Indications & contra indications of implant supported prosthesis /certified fixed orthodontic courses by Indian dental academy

INDICATIONS AND
CONTRAINDICATIONS OF IMPLANT
SUPPORTED PROSTHESIS

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INDIAN DENTAL ACADEMY
Leader in continuing dental education


INTRODUCTION
The goal of modern dentistry is to restore
the patients to normal contour, function,
comfort, esthetics speech and health,
regardless of the atrophy, disease or injury of
the stomatognathic system. However the more
teeth a patient is missing, the more arduous
this goal becomes with traditional dentistry. As
a result of continued research in treatment
planning, implant designs, materials and
techniques, predictable success of implants is
now a reality for the rehabilitation for many
challenging clinical situations.

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The increased need and use of implant related
treatments results from the combined effect of
a number of factors including,
aging population
tooth loss related to age
anatomic consequences of edentulism
poor performance of removable prostheses
psycholoicgal aspects of tooth loss
predictable long term results of implant
supported prostheses
advantages of implant supported prostheses

Research advances in dental implantology
have led to the development of several different
types of implants, and it is anticipated that
continued research will lead to improved
devices. At present, continued evaluation is
necessary to determine that appropriate
implant devices are available to meet the
therapeutic demands of the different portions of
the jawbones and the unique needs of patients.
The medical evaluation remains of paramount
importance in implant dentistry, perhaps more
so than in other disciplines of dentistry. Implant
treatment is primarily a surgical, prosthetic and
maintenance discipline for a selected particular
segment of the population.

Many patients who are partially or fully
edentulous are better served with tissue
integrated prostheses, rather than other
classical forms of therapy. However not all
patients can or should be considered for this
procedure. The first step in the clinical protocol
is a thorough medical and dental evaluation to
screen out those patients who can be better
served by an alternative treatment modality.
Therefore a thorough understanding of the
indications and contraindications of implant
supported prostheses (intra oral implant) is
mandatory for the success of the treatment.

INDICATIONS
Generally any edentulous area can be an
indication for dental implants. A decision has to
be made whether it is a good idea based on the
patients requirements and expectations, the
amount of additional procedures required (bone
grafting etc.), the doctor’s skill level and the
long term prognosis.
It is generally a good idea to assume that a
toothless area can be considered a future
implant site; however a thorough evaluation will
help give better insight as to whether
alternative, more conventional treatment
options would be a better choice in each
individual situation.

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Some general indications for treatment
are:
Severe morphologic compromise of denture
supporting areas that significantly undermine
denture retention.
Poor oral muscular coordination.
Low tolerance of mucosal tissues.
Parafunctional habits leading to recurrent
soreness and instability of prostheses.
Active or hyper active gag reflexes, elicited by a
removable prosthesis.

• Psychological inability to wear a removable
prosthesis even if adequate denture retention
and stability is there.
• Unfavorable number and location of potential
abutments in a residual dentition. (Adjunctive
location of optimally placed osseointegrated
root analogues would allow for provision of a
fixed prosthesis.)
• Single tooth loss to avoid involving neighboring
teeth as abutments.


Dental implants may be broadly classified as:
• ENDOSSEOUS
• SUBPERIOSTEAL,
• TRANSOSSEOUS
These implant types are subdivided as follows:
– Endosseous:
– Root form.
– Blade (plate) form.
– Ramus frame.

Ramus frame


– Subperiosteal:
– Complete.
– Unilateral.
– Circumferential.
– Transosseous:
– Staple.
– Single pin.
– Multiple pin


Indications for each implant type are specified
below:
• ENDOSSEOUS: root form, blade (plate) form:
– Adequate bone to support the implant with width
and height being the primary dimensions of
concern.
– Maxillary and mandibular arch locations.
– Completely or partially edentulous patients.

• ENDOSSEOUS: ramus frame:
– Adequate anterior bone to support the implant with
width and height being the primary dimensions of
concern.
– Mandibular arch location.
– Completely edentulous patients.

• SUBPERIOSTEAL: complete, unilateral,
circumferential:
– Atrophy of bone but with adequate bone to support
the implant.
– Maxillary and mandibular arch locations.
– Completely and partially edentulous patients.
– Stable bone for support.

• TRANSOSSEOUS: staple, single pin, multiple
pin:
– Adequate anterior bone to support the implant with
width and height being the primary dimensions of
concern.
– Anterior mandibular arch location.
– Completely and partially edentulous patients.

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For long-term successful performance of all
dental implant types the following general
factors should be considered:
Biomaterials.
Biomechanics.
Dental evaluation.
Medical evaluation.
Surgical requirements.
Healing processes.
Prosthodontics.
Post insertion maintenance.

With regard to indications for a specific
implant type, the bone available to support the
implant is the primary factor after prosthodontic
diagnosis and treatment plan. This bone is
measured in width, height, length, anatomical
contour, and density. These physiological and
anatomical factors may be altered by either
osteoplasty or augmentation of the bone. In
addition, other factors affecting indications for
implant type are the degree and location of the
edentulism of the patient.

