systemic diseases of concern to dentist

1. SyStemic DiSeaSeS of
concern to ProSthoDontiSt

2. introDuction
• Systemic disease is disease that affects the whole
body, instead of being restricted to a body part or organ
(MedlinePlus).
• Many systemic diseases are reflected in the oral
mucosa, maxilla, and mandible.
• Bone disease can affect the maxilla and mandible.
• Systemic disease can cause dental and periodontal
changes
Prosthodontic procedures should not be planned until
the systemic status of the patient is evaluated.

3. meDical hiStory
• Recognition of existing medical conditions
• Adequate preparation
 Premedication
 Prophylaxis
 Adjustment
 Preparation of any adverse effects
• Postoperative considerations to consider
 Bleeding
 Infection

5. General PrinciPleS to follow
• Early and short appointments.
• Short acting barbiturates.
• Stress reduction protocols.
Relaxing background music
Reassurance
No unnecessary noise
Effective analgesic if required
Antibiotics for extensive surgical process

6. why concern to a
ProSthoDonticS ?

7. how Geriatric Patient are
Different ?

9. eviDence-baSeD DentiStry (ebD)
• (EBD) is an approach to oral health care that requires the judicious
integration of systematic assessments of clinically relevant scientific
evidence, relating to the patient's oral and medical condition and history,
with the dentist's clinical expertise and the patient's treatment needs
Empowers practitioners a strong scientific basis rather than common
practice or expert’s opinion.

10. eviDence-baSeD GuiDelineS for ProSthetic
treatment PlanninG:

11. conDitionS for concern to a ProSthoDonticS
• CARDIOVASCULAR DISEASES
• ENDOCRINE DISORDERS
• ADRENAL GLAND DISORDER
• HEMATOLOGIC DISEASES
• BONE DISEASES
• NEUROLOGIC AND PSYCHIATRIC CONDITIONS
• AUTOIMMUNE DISEASE
• SALIVARY DYSFUNCTION
• HIV

12. carDiovaScular DiSeaSeS
ANGINA PECTORIS:
In medical terms it is acute chest pain or discomfort.
3 types are there:
a) Stable b) Unstable c) Variant
Mechanism of angina
Supply to demand mismatch
So need to improve cardiac oxygen
supply to demand

13. myocarDial infraction
Partial or total occlusion of one or
more of the coronary arteries due to
an atheroma, thrombus or emboli
resulting in cell death (infarction) of the
heart muscle
Chest Pain
Site
Radiation
Quality/severity
Precipitating/relieving factors
Autonomic symptoms

14. Dental conSiDerationS for ihD
• Common Situations:
 Orthostatic Hypotension due to use of anti-hypertensives (beta
blockers, nitroglycerin…)
 Post-Op Bleeding:
• Emergent Situations:
 Possible MI:
 Angina:

15. manaGment
Potential problem related to dental care
Stress and anxiety related to dental visit may precipitate angina
attack
Prevention of complication
1.Detection of patient
2. Referral of patient for medical evaluation and treatment
3. Known case with medical treatment for angina or MI
Stress reduction protocol
Minimize time in waiting room
Short, morning appointments
Preop, intra-op, and post-op vital signs
Pre-medication as needed

16. Avoid excessive amounts of epinephrine both in LA and Retraction cord
If highly suspected a MI
MONA: Morphine, Oxygen, NTG, Aspirin
Dental imPlant manaGement

17. Dental imPlant manaGement
Mild angina-
Vital sign has to be monitored,
patient in instructed to have
nitroglycerine.
Surgery is performed with nitrous
oxide or oral reduction.
Vasoconstrictors is limited to 0.04 to
0.05 mg epinephrine.
Moderate angina
Nitroglycerine sublingually just before implant surgery.
Antianxiety sedation with supplemental oxygen are also required.
Severe angina
Elective implant surgical procedure is usually not performed on these patients.
Medical consultation is required for any of the additional treatment.

18. Subacute bacterial
enDocarDitiS:
• The Endocarditis prophylaxis not recommended for the placement
of removable prosthodontics appliances and making oral
impressions.
• Endocarditis prophylaxis are recommended for procedures like
dental implant placement

19. hyPertenSion:
A condition in which the force of the blood against the artery walls is too
high.
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.

20. manifeStation of hyPertenSion

21. Dental manaGement
• Accurate measurement of blood pressure is mandatory
• Stress reducing protocol(diazepam 5 to 10mg ,night before a
procedure)
• It is preferable for the visits to be briefand in the morning.
• 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.

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

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

24. ENDOCRINE DISORDERS
• 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

25. ADRENAL GLAND DISORDER:
• It is preferable for the visits to be
briefand in the morning.
• Non invasive procedures can
be performed normally.
Dental implant management.
• The physician should be contacted for consultation.
• If taking steroid between 2 weeks to 2 years, in these patients the
steroid dose should be doubled the day before the surgery and the
maintenance dose is returned to normal after surgery, otherwise
chances of adrenal suppression.
• Judicious use of antibiotics recommended

26. 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

28. COmPLICATIONS
• Short term complications
• Hypoglycemia
• Diabetic ketoacidosis
• Long term complications
• Diabetic retinopathy
• Diabetic neuropathy
• Diabetic nephropathy
• Cardiovascular disease

29. ORAL mANIFESTATIONS OF DIAbETES
• Burning mouth syndrome
• Altered wound healing and taste
sensation
• Xerostomia
• Fungal infections(C.ALBICANS)
• Glossitis and Angular chelitis
• Increased RRR

30. 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.

31. APPOINTmENT TImING AND EmERGENCY
mANAGmENT
• Early morning appointment
• Hypogycemic 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.

