial fullness Decreased vertical dimension. Unrealistic Aging process Paranoid delusions. Not associated Burning tongue due to candida infection

Social /personal:

www.indiandentalacademy.com 6 Social /personal The impact and relevance of the dental condition to the patient’s lifestyle should be explored. Wind instrument musicians Singers Actores may have particular problems Absolute need for a fixed appliance.

Medical :

www.indiandentalacademy.com 7 Medical A full and comprehensive review of a patients medical history should be undertaken.

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www.indiandentalacademy.com 8 HISTORY CLINCAL EXAMINATION Diagnostic imaging Mounted study casts. Joint assessment Surgeon/restortive dentist. Treatment plan Informed consent Medical assessment Psychological assessment

Medical assessment :

www.indiandentalacademy.com 9 Medical assessment It comprises of Vital signs Laboratory evaluation Systemic diseases

Vital signs :

www.indiandentalacademy.com 10 Vital signs Blood pressure Pulse Temperature Respiration.

Blood pressure.:

www.indiandentalacademy.com 11 Blood pressure. The blood pressure is measured in the arterial system. The maximum pressure is called systolic The minimum pressure is diastolic. Normal systolic Diastolic. Blood pressure is influenced by Cardiac output. Blood volume. Viscosity of the blood. Condition of blood vessels.(especially arterioles) Heart rate.


www.indiandentalacademy.com 12 There are two methods of determining blood pressure. Direct Indirect. Dentist uses the indirect method. Technique was first developed by Italian physician Riva-Rocca Sphygmomanometer consists of inflatable bag covered by a cuff and monometer to register the force and rate of air within the bag. Blood pressure

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www.indiandentalacademy.com 13 Two most common monometer systems Mercury gravity Aneroid gauges. Mercury system is more accurate with changing climates. Blood pressure


www.indiandentalacademy.com 14 Technique. Patient is seated comfortably. Inflatable bag is positioned over the bare upper arm at the level of the patients heart,with the patients palm supine. The brachial or radial artery is palpated and the bag is inflated to obliterate the vessel,about 30mm Hg above the estimated systolic pressure. The cuff is deflated 2 to 4 mm Hg at every heartbeat. Using a stethoscope over the brachial artery, the systolic pressure is recorded at the first tapping sound heard. When the sounds become muffled or inaudible the diastolic pressure is noted . Blood pressure

Relevance to implant patient.:

www.indiandentalacademy.com 15 Relevance to implant patient. Helps in diagnosing hypertensive patients.


www.indiandentalacademy.com 16 Pulse. Pulse represents the force of the blood against the aortic walls for each contraction of the left ventricle. Location to record pulse Radial artery in wrist. Carotid artery in neck. Temporal artery in temporal region. It has 3 components Rate. Rhythm. Strength.

Pulse rate.:

www.indiandentalacademy.com 17 Pulse rate. Beats/min >110 medical consultation needed - Tachycardia 100 Upper limit of normal 60-90 beats /min Normal in a relaxed nonanxious patient. < 60 Medical consultation needed. Bradycardia 40 to 60 Normal for People in excellent physical condition


www.indiandentalacademy.com 18 Bradycardia. Decreased pulse rate of normal rhythm (less than 60 beats /min) Most patients become unconscious below 40 beats/minute (in few its normal) During implant surgery inappropriate Bradycardia may indicate impending sudden death. Pulse rate

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www.indiandentalacademy.com 19 If Pulse rate below 60 accompanied with Sweating Weakness Chest pain Dyspnea Implant procedure should be stopped , oxygen administered and immediate medical assistance obtained. Pulse rate


www.indiandentalacademy.com 20 Tachycardia. Increase pulse rate of regular rhythm (more than 100 beats per minute) Symptoms Blurred vision Increased bleeding during surgery. Seen in underlying medical conditions Hyperthyroidism Acute or Chronic heart disease Anaemia Severe hemorrhage- as heart rate increases to compensate for oxygen depletion in tissues Pulse rate

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www.indiandentalacademy.com 21 These conditions favors postoperative swelling and occurrence of infections during the first critical weeks after implant placement. This in turn compromises the subsequent years of implant service to the patient. Pulse rate

Pulse rhythm:

www.indiandentalacademy.com 22 Pulse rhythm In history of cardiovascular disease and hypertension, pulse rhythm should be always recorded. 2 types of abnormal pulse rhythm. Regular Irregular.

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www.indiandentalacademy.com 23 Which Increases during exercise indicates Atrial fibrillation Hyperthyroidism. Mitral stenosis. Hypertensive heart disease. Stress reduction protocols. Implant may be contraindicated. Regular irregularity. Pulse rhythm

Irregular irregularity.:

www.indiandentalacademy.com 24 Irregular irregularity. Premature ventricular contractions(PVC) Noticed as a distinct pause in an otherwise normal rhythm. Associated with Fatigue Stress Excessive use of tobacco or coffee Myocardial infarction Precursor to cardiac arrest. Pulse rhythm

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www.indiandentalacademy.com 25 If more than 5 PVC’s are recorded within 1 minute + dyspnea or pain, the surgery should be stopped, oxygen administered Patient placed in supine position. Immediate medical assistance obtained. Pulse rhythm

Pulse strength.:

www.indiandentalacademy.com 26 Pulse strength. Sometimes pulse rate and rhythm can be normal, yet the blood volume can affect the character of the pulse. Pulsus alternans Pulse may alternate between strong and weak beats. It indicates severe myocardial damage. Patients life span rarely extends beyond 1-2 years. Implant surgery is contraindicated.


www.indiandentalacademy.com 27 Temperature. Thermometer was invented by Galileo. First used clinically by Santorio of Padua in 17 th century. Every degree of fever increases the pulse rate by 5 and respiratory rate by 4 per minute. Temperature Condition Oral temperature of 99.5 0 or higher febrile range (feverish). 96.8 0 to 99.4 0 F. Normal. Lowest in morning, highest in late afternoon or evening.

Causes of increased body temperature.:

www.indiandentalacademy.com 28 Causes of increased body temperature. Bacterial infection and its toxic products. Exercise Hyperthyroidism Myocardial infarction Congestive heart failure. Tissue injury from trauma or surgery. Dental conditions Dental abscess Cellulitis Acute herpetic stomatitis. Temperature

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www.indiandentalacademy.com 29 No elective surgery,including implants should be performed in febrile patients. increases the patient's pulse rate Hemorrhage Edema Infection Postoperative discomfort . Elevated temperature may complicate the healing Temperature

Low body temperature :

www.indiandentalacademy.com 30 Low body temperature Hypothyroidism. Temperature.


www.indiandentalacademy.com 31 Respiration. Should be noted while patients is at rest. Breaths per minute Condition >20 requires investigation 16-20 normal regular in rate and rhythm.