The AMERICAN SOCIETY OF ANESTHESIOLOGY has
given a classification in which patients have been
categorized according to presurgical risk.
• CLASS 1: patient is physiologically normal, no medical
diseases, lives a normal lifestyle.
• CLASS 2: patient has some type of medical disorder
but the disorder is controlled with various medications.
Patient can thus engage in normal activity.
• CLASS 3: patient who has multiple medical problems
with impaired normal activity.
• CLASS 4: advanced stage of disease, serious medical
condition requiring immediate attention.
• CLASS 5: patient usually is suffering from a fatal
disease, is in the terminal end of the disease and will
not survive the next 24 hours.

CONTRAINDICATIONS AND THEIR MANAGEMENT
Systemic screening of a patient prior to implant
or/biomaterial insertion is critical to a patient’s well
being and success of the surgical procedure. It is no
longer
appropriate
to
limit
the
general
contraindications to the malfunction of major organs
and systems and not consider the devastating long
term effects of an unhealthy lifestyle (smoking,
inadequate diet etc.). However, modern standards of
care should not systemically exclude patients with
relative or marginal health conditions without exploring
the possibilities of improving and stabilizing those
conditions. Based on the classification of American
Society of Anesthesiology, a number of absolute and
relative contraindications have been ascertained.
(Chanavaz M, 1999)

These conditions relate to health conditions that
have the potential to jeopardize the patient’s overall
health. Elective dental procedures are rarely indicated
for these patients. However, some of the problems are
self limiting or treatable, so elective surgery may be a
realistic possibility in future. Thus even an absolute
contraindication may become relative over a period of
time.
Treatments are proposed for optimizing some
marginal health conditions and stabilizing unbalanced
physiological function prior to surgery. Knowledge of
the fundamentals of internal medicine is an important
prerequisite for predictable implant and preprosthetic
surgery.

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Standards of dental practice would suggest the
following general contraindications for the above three
categories of dental implants:
Debilitating or uncontrolled disease.
Pregnancy.
Lack of adequate training of practitioner.
Conditions, diseases, or treatment that severely
compromise healing, e.g., including radiation therapy.
Poor patient motivation.
Psychiatric disorders that interfere with patient
understanding and compliance with necessary
procedures.
Unrealistic patient expectations.
Unattainable prosthodontic reconstruction.
Inability of patient to manage oral hygiene.
Patient hypersensitivity to specific components of the
implant.

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DENTAL TREATMENTS CAN BE CLASSIFIED AS:
TYPE 1: Examinations, radiographs, model
impressions, oral hygiene, instruction, supragingival
prophylaxis, simple restorative dentistry.
TYPE 2: Scaling, root planning, endodontics, simple
extractions, curettage, simple gingivectomy, advanced
restorative procedures, simple implants.
TYPE 3: Multiple extractions, gingivectomy, quadrant
periosteal reflections, impacted extractions,
apicectomy, plate form implants, multiple root forms,
ridge augmentation, unilateral sius grafts, and
unilateral subperiosteal implants.
TYPE 4: Full arch implant (complete Subperiosteal
implants, ramus frame implants, full arch endosteal
implants), orthognathic surgery, autogenous bone
augmentation, bilateral sinus graft.

ENDOCRINE DISORDERS
• UNCONTROLLED DIABETES MELLITUS:
This refers to confirmed severe diabetes which does
not respond to treatment. The major symptoms are
polyuria, polyphagia, polydypsia and weight loss.
Diabetes patients are prone to develop infections and
vascular complications. The healing process is
affected by impaired vascular function, chemotaxis,
impaired neutrophil function and an anaerobic milieu.
Protein metabolism is decreased and healing of soft
and hard tissue is delayed. Nerve regeneration is also
altered and angiogenesis impaired. Such patients are
pre-disposed to tissue degeneration and compromised
healing with increased risk of infection.

The implant dentist will confirm or discover diabetes
by the presence of glucose levels above 120 mg/dl. of
these patients 90%have adult onset diabetes mellitus,
which develops after age 40 and is common in adults
over 55. About 80%of non-insulin dependent diabetes
mellitus are overweight. All diabetic patients are
subject to a greater incidence and severity of
periodontal disease, dental caries due to xerostomia,
candidiasis, burning mouth syndrome and lichenoid
reactions. Approximately 75%of these patients suffer
from periodontal disease and exhibit increased
alveolar bone loss and inflammatory gingival changes.
Tissue abrasions are more likely in denture wearers
because the depletion in oxygen tension decreases
the rate of epithelial growth and decreases tissue
thickness.

DENTAL IMPLANT MANAGEMENT
• The most serious complication for diabetic patients
during dental procedure sis hypoglycemia, which
usually occurs as a result of excessive insulin level,
hypoglycemic drugs or inadequate food intake.
Weakness, nervousness, tremor, palpitations and/or
sweating are all signs of hypoglycemia. If the
symptoms are not addressed, they may evolve from
confusion and agitation to seizure, coma and even
death.
• The stress of surgery may provoke the release of
counter regulatory hormones that will impair insulin
regulation and may result in hyperglycemia and a
catabolic state. A careful planning for post operative
food and medication intake is needed to ensure the
patient’s welfare. www.indiandentalacademy.com

Patients at low risk of complications related to
diabetes are those who are asymptomatic and have
good metabolic control. Their blood glucose levels are
less than 150 mg/dl (average 100mg/dl).these patients
may be treated with a normal protocol for all nonsurgical appointments(type1). For surgical procedures
these patients need a little more care and attention.
Need for a stress reduction protocol, diet evaluation
before and after surgery and control of the risk of
infection are all addressed. Sedative procedures and
antibiotics are often used for implant or advanced
surgical procedures (type 3 or 4). Insulin therapy is
adjusted to half the dose in the morning of the surgery
if oral intake is expected to be compromised. Oral
medications can be discontinued for the day if the
patient has taken morning dose on the day of the
surgery.

