Dental Implant 1 /certified fixed orthodontic courses by Indian dental academy

Medical And
Pharmacological
Considerations In Implant
Supported Prosthesis

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INDIAN DENTAL ACADEMY
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Complications and loss of implants can be costly in
terms of time, psyc and financial resources.
Additionally it results in an edentulous space more
difficult to restore than prior to implant placement.
Therefore ability to reliably identify patients systemic
conditions with greater potential to implant failure
would be valuable.


Medical considerations


Evaluation of patient’s
systemic statusA thorough systemic checkup includes1. complete medical and dental history
2. physical examination
3. laboratory investigation


Medical historyA complete medical history must include1.
any history of medication usage within preceding 6
months
2.
any history of allergies
3.
Medical history related to systems of body i.e. CVS,
CNS, respiratory system, digestive system,
endocrine system, hematopoetic system, bones and
joints, malignancies, complete dental history along
with a consent statement.


Physical examinationIt includes1. complete extra oral and intra oral examination
2. palpation of submental, submandibular, parotid
and cervical areas for lymphadenopathy
3. vital signs- blood pressure, pulse, temperature,
respiration, weight and height

Laboratory evaluationIt should include
1. Complete blood cell count
white blood cell (WBC) count
red blood cell (RBC count)
2. Hemoglobin and Packed cell volume
3. Bleeding tests- platelet count, bleeding time,
prothrombin time ( PT), partial thromboplastin
time (PTT )

WBC countNormal values- 5000 - 10000/ml
Leucocytosis- infections, leukemic diseases, immune
diseases, allergies
Leucopenia- liver cirrhosis, anemia, viral infections
RBC countNormal valuesmale- 4.5 - 5 million/ml
females- 4 - 4.5 million/ml
HemoglobinNormal valuesmale- 13.5 - 18 g/dl
females- 12 - 16 g/dl
Lesser values- anemia

Packed cell volumeNormal valuesmale- 40 - 45%
females- 38 -42%
Lesser values- anemia


Bleeding testsPlatlet count-

Normal values- 2 - 4 lakhs / ml

Bleeding time-

Time interval from oozing of blood from a blood vessel
till the bleeding arrests.
Normal values- 3 - 6 minutes

Clotting time-

Time taken by the blood to clot after collecting from
blood vessels.
Normal values- 3 - 8 minute

Prothrombin timeTime taken for plasma to clot in presence of
exogenously added tissue thromboplastin and
calcium ions.
Test to check the extrinsic pathway i.e. factor 5, 7,
10
Normal values- 12-14 seconds


Partial thromboplastin timeTime taken for plasma to clot in presence of
exogenously added factor 12.
Test to check the intrinsic pathway i.e. factor 5,
8, 9,10, 11,12
Normal values- 26-32 seconds


Diabetes mellitusDiabetes mellitus is related to absolute or relative
insulin insufficiency.
2 types, Type-1 (IDDM) and Type – 2 (NIDDM)
It is most common endocrine disorders and one of the
leading causes of death.
An implantologist will confirm diabetes by presence of
glucose levels above 120mg/dl.

Currently number of diabetic patients has
exceeded 150 million all over the world.
Number of diabetic patients are expected
to be doubled by year 2025.


Prevalence in Indian population-

Rural population- 2.4% of adult population
Urban population- 4 – 11.6% of adult population is
diagnosed diabetic.


ComplicationsDiabetic patients show
1. Decreased collagen synthesis- delayed wound
healing
2. Impairment of leukocyte function
3. Increased susceptibility to infections
4. Increased incidence of perimplant diseases

5. Increased inflammatory tissue destruction as a
result of exaggerated production of inflammatory
mediators.
6. Increased alveolar bone loss , as reported by
Fiorellini et al ( in 2000 ) that bone and mineral
metabolism is altered in diabetics.

All potentially complicating factors during
implant surgeries.


Fiorellini et al (in 1990) in a study of 40 patients
found lower success rates in diabetic patients,
approximately 85%, but the authors concluded that
this was still a reasonable treatment outcome
potential. Most of the failures were in the first year
after loading.


