PROSTHETIC CONSIDERATIONS IN MEDICALLY COMPROMISED PATIENTS

1. PROSTHETIC CONSIDERATIONS IN
MEDICALLY COMPROMISED
PATIENTS
PRESENTED BY:-
DR. ARATI
1ST YEAR MDS

2. CONTENTS
 Introduction
 Definition
 Systemic diseases
Conclusion
 Reference

3. INTRODUCTION
PHARMACOLOGY :-
Greek: Pharmacon – Drug
Logos – science
- ‘ Pharmacology is the science of drugs. In broad sense, it deals with interaction of exogenously
administered chemical molecules (drugs ) with living systems’.
DRUG :- ( Drogue – a dry herb in French )
- ‘A Drug is any substance or product that is used or intended to be used to modify or explore
physiological systems or pathological states for the benefit of the recipient.’

4. CARDIOVACULAR DISEASES

5. ANGINA PECTORIS
CLINICAL FEATURES :
Chest pain
Discomfort
Dyspnea on exertion
MANAGEMENT :
Identification & control of risk factors
Careful assessment of the extent & severity of the disease
Sublingual Nitroglycerine – 0.3mg
‘Ca’ channel blockers – moderate or severe angina

6. DENTAL MANAGEMENT :
Mild Angina – normal protocol
Moderate Angina – Physician’s consultation
normal protocol
prophylactic nitroglycerine
Severe Angina – treatment under hospitalization

7. MYOCARDIAL INFECTION
Partial or total occlusion of one or more of coronary arteries due to an atheroma,
thrombus or emboli resulting in cell death (infarction) of the heart muscle.
Irreversible myocardial damage as a result of prolonged ischemic injury.
CLINICAL FEATURES :
Severe chest pain
Dyspnea
Palpitations
Tachycardia
Hypotension
Oliguria

8. MANAGEMENT :
MEDICAL MANAGEMENT :
History
Immediate measures – high flow oxygen
IV analgesics
ECG monitoring
Defibrillation
Aspirin (75 – 300 mg)
Thrombolytic therapy
DENTAL MANAGEMENT :
 < 6 months post MI – defer the treatment
 6 months - 1 year – normal protocol
1) physician’s consultation
2) minimization of stress
adjunctive sedation therapy
3)Short, morning appointment

9. DENTAL IMPLANT MANAGEMENT
Avoid excessive amounts of epinephrine both in LA and retraction cord
if highly suspected a MI
MONA : Morphine, Oxygen, NTG, Aspirin

10. SUBACUTE BACTERIAL ENDOCARDITIS
•Bacterial infection of the endocardial surfaces & certain arteries
•Susceptibility: -
–Congenital / rheumatic heart disease
–Congenital anatomic heart defect
–Cardiac surgery

11. •Types of endocarditis: -
–Acute bacterial endocarditis:
• Characterized by high fever & chills
• Usually of a previously normal heart valve with a highly virulent organism.
• Progressive valve destruction and metastatic infection developing in days to week
• Staphylococcus aureus
• Death – cardiac failure
–Subacute bacterial endocarditis: -
• Mild toxic
• Presentation over weeks to months
• Pyrexia, malaise, anorexia, weight loss, arthralgia
• Petechiae on oral mucous membrane, conjunctivae & skin of the wrist & ankles
• Streptococcus viridans

12. The Endocarditis prophylaxis are recommended for procedures like dental
implant placement, sub gingival placement of antibiotic fibers or strips.
The Endocarditis prophylaxis not recommended for the placement of removable
prosthodontic appliances and making oral impressions

13. Prophylactic regimen for dental procedures in patients who are
at risk*
Drug standard regimen Dosing regimen
Amoxicillin
Patients allergic to
Amoxicillin/Penicillin:-
Erythromycin
Clindamycin
3.0gm orally 1 hr. before procedure;
then 1.5gm 6 hrly after initial dose.
Erythromycin ethylsuccinate 800mg
or erythromycin stearate 1.0gm orally
2hr before procedure; then half the
dose 6 hrly after initial dose.
300mg orally 1hr before procedure
and 150mg 6 hrly after initial dose.
Felpel P. Leslie -Part II, JPD, 77(3); 1997.