Patients at moderate risk show periodic
manifestations of the disease but are in metabolic
balance because few complications of diabetes are
present. Their blood glucose levels are below
200mg/dl. Diet control, stress reduction protocol,
aseptic techniques and antibiotics are more important
for these individuals than for those in the low risk
group. Most non-surgical procedures can follow a
normal protocol (type 1). Oral or intravenous sedation
should be considered for many surgical or restorative
types 2 procedures. Corticosteroids, often used to
decrease edema, swelling and pain may not be used
in the diabetic patient because they adversely affect
blood glucose levels. Medical consultation should
precede moderate or advanced surgical procedures
(type 3 or 4). Insulin dosage is often altered. Sedative
techniques and hospitalization should be considered
for advanced surgical procedures (type 4).

Patients at high risk report a history of
frequent hypoglycemia and show multiple
complications of diabetes. Their fasting blood
sugar fluctuates widely, often exceeding 250
mg/dl. These patients can follow type 1
procedures only when a conscious effort is
made to decrease stress. All other procedures
whether non-surgical or surgical require
medical consultation. Any treatment should be
deferred until the medical condition is
stabilized.

THYROID DISORDERS:
• Second most common endocrine problem
affecting approximately 1% of the population,
particularly women.
• Excessive production of Thyroxine ( hormone
of the thyroid gland) results in hyperthyroidism.
Symptoms of this disorder include increased
pulse rate, nervousness, intolerance to heat,
excessive sweating, weakness of muscles,
diarrhea, increased appetite, increased
metabolism and weight loss. excessive
thyroxine may also cause atrial fibrillation,
angina and congestive heart failure.

An insufficient production of thyroxine produces
hypothyroidism. The related symptoms are a result of
decreased metabolic rate. The patient complains of
cold intolerance, weight gain and fatigue. Eventually
hoarseness of voice and decreased mental activity
occurs which may even lead to coma if left untreated.
Thyroid function tests are used to confirm the
diagnosis of hypothyroidism.
• Patients with hyperthyroidism are especially sensitive
to epinephrine used in local anesthetics and gingival
retraction cords. When exposed to such
catecholamines is coupled with stress (often related to
dental procedure) and tissue damage (dental implant
surgery), an exacerbation of the symptoms of
hyperthyroidism may occur. The result is termed
thyrotoxicosis or thyroid storm and this is a life
threatening condition.

• The hypothyroid patient is particularly sensitive
to CNS depressant drugs, especially narcotics
and sedatives drugs like diazepam and
barbiturates. The risk of respiratory depression
and/or cardiovascular depression must be
considered.
• Any patient with a thyroid disorder and a
medical examination in the preceding 6 months
who reports normal thyroid function and has no
symptoms of the disease is at low risk and a
normal protocol can be followed for all dental
implant surgery and restorative appointments
(type 1 – 4).

• The thyroid disorder patient who has no
symptoms related to thyroid disorders, but has
not had a physical or thyroid function test
recently, is placed in the moderate risk
category. The patient may follow a normal
protocol for type 1 procedures. For any further
treatment the physician needs to be consulted.
• A symptomatic patient is at high risk regardless
of when the last medical evaluation was
performed. All treatment is deferred until a
medical and laboratory evaluation confirms
control of the disorder.

ADRENAL GLAND DISORDERS:
• Epinephrine, nor epinephrine (adrenal
medulla), glucocorticoids, mineralocorticoids
and sex steroids (adrenal cortex) are the major
hormones of the adrenal gland.
• Addison’s disease corresponds to a decrease
in adrenal function.
• Cushing’syndrome results from hyper
functioning of the gland.


DENTAL IMPLANT MANAGENENT
• Patients with a history of adrenal gland disease,
whether hyperfunctioning or hypofunctioning, face
similar problems related to dentistry and stress. The
body is unable to produce increased levels of steroids
during stressful situations and cardiovascular collapse
may occur. Therefore for patients with known adrenal
disorders the physician should be consulted before
any implant related treatment. The nature of the
disorder and the recommended treatment should then
be evaluated.
• Steroids act in three different ways that affect implant
surgery. They decrease inflammation and are useful in
decreasing swelling related pain. However, steroids
also decrease protein synthesis, delay healing, also
decrease leucocytes and thereby reduce the patient’s
ability to fight infection.

SEVERE HORMONE DEFICIENCY:
• This refers to patients with disorders affecting
more than two different hormone families. The
endocrine organs most often affected are the
thyroid, parathyroid, pancreas, suprarenals
prostrate and hypophysis.


