placing implants yes or no

1. Member A.O.I.A
Fellow I.C.O.I
Scientific consultant of sybron implant solutions
Manager of implant direct company
Dr. Amr Saad

2. Dr. Amr Saad

3. . Bad oral hygiene
. Bad habits (clenching , nail biting …etc)
. Smoking
. Diabetes
. Osteoporosis
. Hormonal disorders
. Radiation therapy
. Chemo therapy
Dr. Amr Saad

4.  It is the evaluation of all circumstances that
can affect the outcome of a therapeutic
intervention.
 In the case of dental implants the
assessment is to identify variables that
increase the risk of complications leading to
implant loss.
Dr. Amr Saad

5.  Risk assessment should be performed:
1) Before placement of implants (designed to
avoid high failure rates by identifying suitable
candidates for implant treatment).
2) During the phase of implant placement and
osseointegration (designed to identify and
avoid technical issues that can affect implant
survival).
Dr. Amr Saad

6. 3) During the phase of implant maintenance
(designed to minimize failure by heading
off problems).
4) After an implant has failed and been
removed ( to identify the causes of failure )
.
Dr. Amr Saad

7.  It is an environmental, behavioral, or
biological factor.
 If present directly increases the
probability of a disease occurring and, if
absent or removed, reduces that
probability.
Dr. Amr Saad

8.  In the case of risk assessment for implant
failure, risk factors can be broadly
categorized as
1) Local risk factors.
2) Systemic risk factors.
3) Behavioral risk factors.
Dr. Amr Saad

9. 1. Taking thorough medical/dental histories.
2. Complete examination of the prospective
candidate for dental implants.
Dr. Amr Saad

10.  A comprehensive evaluation of the patient
should contain a review of past dental
history including:
1) Earlier periodontal treatment.
2) Reasons for tooth loss.
3) How extraction sockets were treated at the
time of extraction.
4) History of increased susceptibility to
infection.
Dr. Amr Saad

11. 5) Awareness of parafunctional habits such
as clenching and grinding.
6) Evaluation of the patient’s socioeconomic
status.
7) Dissatisfaction with earlier dental
treatment may indicate an increased risk
for complications during implant therapy.
 The comprehensive medical history should
include past and present medications and
any substance abuse.
Dr. Amr Saad

12.  A complete intraoral examination should be
performed to determine the feasibility of placing
implants in desired locations.
 This examination includes:
1. Oral hygiene status.
2. Periodontal status.
3. Jaw relationships.
4. Occlusion.
5. Signs of bruxism.
6. Temporomandibular joint conditions.
Dr. Amr Saad

13. 7. Endodontic lesions.
8. Status of existing restorations.
9. Presence of non-restored caries.
10. Crown-root ratio.
11. Interocclusal space.
12. Available space for implants.
13. Ridge morphology.
14. Soft and hard tissue conditions.
15. Prosthetic restorability.
Dr. Amr Saad

14.  Radiographic evaluation of the
quality and quantity of available bone
is required in order to determine the
optimal site(s) for implant placement.
Dr. Amr Saad

15. 1. Periapical radiographs.
2. Panoramic projections.
3. Cross-sectional tomographic images give
accurate estimation of bone height and
width.
Dr. Amr Saad

16.  A comprehensive radiographic evaluation
minimizes the risk of injuring vital
anatomic structures during the surgical
procedure and is also helpful in
determining which cases require bone
augmentation surgery before implants can
be placed.
Dr. Amr Saad

17.  An evaluation of the quality and quantity
of peri-implant soft tissues at the
proposed implant site will help determine
how closely this tissue will mimic the
appearance of gingival tissue once the
implant has been inserted.
Dr. Amr Saad

18.  The presence of keratinized mucosa around
a dental implant is an important part of an
esthetically successful dental implant.
 It is important to evaluate the patient’s
perception of esthetics prior to implant
placement especially in situations with
compromised hard and soft tissues.
Dr. Amr Saad

19.  Diagnostic casts and intraoral photographs
can be helpful in evaluating potential esthetic
outcomes as well as in the overall treatment-
planning process.
 In general, to minimize the risk of implant
complications and failure, any diseases of
the soft or hard oral tissues should be
treated before implant therapy.
Dr. Amr Saad