Dyspnea :

www.indiandentalacademy.com 32 Dyspnea It should be suspected when patients Use accessory muscles in the neck or shoulders for inspiration, whether before or during surgery. Causes: drugs –narcotics Congestive heart failure Bronchial asthma. Advances pulmonary emphysema. Evaluate the pulse to rule out the presence of PVC or Myocardial infarction. Respiration

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www.indiandentalacademy.com 33 due to increase in both rate and depth of respiration. in anxious patients seen after deep sighs. Sedatives or Stress –reduction protocols is indicated. Underlying medical conditions. Severe Anaemia. Advanced branchopulmonary disease. Congestive heart failure. They can affect surgical procedure and/or healing response of the implant candidate. Hyperventilation Respiration

Laboratory Evaluation:

www.indiandentalacademy.com 34 Laboratory Evaluation Urinalysis. Complete blood cell count RBC count WBC count WBC differential. Cellular morphology and maturity. Hemoglobin determination. Hematocrit. Platelet count. Bleeding tests. Check the medical history Review the physical examination. Screen the clinical laboratory tests. Platelet count. Bleeding time Partial thromboplatin time.(PTT) Prothrombin time(PT) Additional tests Fibrinogen level. Thrombin clotting time (TCT) Biochemical profiles. Serum glucose Serum calcium Inorganic phosphorous. Alkaline phosphatase. Lactic dehydrogenase. Creatinine. Bilirubin

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www.indiandentalacademy.com 35 Routine laboratory screening of patients in a general dental setting who previously reported a normal health history have found that 12% to 18% have undiagnosed systemic diseases. Justification of the laboratory procedure should relate to the specific type of surgery and the patients condition.


www.indiandentalacademy.com 36 Urinalysis. Not indicated as a routine procedure, and is used rarely in implant dentistry. Has more Qualitative than Quantitative information. It is primarily a screening test for Diabetes- Examination of blood is a more reliable test for patients glucose metabolism. Deficiencies or irregularities in Metabolism Renal disease Liver function Suspected infection.

Complete blood cell count.:

www.indiandentalacademy.com 37 Complete blood cell count. Completer blood count (CBC) consists of several individual measurements on a single sample of venous blood. RBC count WBC count WBC differential. Cellular morphology and maturity. Hemoglobin determination. Hematocrit. Platelet count.

Indications for CBC.:

www.indiandentalacademy.com 38 Indications for CBC. Suspected dyscrasia (WBC and RBC ) Glucocorticoid therapy within 1 year. Chemotherapy. Renal diseases. Expected major blood loss during surgery. Bleeding disorders. Complete blood cell count.

1. RBC count.:

www.indiandentalacademy.com 39 1. RBC count. RBC’s are responsible for the transport of oxygen and carbon dioxide throughout the body and for control of the blood pH. No of RBC’s per ml Clinical condition Men - 4.5-6.5 million. Woman - 3.8-5.8 million. Normal Increase Polycythemia Congenital heart disease Cushing syndrome. Decreased anemia. Complete blood cell count.

2. White blood cell count.(WBC):

www.indiandentalacademy.com 40 2. White blood cell count.(WBC) Can indicate infections Leukemic disease Immune diseases. Chemotherapy. Inflammatory process may be present without leukocytosis. WBC count 5000 to 10,000/ml Normal increase in WBC . Leukocytosis decrease in WBC. Leukopenia Complete blood cell count.

3. WBC differential. :

www.indiandentalacademy.com 41 3. WBC differential. Complete blood cell count.

Neutrophils :

www.indiandentalacademy.com 42 Neutrophils An increase indicates inflammation. Helps in finding if infection around an implant is affecting the patients overall health. Absolute neutrophil count (ANC) management 2000. normal dental treatment without antibiotic prophylaxis 1000-2000 need antibiotic coverage. Less than 1000 physician referral. Complete blood cell count.


www.indiandentalacademy.com 43 Lymphocytes. Necessary to evaluate the immune response potential of the patient. Many immunodeficiency patients ,including HIV positive, may have no systemic symptoms, yet have deficient lymphocytes. Complete blood cell count.

4. Cellular morphology and maturity.:

www.indiandentalacademy.com 44 4. Cellular morphology and maturity. Complete blood cell count.

5. Hemoglobin.:

www.indiandentalacademy.com 45 5. Hemoglobin. It is responsible for the oxygen carrying capacity of the blood. Threshold is related to the underlying condition of the patient and the anticipated blood loss.. men 13.5-18 g/dl Woman 12-16 g/dl. Normal 10 g/dl : pre-operative threshold minimum baseline for surgery 8 g/dl. Many patients can undergo surgical procedure safely Complete blood cell count.

6. Hematocrit.(PCV):

www.indiandentalacademy.com 46 6. Hematocrit.(PCV) Indicates the percentage of red blood cells in a given volume of whole blood. Prime indicator for Anaemia and blood loss. 0.40-0.54 : men 0.35-0.47 : woman normal Values within 75 to 80 % of normal are required before sedation or general anesthesia. Complete blood cell count.

7. Platelet count.:

www.indiandentalacademy.com 47 7. Platelet count. per /ml 2,00,000-3,00,000 Normal below 80,000 A clinical symptoms occur 20,000 Spontaneous bleeding Complete blood cell count.

Bleeding tests.:

www.indiandentalacademy.com 48 Bleeding tests. Bleeding disorders are one of the most critical conditions encountered in surgery. Ways to detect potential bleeding problems are Check the medical history Review the physical examination. Screen the clinical laboratory tests. Over 90% of bleeding disorders can be diagnosed on the basis of medical history alone. Urinalysis. CBC Bleeding tests . Biochemical profiles

1. Medical history:

www.indiandentalacademy.com 49 1. Medical history History should include questions covering 5 topics. Bleeding problems in relatives. Indicate inherited coagulation disorders. Hemophilia Christmas factor disease. Bleeding tests

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www.indiandentalacademy.com 50 Spontaneous bleeding from the nose, mouth, or other apertures. Bleeding problems after operations, tooth extractions, or trauma. Use of medications that may cause bleeding disorders. Anticoagulants Aspirin Long term antibiotics. Bleeding tests

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www.indiandentalacademy.com 51 Past or present illness associated with bleeding disorders. Leukemia Anemia Thrombocytopenia Hemophilia Hepatic disease. Approximately half of the patients with liver disease have a decrease in platelet count. Bleeding tests

2. Physical examination.:

www.indiandentalacademy.com 52 2. Physical examination. Exposed skin and oral mucosa must be examined for objective signs. Liver disease Petechiae Ecchymoses. Spider angioma Jaundice Genetic bleeding disorders. Intraoral petechia bleeding gingiva ecchymoses Hemarthroses hematomas Acute or chronic leukemia. Oral mucosa ulceration. Hyperplasia of gingiva. Petechiae or ecchymoses of skin or oral mucosa Lymphadenopathy. Bleeding tests

Clinical laboratory testing.:

www.indiandentalacademy.com 53 Clinical laboratory testing. If health history and physical examination do not reveal bleeding disorder routine screening with a coagulation profile is not indicated. If extensive surgical procedures are expected a coagulation profile is indicated. Bleeding tests

Tests used to screen patients for bleeding disorders. :

www.indiandentalacademy.com 54 Tests used to screen patients for bleeding disorders. Platelet count. Bleeding time Partial thromboplatin time.(PTT) Prothrombin time(PT) Additional tests Fibrinogen level. Thrombin clotting time (TCT) Bleeding tests

Bleeding time. :

www.indiandentalacademy.com 55 Bleeding time. Ivy bleeding time Measures Coagulation pathways. Platelet function. Capillary activity. Normal 2-8 minutes. Bleeding tests

Partial thromboplastin time.(PTT):

www.indiandentalacademy.com 56 Partial thromboplastin time.(PTT) Used to determine the ability of blood to coagulate within the blood vessels. It tests the intrinsic and common pathways of coagulation. Normal 30-40 secs Bleeding tests