14. Alternate prophylactic regimens for dental procedures in
patients who are at risk
Drug Dosing Regimen
Patients unable to take oral
medications:- Ampicillin
Patients allergic to ampicillin/
amoxicillin/ penicillin and unable to
take oral medications:- Clindamycin
Intravenous or intramuscular
administration of ampicillin, 2.0gm,
30 min before procedure; then
intravenous or intramuscular
administration of ampicillin 1.0gm or
oral administration of amoxicillin
1.5gm 6 hrly after initial dose
Intravenous administration of 300mg
30 min before procedure and an
intravenous or oral administration
150mg 6hr after initial dose

15. HYPERTENSION
Abnormal elevation of resting arterial systolic blood pressure above 140 mm Hg and/or
elevation of diastolic blood pressure above 90 mm Hg
Essential hypertension is high blood pressure that doesn't have a known secondary
cause. It is also referred to as primary hypertension.
 Secondary hypertension (secondary high blood pressure) is high blood
pressure that's caused by another medical condition.
The 7th Report Of The Joint National Committee On Prevention,detection,evaluation And Treatment Of High Blood Pressure ( JNC 7 ), Dec 2003

16. MANIFESTATION OF HYPERTENSION
 Extra oral manifestation of antihypertensive
drugs :
- Sialadenosis.
 oral manifestations of antihypertensive drugs :
- Xerostomia (Diuretics)
- Lichenoid reaction (ACEIs)
- Burning mouth sensation (ACEIs)
- Loss of taste sensation (ACEIs)
- Gingival hyperplasia (CCB)

17. DENTAL MANAGEMENT
• Accurate measurement of blood pressure is mandatory.
• Stress reducing protocol (diazepam 5 to 10mg ,night before a procedure).
•The antihypertensive effect of diuretics, beta blockers, alpha blockers, vasodilators,
ACE inhibitors may be antagonized by the long-term use of NSAID.
•Hypertensive patients are at a higher risk of developing septicaemia following
prosthodontic treatments.
•The sharp edges of the removable partial dentures should be trimmed off.
•Fabricating a complete denture demands utmost care to avoid causing soft tissue
abrasion.

18. J Am Dent Assoc. 1997 Aug;128(8):1109-20.

19. HYPOTENSION
• It is low blood pressure (less than 90/60)
Two types
• Primary- without any known cause
• Secondary- due to MI, Hypoactivity of
pituitary etc.
Other types
• Orthostatic hypotension
• Supine hypotensive syndrome.

20. ENDOCRINE DISORDERS

21. THYROID DISORDERS
Without any symptom
• Considered as low risk
• Normal protocol can be followed for implant
surgery and prosthodontic appointments.
Moderate to high risk
• Epinephrine and CNS depressant drugs should
be limited
• High risk in such patients only examination
procedures formed and all other treatment is
defaced

22. DIABETES MELLITUS
• Diabetes mellitus is a disease resulting from impaired insulin secretion, varying degree of insulin resistance
or both.
• Disease of glucose, fat & protein metabolism.
• CLASSIFICATION
• 1. Primary :- a. Type 1 or (IDDM)
b. Type 2 or (NIDDM)
2. Other specific types of Diabetes
a. Pancreatic Disease
b. Excess Endogenous production of hormonal antagonists to insulin
c. Medication (Corticosteroids, thiazide diuretics, phenytoin)
d. Associated with genetic syndromes.
3. Gestational Diabetes

23. COMPLICATIONS
• Short term complications
• Hypoglycemia
• Diabetic ketoacidosis
• Long term complications
• Diabetic retinopathy
• Diabetic neuropathy
• Diabetic nephropathy
• Cardiovascular disease

24. ORAL MANIFESTATIONS OF DIABETES
• Altered wound healing and taste
sensation
• Xerostomia
• Fungal infections(C.ALBICANS)
• Glossitis and Angular chelitis
• Increased RRR

25. MANAGEMENT OF DIABETIC DENTAL
PATIENT
1) Medical history
2) Establishing the levels of glycemic control early in the treatment process
3) Stress Reduction
4)Oral hygiene instructions, frequent prophylaxis & monitoring of periodontal
health
5)The use of antibiotics in case of infection and Diet Modification.

26. APPOINTMENT TIMING AND EMERGENCY
MANAGMENT
• Early morning appointment
• Hypoglycemic emergency :
1) Blood glucose with a glucometer should be
checked.
2)Oral administration of 15g of carbohydrate.
3)I.V line is in place, 25-50 ml of 50%
dextrose solution (D50) or 1mg of glucagon
can be given.