20.  Poor oral hygiene and microbial biofilms are
important etiologic factors leading to the
development of peri-implant infections and
implant loss.
Dr. Amr Saad

21.  There are several reasons to believe that
untreated or incompletely treated
periodontitis increases the risk for implant
failure.
1) There are case reports that suggest an
association (Malmstrom et al. 1990,
Fardal et al. 1999)
Dr. Amr Saad

22. 2) A similar subgingival microbiota has
been found in pockets around teeth and
implants with similar probing depths.
3) Evidence exists that periodontal
pockets might serve as reservoirs of
pathogens that hypothetically can be
transmitted from teeth to implants.
Dr. Amr Saad

23.  Subgingival sites are the natural or preferred
habitat of a diverse group of oral
microorganisms.
 In an interesting study of 15 patients, Devides
and Franco (2006) sampled mucosa-associated
biofilms of edentulous sites with paper points
and analyzed the specimens using polymerase
chain reaction (PCR) methods to detect certain
periodontal pathogens.
Dr. Amr Saad

24.  At the edentulous sites Aggregatibacter
actinomycetemcomitans was detected in 13.3% of
subjects, Prevotella intermedia was detected in
46.7% of subjects, and Prophyromonas gingivalis
was not detected.
 Six months after placement of endosteal implants
at the same sites, subgingival plaque samples
taken from around the implants were positive for
A. actinomycetemcomitans in 73.3% of subjects,
Pr. Intermedia in 53.3% of subjects, and P.
gingivatis in 53.3% of subjects.
Dr. Amr Saad

25.  None of the implants showed any clinical
signs of either failure or peri-implantitis.
 These results indicate that healthy
subgingival sites around implants are
readily colonized by periodontal
pathogens without any development of
clinically detectable disease.
Dr. Amr Saad

26.  It is important to remember that the
microbiota adjacent to failing implants will
differ depending on the cause of the failure.
 For example, the microbiota associated with
implants failing because of traumatic loads
was different to that found around implants
failing because of infection.
Dr. Amr Saad

27.  There are several reports that the survival
rate of implants is decreased when the
patient has a history of periodontitis.
 Patients who have had periodontitis might
also be more susceptible to peri-implant
infections.
Dr. Amr Saad

28.  Acute infections
 Chronic infections
Dr. Amr Saad

29.  It is clear that implants can be quite
successful when placed in patients who are
in their eighth and ninth decades of life.
 Several reports indicate that there is not a
statistically significant relationship between
age of the patient and implant failure.
Dr. Amr Saad

30.  A potential problem associated with the
placement of dental implants in still-growing
children and adolescents is the possibility of
interfering with growth patterns of the jaws.
 Osseointegrated implants in growing jaws
behave like ankylosed teeth in that they do
not erupt and the surrounding alveolar
housing remains underdeveloped.
Dr. Amr Saad

31.  It is highly recommended that implants
not be placed until craniofacial growth
has almost complete.
 14-15 years in females
 17 years in males
Dr. Amr Saad

32.  Cigarette smoking is often identified as a
statistically significant risk factor for implant
failure.
 The reasons that smokers are more
susceptible to both periodontitis and peri-
implantitis, but usually involve impairment of
innate and adaptive immune responses and
interference with wound healing.
Dr. Amr Saad

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34.  Smoking is such a strong risk factor for
implant failure that some clinicians
highly recommend smoking-cessation
protocols as part of the treatment plan
for implant patients.
Dr. Amr Saad

35.  Bisphosphonates are drugs used for the
treatment of osteoporosis.
 These drugs are potent inhibitors of osteoclast
activaty (apoptosis) , have a high affinity for
hydroxyapatite and have a very long half-life.
Dr. Amr Saad

36.  An uncommon complication associated with
the use of bisphosphonates is the increased
risk of developing osteonecrosis of the jaws
(ONJ) after implant placement.
 In general, it is not recommended that
implants be placed in patients who have
been on the drug for more than 3 years.
Dr. Amr Saad

37.  Gingival enlargement has been reported
around dental implants in individuals taking
either phenytoin or a calcium-channel
antagonist.
Dr. Amr Saad