Morris et al (in 2000) studied over 650 patients
with Type 2 diabetes and found only marginally
more failures than with nondiabetic patients. The
authors also found increased success with
hydroxyapatite (HA)–coated implants and the
use of chlorhexidine mouth rinses at the time of
surgery.
Kapur et al (in 2001) compared diabetics who
had moderate levels of metabolic control and
also concluded that implants could be used
successfully in diabetic patients. The type of
diabetes does not play any role in implant
therapies.

This was substantiated by Olson et al (in 2000), who
studied diabetics with implants over a 5-year period
that the duration of diabetes had an effect on implant
success. Greater failure rates were found in patients
who had diabetes for longer time periods.
However, no definitive length of time associated with a
diagnosis of diabetes has been established as a
guideline for treatment planning.
Payam et al (in 2004) studied 782 diabetic patients
and found implant success rate was 96.3% during the
healing period and 94.1% one year after surgery.

Dental implant managementHigh blood sugar levels are definite contraindication
for implant surgeries not the diabetic status of the
patient.
Diabetic patients are classified in 3 categoriesMild-

blood sugar level < 150 mg/dl

Moderate- blood sugar level < 200
mg/dl
Severemg/dl

blood sugar level >200

All surgical
procedures
to be
postponed

Protocol to be followed during implant
surgeryStress reduction protocol
Diet evaluation before and after surgery
Control of risk of infection- aseptic techniques and
proper antibiotic coverage
Insulin doses are adjusted to the half of routine doses
and oral hypoglycemic drugs are discontinued on the
day of surgery.
Use of corticosteroids must be avoided as it
adversely effects blood glucose levels.

Most serious complication for diabetic patients during
implant procedures is hypoglycemia.
It occurs as a result of
-excessive insulin levels or hypoglycemic drugs
-inadequate food intake
It is characterized by weakness, nervousness,
tremors, palpitations, sweating and if not attended can
lead to seizures, coma and death.
Hypoglycemia is treated by by giving sugar or glucose
orally and if not controlled IV dextrose solutions are
given.

Cardiovascular
diseases-


HypertensionA patient is classified as hypertensive when resting
systolic blood pressure is at or above 140 mm Hg or
mean diastolic blood pressure at or above 90 mm Hg.

Patients with essential hypertension are susceptible to
3 times as much coronary diseases and 4 times as
much cardiac failures. Apart from this most common
complication that is seen during implant surgeries is
excessive uncontrolled bleeding.


Prevalence in Indian
populationBetween the age of 20 – 60 years 59.9 males
and 69.9 females/ 1000 population in urban
areas
35.5 males and 35.9 females/1000 population in
rural areas.


Dental implant management-

All surgical
procedures
to be
postponed

Dental implant managementAnxiety greatly affects the blood pressure so a stress
reduction protocol is indicated for hypertensive
patients.
NSAIDS are commonly used postoperatively after
implant surgeries. Johnson et al ( in1994) and
Anderson et al ( in 1993 ) have reported reduced
efficacy of antihypertensive drugs when NASAIDS are
used after implant surgeries.
Therefore it is recommended that NSAIDS should be
limited to short therapy or other analgesic agents
should be used.

Angina pectorisIt is a symptomatic expression of temporary
myocardial ischemia.
Classical symptom is retrosternal pain which
often develops during stress or physical exertion
and radiates to shoulder, left arm, neck, palate
or tongue.


populationOver the age of 30 years 65.4 males and 47.8
females/1000 population in urban areas
22.8 males and 17.3 females/1000 population in
rural areas


Dental implant management• Premedication to relieve

anxiety
• Sedation preferred during
surgeries
• Supplemental oxygen
• Treatment should be done
with physician consent and
after hospitalization

Surgical procedures
contraindicated

Dental emergency kit should include nitroglycerine
tablets or spray while treating a patient with history of
angina.
During anginal attack- All dental treatments should be stopped
immediately
- Nitroglycerine is administered sublingually and
100% oxygen is given at 6L/ min.
- If the pain is not relieved in 8-10 minutes the
patient should be shifted to hospital.

Myocardial infarctionMyocardial infarction ( MI ) is prolonged ischemia
that causes irreversible injury to cardiac muscles.
Approximately 18-20% of patients with recent
history of MI will have recurrent MI attack, with a
high mortality rate of 40-70%.
If surgery is done within 3 months of MI, risk of
recurrent attack is 30%, if within 3-6 months, it is
15%. After 12 months the incidence of recurrence is
less than 5%.