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www.indiandentalacademy.com 57 Normal PT Abnormal PTT Hemophilia Abnormal PT Normal PTT Factor VII deficiency Abnormal PT Abnormal PTT Deficiency of factors II,V,X or fibrinogen. Bleeding tests

Prothrombin time (PT).:

www.indiandentalacademy.com 58 Prothrombin time (PT). Determines the ability of the blood to coagulate outside the vessels. It tests the extrinsic and common pathways of coagulation. Normal 10.5 -14.5 sec. Bleeding tests

Patients on Aspirin: :

www.indiandentalacademy.com 59 Patients on Aspirin: Tests to be obtained. bleeding time PTT. One 5 gm tablet can affect platelet agglutination for 3 days. 4 or more tablets taken a day for a period of more than a week will affect both bleeding time and PTT. & Bleeding tests

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www.indiandentalacademy.com 60 bleeding complications associated with aspirin are one of the most common complications in implant surgery. Is rarely life threatening,but constant oozing of blood concerns the patient and can result in considerable blood loss. Bleeding tests

&Patients on anticoagulant medication.:

www.indiandentalacademy.com 61 &Patients on anticoagulant medication. Mainly coumarin derivatives(coumadin). Usually due to recent myocardial infarction, cerebrovascular accident, or thrombophlebitis. PT should be checked Normal range is 12-14 seconds. Recently the international normalized ratio(INR) is used to asses bleeding and anticoagulation potentials. 2.0 INR are acceptable for routine treatment. Bleeding tests

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www.indiandentalacademy.com 62 There are several studies now that support the continuation of anticoagulant therapy during surgery. Others studies support the reduction of anticoagulant to bring PT to a normal value. ADA guidelines states that patients on anticoagulant therapy can even undergo surgical procedures. Still majority of physician surveyed recommend anticoagulant alteration for a single surgical extraction. Bleeding tests

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www.indiandentalacademy.com 63 In light of such controversial opinions.it is advisable to consult with the physicians administering the medication regarding the need and amount of reduction and sequencing. Bleeding tests

Patients on Heparin therapy.:

www.indiandentalacademy.com 64 Patients on Heparin therapy. it is an anticoagulant prescribed for renal dialysis patients. It is a short acting anticoagulant. Implants are usually contraindicated. These patients often experience healing and maintenance complications with their natural teeth. A dentist may have to treat a dialysis patient who has previously had implant therapy. Bleeding tests

Patients on long term antibiotics.:

www.indiandentalacademy.com 65 Patients on long term antibiotics. Long term antibiotic therapy can affect the intestinal bacteria that produce the vitamin K necessary for prothrombin production in the liver. PT should be obtained to evaluate possible bleeding complications. Bleeding tests

Alcoholics liver dysfuction patients.:

www.indiandentalacademy.com 66 Alcoholics liver dysfuction patients. The liver is the primary site of synthesis of the vitamin K dependent clotting factors 2 ,7 9 and 10 Alcoholism,independent of liver disease too has been shown to decrease platelet production and increases platelet destruction. The bleeding time and PT should be evaluated in these patients. Bleeding tests

Biochemical profiles(Serum chemistry).:

www.indiandentalacademy.com 67 Biochemical profiles(Serum chemistry).

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www.indiandentalacademy.com 68 Interpretation of biochemical profiles and the ability to communicate effectively with medical consultants will enhance the treatment of many patients. This discussion is limited to the factors of most benefit to the implant dentist. The patient should fast before the blood is collected to avoid artificial elevations of blood glucose and depressed inorganic phosphorus.

Serum glucose.:

www.indiandentalacademy.com 69 Serum glucose. Normal range. 70-110 mg/ 100ml. 3.6-5.8 mmol/l Serum glucose Serum calcium Inorganic phosphorous. Alkaline phosphatase. LDH Creatinine. Bilirubin


www.indiandentalacademy.com 70 Is a relatively common finding. Cause diabetes mellitus. Cushing’s disease. Hyperglycemia. Serum glucose Serum calcium Inorganic phosphorous. Alkaline phosphatase. LDH Creatinine. Bilirubin


www.indiandentalacademy.com 71 Hypoglycemia. It is unusual and can be due to varied causes. Addison’s disease. Bacterial sepsis. Excessive insulin administration. Serum glucose Serum calcium Inorganic phosphorous. Alkaline phosphatase. LDH Creatinine. Bilirubin

Serum calcium.:

www.indiandentalacademy.com 72 Serum calcium. Normal- 2.12 - 2.62 mmol/L Implant dentist may be the first to detect disease affecting the bones. Confirmation of disease is dependent on levels of calcium,phosphorous and alkaline phosphatase. Medical evaluation and treatment are indicated before implant surgery. Serum glucose Serum calcium Inorganic phosphorous. Alkaline phosphatase. LDH Creatinine. Bilirubin

Increased calcium.:

www.indiandentalacademy.com 73 Increased calcium. Reasons Bone resorption.- as in Carcinoma of bones Intestinal absorption.- Dietary and absorptive disturbances. Renal reabsorption. Hyperparathyroidism Paget’s disease. Also Increased alkaline phosphatase. All other biochemical values being normal an elevated calcium value may be the result of laboratory error. Serum glucose Serum calcium Inorganic phosphorous. Alkaline phosphatase. LDH Creatinine. Bilirubin

Decreased calcium.:

www.indiandentalacademy.com 74 Decreased calcium. Seen in Hypoproteinemic conditions Renal disease. Diet of potential implant patient may be severely affected by the lack of denture comfort and stability. Serum glucose Serum calcium Inorganic phosphorous. Alkaline phosphatase. LDH Creatinine. Bilirubin

Inorganic phosphorus.:

www.indiandentalacademy.com 75 Inorganic phosphorus. It maintains a ratio of 4 to 10 compared with calcium ,and there is usually a reciprocal relationship. Serum glucose Serum calcium Inorganic phosphorous . Alkaline phosphatase. LDH Creatinine. Bilirubin

Elevated phosphorous.:

www.indiandentalacademy.com 76 Elevated phosphorous. Chronic glomerular disease (common ). Hypoparathyroidism. Decrease calcium and normal renal function . Hyperthyroidism Increases growth hormone. Cushing’s syndrome. Serum glucose Serum calcium Inorganic phosphorous. Alkaline phosphatase. LDH Creatinine. Bilirubin

Decreased phosphorus.:

www.indiandentalacademy.com 77 Decreased phosphorus. Hyperparathyroidism. With associated hypercalcemia. In chronic user’s of aluminium hydroxide antacids. Serum glucose Serum calcium Inorganic phosphorous. Alkaline phosphatase. LDH Creatinine. Bilirubin

Alkaline phosphatase.:

www.indiandentalacademy.com 78 Alkaline phosphatase. Its level helps in determining hepatobiliary and bone diseases. Normal : 40-125 U/L Serum glucose Serum calcium Inorganic phosphorous. Alkaline phosphatase. LDH Creatinine. Bilirubin

High levels:

www.indiandentalacademy.com 79 High levels Extreme- indicate hepatic disease In absence of hepatic disease –indicate osteoblastic activity in the skeletal system. Bone metastases Fractures. Paget’s disease. Hyperparathyroidism. Normal in patients with adult osteoporosis. Low levels – of no clinical significance to dentist. Serum glucose Serum calcium Inorganic phosphorous. Alkaline phosphatase. LDH Creatinine. Bilirubin

