1 / 249

Prevention and Management Of Complications In Implant Dentistry

Prevention and Management Of Complications In Implant Dentistry. Evidence Based Medicine / Dentistry. EBM is the conscientious, explicit and judicious use of best evidence in making decisions about care of individual patients. Cochrane Center Oxford, England.

zalika
Download Presentation

Prevention and Management Of Complications In Implant Dentistry

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Prevention and Management Of Complications In Implant Dentistry

  2. Evidence Based Medicine / Dentistry EBM is the conscientious, explicit and judicious use of best evidence in making decisions about care of individual patients. Cochrane Center Oxford, England

  3. 3 Components of Evidence Based Dentistry 1) Scientific Literature 2) Professional Experience and advise 3) Patient’s treatment desire and goal

  4. “Train The Brain” Dr. Mark H.E. Lin

  5. Host / Patient Related: Medical Status AbsoluteContraindications to Surgery Relative Contraindications / Risk Factors to Surgery • Susceptibility to Infections and healing response in question

  6. Host / Patient Related: Medical Status: Absolute Contraindications For Surgery (Dental alveolar, implant, hard or soft tissue grafting) • Debilitating diseases: • Active cancer • chemotherapy • radiation therapy • transmittable infections- hepatitis, HIV • Impaired healing capacity diseases: • Uncontrolled diabetes • Uncontrolled hypertension • immune compromised disease • history of osteomylitis in operative site

  7. Host / Patient Related: Medical Status: Absolute Contraindications • Recent myocardial infarction (M.I.), cerebrovascular accident, uncontrolled clotting / bleeding disorders • Pregnancy • Chronic or severe alcoholism • Drug abuse • Psychiatric disorders • I.V. bisphosphonate use or long term oral bisphosphonate • Uncontrolled periodontal disease • ASA IV or V patients

  8. Host / Patient Related: Medical Status: Relative Contraindications / Risk Factors For Surgery (Dental alveolar, implant, grafting) • Debilitating diseases: Inactive cancer • Impaired diseases: Controlled diabetes, controlled hypertension • Myocardial infarction (M.I.) history of >1 year • Oral bisphosphonate • Smoking habits • Periodontal disease

  9. American Society of Anesthesiologists (ASA) Classifications ASA I: a normal, healthy patient, without systemic disease. ASA II: a patient with mild to moderate systemic disease. ASA III: a patient with severe systemic disease, which limits or alters activity but is not incapacitating. ASA IV: a patient with severe systemic disease, which is incapacitating and is a constant threat to life. ASA V: a moribund patient not expected to live more than 24 hours without an operation.

  10. Elective Implant surgeries are NOT indicated for ASA IV or V patients

  11. For a patient at risk, strict adherence to the standard protocol does not always yield the expected results.

  12. Infection Invasion and multiplication of microorganisms in body tissues, which may be clinically inapparent or result in local cellular injury due to competitive metabolism, toxins, intracellular replication, or antigen-antibody response. Dorland’s Illustrated Medical Dictionary 27th, Edition

  13. Factors Associated with Increased risk of infection for dental implant procedures Systemic Factors • Diabetes • Long term corticosteroid use • Immunocompromised systemic disorders • Smoking • Malnutrition, obesity • Elderly population • ASA III or IV classifications

  14. Factors Associated with Increased risk of infection for dental implant procedures Local Factors • Use of type or procedures of graft material • Generalized periodontal disease • Tissue inflammation • Odontogenic infections • ill-fitting provisional prosthesis • Incision line opening • Inadequate oral hygiene

  15. Factors Associated with Increased risk of infection for dental implant procedures Surgical Factors • Poor aseptic technique • Compromised skill and experience of the surgeon • Increased duration of surgical time • Wound contamination during surgery • Foreign body introduction (graft material, implants, debris, etc….)

  16. Infection Prophylaxis • Aseptic Surgical techniques applied during all clinical grafting procedures. 2) Pre-operative Rx: Amoxicillin 500mg x 4 tablets (2 g), 1 hour prior to surgery (Scientific Evidence) Post-operative 1 tablet t.i.d. for 1 week following surgery (Optional)

  17. Infection Prophylaxis 3) Chemical Plaque control: Preoperative rinsing with .12% Chlorhexidine digluconate for 1 minute. Postoperative rinsing for 2-3 weeks with good oral hygiene. • 4) Monitor and close follow up: • Patient to return to clinic at 1-2 weeks to evaluate healing status.

  18. Infection Prophylaxis 5) Confirm lack of localized infection from adjacent tooth (endodontic origin) or soft tissues (periodontitis) spreading into grafting site.

  19. Diabetes • Higher prevalence in Adult African Americans, native and Hispanic Americans • Risk factors: Genetics, obesity, advancing age and inactive lifestyles. • Characterized by: • Peripheral resistance to insulin • Increased production of glucose by the liver • Altered pancreatic insulin secretion.