CARDIOVASCULAR DISEASES
RECENT MYOCARDIAL INFARCTION(MI):
MI is a prolonged ischemia or lack of oxygen
that causes injury to the heart. The patient
usually has severe chest pain in the sub sternal
or left precordial area during an MI episode. It
may radiate to the left arm or mandible.
Cyanosis, cold sweat, weakness, nausea,
vomiting and irregular and increased pulse
rates are all signs of MI. The complications of
MI include arrhythmias and congestive heart
failure. Any history of MI indicates significant
problems in the coronary vessels. Recent
infarctions correspond to higher morbidity and
death rates with even simple elective surgery.

• Approximately 18 – 20% of patients with a
recent history of MI will have complications of
recurrent MI, with a high mortality rate of 40 –
70%.
• If surgery is done within 3 months of MI, the
risk of another MI is 30%.
• If within 3 – 6 months, it is 15%.
• After 12 months the incidence of recurrent MI
stabilizes at about 5%.


DENTAL IMPLANT MANAGEMENT:
• Contemporary cardiology, including non-surgical
intervention procedures has greatly improved the care
and treatment of patients suffering from MI. this has
led to a much reduced use of patent anti-coagulants
on a permanent basis, while the cardio-vaso
protectors, beta-blockers, hypotensive drugs and mild
anti-coagulants are used extensively. A stable
condition for these patients is usually reached 6 – 12
months after initial care and treatment. However, it is
important to avoid any surgical stress which could
trigger uncontrolled vasoconstriction with tachycardia
and arrhythmia, until the patient is stabilized for at
least 6 – 12 months. Further more, if anti-coagulants
are prescribed, their interruption in the early stages of
the disease may also prove extremely risky.

• The dental evaluation should include the dates of all
episodes of MI, especially the latest, and any
complications. Medical consultation should preclude any
extensive restorative or surgical procedure.
• Patients with a MI in the preceding 6 months may have
dental examinations (type 1) without any special protocol.
Any treatment should be postponed for 6 months.
• Patients who experienced MI 6 – 12 months preceding
consultation may have examination, non-surgical
procedures and simple emergency surgical procedures
performed after medical consultation. Longer procedures
should be segmented into several shorter appointments
whenever possible. Stress reduction protocol is always
indicated. Elective implant procedures should be
postponed for at least 12 months following MI.
• Elective hospitalization is an accepted modality for all
advanced surgical procedures, regardless of the time
elapsed after a MI; (it is mandatory if general anesthesia is

CONGESTIVE HEART FAILURE(CHF):
• CHF is a chronic heart condition in which the
heart is failing as a pump. Symptoms include,
abnormal tiredness, shortness of breath,
wheezing, edema of legs and ankle, frequent
urination, nocturnal dyspnea, weight gain,
orthopnea, pulmonary edema etc.


SUB ACUTE BACTERIAL ENDOCARDITIS/VALVULAR
HEART DISEASE
Bacterial endocarditis is an infection of the heart
valves or endothelial surfaces of the heart. It is the
result of growth of bacteria on damaged/altered
cardiac surfaces. The microorganisms most often
associated with endocarditis following dental treatment
are ά-hemolytic streptococcus viridans and less
frequently staphylococci and anaerobes. The disorder
is serious with a mortality rate of 10%. Dental
procedures causing transient bacteremia are a major
cause of bacterial endocarditis. As a result the implant
dentist should identify the patient at risk and
implement prophylactic procedures.

• The risk of bacterial endocarditis increases with
the amount of intra oral soft tissue trauma.
• A correlation exists between the incidence of
endocarditis and the number of teeth extracted
or the degree of a pre existing inflammatory
disease in the mouth. A 6 times higher
incidence of bacteremia is found in patients
with severe periodontal disease.
• Endocarditis has also been reported to occur in
an edentulous patient with denture sores.


VALVULAR PROSTHESES:
• The onset of bacteremia in patients fitted with valvular
prostheses constitutes a major threat to the longevity
of the cardiac valve. The oral cavity has been
traditionally recognized as the principal gateway to
such infections. It is therefore important to avoid
dental surgery or invasive periodontal procedures in
until a stable condition is achieved, usually 15 – 18
months after cardiac surgery. According to the type of
valve the patient may be on potent anti-coagulants (for
metallic valves) and mild plasma volume elevators (for
porcine valves). Any planned procedure must take into
consideration the occurrence of the surgical stress,
anti-coagulant imbalance and infection risk.

• The implant dentist must be familiar with the antibiotic
regimens for heart conditions requiring prophylaxis. A
similar regimen is required for any person requiring
antibiotic coverage.
• In some patients implant therapy is contraindicated
because of high risk for endocarditis like, patients with
previous history of endocarditis, prosthetic heart valve,
surgical systemic pulmonary shunt, rheumatic valvular
defect, congenital heart disease, acquired valvular
disease, intravascular prostheses and coarctation of
aorta. Edentulous patients restored with implants must
contend with transient bacteremia from chewing,
brushing or peri-implant disease.

As a result implant may be contraindicated in
patients with limited oral hygiene potential and
those with a history of stroke. In addition intramucosal inserts may be contraindicated for
many of these patients because a slight
bleeding can occur on a routine basis for
several weeks during the initial healing
process. Endosseous implants with an
adequate width of attached gingival are the
implants of choice for patients in this group who
need implant supported prostheses.

HYPERTENSION:
A patient is classified as hypertensive when
the mean value after three 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.
Hypertension
is
usually
asymptomatic and is the major risk factor for
coronary heart disease and cerebro-vascular
accidents leading to cardiovascular morbidity
and mortality for people more than 50 years of
age.