27. PROSTHODONTIC MANAGMENT

28. HEMATOLOGIC DISEASES

29. ANEMIA
• Anemia is defined as a low number of red blood cells.
• Decreased production of erythrocytes.
Symptoms
•Dizziness, lightheadness, or feeling like you are about to pass out
•Fast or unusual heartbeat
•Headache
•Pain, including in your bones, chest, belly, and joints
•Problems with growth, for children and teens
•Shortness of breath
•Skin that’s pale or yellow
•Cold hands and feet
•Tiredness or weakness

30. PROSTHODONTIC IMPLICATION
• As no such changes in removable prosthesis.
• Bone maturation and development are often impaired, character of the bone
needed to support the implant is significantly reduced. The time needed for a
proper interface formation is longer in anemic patients.
• The abnormal bleeding in anemic patients, due to hemorrhage causes difficulty
in placement of sub periosteal implants.
• The increased edema increases the risk of postoperative infection.
• The minimum baseline recommended for Hb is 10mg/dl especially for implant
surgery.

31. HEMOPHILIA
TYPES:
1. Hemophilia A  factor VIII deficiency
2. Hemophilia B  factor IX deficiency
3. Hemophilia C  factor XI deficiency
CLINICAL FEATURES:
Persistent bleeding – either spontaneous or following slight trauma
Hemorrhage in subcutaneous tissues, internal organs and joints
ORAL MANIFESTATIONS:
Gingival bleeding

32. Comparison of characteristics of hemophilia A and B. FIX: factor IX.52 Gouw et al. (2012);7 Belvini et al. (2005);53 Brummel-Ziedins and Mann.
(2014);54 Nazeef and Sheehan (2016).

33. MECHANISM OF CLOTTING

34. MANAGEMENT :
Depends on nature of hemostatic defect & its cause
1. Fresh frozen plasma
2. Cryoprecipitate
3. Amino caproic acid
DENTAL MANAGEMENT :
1. History
2. Physician’s consultation
3. BT, CT checked prior to treatment
4. Local hemostatic measures
5. Avoid aspirin

35. Acute leukemia's = usually in children younger than 5 years and
most often before 25 months of age
Chronic leukemia's = occurs in 5th – 7th decade, is rare before 25
years
CLINCAL FEATURES:
Lymphadenopathy
Anemia
Petechiae, ecchymosis
Splenomegaly
Hepatomegaly
LEUKEMIA

36. ORAL MANIFESTATIONS:
Oral manifestations are not observed in edentulous patients and
very young patients
Leukemic cells infiltrate the gingiva particularly if gingivitis or
periodontitis is present.
Gingival hyperplasia
MANAGEMENT :
Chemotherapy or Radiotherapy

37. DENTAL MANAGEMENT :
Low risk patients (successful therapy, no malignancy evident)
- Normal dental procedures
Moderate risk pts. (remission & receiving chemotherapy)
•Physician’s consultation
•Treatment around chemotherapy or WBC >3500 cells/mm³ or platelets >1,00,000/mm³
•Antibiotic prophylaxis
High risk pts. (active leukemia)
Control of infection – hospitalization
I.V. broad spectrum antibiotics
Control of bleeding – local hemostatics
platelets

38. DISEASES OF BONES

39. Osteoporosis :-
Osteoporosis shows a decrease in skeletal mass without alteration in the chemical
composition of bone.
According to WHO it is BMD greater than 2.5 times of standard deviation below
that of young BMD

41. PROSTHETHIC MANAGMENT
Designing complete denture requires special consideration for these patients to
preserve the underlying tissue structure as much as possible.
Mucostatic or open mouth impression technique.
 Use of acrylic non or semianatomic teeth.
Narrowing of occlusal table and decreasing no. of posterior teeth.
Extended tissue rest (by keeping denture out for 10-12 hrs).
Soft liners and shorter recall intervals.

42. DENTAL IMPLANT MANAGEMENTAND
DIETARY MODIFICATIONS
Although osteoporosis is significant factor for bone volume and density, it is not
a contraindication for dental implants
Implant designs should be greater in width and coated with hydroxyapatite to
increase bone contact and density.

43. OSTEOARTHRITIS:
 Most common chronic disease in older adults, is characterized by chronic
degeneration of the various hard and soft tissues around the joint.
 Patients are managed by both medicine and physiotherapy.
 Osteoarthritis can also affect TMJ, it affects the cartilage, subchondral bone,
synovial membrane, and other hard and soft tissues causing changes.
 American Academy of Orofacial Pain, TMJ Osteoarthritis is categorized
a)Primary TMJ osteoarthritis- absence of any distinct local or systemic factor.
b) Secondary TMJ osteoarthritis-previous traumatic event or disease.

44. RHEUMATOID ARTHRITIS:
• A chronic inflammatory disorder affecting many joints, including those in the
hands and feet.
• In rheumatoid arthritis, the body's immune system attacks its own tissue,
including joints. In severe cases, it attacks internal organs.