Lactic dehydrogenase.:

www.indiandentalacademy.com 80 Lactic dehydrogenase. It is an intracellular enzyme present in all tissues. Normal : 0 to 625 U/L. False elevated LDH levels occur as result of hemolyzed blood specimens . Elevations are seen in Myocardial infarction. Hemolytic disorders such as pernicious Anaemia. Liver disorders. Serum glucose Serum calcium Inorganic phosphorous. Alkaline phosphatase. LDH Creatinine. Bilirubin


www.indiandentalacademy.com 81 Creatinine Normal: 0.7 - 1.5mg/dl Creatinine is freely filterable by glomeruli and not reabsorbed. The constancy of formation and excretion permits creatinine levels to be an index of renal function. Kidney dysfunction may lead to osteoporosis and decreases bone healing because the kidney is required for complete formation of vitamins D. Serum glucose Serum calcium Inorganic phosphorous. Alkaline phosphatase. LDH Creatinine . Bilirubin


www.indiandentalacademy.com 82 Bilirubin. Total Bilirubin: 2-17 µmol/L For evaluation of liver disease,bilirubin measurement is of primary importance. Liver function should be adequate for proper healing,drug pharmacokinetics,and long term health. Serum glucose Serum calcium Inorganic phosphorous. Alkaline phosphatase. LDH Creatinine. Bilirubin

Systemic disease and oral implants.:

www.indiandentalacademy.com 83 Systemic disease and oral implants.

Classification of Pre surgical Risk.:

www.indiandentalacademy.com 84 Classification of Pre surgical Risk. Formulated by American society of anesthesiology. Class I Patients who are physiologically normal Has no medical diseases Lives a normal daily lifestyle. Class II Patients who have some type of medical disease but the disorder is controlled with various medications.the patient can thus engage in normal daily activity. E.g. Controlled hypertension. Class III Patient who has multiple medical problems,such as advanced –stage hypertensive cardiovascular disease or insulin dependent diabetes with impaired normal activity

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www.indiandentalacademy.com 85 Class IV Serious medical condition requiring immediate attention. E.g acute Gallbladder disease. Class V Patient is usually Moribund and will not survive the next 24 Hours. Most patients who seek implant reconstruction fall in class 1 or II categories. Same patients fall in Class III and preparatory measures have to be taken before treatment.

Cardiovsascular diseases.:

www.indiandentalacademy.com 86 Cardiovsascular diseases. Hypertension. Angina pectoris. Myocardial infarction. Congestive heart failure. Sub acute bacterial endocarditis.


www.indiandentalacademy.com 87 Hypertension. A patient is classified as hypertensive When the mean value after 3 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.

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www.indiandentalacademy.com 88 90% of hypertensive patients have essential or idiopathic hypertension. Essential hypertensive patients are susceptible to Coronary disease 3 times more cardiac failure 4 times more Strokes 7 times more Than normaotensive paitents. Predisposing factors. Excessive alcohol intake. History of renal disease. Stroke. Cardiovascular disease. Diabetes Obesity smoking Hypertension

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www.indiandentalacademy.com 89 Essential hypertension is treated with medications many of which have an impact on implant therapy because of their side effects. common Side effects of hypertensive drugs Xerostomia Orthostatic hypotension. When the patient is suddenly brought from supine position to upright position , patient may feel lightheaded or even faint . Dehydration Sedation Depression. Gingival hyperplasia. Hypertension

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www.indiandentalacademy.com 90 Rapid increase in blood pressure during an injection or surgery in severe hypertensive can lead to Angina pectoris. congestive heart failure. Cerebrovascular episode. Hypertension

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www.indiandentalacademy.com 91 Mild hypertension Single diuretics drugs are used. Fewest complications that can modify implant treatment. Combination drugs indicate a more severe hypertension. Patients taking additional drugs like clonidine exhibit severe hypertension and need medical consultation. Hypertension

Implant management.:

www.indiandentalacademy.com 92 Implant management. Stress reducing protocol As anxiety greatly affects blood pressure. Flurazepam 30mg or diazepam 5 to 10mg in the evening to help the patient sleep quietly night before the operation. An early appointment.as medication may still be effective in elderly. Hypertension

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www.indiandentalacademy.com 93 Risk Systolic mm hg Diastolic mm hg Type 1 Type 2 Type 3 Type4 High normal 130-139 85-89 + + Sedation sedation Hypertension Stage 1 140-159 90-99 + Sedation Sedation Sedation Stage 2 160-179 100-109 + Sedation Postpone all elective procedures. Stage 3 180-209 110-119 Refer andpostmpone all elective procedure. Stage 4 >210 >120 Refer and postpone all elective procedures. Type 1. Examination. Radiographs. Study model impressions. Oral hygiene instructions. Supragingival prophylaxis. Simple restorative dentistry. Type 2 Scaling and root planning. Endodontics Simple extractions Curettage Simple Gingivectomy. Advanced restorative procedures. Simple implants. Type 3 Multiple extractions Gingivectomy Quadrant peroseal reflections Impacted extractions Apicoectomy Plate form implants Ridge augmentation. Unilateral sinus graft. Unilateral subperiosteal implants. Type 4 Full arch implants Orthognathic surgery Autogenous bone augmentation Bilateral sinus graft.

Angina pectoris.:

www.indiandentalacademy.com 94 Angina pectoris. Angina pectoris or chest pain or cramp of the cardiac muscle, is a form of coronary heart disease. It is a symptomatic expression of temporary myocardial ischemia. Classical symptoms; Retrosteranl pain with stress or physical exertion. Radiates to the shoulder, left arm or mandible, Or right arm neck palate and tongue. Symptoms are relived by rest. Angina pectoris

Risk factors for Angina:

www.indiandentalacademy.com 95 Risk factors for Angina Smoking Hypertension High cholesterol Obesity Diabetes. Angina is classified as Mild. moderate. Severe. Angina pectoris

Precipitating factors.:

www.indiandentalacademy.com 96 Precipitating factors. Exertion. Cold. Heat. Large meals. Humidity. Psychological stress. Dental related stress. Angina pectoris

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www.indiandentalacademy.com 97 Risk Type 1 Type 2 Type3 Type 4 Mild One or less /month + + Sedation supplemental oxygen Moderate One or less/week + Sedation premedicate nitrates supplemental oxygen Premedicate Sedation Outpatient hospitilization Severe Daily/more Unstable + Physician Elective procedures contraindicated. Mild Type 3 and 4 Appointments should be as short as possible. Concentrations of vasoconstrictor greater than 1/100000 avoided Moderate Type 2 and 3: vasoconstrictor is contraindicated. Antianxiety sedation with supplemental oxygen Type 4 may require a hospital setting.