Dental implant managementPremedication to relieve
anxiety
Sedation preferred during
surgeries
Supplemental oxygen
Treatment should be done
with physician consent
and after hospitalization
Surgical procedures
contraindicated


Subacute bacterial endocarditis
and valvular heart diseasesBacterial endocarditis is an infection of heart
valves or endothelial surfaces of heart.
Dental procedures causing transient bacterimia
are major cause of bacterial endocarditis, so a
implantologist should identify the patient at risk
and implement prophylactic procedure.


populationComprises of 3% of total deaths due to
cardiovascular diseases
In 1998 total no. of deaths in India due to RHD –
86000
Chances of RHD after streptococcal infection –
3%

Incidence of bacterial endocarditis

-

Surgical
procedures
contraindicated

Surgical
procedures
under
proper
antibiotic
coverage


Dental implant
managementIn patients of high risk of bacterial endocarditis
implant therapy is contraindicated, especially
those with limited oral hygiene or history of
stroke.
Patients in other category can undergo implant
treatment with adequate antibiotic prophylaxis.


Antibiotic prophylaxis to prevent
endocarditis


Tab 4-3


AnemiaIt is defined as a reduction in oxygen carrying
capacity of blood as result of decrease in number of
erythrocytes or abnormality of hemoglobin.
Normal values of hemoglobin areMales - 13.5 - 18 g/dl
Females - 12 - 16 g/dl
A patient is diagnosed as anemic when hemoglobin
values are below 10 g/dl.

ComplicationsBone maturation and development are impaired, so
bone needed to support implant is significantly
affected.
Prolonged and excessive bleeding .
Increased postoperative edema and discomfort.
Increased risk of postoperative infection.

PrecautionsMinimum base line recommended for surgeries is
10g/dl.
For majority of patients implant procedures are not
contraindicated.
Pre and post operative antibiotics
Aspirin should be avoided to relieve post operative
inflammation.

Osteoporosis and estrogen
statusOsteoporosis is age related disorder of bone
characterized by a decrease in bone mass,
increased micro architectural deterioration and
susceptibility to fractures.
Past the age of 60 almost 1/3 of the population has
this disorder and occurs in twice as many women as
man.


Role of estrogenEstrogen, a female sex hormone is secreted in large
quantities from ovaries and small quantities from
adrenal cortex (pregnancy - placenta ).
Estrogen plays a major role in bone metabolism by
increasing osteoblastic activity.
In menopause which results due to atrophy of
ovaries, either estrogen is not secreted or becomes
very scanty.

Osteoporosis in malesTestosteron also induces osteoblastic activity like
estrogen but the incidence of osteoporosis in
males is almost half in comparison to females .
It is because of –
Effect of testosteron in osteoblastic activity is
not as pronounced as that of estrogen.
Secretion of testosteron reduces slowly as the age
advances.

Bone metabolism is impaired with emphasis on
resorption, cortical plates become thinner,
trabecular bone pattern more discrete and
advanced demineralization occurs, thus as
reported by Jeffcoat et al ( in 2000 ) this patient
group exhibit reduced alveolar bone mass and
density.
Theoretically, osseous integration may be more
difficult to achieve.


However, established systemic osteoporosis does
not imply that a jaw bone is unsuitable for osseous
integration, nor is it an absolute contraindication to
implant therapy.
Dao et al (in 95) and Becker et al ( in 2000) in
studying the association between premenopausal
and postmenopausal women and implant failure, did
not find a higher failure rate for implants placed in
women older than 50 as compared with women
younger than 50 or between women and men older
than 50.

August et al (in 2001) examined jaw differences in preand postmenopausal women and found more failures
in postmenopausal women with maxillary implants, but
not mandibular implants.
The authors found that postmenopausal women not
taking hormone replacements had the highest failure
rates.
They reasoned that because osteoporosis affects
trabecular bone more than cortical bone and the
maxilla has more trabecular bone content than the
mandible, the maxilla is more susceptible to the
effects of systemic osteoporosis.