  20. Oral Manifestations for a Diabetic Patient • Poor wound healing (soft tissues, osseointegration) • Higher susceptibility to oral infections • Xerostomia • Higher incidence of dental caries • Pronounced hyperplasia of attached gingival • Increased accumulation of plaque and food debris • Neuropathy (burning mouth, tingling, numbness) • Greater incidence and severity of periodontal disease • Candidiasis and lichenoid reactions

  21. Signs of Hypoglycemia: • Sweating • Palpitations • Tachycardia • Nausea • Hunger • Tremulousness • The symptoms may progress to coma and convulsions without intervention.

  22. Management of type I diabetic patients: (To prevent Insulin shock) • Patient instructed to take their usual dosage of insulin medications • To eat a normal meal prior to appointment • Schedule the appointment early in the morning • Patient to communicate with dentist if they feel symptoms of an insulin reaction • A source of sugar available in office (orange juice, candy, sugar packs) • May consider Antibiotic prophylaxis coverage to prevent infections which is related to the fasting blood glucose levels.

  23. Dental Managements • Minimize stress • Decrease risks of infection (Post operative antibiotics: Amoxicillin 500 mg, t.i.d. or Clindamycin 300 mg, t.i.d. for 7-10 days) • Avoid untoward metabolic imbalances during dental therapy • Instructions for diet and medications to avoid hypoglycemia.

  24. Management of Hypoglycemia • Sugar source readily available (sugar packets, candy, orange juice) • Dextrosol 3mg tablets of glucose • Glucagon 1 mg IM • 50% Glucose solution 50 ml IV

  25. Bisphosphonates Induced Osteonecrosis of the Jaws (ONJ) Defined as a non healing bone in the mandible or maxilla present for 8 weeks in a person that is on Bisphosphonates and hasn’t received radiation to the jaws.

  26. Risk of osteonecrosis of the jaws • Exposed bone is dead with usually no pain. • Pain may occur due to secondary infection • The jaw bones are susceptible because the jaw bone remodels 10 times that of long bones in the body.

  27. Bisphosphonates • Used for treatment of osteoporosis, metastatic bone cancer and Paget’s disease. • Oral form: Fosamax, Boniva, Actinol • IV form: Aredia, Zonita

  28. Mechanism of Bisphosphonates • Mechanism of action by suppressing and reducing bone resorption by osteoclasts. • Bisphosphonates inhibit osteoclasts by killing them when they take up the drug during resorption. • Bisphosphonates binds to the hydoxyapatite in the bone

  29. Bisphosphonates • IV medications are worse then oral types. • Risk increase after being on oral medications for > 3 years. • IV takes 6 months to build to toxic level • Oral takes 3 years to build to toxic level • 140 IV reported cases versus 40 Oral cases • Incidence: IV: .8%-12% • Incidence: Oral: .01%-1%

  30. Signs of ONJ • Sclerosis and thickening of the lamina dura • Widening of the periodontal ligament (PDL) • Mobile teeth with pain • Exposed bone with necrosis of bone and soft tissues • Non healing bone post surgical wound

  31. Treatment of ONJ • We don’t know what is the best treatment protocol. Dr. Robert Marx seems to be the expert on this topic. • Peridex rinse over surgical wound • Antibiotics: a) Pen VK b) Levoquin (limit to 21 days due to liver toxicity) • Reduce risk of secondary infections and osteomylitis of the jaws. • 50 % of cases will spontaneously heal. • 50 % of cases will require additional surgeries.

  32. Prevention of ONJ • Non invasive dental procedures are safe. • Invasive dental procedures safe before 3 years. • After 3 years- a drug holiday with consent of prescribing physician to a CTX of >= 150 pg/ml.

  33. Serum C terminal telopeptide test (CTX) • After 3 years of Bisphosphonate use, need a CTX to determine safety level. • CTX <= 100 pg/ml: HIGH risk • CTX = 101-150 pg/ml: Moderate risk • CTX >= 150 pg/ml: Low risk • CTX improves significantly with discontinued oral Bisphosphonates use. • CTX is a marker for bone turnover and healing. • Measures osteoclast function as a C terminal fragment is cleaved during bone resorption.

  34. Suggested Treatment Regimen • 1) Obtain references for CTX level • 2) Drug holiday of 4-6 months with approval from prescribing physician. • 3) Treat with Peridex (.12%) and antibiotics. • 4) Monitor CTX until value is >150 pg/ml • 5) Decide to refer or monitor for treatment options: A) Spontaneous resolution B) Treat surgically

  35. Host / Patient Related: Psychological Status • Psychological and mental stability for patient to accept and tolerate required procedures • Normal healing response and sequelae of bone and soft tissue grafting procedures • The 3 “C’s” prior to treatment: a) Communication b) Compliance c) Consent

  36. Host / Patient Related: Normal healing response and sequelae of bone and soft tissue grafting procedures are: • Hemorrhage / bleeding • Ecchymosis / bruising • Pain / discomfort • Swelling

  37. Hemorrhage / bleeding Management 1) Management of intra operative bleeding source (soft tissue / bone) prior to suturing. 2) Proper soft tissue suturing techniques to ensure primary closure without tension of soft tissues. 3) Proper use of sterile gauze pads with moistened sterile saline solution with FIRM pressure over wound for 20 minutes. 4) Oral and written instructions for care to prevent vasoactive substance (caffeine or alcohol), minimize exercise, post operative care to minimize disturbance to wound clotting, oral hygiene instruction care.