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www.indiandentalacademy.com 98 Dental emergency kit should include nitroglycerin tablets (0.3 to 0.4 mg) or translingual spray,which are replaced every 6 months. During angina attack all dental treatment should e stopped immediately. Nitroglycerin is administered sublingually 100% oxygen given at 6L/min with the patient in a semi supine or 45 degree position. Angina pectoris

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www.indiandentalacademy.com 99 Vital signs should be monitored as Transient hypotension can occur after nitroglycerin administration. If systolic BP falls below 100mm Hg patients feet should be elevated. Pain if not relived in 8 to 10 minutes with the use of nitroglycerin at 5 minute intervals, the patient should be transported by ambulance to a hospital. Angina pectoris

Side effects of nitroglycerin:

www.indiandentalacademy.com 100 Side effects of nitroglycerin Decrease in blood pressure –can cause fainting . Patient should be sitting or lying down during administration. As heart attempts to compensate decreased BP- pulse rate may increase as much as 160 beats /min. Blushing of face and shoulders. Headache –analgesics may be needed. Tolerance to drug can occur and so 2 tablets may be needed Angina pectoris*

Myocardial infarction.:

www.indiandentalacademy.com 101 Myocardial infarction. Myocardial infarction(MI) is a prolonged ischemia or lack of oxygen that causes injury to the heart. 10% of patients 40 years or older undergoing noncardiac surgery in a hospital setting indicate a history of previous MI. It is of interest as implant dentist primarily treats patients in this age group.

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www.indiandentalacademy.com 102 Signs and symptoms. Cyanosis Cold sweat Weakness Nausea or vomiting Irregular or increased pulse rate. Severe chest pain in the substernal or left precordial area.it may radiate to left arm or mandible. Pain is similar to angina pectoris but more severe. Myocardial infarction

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www.indiandentalacademy.com 103 Complications of MI Arrhythmias Congestive heart failure. The risk of MI is less than 1% in general population in preoperative setting. 18-20% of patients with a recent history of MI will have complications of recurrent MI (mortality rate 40-70 %) Surgery done within Risk of another MI 3 months 30% 3-6 months 15% 12 months 5% Myocardial infarction*

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www.indiandentalacademy.com 104 Risk Type 1 Type 2 Type 3 Type 4 Mild >12 months + + Physician Physician hospitalization if anesthesia required. Moderate 6-12 months + Postpone all elective procedures. Severe < 6months + Postpone all elective procedures. Myocardial infarction

Congestive Heart failure.:

www.indiandentalacademy.com 105 Congestive Heart failure. CHF is a chronic heart condition in which the heart is failing as a pump. Symptoms of congestive Heart failure. Abnormal tiredness. Shortness of breath. Wheezing. Edema of legs or ankles. Frequent urination Paroxysmal nocturnal dyspnea. Excessive weight gain. Orthopnea. Pulmonary edema Jugular venous distention.

Medications for CHF.:

www.indiandentalacademy.com 106 Medications for CHF. Digitalis.(digoxin, Lanoxin) increases the heart pumping action. Lethal dose is only twice the treatment dose. Common side effects. Nausea Vomiting Anorexia Decreases heart rate Premature ventricular contractions. Less common. Chromatopsia Spots Halo around objects. Decrease of medication dose partially relieves the symptoms.

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www.indiandentalacademy.com 107 Diuretics.(furosemide) eliminate excess salt and water. Dilators. Expands the blood vessels so that pressure decreases . Calcium channel blockers. Gingival hyperplasia around teeth implants,or superstructure bars of overdentures, especially with nifedipine. Congestive heart failure*

Subacute bacterial Endocarditis.:

www.indiandentalacademy.com 108 Subacute bacterial Endocarditis. Bacterial endocarditis is an infection of the heart valves or the endothelial surfaces of the heart. Results from growth of bacteria on damaged /altered cardiac surfaces. Organisms most often associated in dentistry. Alpha-hemolytic streptococcus viridans Sometimes staphylococci and anaerobes. Mortality rate is about 10%.

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www.indiandentalacademy.com 109 Dental procedures causing transient bacteremia are a major cause of bacterial endocarditis. High risk Previous endocarditis. Prosthetic heart valve Surgical systemic pulmonary shunt. Significant. Rheumatic valvular defect. Acquired valvular disease Congenital heart disease. Intravascular prostheses. Coarctation of the aorta. SABE

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www.indiandentalacademy.com 110 Minimal risk Transvenous pacemaker. Rheumatic fever history and no documented rheumatic heart disease. Least risk. Innocent of functional heart murmur. Uncomplicated atrial septal defect. Coronary artery bypass graft operations. SABE*

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www.indiandentalacademy.com 111 Any patient with one previous episode of endocarditis has a 10% per year risk of second infection. Once the second infection occurs, the risk factor increases to 25 %. There is correlation between the incidence of endocarditis and the number of teeth extracted or the degree of a preexisting inflammatory disease of the mouth, SABE*

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www.indiandentalacademy.com 112 Bacteremia has also been reported with traumatic tooth brushing, Endodontic treatment, chewing paraffin. Denture sores in edentulous patients. Scaling and root planning before soft tissue surgery reduces the risk of endocarditis. Chlorhexidine painted on isolated gingiva or irrigation of the sulcus 3 to 5 minutes before tooth extraction reduces post extraction bacteremia. SABE*

Antibiotic regimens:

www.indiandentalacademy.com 113 Antibiotic regimens SABE*

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www.indiandentalacademy.com 114 Edentulous patients restored with implants must contend with transient bacteremia from chewing, brushing,or periimplant disease. Therefore implants are contraindicated for patients with a limited oral hygiene potential and for those with a history of stroke. SABE*

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www.indiandentalacademy.com 115 Intramucosal inserts maybe contraindicated for many of these patients because a slight bleeding can occur on a routine basis for several weeks during initial healing process. Endoosteal implants with adequate width of attached gingiva,are the implants of choice for patients who need implant supported prosthesis. SABE*

Diabetes mellitus :

www.indiandentalacademy.com 116 Diabetes mellitus Diabetes mellitus is related to an absolute or relative insulin insufficiency. It is the most common metabolic disorder and major cause of blindness in adults. The increase in number of diabetics is expected due to Increase in population size Greater life expectance. Obesity.

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www.indiandentalacademy.com 117 Symptoms are: Polyuria Polydypsia Polyphagia Weight loss. Diabetics are more prone to Delayed soft and hard tissue healing Altered nerve regeneration. Infections Vascular complications. Diabetes mellitus*

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www.indiandentalacademy.com 118 Specific questions to be asked in medical history to evaluate the level of control achieved in Diet Insulin dosage Oral medication Method used to monitor the blood glucose Recent glucose levels. A glycohemoglobin determination test is a good indicator of a diabetic’s long term blood glucose level. Diabetes mellitus*

Diabetic patients are subject to greater incidence and severity of:

www.indiandentalacademy.com 119 Diabetic patients are subject to greater incidence and severity of Periodontal disease Dental caries due to xerostomia Candidiasis Burning mouth Lichenoid reactions. Increased alveolar bone loss Inflammatory gingival changes. Tissue abrasions in denture wearers oxygen tension decreases the rate of epithelial growth and decrease tissue thickness . Diabetes mellitus*

Implant protocol.:

www.indiandentalacademy.com 120 Implant protocol. Most serious complication during implant procedure is hypoglycemia. It can be due to Excessive insulin level Hypoglycemic drugs Inadequate food intake. Diabetes mellitus*

Symptoms Weakness Nervousness Tremor Palpitations sweating :

www.indiandentalacademy.com 121 Symptoms Weakness Nervousness Tremor Palpitations sweating Can be treated with sugar inform of candy or orange juice. Confusion Agittion Seizure Coma death Diabetes mellitus*

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www.indiandentalacademy.com 122 Insulin therapy is adjusted to half the dose in the morning of surgery if oral intake is expected to be compromised. Oral medications are discontinued after the patient has taken a morning dose on the day of surgery. Intravenous conscious sedation and infusion of glucose and saline solution(D 5 W) can be used for lengthy procedures. Diabetes mellitus*