Minsk and Polson ( in 2000 ) studied postmenopausal
women undergoing hormone replacement therapy and
found that the combination of osteoporosis and
smoking did result in more implant failures.
Osteoporosis has been shown to result in loss of
periodontal attachment in natural tooth, but a similar
loss of peri-implant tissue has not been established.


Dental implant managementFor patients with extreme osteoporosis, it may
be wise to be cautious with maxillary implant
treatment planning .
Reduced bone density does effect the treatment
planning surgical approach, length of healing,
necessitates need of progressive bone loading
and hydroxyapatite coating on implants.
Daily calcium uptake up to 1500 mg/day pre and
post surgically.

Cancer and cancer
treatmentsPatients who have undergone tumor resection in
the oral region are some of the most difficult
patients to restore with conventional prosthetic
treatment modalities and these are the patients
who could benefit most from the placement of
endosteal dental implants.
However, there are concerns about the ability of
irradiated tissue to support osseous integration
and the effects of systemic chemotherapy on
bone quality.

Prevalence in Indian population-

Oral cancer comprises of 50 - 70 % of all
cancers diagnosed in Indian population as
compared to 2 – 3 % in USA or UK.
16.4 males and 8.8 females/ 1000 population.


Radiation treatmentThe oral effects of radiation treatment include
xerostomia, mucositis, hypovascularity, fibrosis,
hypoxia, and most seriously osteoradionecrosis,
all potential hindrances to implant treatment
success.
August et al (in 98) in a retrospective study,
concluded that past tumoricidal radiation is no
longer an absolute contraindication to implant
placement, but a reduced success rate usually
reported around 70% is seen.

To counteract the effects of radiation on bone
growth and remodeling, Granstorm et al ( in 1993)
and Larsen et al (in 1998) have suggested the use
of hyperbaric oxygen therapy to improve osseous
integration.
HBO increases the blood to tissue oxygen gradient
and improves the healing capacity of irradiated
tissue by stimulating capillary growth and
osteogenesis.
Treatment consists of breathing 100% pressurized
oxygen for approximately 90 minutes for about 20
sessions presurgery and 10 sessions postsurgery.

Albrektsson et al (in 1995) suggest that without HBO
therapy, implant surgery should be delayed for 12
months after radiation.
Weischer et al (in 2001) reported on a retrospective
study that include follow-up of irradiated patients for 9
years and concluded that irradiation does not
significantly affect osseous integration after HBO
therapy though they concluded that soft tissue
support should be avoided if possible, or at least
minimized, due to the complications associated with
poorer soft tissue healing.

ChemotherapyChemotherapy cancer treatment causes malnutrition
of osseous tissue, xerostomia, and mucosal
inflammation.
While implant integration during active chemotherapy
cannot be supported by available data, Steiner et al
( in 1998) reported on success in 1 patient who started
chemotherapy 1 month after having implants placed.


Kovacs (in 2002) reported on patients who had
previously received courses of 3 common
chemotherapeutic agents, but no radiotherapy
prior to implant placement. The author
concluded that there was no clinically significant
detriment to the success of implants in the
mandible over the study length, which averaged
3 years per patient.


ParafunctionParafunctional habits (clenching and bruxism)
have been identified as concerns in implant
treatment planning due to the increased
pressure on the implants, resulting in possible
metal fatigue and fracture and possible
surrounding bone loss.
Overload caused by either improper prosthesis
design or parafunctional habits is considered
one of the primary causes of late stage implant
failures.

However, Engel et al, ( in 2001 ) in a study of
379 patients who had worn implant retained
restorations for many years, found that
increased occlusal wear, usually an indicator of
the severity of a bruxism parafunction, had no
effect on implant integration and did not result in
an increased loss of bone around implants.