38.  It has been reported that some cancer
patients who had received cytotoxic
antineoplastic drugs experienced
infections around existing transmucosal or
endosteal dental implants (Karr et al. 1992).
Dr. Amr Saad

39.  Patients who are receiving cancer
chemotherapy should have thorough
periodontal and implant maintenance care to
minimize the development of adverse events.
Dr. Amr Saad

40.  Patients who have blood-coagulation
disorders or are taking high doses of
anticoagulants are at an elevated risk of
post-operative bleeding problems after
implant surgery.
Dr. Amr Saad

41.  Corticosteroids can interfere with wound
healing by blocking key inflammatory events
needed for satisfactory repair.
 In addition, through their
immunosuppressive effects on lymphocytes,
they can increase the rate of post-operative
infections.
Dr. Amr Saad

42.  In the early years of the AIDS epidemic
placement of dental implants was ill advised
since affected patients developed major life-
threatening oral infections.
 With the advent of effective HAART (highly
active anti-retroviral therapy) regimens, most
HIV-positive patients who take their
medications live for many years without
developing Amr Saad
Dr. severe opportunistic infections.

43.  Low T-helper (CD4) cell counts (i.e.<200/L)
do not appear to predict increased
susceptibility to intraoral wound infections or
elevated failure rates of dental implants
(Achong et al. 2006).
 Although more studies are needed, it appears
that it is safe to place dental implants if the
patient’s HIV disease is under medical control.
Dr. Amr Saad

44.  Patients who have received radiation to the
head and neck as part of the treatment for
malignancies are at an increased risk of
developing osteoradionecrosis (ORN).
 Implant failure rates of up to 40% have been
reported in patients who have had a history of
radiation therapy.
Dr. Amr Saad

45. Dr. Amr Saad

46.  It has been recommended that oral surgical
procedures in patients at risk of ORN be
performed in conjunction with hyperbaric
oxygen (HBO) therapy.
 From the perspective of risk- assessment
procedures for implant placement, patients
who have a history of irradiation to the jaws
should be considered at high risk or implant
failure and HBO interventions will probably
lower that risk.
Dr. Amr Saad

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48. Dr. Amr Saad

49.  In the risk evaluation of diabetics it is
important to establish the level of
metabolic control over the last 90 days is a
blood test for glycosylated hemoglobin
(HbA1C).
 Normal values for a non diabetic or a
diabetic under good metabolic control are
HbA1C 6-6.5%
Dr. Amr Saad

50.  Diabetics with HbA1C values of ≥8% are
under poor control and have an elevated
risk of encountering wound healing
problems and infection if dental implants
are placed.
Dr. Amr Saad

51. Osteoporosis is a skeletal conditions
characterized by low bone mineral.
There are multiple case reports that
conclude that osteoporosis alone is not a
significant risk factor for implant failure (Dao
et al. 1993; Freiberg 1994; Fujimoto et
al.1996; Freiberg et al. 2001).
Dr. Amr Saad

52. Implants placed in individuals with
osteoporosis appear to successfully Osseo
integrate and can be retained for years.
However, in cases of secondary
osteoporosis there are often accompanying
illnesses or conditions that increase the risk
of implant failure (e.g. poorly controlled
diabetes mellitus, corticosteroid
medications).
Dr. Amr Saad

53.  Long-term success of dental implants
requires that the patient is able to
comply with the recommended post-
insertion maintenance procedures
required for long-term survival and
success of implants.
Dr. Amr Saad

54.  Since poor oral hygiene is a documented
risk factor associated with failure of
implants, it is critically important that
patients understand this and are taught
the skills necessary to perform plaque
removal on a daily basis.
Dr. Amr Saad

55.  In addition, since patient-performed oral
hygiene does not adequately remove disrupt
dental plaque biofilms at subgingival
locations, periodic maintenance visits are
needed.
 It is recommended that these visits be at 3-
month intervals.
 The patient’s compliance with the
recommended maintenance schedule is a
major key to long-term success.
Dr. Amr Saad