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www.indiandentalacademy.com 123 Corticosteroids often used to decrease edema,swelling,and pain may not be used in the diabetic patient because they adversely effect blood sugar levels. Diabetes melllitus*

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www.indiandentalacademy.com 124 Risk Type 1 Type 2 Type 3 Type 4 Mild < 150 mg /dl Glyc.0-1+ ketonuria 0 + + Sedation Premedication Diet/insulin Adjustment. Moderate < 200 mg/dl GLYC 0-3+ ketonria 0 + + Sedation Premedication Diet/insulin Adjustment. Physician Diet/insulin Adjustment. Physician Hospitalization. Severe Uncontrolled> 250 mg/dl glyc 3+ Ketonuria 0 + Postpone all elective procedures

Thyroid disorders.:

www.indiandentalacademy.com 125 Thyroid disorders. Affects proximately 1% of general population, primarily woman. As the vast majority of patients in implant dentistry are woman, a slightly higher prevalence of this disorder is seen in the dental implant practice.


www.indiandentalacademy.com 126 Hyperthyroidism. Excessive production of hormone thyroxin(T 4 ). Symptoms Increased pulse rate. Nervousness Intolerance to heat Excessive sweating Weakness of muscles Diarrhea Increased appetite Increased metabolism Weight loss Can led to atrial fibrillation angina congestive heart failure. Thyroid


www.indiandentalacademy.com 127 Hypothyroidism Symptoms are related to decrease in metabolic rate. Cold intolerance Fatigue Weight gain Hoarseness Decreased mental activity Coma. Thyroid

Potential implant patients.:

www.indiandentalacademy.com 128 Potential implant patients. Patients with hyperthyroidism are sensitive to epinephrine in LA and gingival retraction cords. Exposure to catecholamines (LA)+ stress+tissue damage(implant surgery) “thyroid storm” - high temperature Agitation and psychosis Life threatening arrhythmias Congestive heart failure. Thyroid

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www.indiandentalacademy.com 129 Hypothyroid patients are sensitive to CNS depressant drugs.(diazepam or barbiturates) The risk of respiratory depression,Cardiovascular depression or collapse should be considered. Thyroid

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www.indiandentalacademy.com 130 Risk Type 1 Type 2 Type 3 Type 4 Mild Med exam < 6 months normal fct last 6 months + + + + Moderate No symptom no med exam no Fct test + Decrease epinephrine steroids CNS depressants Physician consultation. Severe Symptoms + Postpone all elective procedures.

Adrenal gland disorders.:

www.indiandentalacademy.com 131 Adrenal gland disorders. Epinephrine and nor epinephrine are produced by the cells of adrenal medulla. These hormones are responsible for the Control of blood pressure. Myocardial contractility and excitability. General metabolism.

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www.indiandentalacademy.com 132 It corresponds to the decrease in the adrenal function. Dentist can notice hyper pigmented areas on the face lips gingiva. These patients cannot increase their steroid production in response to stress and in the midst of surgery may have cardiovascular collapse. Addisons's disease Adrenal gland disorder

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www.indiandentalacademy.com 133 Corticosteroids are potent anti-inflammatory drugs used to treat a number of systemic diseases and one of the most prescribed drugs in medicine. Continued administration of exogenous steroids suppress the natural function of the adrenal glands. Therefore patients under long term steroid therapy are placed on the same protocol as patients with hypo function of the adrenal gland. Adrenal gland disorder

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www.indiandentalacademy.com 134 Hyper function of adrenal cortex. Symptoms Bruise easily Poor wound healing Experience osteoporosis Increased risk of infection. Cushing's syndrome. Characteristic symptoms Moon facies Truncal obesity or “buffalo hump” Muscle wasting hirsutism Adrenal gland disorder

Potential implant patient:

www.indiandentalacademy.com 135 Potential implant patient Whether hypo or hyper functioning a patient with adrenal gland disease face similar problems related to dentistry and stress. Their body is unable to produce increased levels of steroids during stressful situations and cardiovascular collapse may occur. Additional steroids are prescribed just before surgery and stopped within 3 days. Adrenal gland disorder

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www.indiandentalacademy.com 136 Steroids in implant surgery patient. Decrease inflammation,swelling and related pain. Also decrease protein synthesis and delay healing. Decrease leukocytes and therefore reduce ability to fight infection. Therefore antibiotics are always prescribed whenever steroids are given to patients for surgery. Adrenal gland disorder

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www.indiandentalacademy.com 137 Risk Type 1 Type 2 Type 3 Type 4 Mild Equiv. Prednisone alternate day >1 year + Surgery on day of steroids Sedation and antibiotics Steroids < 60mg prednisone day1 dose X/2 day 2 maintenance dose day 3 Moderate Equiv prednisone>20 mg or > 7 days in past year. + Sedation and antibiotics 20-40 mg day 1 Dose X /2 day 2 Dose X /4 day 3 60 mg day1 Dose X/2 day 2 Dose X /4 day 3 Severe. Euiv. Prednisone 5mg/day + Elective procedures contraindicated

Hematologic disorders.:

www.indiandentalacademy.com 138 Hematologic disorders. Erythrocytic disorders. Polycythemia Anemia Leukocytic disorders.


www.indiandentalacademy.com 139 Polycythemia. It is a rare chronic disorder characterized by splenic enlargement, hemorrhages and thrombosis of peripheral veins. Death usually occurs in 6 to 10 years. Implant or reconstruction procedures are usually contraindicated.


www.indiandentalacademy.com 140 Anemia. It is the most common hematologic disorder. It is not a disease entity; rather it is a symptom complex that results from a decreased production of erythrocytes, an increased rate of their destruction. Deficiency of iron. It is defined as a reduction on the oxygen-carrying capacity of the blood and results from a decrease in the number of erythrocytes or abnormality of hemoglobin.

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www.indiandentalacademy.com 141 General signs. Jaundice Pallor Spooning or cracking of nails Hepatomegaly and splenomegaly Lymphadenopathy Oral signs. Sore painful smooth tongue. Loss of papillae Redness Loss of taste sensation Paresthesia. Anemia

Mild anemia :

www.indiandentalacademy.com 142 Mild anemia Fatigue Anxiety Sleeplessness Men mild anemia in man may indicate a serious underling medical problem Peptic ulcer Carcinoma of colon. Female may normally be anemic in Mensus Pregnancy Anemia

Chronic anemia. :

www.indiandentalacademy.com 143 Chronic anemia. Shortness of breath. Abdominal pain Bone pain Tingling of extremities Muscular weakness Headaches Fainting Change of heart rhythm nausea Anemia

Potential implant patients.:

www.indiandentalacademy.com 144 Potential implant patients. Bone maturation and development are often impaired in the long term anemic patients. Sometimes radiographically a faint ,large trabecular pattern of bone may even appear – it indicates 25-40% loss in trabecular pattern. Decreased bone density affects Initial implant placement Initial amount of lamellar bone formation at interface. Anemia

Other complications.:

www.indiandentalacademy.com 145 Other complications. Abnormal bleeding.-decreased field of vision. Increased edema and discomfort postoperatively. Increased risk of postoperative infection and its consequences. Anemia