Rather than regarding excessive occlusal forces in
patients with parafunctional habits as absolute
contraindications, many authors have recommended
attempting to mitigate these forces.
Methods suggested include
Educating patients about habits and paying
diligent attention to occlusal contact design, ( Mc
coy in 2002 )
Placing increased number of implants ( Balsi et al
in 1996 ),

Avoiding the use of cantilevers
Using bruxism appliance therapy ( Perel in 1994 )
Increasing time intervals during the prosthetic
restoration stages to provide more opportunity for
progressive loading techniques, ( Misch 1999 )
Using acrylic resin teeth in the prosthesis ( Gracis in
1994 )


CorticosteroidsSteroids act in 4 different ways that affect implant
surgery- decrease inflammation and related
post operative pain and swelling
- inhibit protein synthesis and so delays
wound healing
- inhibits leucocytic functions thus
increased chances of infections
- causes adrenal suppression

Cranin ( in 1995) concluded long-term use of
corticosteroids generates a systemic loss of bone
mass.
Fujimoto et al (1998 ) studied Osseo integrated
implants in rabbits and found that systemic
corticosteroids had less effect on the integration of
titanium implants in the mandible than in other
skeletal bones.
Steiner et al ( in 2000) concluded that prolonged
use of corticosteroids is not a contraindication to
the placement of implants.

Dental implant managementOn basis of severity of adrenal suppression patients
are classified in –
1. Mild –steroid therapy ended 1 year prior to surgery
2. Moderate - were on steroid therapy in preceding
year to surgery
3. Severe- on steroid therapy at the time of surgery

Protocol to be followed in these patients is as followsOn the day of surgery- prednisone up to 60 mg
Second day of surgery- dose is reduced to half
Third and consecutive days- dose is slowly reduced
down


This regimen is necessary because due to steroidal
gland suppression, body is unable to produce
additional natural steroids which are essential to
fight stressful conditions like implant surgery.
Antibiotic follow-up by amoxycillin or clindamycin
for 3-5 days


HyperparathyroidismAdvanced stages of hyperparathyroidism show
bony lesions in form of altered trabecular pattern
and ground glass appearance of involved area.
Implants are contraindicated if bony lesions are
present in the region of implant placement.


Fibrous dysplasiaA disorder where fibrous connective tissue
replaces areas of normal bone.
Implants are contraindicated in the region of
disorder as lack of bone and increased fibrous
tissue decreases rigid fixation of the implant.


Pagets diseaseIt is a chronic bone disease characterized by
increased osseous vascularity and osteoclastic
activity in bone.
Radiographically characterized by cotton wool
appearance of bony lesion.
Implants are contraindicated in the region of
disorder.

Other diseasesThere have been case reports of the successful
placement of implants in patients with a wide variety
of systemic conditions that could potentially affect
biologic functions, particularly healing mechanisms.
These diseases include scleroderma, Sjogren’s
syndrome, HIV infection, multiple myeloma,
chronic leukemia, pemphigus vulgaris, and
hypohidrotic ectodermal dysplasia.

TobaccoPatients who smoke have an increased risk for
occurrence and severity of periodontal disease. Also,
the deleterious effect of smoking on wound healing
after tooth extraction is well documented.
Therefore, the negative effect of tobacco use on
implant success should be expected, and indeed this
is established by several studies.
Various cohort and clinical trials done in last decade
consistently rate smoking as a primary patient
centered risk factor for implant loss.

Local and systemic effects of
smoking-

Cigarette smoke has various effects on implants either
locally and systemically.
Local effects are regulated by cytotoxic and
vasoconstrictive substances within smoke such as
nicotine.
Systemically it adversely affects the immunologic
response and results in a disturbance of peripheral
and oral neutrophill function. It also causes direct
vasoconstriction, and limited production of antibodies.
Krall ( in 1991) reported association of smoking with
decreased calcium absorption.

Specifically, rather than affecting the process of
integration, the negative effect of smoking
seems to occur after second-stage surgery.
Gorman et al ( in 1996) in a study of patients
receiving over 2000 implants, found significantly
more failures in smokers after second-stage
surgery.
Success in smokers was increased by use
of presurgical antibiotics and HA-coated
implants.

Hass et al ( in 1998 ) reported that smoking has
been associated with an increased incidence of
peri-implantitis.
After implant uncovering, smokers
tend to have faster rates of peri-implant bone
loss, especially in the first year, compared with
nonsmokers or patients who have stopped
smoking.