  38. Ecchymosis (Bruising) • Due to extravasation and subsequent breakdown of blood in the subcutaneous tissues. • Deposition of blood from the surgery in the interstitial tissues spaces and will be resorbed over a time period of 1-3 weeks. • Occurs more in fair skinned patients and elderly patients with fragile capillaries.

  39. Ecchymosis Management 1) Inform patient that it will be a normal sequelae of any surgical procedure. 2) Inform patient that degree of bruising is NOT an indicator of success / failure, traumatic / atraumatic nature of procedure or operator. 3) Application of ice bag or cold packs immediately after surgery for 2 days.

  40. Pain / discomfort Management • Long term Local anesthetics: • Bupivacaine (Marcaine / Vivacaine): 0.5% w 1:200,000 epinephrine used for block anesthesia. Duration time of 6-8 hours. • Articaine (Ultracaine Forte / Astracaine): 4% w 1: 200,000 epinephrine. Duration time of 4 hours. • Analgesics: • a) NSAIDS: Ibuprofen 400mg (600-800mg if anticipate swelling), 1 hour prior to surgery, then 1 tablet every 6-8 hours continuous for 2-3 days. • b) Narcotics: Tylenol #3, 1-2 tablets every 4-6 hours as required for pain relief.

  41. Swelling Management 1) Application of ice bag or cold packs immediately after surgery for 2 days. 2) I.V. administration of glucocorticoid steroids (prednisolone 250mg or dexamethasone 8 mg) prior to start of surgery. 3) I.M. administration of Dexamethasone / Decadron (Celestone Soluspan Injectable)6mg/per site adjacent to surgical wound. • P.O. prescription of Dexamethasone (Decadron) 4 mg with regimen as follows: • Preoperative 4mg x 2 tablets = 8 mg, 1hour prior to surgery • Postoperative 4mg x 1 tablet = 4 mg, 1st day after surgery • Postoperative 4mg x .5 tablet = 2 mg, 2nd day after surgery • Postoperative 4mg x .5 tablet = 2 mg, 3rd day after surgery

  42. Complication A secondary disease or condition aggravating an already existing one. Dorland’s Illustrated Medical Dictionary 27th, Edition

  43. Complication Defined as a secondary condition that developed during or after implant surgery or prosthesis placement. The occurrence of a complication does not necessarily indicate that substandard dental care was provided and also does not necessarily mean that clinical failure has occurred.

  44. Sequelae Any lesion, condition, consequence or affection following a clinical procedure injury or caused by an attack of previous disease. Dorland’s Illustrated Medical Dictionary 27th, Edition

  45. a) Communication Share or exchange information, news, or ideas Oxford Dictionary 10th Edition Allocate appropriate amount of TIME to educate and communicate prior to consent to treatment. Utilize patient education video, documents and software to aid in communication process.

  46. b) Compliance Disposed to agree with others or obey rules, especially to an excessive degree. Meeting or in accordance with rules or standards. Oxford Dictionary 10th Edition A quality of yielding to pressure or force without disruption, or an expression of the measure of the ability to do so. Dorland’s Illustrated Medical Dictionary 27th, Edition

  47. COMPONENTS OF CASE MANAGEMENT FOR IMPROVED CASE ACCEPTANCE RATE New Patient Telephone Interview New Patient First Appointment Interview/ Consultation Interview Diagnostic Records Appointment - Consult with Specialists and Labs Case Presentation(Within 1 Week), (Bring Spouse) Acceptance Pending Pre-Appointment Work Up -Pre Medications -Inform Consents -Financial Arrangements Confirmed -Diagnostic Work Up -Q/A Period Case Discussion Letter Follow Up Report(1wk, 2 wks, 1 months) Post Treatment Interview -Follow Up photos for Patients B/A -Request for Testimonial Letter -Referral Request Treatment

  48. c) Consent Process • Communication and patient education • Process of informed consents and financial arrangements confirmed • Relationship and rapport development with patients • Continuous monitoring support, empathy and sincere compassionate care

  49. Consequences of Smoking on wound healing • Arteriolar vasoconstriction reduces vascularization and microcirculations of tissues. • May lead to increase incidence of flap necrosis and dehiscence to early graft exposures. • Tobacco's toxic byproducts have been implicated as risk factors for impaired healing.

More Related