45. PROSTHODONTIC IMPLICATION
• The TMJ are frequently affected in this disease.
• The problem encountered in the prosthodontic rehabilitation.
a. Changes in occlusion:
• the prosthetic reconstruction’s should be aimed at giving unloading appliances
and improve the distribution of occlusal force
• removable denture in the lower jaw was not only beneficial for chewing but
also for unloading the diseased joints.

46. b. Jaw relation
Difficulty in recording an acceptable jaw relationship because of the destruction
of joint tissues.
Treatment :-
While there's no cure for rheumatoid arthritis, physiotherapy and medication can
help slow the disease's progression.
Most cases can be managed with a class of medications called anti-rheumatic
drugs (DMARDS)

47. Medications:-
Nonsteroidal anti-inflammatory drug
Relieves pain, decreases inflammation and
reduces fever.
Immunosuppressive drug
Reduces immune response.
Anti-inflammatory
Prevents or counteracts swelling (inflammation) in joints and tissues.
Steroid
Modifies or simulates hormone effects, often to reduce inflammation or for tissue
growth and repair.

48. NEUROLOGIC AND PSYCHIATRIC CONDITIONS

49. NEUROLOGIC AND PSYCHIATRIC
CONDITIONS
• The neurologic emergencies like stroke, syncope and seizures require
thorough history and list of medications. A consultation with physician is helpful
in treating these patients.
• Strokes occur due to problems with the blood supply to the brain: either the
blood supply is blocked or a blood vessel within the brain ruptures, causing brain
tissue to die.

51. EPILEPSY
Types :
Grand mal
Petit mal
Simple partial
Complex partial
CLINICAL FEATURES :
Generalized seizures
Loss of consciousness
Abnormal motor activity may be seen
ORAL MANIFESTATION :
Gingival hyperplasia

52. MANAGEMENT :
History & physical examination
Eliminate causative factors
Drugs – Phenytoin , Carbamazepine , Ethosuximide.
DENTAL MANAGEMENT :
Patients with poor control – dental therapy contraindicated
NSAIDs preferred
Opioids – dose reduced
Gingival hyperplasia – recall oral prophylaxis
surgical correction
alternate anticonvulsant
Minimize aspiration – rubber dam & clamp with floss
fixed prosthesis
metal reinforced crowns preferred

53. MANAGEMENT OF SEIZURES :
Place patient in supine position
Gently restrain the patient
Maintain airway patency
Place towel or padded tongue depressor
Remove sharp objects from patient’s vicinity
Recurrent seizures – medical assisstance
Diazepam i.v. slowly

54. Parkinson’s Disease:
• Parkinson’s disease is a neurological disorder
characterized by tremors, rigidity, bradykinesia
and postural instability.
• India has low prevalence.
• Due to loss of manual dexterity, oral hygiene
is poor.
• Due to poor oral hygiene the extent of dental
caries and edentulism increases.

56. PROSTHODONTIC CONSIDERATION
• Tremor and rigidity may cause problems with patient ability to
cooperate.
• Should be seen at a time of day when their medication produce their
maximum effect.
• The dental chair should be raised slowly so that the patient is
adjusted to the upright sitting position to prevent orthostatic
hypotension.
• Positioned in a semi reclined position to avoid pooling of saliva,
airway obstruction, and aspiration.

57. REMOVABLE PROSTHESIS
Denture retention, stability and support are compromised due to tremors,
rigidity of the orofacial musculatures and drooling of saliva.
Impressions should be recorded with quick setting impression materials.
Neutral zone technique, flange technique and selective grinding of the occlusion
(to remove the interferences) to obtain the maximum stability and retention.
Moisture based denture adhesives or artificial salivary substitutes can be
prescribed depending on the patient’s manual disability and xerostomia.
Overdentures can provide better masticatory efficiency as compared to patient
wearing conventional complete dentures.
When dentist is providing replacement complete denture, duplication technique
should be used in order to retain the learned muscle control of familiar denture.

58. BELL’S PALSY
Bell's palsy causes sudden, temporary weakness of face over the affected side.
Types:
A) Temporary
•Most common
•Lasts for weeks to months only
•Recovers but can reoccur
•Causes includes:
 viral infections, ear infections, high B.P. , Diabetes, headaches etc.
B) Permanent
•Less common
•Considered when lasts for more than 9 months
•Causes includes:
 birth trauma, major damage to the nerve due to trauma, laceration etc.