In hypertensive patients 90% have
essential or idiopathic hypertension. The
medical history should focus on predisposing
factors such as excessive alcohol intake,
history of renal disease, stroke, other cardiovascular diseases, diabetes, obesity and
smoking. Essential hypertension is treated with
medications, many of which have an impact on
implant therapy because of their numerous side
effects. These include orthostatic hypotension,
dehydration, sedation, and xerostomia, gingival
hyperplasia around teeth and implants and
depression. The side effects may alter
treatment or require special precautions.

• Anxiety greatly affects the blood pressure. Therefore a
stress reducing protocol is indicated for the
hypertensive patient. Premedication may be indicated
before the procedure. Monitoring of the blood pressure
is recommended for all patients, especially if the
patient is diagnosed with hypertension. Patients in the
normal and high normal (140-159/90-99 mmHg) range
with no other systemic disease may follow regular
treatment and can tolerate all non-surgical and single
implant surgical type 1 and type 2 procedures.
• However, patients in the range of 180-209/110119mm Hg (stage 3) or 210/120mm Hg or greater
(stage 4) can follow only emergent non-stressful
procedures therapy (type 1) and should be
immediately referred to a physician.

ANGINA PECTORIS:

Angina pectoris or chest pain or cramp of
the cardiac muscle is a form of coronary heart
disease. The classical symptom of retrosternal
pain often develops during stress or physical
exertion, radiates to the shoulder, left arm or
mandible, or right arm, neck, palate, tongue,
these symptoms are relieved by rest.

The major concern of the dentist is the
precipitation and/or management of the actual
attack. Precipitating factors can be exertion,
cold, heat, large meals, humidity, psychological
stress and dental related stress. All these
factors cause catecholamines release which in
turn increases heart rate, blood pressure and
myocardial oxygen demand. However, the
physician must be consulted before any
surgical procedures in a patient with history of
angina.

BONE DISEASES
OSTEOPOROSIS
The most common disease of bone metabolism the
implant dentist will encounter is osteoporosis, an age
related disorder characterized by a decrease in bone
mass, increased microarchitectural deterioration and
susceptibility to fractures. This condition is common in
post menopausal women. The osteoporotic changes
in the jaws are similar to other bones in the body. The
structure of the bone is normal, however, due to the
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. Oral
bone loss related to osteoporosis may be expressed in
both dentate and edentulous patients. Recent
advances in radiology such as DXA can measure as
little as 1 mg of bone mass change and can therefore
predict high risk cases.

DENTAL IMPLANT MANAGENENT
• The bone density affects the treatment plan,
surgical approach, length of healing and the
nature of progressive loading. Implant designs
should be greater in width and coated with
hydroxyapatite to increase bone contact and
density.


• VITAMIN D DISORDERS:
• Vitamin D is synthesized by the body in several steps
involving the skin, liver, kidney and intestine. Its
deficiency leads to osteomalacia in adults. Oral
symptoms include a decrease in trabecular bone,
indistinct lamina dura and an increase in chronic
periodontal disease.
• HYPERPARATHYROIDISM:
• Oral changes occur with the advanced state of this
disease. Loss of lamina dura, loosening of teeth,
altered trabecular bony pattern are some of the
features of this disorder. It has been noted that when
skeletal depletion occurs as a result of stimulation by
the parathyroid gland, alveolar bone may be affected
before that of the rib.

• FIBROUS DYSPLASIA:
• A disorder in which fibrous connective tissue replaces
areas of normal bone. It is found twice more
commonly in women than men and may affect a single
bone or multiple bones, twice more commonly in the
maxilla than mandible. Implant dentistry is
contraindicated in the regions of this disorder.
• PAGET’S DISEASE:
• A slowly progressive chronic bone disorder where
both osteoblasts and osteoclasts are involved, but
osteoblastic activity is more predominant. The maxilla
is more often involved than the mandible. Oral
implants are contraindicated in the regions affected by
this disorder.

• MULTIPLE MYELOMA:
• Plasma cell neoplasm originating in the bone
marrow. Usually seen in patients between 40 –
70 years of age. Pathologic fractures may
occur. Paresthesia, swelling, tooth mobility and
gingival enlargements are also seen. Implants
are contraindicated in these patients.


• SEVERE RENAL DISORDER:
• Etiology may be repetitive kidney infections
(nephritis), malignant or voluminous benign
tumors (or multiple cystic kidneys), uncontrolled
diabetes, and/or complications arising from
kidney stones. Damage to the nephrons may
lead to bone destruction via calciuria and loss
of production of 1,25-DHCC. In fact the lack of
reabsorption of calcium together with the
malfunction of PTH could rapidly lead to
metabolic osteopenia and retention of plasma
endotoxins with major infection risks. Excessive
use of common analgesics may also contribute
to kidney failure.

• HEAVY SMOKING HABITS:
• Smoking more than 20 cigarettes a day is an
absolute contraindication. The deleterious
effects of tobacco use (smoking or chewing)
have been well documented over the last
decade. A definite correlation has been
established between smoking and poorer levels
of periodontal conditions. Tobacco smoke
decreases PMNs activity leading to reduced
phagocytic activity. Smoking is also associated
with decreased calcium absorption. A reduced
mineral content in the bone of aging smokers
and to a greater degree in post menopausal
women.