56.  Patients who have addictions to alcohol and
drugs are usually poor candidates for dental
implants.
 Since the success of implant therapy
requires a considerable amount of patient
cooperation at all stages of care, individuals
with substance-abuse problems should
receive prosthetic care that does not
depend on implants.
Dr. Amr Saad

57.  In general, Patients who have severe mental
health problems or exhibit psychotic
behavior are not good candidates for dental
implants.
 The cooperation needed for successful
implant therapy is missing.
 However, people with medically controlled
mental health problems, such as depression,
can be successfully treated with implants.
Dr. Amr Saad

58.  It is important that the practitioner determine if
the information they tried to convey was
understood.
 One of the best ways to do this is to convey the
information in easily understood (nontechnical)
language and in small increments.
 Patients who understand what is being done are
usually quite cooperative and this cooperation
leads to the increased probability of successful
therapeutic outcomes.
Dr. Amr Saad

59.  Daily self-care (oral hygiene) and
adherence to a maintenance-recall
schedule is absolutely required for long-
term success.
 This is best discussed to the patient at the
consultation Saad
Dr. Amr visit.

60.  An effective way to reduce the risk of
implant complications and failure is to
stress the importance of the patient’s
role as and active participant in the
overall therapeutic program.
 Long-term success of both periodontal
and implant therapy depends on an
effective partnership between the patient
and practitioner.
Dr. Amr Saad

61. ASA Classification of Physical Status
P1: Normal, healthy patient
P2: Patient with mild systemic disease with no functional
limiltation,
ie, a patient with a significant disease that is under good day to
day control,
eg controlled hypertension, oral agents for DM, mild COPD
P3: Patient with severe systemic disease with definite functional
limitations, ie, patient who is concerned with their health
problems each day, eg. a
DM on Insulin, significant COPD
P4: patient with severe systemic disease that is constant threat to
life
P5: Moribund patient who is not expected to survive 24hrs
P6: Declared brain dead
Dr. Amr Saad

62.  Post-operative infections increase the risk of
early implant failure.
 It is important to perform implant surgeries
with a strict hygiene protocol to minimize
bacterial contamination of the surgcial site.
Dr. Amr Saad

63.  The incidence of post-operative infection
associated with implant placement is only about
1% (Powell et al. 2005), some clinicians attempt
to reduce this risk by prescribing pre-operative
systemic antibiotics (Dent et al. 1997; Laskin et
al. 2000).
 In addition, the results of several case-control
studies indicate that there is no advantage in
using antibiotics in conjunction with implant
placement (Gynther et al. 1998; Morris et al.
2004; Powell et al. 2005).
Dr. Amr Saad

64.  Thermal damage to bone can be caused
during the drilling sequence if dull drills are
used or if osteotomy is performed without
using enough liquid coolant.
Dr. Amr Saad

65.  Post-insertion stability lowers the risk of
implant complications or failure.
Dr. Amr Saad

66.  In situations where there are less than
optimal bone conditions. (thin cortex, low
trabecular density), increased initial
stability have to be established
Dr. Amr Saad

67.  Anatomic structures that are at risk of
damage during the placement of implants
include:
 Nerves,
 Blood vessels,
 Floor of the mouth,
 Nasal cavity, maxillary sinuses,
 Adjacent teeth.
Dr. Amr Saad

68. 1. A Key part of implant therapy is the risk-
assessment process that includes thorough
medical and dental histories, a complete
clinical examination, and an appropriate
radiographic survey.
2. The presence of one risk factor alone is
usually insufficient to cause the adverse
outcome. It is the combination of multiple
risk factors that the has clinical importance.
Dr. Amr Saad

69. 3. To minimize the risk of implant complication
clinicians can use a number of technical
procedures, such as adhering to a strict
hygienic surgical protocol, performing the
osteotomies with sharp drills, achieving early
implant stability, and avoiding damage to vital
anatomic structures during surgery.
4. Any endodontic, periodontal, and other oral
infections be treated prior to implant
placement.
Dr. Amr Saad

70. 5. Existing evidence does not support the
routine use of pre-operative systemic
antibiotics in implant therapy.
6. Most of the systemic risk factors for implant
complications are those that increase the
patient’s susceptibility to infections or those
that interfere with wound healing.
Dr. Amr Saad

71. Dr. Amr Saad