59. CLINICAL FEATURES :-
•Facial asymmetry
•Eyebrow droop
•Uncontrolled tearing
•Drooping of corner of mouth
•Loss of forehead & nasolabial folds
•Inability to close eye
•Difficulty in keeping food on occlusal table
•Lips not held tightly together: Difficulty keeping food in mouth

60. The facial muscles which are affected:
Occipitofrontalis
Procerus
Nasalis muscle
Depressor septi nasi
Orbicularis oculi
Corrugator supercilii
Depressor supercilii
Auricular muscles (anterior, superior,
posterior)
Facial muscles that affect denture stability:
Buccinator
Orbicularis oris
Levator anguli oris
Depressor anguli oris
mentalis

61. PROSTHODONTIC CONSIDERATION
In unilateral facial paralysis patient, it is essential to record neutral zone because of
imbalanced forces generated by unaffected and affected side causing instability in
dentures.
Occlusal wax Rims:-
Midline placed in the middle of the oral cavity rather than the facial midline.
Teeth Set-up:-
Teeth are arranged according to the neutral zone matrix.
Non anatomic posterior teeth are used to establish the centric occlusion.
Placing the mesio-incisal point in the middle of the mouth rather than the middle of
the face
Keep the cant of the occlusal plane on the right side a little low for incisal show

62. TRIGEMINAL NEURALGIA
Trigeminal neuralgia is defined as sudden, usually unilateral, severe, brief, stabbing,
lancinating type of pain in the distribution of one or more branches of the 5th cranial
nerve.
Synonyms:- Tic douloureux, Trifacial neuralgia, Fothergill’s diseases
ETIOLOGY
Peripheral compression
i. Tumors compressing the trigeminal nerve
ii. Multiple sclerosis
iii. Intracranial tension
Central damage :- to trigeminal nerve

63. CLINICAL CHARACTERISTICS
Older adults are more commonly affected.
F:M = 3:2
Right side of the face is affected in more patients than the left by a ratio of
about 1.7:1
It is characterized by sudden, unilateral, intermittent paroxysmal, sharp,
shooting, lancinating, like pain.
Pain is elicited by slight touching superficial ‘Trigger points’ which radiates
from that point, across the distribution of one or more branches of trigeminal
nerve.

64. TREATMENT WITH MEDICATIONS
Anticonvulsant medications, which slow down the nerve’s conduction of pain signals, are usually the first
treatment option. These include:
Tegretol (carbamazepine)
Trileptal (oxcarbazepine)
Carbatrol (carbamazepine)
Dilantin (phenytoin)
Lamictal (lamotrigine)
Topamax (topiramate)
 Neurontin (gabapentin)
 Klonopin (clonazepam)
Tegretol (carbamazepine) is the primary drug used to treat TN.

65. SURGICAL TREATMENTS
 Microvascular Decompression (MVD)
 Balloon Compression
 Glycerol Injection
 Radiofrequency Lesioning
 Radiosurgery (GammaKnife, CyberKnife, etc.)

66. DENTAL CONSIDERATIONS IN TRIGEMINAL
NEURALGIA
ACRYLIC RESIN STENT AS VEHICLE FOR
MAINTAINING TOPICAL APPLICATION OF
ANALGESIC GEL TO TISSUES
ACRYLIC RESIN STENT in situ.
ANALGESIC GEL IS COATED ON
FITTING SURFACE
Neuropathic implications of prosthodontic treatment Robert E. Delcanho, BDSc, MS a Perth Pain Management Center, Applecross,
Western Australia

67. CONCLUSION
Understanding the role of pharmacology in prosthodontics is imperative because
this is one of the most neglected parts of research even though there are a large
number of dental patients suffering from systemic diseases which have to be taken
care of before the commencement of dental treatment.
Another main reason is that the prosthodontist may have to deal with a medical
emergency arising on the dental chair.

68. REFERENCES
BURKET’S oral medicine, diagnosis & treatment planning . 10th ed.
Felpel P. Leslie – A review of pharmacotherapeutics for prosthetic dentistry, Part I, JPD, 77(3); 1997.
 Felpel P. Leslie - A review of pharmacotherapeutics for prosthetic dentistry, Part II, JPD, 77(3); 1997.
Tripathi D.K. – Essentials of medical pharmacology
Dental management of medically compromised patients . 6th ed. LITTLE , MILLER .
Principles & practice of oral medicine . 2nd ed. SONIS , FAZIO.
Medical problems in dentistry. CAWSON.
DAVIDSONS principles and practice of medicine. 19th ed.
J Prosthet Dent 2001; 86(6) : 569-73
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000; 89(5) : 570-6
Dent Clin North Am. 2005 Jan;49(1):15-29
Oral Surg Oral Med Oral Pathol. 1988 Feb;65(2):167-71.
Dent Clin North Am. 2003 , vol 47 ( 3,4)