Diagnosis of anemia.:

www.indiandentalacademy.com 146 Diagnosis of anemia. Hematocrit. Most accurate Men 40%- 54% Woman 37-47 % Hemoglobin. Minimum base line recommended for surgery is 10 mg/dl especially for elective implant surgery. Red blood cell count. least accurate. Anemia

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www.indiandentalacademy.com 147 For majority of anemic patients implant procedures are not contraindicated. Aspirin should be avoided. Preoperative and postoperative antibiotics should be administered. Hygiene appointments should be scheduled more frequently. Anemia

Leukocytic disorders.:

www.indiandentalacademy.com 148 Leukocytic disorders. Leukocytosis –increase in circulating WBC in excess of 10,000/mm 3. Can be due to Infection. Leukemia Neoplasm Acute hemorrhage Exercise,emotional stress,pregnancy.


www.indiandentalacademy.com 149 Leukopenia Reduction of WBC below 5000/mm 3. Can be due to Certain infections (infectious hepatitis) Bone marrow damage (radiation therapy) Nutritional deficiency. Blood diseases. WBC disorders

Consequences of WBC disorder.:

www.indiandentalacademy.com 150 Consequences of WBC disorder. Infection. Delayed healing. Severe bleeding. Increases edema Postoperative discomfort and secondary infection. Complications are more common than in Erythrocytic disorders. WBC disorders

Implant patient.:

www.indiandentalacademy.com 151 Implant patient. Oral implant procedures are contraindicated in acute or chronic leukemia. Treatment planning modifications should shift toward a conservative approach when dealing with leukocyte disorders. WBC disorders

Chronic obstructive pulmonary diseases.:

www.indiandentalacademy.com 152 Chronic obstructive pulmonary diseases. It is the second most common cause of death after cardiovascular disease. Two common forms of COPD are emphysema and chronic bronchitis. 3% of population has COPD. This disease affects men over the age of 40 and is closely related to smoking.

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www.indiandentalacademy.com 153 Symptoms Chronic cough Sputum production Shortness of breath Dentist should enquire about carbon dioxide retention capability of these patients. Patients who retain CO 2 have a severe condition and are prone to respiratory failure when given sedatives,oxygen or nitrous oxide,and oxygen analgesia. COPD

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www.indiandentalacademy.com 154 Risk Type 1 Type 2 Type 3 Type 4 Mild + + + + Moderate + PHYSICIAN PHYSICIAN/MODERATE TREATMENT. severe + POSTPONE(HOSPITALIZATION) ELECTIVE PROCEDURES CONTRAINDICATED. Difficulty breathing only on significant exertion Normal laboratory blood gases Difficulty breathing upon exertion Those on chrnic bronchodilator therapy. those who have used corticosteroids. Procedure should be performed in hospital setting No vasoconstrictor to be added to anesthetics or gingival cord if patient is on bronchodilators Previously unrecognized COPD Acute exacerbation of respiratory infection Patients with dyspnea at rest Those with history of CO 2 retention


www.indiandentalacademy.com 155 Cirrhosis. Major cause is alcoholic liver disease. Important to implant dentist as liver is involved in synthesis of clotting factors –abnormal bleeding. Ability to detoxify drugs- can result in oversedation or respiratory depression. Elective implant therapy is a relative contraindication in the patient with symptoms of active alcoholism.

Implant patient management.:

www.indiandentalacademy.com 156 Implant patient management. No abnormal laboratory values Low risk normal protocol Elevated PT less than 1-1.5 times control value Bilirubin slightly affected Moderate risk referred to physician. Nonsurgical and simple surgical procedure follow normal protocol. Strict attention to hemostasis is indicated. Moderate or advanced surgical procedures may require hospitalization PT greater tan 1.5 times control value Mild to severe thrombocytopenia Liver related enzymes affected. High risk Hospitalization recommended for surgical procedures. Elective procedures on previously inserted implants usually contraindicated. Platelet transfusion required for even scaling and nerve block

Bone diseases.:

www.indiandentalacademy.com 157 Bone diseases. Diseases of the skeletal system and specifically the jaws often influence decisions regarding treatment in the field of oral implants. Bone and calcium metabolism are directly related. Regulators of extracellular calcium. Parathyroid hormone. Vitamin D Prostaglandins. Lymphocytes. Insulin Glucocorticoids Estrogen.


www.indiandentalacademy.com 158 Osteoporosis. Most common disease of bone metabolism for implant dentist. Its an age related disorder characterized by a decrease in bone mass and susceptibility for fracture. Above 60 years one third of population is affected. Denture is less secure and patient may not be able to follow the good diet.

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www.indiandentalacademy.com 159 Osteeoporotic changes in the jaws are similar to other bones in the body. The structure of bone is normal; however due to 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. Bone mass Men woman peaks at 35- 40 years. 30 % more than woman At 80 years 27 % loss. 40 % loss Osteoporosis

Persons at risk :

www.indiandentalacademy.com 160 Persons at risk Thin Postmenopausal. Caucasian woman with history of poor dietary intake. Cigarette smoking British or north European ancestry. Estrogen replacement therapy [ERT] Premarin can halt or retard severe bone demineralization caused by osteoporosis. Can reduce fractures by about 50% compared with fracture rate of untreated woman. Osteoporosis

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www.indiandentalacademy.com 161 Recommended calcium intake 800 mg/day. Average intake in United states 450 to 550 mg. Postmenopausal woman 1,500 mg is required. Osteoporosis

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www.indiandentalacademy.com 162 Osteoporosis is a significant factor for bone volume and density, but is not a contraindication for dental implants. The bone density does affect the treatment plan surgical approach length of healing and need for progressive loading. Osteoporosis

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www.indiandentalacademy.com 163 The implant dentist can benefit the patient by noteing the loss of trabecular bone and by early referral. Treatment is controversial and concentrates more on the prevention. Regular exercise has shown to help maintain bone mass and increase bone strength. Adequate dietary intake is essential. Implant designs should e Greater in width. Coated with hydroxyapatite. Increases bone contact and density. Bone stimulation increases bone density even in advanced osteoporotic changes. Osteoporosis


www.indiandentalacademy.com 164 Osteomalacia. Caused by the deficiency of vitamin D in adults. Risk factors. Homebound elderly(lack of sunlight) Those Unable to wear dentures. Strict vegetarians. Those on anticonvulsant drugs. Gastrointestinal disorders.

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www.indiandentalacademy.com 165 Oral findings Decrease in trabecular bone Indistinct lamina dura. Increase in chronic periodontal disease. Treatment is similar to osteoporatic patient. Implants are not contraindicated. Osteomalacia

Hyperparathyroidism. :

www.indiandentalacademy.com 166 Hyperparathyroidism. Mild Asymptomatic Moderate Renal colic. Severe Disturbances in Bone- alveolar bone depletion. Renal Gastric

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www.indiandentalacademy.com 167 Oral changes occur in advanced disease Loss of lamina dura Loose teeth. Ground glass appearance of trabecular bone. Implants are not contraindicated if no bony lesions are present in the region of the implant placement. Hyperparathyroidism.

Fibrous dysplasia.:

www.indiandentalacademy.com 168 Fibrous dysplasia. It is a disorder in which fibrous connective tissue replaces areas of normal bone. Twice as common in woman and in maxilla. It may affect single bone or multiple bone. IN jaws it begins as a painless, progressive lesion.