• DENTAL IMPLANT MANAGEMENT
• 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. Therefore a cautious approach is
recommended. Doctors must inform their
patients that smoking will have a detrimental
effect on their treatment and therefore should
advise them to start a cessation program for
successful prognosis of the treatment.
Excessive smoking remains an absolute
contraindication for the long term success of
dental implant systems.

• CHRONIC OR SEVERE ALCOHOLISM:
• This problem frequently leads to liver disorder,
cirrhosis and medullary aplasia with a cascade of
possible complications like platelet disorder, distress
infarction, aneurysm and risk of insidious hemorrhage.
Such patients often present retarded healing
aggravated by malnutrition, psychological disorder,
inadequate hygiene and major infection risk.
Alcoholics frequently suffer from osteopenia.
• DRUG ADDICTION:
• Most patients with drug addictions have a low
resistance to disease, predisposition to infection,
malnutrition, psychological disorders and inadequate
hygiene.

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COPD.
CIRRHOSIS.
PREGNANCY:
Implant surgery procedures are contraindicated
for the pregnant patient. The radiographs or
medications that may be needed for implant
therapy and the increased stress are all
reasons the elective implant surgical procedure
should be postponed till after childbirth.
Periodontal disease is often exacerbated during
pregnancy. All elective dental care with the
exception of dental prophylaxis should be
deferred until after childbirth.

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HEMATOLOGIC DISEASES:
Polycythemia.
Anemia.
Leucocytic disorders.
RADIATION THERAPY IN PROGRESS:
Disruption of defense mechanisms, compromised
Endosseous vascular system, inhibition of
osteoinduction and localized loss of osseous vitality
are the main insults to the body while the patient
undergoes radiation therapy. With regard to bone, the
osteogenic potential of the periosteum is most
severely affected. All these conditions can severely
limit the prognosis for reconstructive dental
procedures. Such patients may be subject to
osteoradionecrosis and should be treated with caution
only after the dentist consults the radiotherapist.

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Aids and seropositive patients
Prolonged use of corticosteroids
Disorders of phosphocalcic metabolism
Bucco-pharyngeal tumors
Chemotherapy in progress
Hepato-pancreatic disorder
Multiple endocrine disorder
Psychological disorders, psychoses
Unhealthy lifestyle
Lack of understanding and motivation
Unrealistic treatment plan
Blood dyscrasias
Regular intake of corticosteroids or
immunosuppressive drugs

• PATIENT’S CURRENT CONDITION:
• Before beginning any implant restorations in the
partially edentulous case, the dentist must thoroughly
evaluate the patient’s current dental condition.
Frequently the patients present with overerupted
and/or tipped teeth and inadequate vertical
dimensions, all of which lead to an unacceptable
occlusal plane. Treatment can be complicated by the
degree of malocclusion, severe caries, periapical
lesions (any infection, abscess, cysts) or periodontal
disease. These conditions require treatment before or
in conjunction with implant therapy to maximize long
term success by eliminating inflammatory disease and
unfavorable excessive occlusal forces.
• Existing residual bone, proximity of the adjacent teeth
and the opposing dentition must be evaluated. (The
optimal dimensions of the available bone for root form
implant placementwww.indiandentalacademy.com
are: 5mm in width, 13-15mm in
height and 5mm in length.)

SUMMARY
Systemic diseases have a broad effect.
They may be categorized as mild, moderate
and severe. Implant therapy also offers a broad
range of treatments. Patients with mild
diseases may follow any type of treatment. A
stress reduction protocol is suggested for
advanced treatment. Patients with moderate
disease usually require more monitoring.
Hospital assistance is usually required for the
more advanced procedures. Several diseases
generally contraindicate implant therapy.

REVIEW OF LITERATURE
• In 1984, Mc Elroy TH, did a study on oral considerations of
infection in patients undergoing chemotherapy for cancer. He
concluded that because of the various factors associated with
the disease process and its treatment, the patient receiving
chemotherapy for cancer was highly susceptible to infection,
and infection accounts for approximately 70% of patient
fatalities. When potential sources of infection were considered
in the patient receiving chemotherapy for cancer, the mouth
provided ideal conditions for microbial growth, particularly in the
debilitated patient, and was a portal of entry for contamination
of the lungs, the digestive tract, and the circulatory system.
These patients were more susceptible to oral infection because
of alteration of oral flora towards greater pathogenicity and
impairment of host-defense mechanisms. Oral/dental
management of the patient receiving chemotherapy for cancer
will enhance the general health and comfort of the patient and
will prevent or reduce oral complications including mucositis
and local and systemic infection.

In 1992, Karr RA, Kramer DC, Toth BB, did a study
on implants and chemotherapy complications. He
concluded that the cancer patient receiving
chemotherapy often suffers severe oral complications
related to the administration of antineoplastic drugs.
Cancer patients who also have transmucosal or
endosseous dental implants pose special problems for
medical oncologists and dentists, both when planning
for chemotherapy and when providing supportive care
during the course of treatment. The relationship
between dental implants and cancer chemotherapy
was described and complications experienced by
implant patients treated with chemotherapy at The
University of Texas M.D. Anderson Cancer Center
were reviewed. Recommendations on various aspects
of management involving implant evaluation and the
removal or retention of dental implants were
evaluated.