Lambert et al (in 2000) conducted a longitudinal
study to assess the influence of smoking in a group
of patients with over 2900 endosteal dental
implants. The results showed more failures after
the second stage of surgery.
The authors theorized that the effect of
tobacco on healing after implant placement is
different from that after tooth extraction because
implant wounds are closed, and the intimate
adaptation of the implant to the bone tissue does
not allow the same magnitude of interference in
healing by the vasoconstrictive nature of nicotine

In general, smoking appears to have a greater impact
for maxillary implants than for mandibular implants.
De Bruyn and Collaert ( in 1996) in a retrospective
study of over 200 implants, found that prior to loading,
there was a difference in success rates in smokers
between maxillary and mandibular implants. Maxillary
success rates were adversely affected, but those in
the mandible were not.
Haas et al ( in 1998) found peri-implantitis significantly
worse in the maxilla in smokers than in nonsmokers.

Kan et al ( in 2000 ) in a study of 60 implant patients
reported the reduced success of implants placed into
grafted maxillary sinuses, regardless of the amount
smoked
In addition, smoking is known to reduce systemic bone
density, and correspondingly, there is an increased
incidence of poorer bone quality.
Bain and Moy ( in 1996) found that the prevalence of
Type IV bone was twice as high among heavy
smokers as compared with nonsmokers or even light
smokers.

Lemon et al (in 1997) also reported smokers
have significantly higher levels of Type IV bone
Schwartz-Arad et al (2002) studied the
complications of smoking in patients with
implants and found a greater incidence of post
operative complications in smokers.
Levin et al ( in 2004) in their study including 145
onlay bone grafts and sinus lift surgeries
concluded that chances of graft rejection and
other surgical complications were almost double
in smokers when compared to non smokers.

The protocol suggested by Bain ( in 2000 )
should be followed, which advises patients to
cease smoking for a minimum of 1 week prior
to and at least 8 weeks after implant surgery.

1.
2.
3.

Apart from this according to Misch
sufficient healing time should be provided
progressive bone loading
antibiotic prophylaxis
should be implemented.

The oral burn syndromeCullen ( in 1998) reported on the deleterious
effects to soft tissues around implants after the
ingestion of hot foods and liquids.
He termed this effect the oral burn syndrome.
Similar to the known harmful effect of overheating
bone during the placement of implants.
Cullen theorized that the amount of metal in
implants hastens the transfer of heat to supporting
tissue and that this is a significant factor of
implant complications.

Alcoholism and implantsBone metabolism is affected by alcohol
consumption because1.
It inhibits osteoblastic proliferation.
2.
Resorption rate is accelerated by increased
osteoclastic activity.


Weyant et al ( in 1994) after a 5 year study of
implant patients reported that abuse of alcohol
was a risk factor for poor implant healing and
eventual failure.
Samuel et al ( in 2004) found that percentage of
direct bone to implant contact is significantly less
in alcoholic population than the nonalcoholic
one.
Karina et al ( in 2004) reported that in their
animal study there was significant delay in
reparative bone formation after implant
placement.

The cluster phenomenonWhile none of the conditions discussed above are
absolute contraindications to implant therapy, a
combination of risk factors might be.
Ekfeldt et al ( in 2001 ) studied a group of implant
patients who had multiple implant failures, in the
hope of identifying patients at risk before treatment.


They concluded that while no one risk factor was
critical, a combination of several factors such as
diabetes, osteoporosis, ongoing medications,
parafunctional jaw movements, and heavy
smoking habits could provide a contraindication.
The authors termed the occurrence of implant
failures due to combination of many risk factors
as ‘‘cluster phenomenon.’’


Pharmacological
considerationswww.indiandentalacademy.com

Management of
postoperative painAfter surgery pain and inflammation commonly
occur, and multiple strategies both pharmacological
and behavioral are essential to optimize patient
comfort.


Non opiod analgesics
(NSAIDS)Arachidonic acid ( a product released in response to
tissue injury ) in presence of cyclooxygenase
produces a variety of biologically active factors as
prostaglandins, prostacyclins, thromboxane and
leucotrines.
These factors along with bradykinin and histamin play
a major role in initiation of inflammation.
NSAIDS primarily inhibits synthesis of prostaglandins
from arachidonic acid.

NSAIDS are also used before or immediately
following surgery to diminish postoperative
inflammation.
Agents most commonly studied are
acetaminophen and ibuprofen.
Aspirin can significantly alter normal hemostasis
it is not used for prophylactic therapy.