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www.indiandentalacademy.com 169 Increase in trabeculation Radiographically seen as the mottled appearance. Facial plate usually expands moving the teeth along with it. Fibrous dysplasia

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www.indiandentalacademy.com 170 Implant dentistry is contraindicated in the regions of this disorder. Lack of bone and increased firous tissue Decreases rigid fixation. Susceptible to local infection processes. Excision of fibrous dysplasia is treatment of choice. Excised area may receive implant in long term. Fibrous dysplasia

Paget’s disease (Osteitis Deformans). :

www.indiandentalacademy.com 171 Paget’s disease (Osteitis Deformans). Is a slowly progressing chronic bone disease. Predeliction for men and those over 40 years of age. Jaws are affected in 20% of cases. Maxilla is more often involved. Symptoms Tooth mobility Discomfort in wearing prosthesis. Bony enlargements can be palpated Spontaneous fractures.

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www.indiandentalacademy.com 172 Cotton or wool appearance radiographically. Paget’s disease

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www.indiandentalacademy.com 173 There is no specific treatment. Patients are predisposed to development of osteosarcoma. Oral implants are contraindicated in the regions affected. Paget’s disease

Multiple Myeloma.:

www.indiandentalacademy.com 174 Multiple Myeloma. It is a plasma cell neoplasm that originates in the bone marrow. Affects several bones. wide spread destruction. Symptoms of skeletal pain. Usually found in patients of 40-70 years. Causes Pathologic fracture due to bone destruction Oral manifestations are common. Paresthesia Swelling Tooth mobility and movement. Gingival enlargements

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www.indiandentalacademy.com 175 Punched out lesions radiographically. There is no treatment and condition is usually fatal 2 to 3 years after onset. Implants are usually contraindicated. Multiple Myeloma

Use of tobacco.:

www.indiandentalacademy.com 176 Use of tobacco. There is established relationship between smoking and… ..Periodontal attachment loss. ..Bone loss. ..decreased resistance to Inflammation. Infection. ..Impaired wound healing. ..Reduced mineral content in bone in aging smokers Postmenopausal female smokers.

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www.indiandentalacademy.com 177 Lower success of endosteal implants in smokers. Failure is more in maxilla. occurs in clusters. 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. Smokers should be told of detrimental effect on their treatment. Should be encouraged to start a smoking cessation program. Tobacco


www.indiandentalacademy.com 178 Pregnancy. Implant surgery procedures are contraindicated in pregnant patient. Reasons for postponement. Radiographs Medications Surgery Stress However, after implant surgery has occurred ,the patient may become pregnant while waiting for the restorative procedures.

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www.indiandentalacademy.com 179 Procedures which can be carried out. Caries control Emergency procedures. Dental prophylaxis. Drugs approved Lidocaine Penicillin Erythromycin Acetaminophen. Pregnancy

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www.indiandentalacademy.com 180 Drugs usually contraindicated. Aspirin Epinephrine(Vasoconstrictor) Narcotics analgesics (cause respiratory depression) Always contraindicated. Diazepam Nitrous oxide Tetracycline. Pregnancy

Prosthetic joints.:

www.indiandentalacademy.com 181 Prosthetic joints. Literature reports there is association between prosthetic joint infection and dental treatment. It is hypothesized that bacteria from the dental treatment may seed the prosthesis and produce infection. The joint ADA – AAOS( American academy of orthopedic surgeons) advisory statement recommends - the aggressive treatment of acute orofacial infections in patients with total joint prosthesis because those bacteremias associated with acute infections can and do cause late implant infections.

Dental procedures with higher risk of bacteremia.:

www.indiandentalacademy.com 182 Dental procedures with higher risk of bacteremia. Dental extractions. Surgical placement of implants Periodontal surgery. Prophylactic cleaning of teeth and implants. Prosthetic joints

Antibiotic prophylaxis:

www.indiandentalacademy.com 183 Antibiotic prophylaxis Recommended for patients with higher risk for hematogenous infections undergoing dental procedures with a higher bacteremic incidence. Prosthetic joints

Radiation therapy.:

www.indiandentalacademy.com 184 Radiation therapy. Approximately 3% of all malignancies occur in head and neck region. 90% of which are squamous cell carcinoma. Treatment reginmens Surgery. Radiotherapy. Chemotherapy. Surgery and radiotherapy are the most effective and therefore most used.

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www.indiandentalacademy.com 185 Early stage disease are treated with single modality therapy In more advanced cancers combination therapies are needed and outcome is less favorable. Microscopic disease 50-55 Gy Macroscopic disease with high riskof recurrance 65-70 Gy

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www.indiandentalacademy.com 186 49 Gy Significant injury to the endothelium of the blood vessels in mandible. > 60 Gy ability of osseous structures to recover from an operative insult independently is minimal.


www.indiandentalacademy.com 187 Osteoradionecrosis Osteoradionecrosis is a condition characterized by the development of non vital areas of osseous tissue in irradiated bone after injury. Treatment Disease should be best prevented whenever possible. Segmental resection and extensive reconstruction. It is extremely costly both in time and resources.

Potential implant patient.:

www.indiandentalacademy.com 188 Potential implant patient. The fields irradiated and the dosages received by the tissues in that area must be analyzed to determine areas of the jaws at risk. If areas receiving radiation doses of 60 Gy must be violated surgically,preoperative hyperbaric oxygen therapy(HBO) can reduce the risk of Osteoradionecrosis.


www.indiandentalacademy.com 189 Chemotherapy Drugs used as chemotherapeutic agents have the capability to disrupt normal cellular events leading to replication. Oral mucosal ulcerations are common and often complicate therapy by secondary infection.

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www.indiandentalacademy.com 190 Granulocyte-stimulating factor Granulocyte-macrophage colony-stimulating factor Can be used in patients exhibiting severe neutropenia. The clinician managing the oral needs of the patients with cancer must weigh the risks of infection and failure inpatients undergoing or likely to require chemotherapy against the benefits of dental rehabilitation.

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www.indiandentalacademy.com 191 HISTORY CLINCAL EXAMINATION Diagnostic imaging Mounted study casts. Joint assessment Surgeon/restortive dentist. Treatment plan Informed consent Medical assessment Psychological assessment

Psychological assesment:

www.indiandentalacademy.com 192 Psychological assesment


www.indiandentalacademy.com 193 Attitute. It is important to assess the patients attitude in relation to Reasons for treatment. Any psychological problems. Realism, regarding timing.

Reasons for treatment. :

www.indiandentalacademy.com 194 Reasons for treatment. Good candidates for treatment. Those with Funcitonal dificulties(poor mastication) Poor esthetics Poor candidates. Existing work has failed Those trying to gain “lost youth”

Psychological problems.:

www.indiandentalacademy.com 195 Psychological problems. Patients with problems of Psychogenic origin may become convinced that provision of a stable dental occlusion will cure their problems. Kiyak et al (1990) reported a correlation between high scores of neuroticism and less satisfaction with treatment results. Such patients should not be denied treatment but require more supportive therapy

Realism, regarding timing.:

www.indiandentalacademy.com 196 Realism, regarding timing. Usually there is a time gap between the placement of fixture and their use for supporting a prosthesis.

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www.indiandentalacademy.com 197 HISTORY CLINCAL EXAMINATION Diagnostic imaging Mounted study casts. Joint assessment Surgeon/restortive dentist. Treatment plan Informed consent Medical assessment Psychological assessment

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www.indiandentalacademy.com 198 Thank You www.indiandentalacademy.com Leader in continuing dental education

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