• In 1994, Wicks RA, did a study on a systematic
approach to definitive planning for osseointegrated
implants. He said that thoughtful design selection is
crucial for the perpetual success of any dental implant
restoration. He reviewed treatment considerations
specific to the postsurgical presentation of the implant
patient and said that deviations from the originally
planned design may be necessary at that stage.
• In 1995, Steiner M, Windchy A, Gould AR, Kushner
GM, Weber R, conducted a study on the effects of
chemotherapy on patients with dental implants.
Endosseous implant placement is generally
considered to be contra-indicated in patients
undergoing chemotherapy for the treatment of cancer.
He presented a case where a patient was diagnosed
with cancer and began chemotherapy four weeks after
endosseous implants were placed. The impact of
chemotherapeutic agents on endosseous implant
acceptance as well as upon oral tissue was examined.

In 1998, Blanchaert RH, conducted a study on
implants in the medically challenged people. He said,
proper patient selection and careful technique will
always be the marks of quality implant dentistry
providers and described the implications for therapy,
of existing systemic disease or systemic therapies. All
health care delivery provided by dental practitioners
must take into account, always and foremost, the
patient. Careful patient evaluation is critical. Patients'
physicians may not fully appreciate the physiologic
ramifications of the complex and sometimes lengthy
appointments required in performing implant
procedures. The final decisions regarding the
prescription of therapy rests with the dentist. Through
increased knowledge of the pathophysiology of
diabetes mellitus, disorders of bone metabolism,
radiotherapy, and chemotherapy, improved patient
selection and perioperative management can benefit
the dental implant www.indiandentalacademy.com
team.

In 1999, Crews KM, Cobb GW, Seago D,
Williams N, conducted a study on tobacco and
dental implants. Dental implants are the ideal
standard of care for many oral health care
providers. They concluded, tobacco use is an
impediment to the success of this sophisticated
procedure. Dentists who are trained to help
their patients stop using tobacco are in position
to improve their success rates with dental
implants. A suggested protocol for tobacco
cessation in the implant practice, if utilized,
could raise the standard of health care in the
dental office. www.indiandentalacademy.com

In 2000, Lambert PM, Morris HF, Ochi S, did a study on the
influence of smoking on a 3-year clinical success of
osseointegrated implants. Health risks associated with smoking
have been exhaustively documented and include increased
incidence of periodontal disease, greater risk of osteitis
following oral surgery, and compromised wound healing due to
hypoxia. Information related directly to dental implants,
although limited, points to higher rates of implant failures
among smokers than non-smokers. They studied long-term
clinical outcomes of osseointegrated dental implants placed in
smokers and non-smokers in a longitudinal clinical study of
endosseous dental implants smokers than non-smokers. They
suggested that increased implant failures in smokers were not
only the result of poor healing or osseointegration, but also of
exposure of peri-implant tissues to tobacco smoke. Data also
suggest that detrimental effects may be reduced by: 1)
cessation of smoking; 2) the use of preoperative antibiotics; and
3) the use of HA-coated implants.

In 2002, Abdulwassie H, Dhanrajani PJ
conducted a clinical study on diabetes mellitus
and dental implants. They concluded, Diabetes
mellitus is no longer considered to be a
contraindication for implant-supported
prostheses, provided that the patient's blood
sugar was under control, and that there was
motivation for oral hygiene procedures. They
presented the experiences of treating diabetic
patients using implants with good success
rates.

In 2002, Sugerman PB, Barber MT, did a study on oral
and systemic considerations in patients selection for
endosseous dental implants.
He reviewed and discusses patient selection for endosseous
dental implants and the effect of systemic and local pathology
on the success rate of dental implants. Endosseous dental
implants may be preferable to conventional dentures in patients
with compromised supporting bone or mucosa, xerostomia,
allergy to denture materials, severe gag reflex, susceptibility to
candidiasis, diseases affecting orofacial motor function or in
patients who demand optimal bite force, esthetics, and
phonetics. Conventional dentures or fixed partial prostheses
may be preferable to endosseous dental implants in growing
and epileptic patients and patients at risk of oral carcinoma,
anaphylaxis, severe hemorrhage, steroid crisis, endocarditis,
osteoradionecrosis, myocardial infarction, or peri-implantitis. He
outlined a systematic approach to dental implant patient
selection and recommended a centralized reporting of dental
implant outcome.

In 2002, Farzad P, Andersson L, Nyberg J, did a
study on dental implant treatment in diabetic patients.
The purpose of their study was to investigate how
many diabetic patients and types of cases that were
treated with dental implants in their clinic and to
assess the outcome of such treatment. Medical
records from 782 patients were examined in patients
treated by the Branemark method for partial or total
edentulism with implant supported bridges. From
these records, 25 patients (3.2%) with diabetes before
implant treatment (136 implants) were identified and
further studied with respect to age, gender, type of
diabetes, treated jaw, degree of edentulism, bone
graft, implant survival, periimplant inflammation,
bleeding on probing, and radiographic bone loss.
Furthermore, the patients' opinion about the outcome
of the treatment was registered. The implant success
rate was 96.3% during the healing period and 94.1% 1
year after surgery.www.indiandentalacademy.com

Of all 38 bridges, one was lost. Few
complications occurred and all patients, except
for one, were satisfied with the treatment.
Today, diabetic patients are being treated
successfully for all types of edentulism,
including bone-grafting treatment. Diabetics
that undergo dental implant treatment do not
encounter a higher failure rate than the normal
population, if the diabetics' plasma glucose
level is normal or close to normal as assessed
by personal interviews.