Jeffcoat et al ( in 1999 ) studied the use of a 3-month
course of NSAIDs for patients receiving dental
implants and reported that 100 mg of flurbiprofen
taken twice daily resulted in less bone loss in the
immediate postloading period. The higher level of
bone was maintained for the first year after initial
surgery.


Prostaglandin E2 is stimulus for bone resorption,
NSAIDS which inhibit prostaglandinE2 synthesis may
play a major role in implant dentistry.
Investigations are under way of newer NSAIDS as
flurbiprofen for use as adjunctive therapy to slow bone
loss and to enhance osseointegration.


Opiod analgesicsThere are no analgesic agents more efffective
than opioids in releiving severe acute pain.
Most commonly used opioids are
morphine ( 10 mg IM ) and
codeine (60 mg PO ).


Management of patient with
severe and moderate pain-


Management of post
operative swellingNSAIDS may be used pre operatively and
postoperatively to limit postoperative swelling but
these are not very effective in managing postoperative
swelling.
Effectiveness of glucocorticoids is well established in
managing postoperative inflammation.
Skjelbred and loken ( in 1998) have reported when
corticosteroids were injected 3 hrs prior to oral
surgeries, swelling was reduced to 47% than without
use of steroids. www.indiandentalacademy.com

Factors
before

to be considered
steroid therapy-

Chosen steroid should have minimal mineralocorticoid
effect.
Should be administered before surgery, allowing
ample time for drug distribution.
Should be given preferbly in morning when cortisol is
naturally released by the body.
Post operative regimen should not exceed 3 days.
Should always be administered along with antibiotic
coverage.

Corticosteroid regimen for
managing postoperative swelling-


Antimicrobial agentsAntibiotics are used not only to treat existing infections
but also used to prevent infection following surgeries.
Routine surgical prophylaxis by antibiotics is
controversial. It may be effective in some cases, but
rapid emergence of antibiotic resistant bacterial strains
makes it questionable to use them frequently.
Leviner et al (in 1994 ) reported development of
resistant streptococcus viridans after administration of
prophylactic antibiotics. They concluded that it can
compromise long term success of implants.

Nevertheless antibiotic prophylaxis is indicated
in following conditionsImmunocompromised status of the patient
Patients at the risk of developing bacterial
endocarditis
When lengthy surgical procedures are
expected


Suggested antibiotics for implant
related infections-


Two way approach to select
antibiotics to treat implant related
infections-


Antibiotic prophylaxis to prevent
endocarditis-


Seative anxiolyticsUse of anxiolytics is a valuable adjunct during
meticulous surgeries required for implant
placement.
Benzodiagepines are drug of choice as
anxiolytics because of their greater therapeutic
index. These act by inhibiting benzodiazapine
receptors which potentiate generalized
depressant effect of GABA.

BENZODIAZEPINES- DOSES



Diazepam- 10-20 mg PO
Lorazepam- 2-4 mg PO
Triazolam- 0.25-0.5 mg PO


References

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

Contemporary implant dentistry, second edition, Carl
E.Misch
Dental clinics of north America 50,2006
American dental association council of scientific affairs.
Dental implants. J am dent assoc 2004;135
Smoking and complications in dental implants, 19, 2004,
Int J Oral Maxillofac Implants
Implants in HIV patient, 19, 3, 2004, Int J Oral Maxillofac
Implants
Dental implants in patients with type 2 diabetes mellitus;
aclinical study. implant dentistry, 12, 2003

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Bragger U, Aeschlimann S, Burgin W, Hammerle CH,
Lang NP. Biological and technical omplications and
failures with fixed partial dentures (FPD) on implants and
teeth after four to five years of function. Clin Oral
Implants Res 2001;12:26-34.
Quirynen M, De Soete M, van Steenberghe D. Infectious
risks for oral implants: a review of the literature. Clin Oral
Implants Res 2002;13:1-19.
Fiorellini JP, Chen PK, Nevins M, Nevins ML. A
retrospective study of dental implants in diabetic
patients. Int J Periodontics Restorative Dent
2000;20:366-73.
Iacopino AM. Diabetic periodontitis: possible lipidinduced defect in tissue repair through alteration of
macrophage phenotype and function. Oral Dis
1995;1:214-29.