In 2002, Attard NJ, Zarb GA, conducted a study on
medically treated hypothyroid patients. Their purpose
was to investigate the success outcomes of implants
and prosthodontic treatment placed in patients with a
previous history of hypothyroidism that was being
controlled with medications. Twenty-seven female
patients with a medically confirmed history of primary
hypothyroid disease who were on replacement
medications at the time of implant surgery were
selected as the study group. Additional factors studied
were medical history, medications, smoking habits,
and bone quality and quantity. They suggested that
medically controlled hypothyroid female patients
treated with dental implants are not at higher risk of
implant failure when compared with matched controls,
and that a history of controlled hypothyroidism does
not appear to be a contraindication for implant therapy
with endosseous implants.

In 2003, Beikler T, Flemmig TF, conducted a study on
implants in the medically compromised patients. Dental
clinicians are confronted with an increasing number of
medically compromised patients who require implant surgery
for their oral rehabilitation. However, there are only few
guidelines on dental implant therapy in this patient category and
thus numerous issues regarding pre- and post-operative
management remain unclear to the dental clinician. They
presented the current knowledge regarding the influence of the
most common systemic and local diseases on the outcome of
dental implant therapy, e.g., abnormalities in bone metabolism,
diabetes mellitus, xerostomia, and ectodermal dysplasias.
Specific pathophysiologic aspects of the above-mentioned
diseases as well as their potential implications for implant
success were critically appraised. In line with these
implications, guidelines for pre- and post-operative
management that may assist in the successful implantsupported rehabilitation of this patient category were proposed.

In 2004, Penarrocha M, Palomar M,
Sanchis JM, Guarinos J, Balaguer J, conducted
a radiologic study of marginal bone loss
around 108 dental implants and its relationship
to smoking, implant location, and morphology.
The concluded, conventional periapical films
and digital radiographs were more accurate
than orthopantomography in the assessment of
peri-implant bone loss. Smoking and implant
location in the maxilla were associated with
increased peri-implant marginal bone
resorption.

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REFERENCES
Contemporary implant dentistry-Carl E. Misch
Dental implants, the art and science-Charles A. Babbush
Practical implant dentistry- Arun K. Garg
The branemark system of oral reconstruction- Richard A.
Rasmussen
Sugerman PB, Barber MT, Patient selection for endosseous
dental implants: oral and systemic considerations, Int J Oral
Maxillofac Implants. 2002 Mar-Apr;17(2):191-201.
Chanavaz M, Patient screening and medical evaluation for
implant and
preprosthetic surgery, J Oral Implantol.
1998;24(4):222-9.
Beikler T, Flemmig TF, Implants in the medically compromised
patient, Crit Rev Oral Biol Med. 2003;14(4):305-16.
Chanavaz M, Screening and medical evaluation of adults:
contraindications for invasive dental procedures, J Indiana Dent
Assoc. 1999 Fall;78(3):10-7.

• Blanchaert RH, Implants in the medically challenged patient,
Dent Clin North Am. 1998 Jan;42(1):35-45.
• Karr RA, Kramer DC, Toth BB, Dental implants and
chemotherapy complications, J Prosthet Dent. 1992
May;67(5):683-7.
• Wicks RA, A systematic approach to definitive planning for
osseointegrated implant prostheses, J Prosthodont. 1994
Dec;3(4):237-42.
• McElroy TH, Infection in the patient receiving chemotherapy for
cancer: oral considerations, J Am Dent Assoc. 1984
Sep;109(3):454-6.
• Farzad P, Andersson L, Nyberg J, Dental implant treatment in
diabetic patients, Implant Dent. 2002;11(3):262-7.
• Crews KM, Cobb GW, Seago D, Williams N, Tobacco and
dental implants, Gen Dent. 1999 Sep-Oct;47(5):484-8.
• Lambert PM, Morris HF, Ochi S, The influence of smoking on
3-year clinical success of osseointegrated dental implants, Ann
Periodontol. 2000 Dec;5(1):79-89.

• Steiner M, Windchy A, Gould AR, Kushner GM, Weber
R, Effects of chemotherapy in patients with dental
implants, J Oral Implantol. 1995;21(2):142-7.
• Abdulwassie H, Dhanrajani PJ, Diabetes mellitus and
dental implants: a clinical study, Implant Dent.
2002;11(1):83-6.
• Attard NJ, Zarb GA, A study of dental implants in
medically treated hypothyroid patients, Clin Implant
Dent Relat Res. 2002;4(4):220-31.
• Penarrocha M, Palomar M, Sanchis JM, Guarinos J,
Balaguer J, Radiologic study of marginal bone loss
around 108 dental implants and its relationship to
smoking, implant location, and morphology, Int J Oral
Maxillofac Implants. 2004 Nov-Dec;19(6):861-7.


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