Morris HF, Ochi S, Winkler S. Implant survival in patients with
type 2 diabetes: placement to 36 months. Ann Periodontol
2000;5:157-65.
Shernoff AF, Colwell JA, Bingham SF. Implants for type II
diabetic patients: interim report. VA Implants in Diabetes Study
Group. Implant Dent 1994;3:183-5.
Kapur KK, Garrett NR, Hamada MO, Roumanas ED, Freymiller
E, Han T, et al. A randomized clinical trial comparing the
efficacy of mandibular implant-supported overdentures and
conventional dentures in diabetic patients. Part I: methodology
and clinical outcomes. J Prosthet Dent 1998;79:555-69.
Olson JW, Shernoff AF, Tarlow JL, Colwell JA, Scheetz JP,
Bingham SF. Dental endosseous implant assessments in a
type 2 diabetic population:a prospective study. Int J Oral
Maxillofac Implants 2000;15:811-8.
Dao TT, Anderson JD, Zarb GA. Is osteoporosis a risk factor for
osseointegration of dental implants? Int J Oral Maxillofac
Implants 1993;8:137-44.
Friberg B, Ekestubbe A, Mellstrom D, Sennerby L. Branemark
implants and osteoporosis: a clinical exploratory study. Clin
Implant Dent Relat Res 2001;3:50-6.











August M, Chung K, Chang Y, Glowacki J. Influence of
estrogen status on endosseous implant osseointegration. J
Oral Maxillofac Surg 2001;59:1285-9.
Barasch A, Safford M, Eisenberg E. Oral cancer and oral
effects of anticancer therapy. Mt Sinai J Med 1998;65:370-7.
Garg AK, Malo M. Manifestations and treatment of
xerostomia and associated oral effects secondary to head
and neck radiation therapy. J Am Dent Assoc
1997;128:1128-33.
Granstrom G, Jacobsson M, Tjellstrom A. Titanium implants
in irradiated tissue: benefits from hyperbaric oxygen. Int J
Oral Maxillofac Implants 1992;7:15-25.
Larsen PE, Stronczek MJ, Beck FM, Rohrer M.
Osteointegration of implants in radiated bone with and
without adjunctive hyperbaric oxygen. J Oral Maxillofac Surg
1993;51:280-7.











Kovacs AF. Clinical analysis of implant losses in oral
tumor and defect patients. Clin Oral Implants Res
2000;11:494-504.
Kovacs AF. Influence of chemotherapy on endosteal
implant survival and success in oral cancer patients. Int J
Oral Maxillofac Surg 2001;30:144-7.
Heckmann SM, Heckmann JG, Weber HP. Clinical
outcomes of three Parkinson’s disease patients treated
with mandibular implant overdentures. Clin Oral Implants
Res 2000;11:566-71.
Laskin DM, Dent CD, Morris HF, Ochi S, Olson JW. The
influence of preoperative antibiotics on success of
endosseous implants at 36 months. Ann Periodontol
2000;5:166-74.
Abdulwassie H, Dhanrajani PJ. Diabetes mellitus and
dental implants: a clinical study. Implant Dent
2002;11:83-6.











Bergendal B. Prosthetic habilitation of a young patient with
hypohidrotic ectodermal dysplasia and oligodontia: a case
report of 20 years of treatment. Int J Prosthodont
2001;14:471-9.
Ekfeldt A, Christiansson U, Eriksson T, Linden U, Lundqvist
S, Rundcrantz T, et al. A retrospective analysis of factors
associated with multiple implant failures in maxillae. Clin
Oral Implants Res 2001;12:462-7.
Lambert PM, Morris HF, Ochi S. The influence of smoking
on 3-year clinical success of osseointegrated dental
implants. Ann Periodontol 2000;5:79-89.
Schwartz-Arad D, Samet N, Samet N, Mamlider A. Smoking
and complications of endosseous dental implants. J
Periodontol 2002;73:153-7.
Wallace RH. The relationship between cigarette smoking
and dental implant failure. Eur J Prosthodont Restor Dent
2000;8:103-6.

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