33. PROSTHODONTIC mANAGmENT
 Salivary reservoir denture
 Metal denture bases
 Tissue conditioner
 Fabrication of denture with
minimal pressure
 Lingualised or Monoplane
occlusion

34. DENTAL ImPLANT mANAGEmENT
• Implant dentistry is not contraindicated in most diabetic
patient, however their medical care should be as
controlled as possible.
JADA 1997 vol 128, Aug: 1109 – M. Glick

35. HEmATOLOGIC DISEASES
• Anemia: When the
body has lack of
RBC , Hb or both
• Decreased
production of
erythrocytes.
• 4 Types

36. 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

37. LEukOPENIA
• Leukopenia is the reduction of circulating WBC’s to less than
5000/mm3. The common cause of Leukopenia is infection.
• Delayed healing and Severe bleeding in these patients
complicates the implant surgery.
• So most implant procedures are contraindicated for the
patient with acute or chronic leukemia.

39. bONE DISEASES
• 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. TYPES
1) Primary osteoporosis
a) Type1 postmenopausal osteoporosis
b) Type2 age relate osteoporosis
2) Secondary osteoporosis
Caused by identifiable agent , disease, drugs or
lifestyle

42. PROSTHODONTIC ImPLICATION

43. 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 tecnique
 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

44. Dental imPlant management, anD
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
hydroxyapetite to increase bone contact and density.

45. 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

46. 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

47. 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.

48. b. Jaw relation
Difficulty in recording an acceptable jaw relationship because of the destruction of
joint tissues.
Large distance between the most retruded and the intercuspal position i.e., CR-CO.

49. Patient with mucosal Problem
• Limits the adaptive capability of OMM, to withstand forces of
dentures
• Most common problems are
 Oral lichen planus
 Erythema multiforme
 Pemphigoid and pemphigous
Poor prognosis of removal denture prosthesis so its prudent to
use fixed osseointegrated prosthesis is a prudent alternative

50. oral submucous fibrosis
• Chronic, progressive ,inflammatory
disease that affects the oral
mucous membrane.
• Considered as premalignant condition.
• Why concern to prosthodontics???
 Microstomia
 Glossitis and stomatitis
 Band formation and impairment of tongue movement

51. moDifications
At impression making and material:
 Use of sectional tray
 Use of addition silicone
 Zoe irritates the OMM
At border movements:
 Restricted movements
At Jaw relation:
 Fragile OMM
 Unstable denture bases
Denture
 Sectional/ Collapsible/ Hinged

52. management oPtion for microstomia
Hinged mandibular CD with
swing lock
Collapsible denture

53. saliVary Dysfunction
• This leads to xerostomia or dry mouth.
• The complaints of xerostomia necessitates the search for an
underlying systemic disease.
• May induce oral alteration and discomfort with the removable
prosthesis.
Xerostomia is a subjective symptom associated with change
in quantity and quality of saliva

54. causes of xerostomia

55. signs anD symPtoms
 Dry and cracked lips
 Increased plaque, dental decay, PDL degeneration.
 Trouble swallowing, speaking, tasting
 Thick and stringy saliva, oral malodor
 Infection prone
 Burning sensation
 Poor retention of denture
 Soreness of denture bearing area

56. treatment

57. Prosthetic moDification
• Maxillary and Mandibular salivary reservoir denture.
• Systemic stimulation of salivary function can be obtained
by pilocarpine 5 mg three times a day

58. 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.

60. 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

62. 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
salvia, airway obstruction, and aspiration

63. 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 of the dentures are useful techniques.
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

64. Implant Surgery
 The quality of oral health and general health has improved by using
dental implant supported prosthesis and is associated with marked,
increase in masticatory ability
 LA containing epinephrine is used cautiously, because if agonises
with levodopa or entacapone, shoots up BP and heart rate
 Epinephrine of less than 0.05 milligram appears to be safe.
 Dentist should be careful when prescribing erythromycin and
ampicillin, as they are known to interfere with biliary excretion
 Monoamine oxidase inhibitor potentiates the action of narcotic
drugs.

65. BurnIng mouth Syndrome:
• Burning sensations accompany many inflammatory or
ulcerative diseases of the oral mucosa, but the term BMS is
reserved for describing oral burning that has no detectable
cause.
• In burning mouth syndrome, burning sensation of the oral
mucosa with no clinically apparent alterations.
• Middle aged, menopausal women
• Mainly women, only 10-20% men
• Onset usually 3-12yrs after
menopause

66. ClaSSIfICatIon and ClInICal featureS
 Type 1: symptoms not present upon waking, and then
increases throughout the day
 Type 2: symptoms upon waking and through the day
 Type 3: no regular pattern of symptoms
• Clinical features
 Mucosal pain
 Burning dorsum of the tongue-
 Irritated or raw feeling
 Dysgeusia
 dysesthesia

68. management of BmS
 Management is usually palliative not curative
 Patient education and encouragement, best approach to
improve quality of life.
 Adjusting or replacing poorly fitting dentures
 Taking nutritional supplements
 Avoiding tobacco and alcohol
 The drug therapies that have been found to be the most
helpful are low doses of TCAS, such as amitriptyline and
doxepin, or clonazepam

69. human ImmunodefICIenCy vIruS
 The human immunodeficiency virus (HIV) is a
lentivirus (a subgroup of retrovirus) that causes
HIV infection and over time
acquired immunodeficiency syndrome (AIDS)
 Infection with HIV occurs by the transfer of blood,
semen, vaginal fluid, pre-ejaculate, or breast milk.
 HIV infects vital cells in the human immune system
such as helper T cells (specifically CD4+
T cells), macrophages, and dendritic cells
 Progressive failure of the immune system allows
life-threatening opportunistic infections and
cancers to thrive.

71. oral manIfeStatIonS of hIv
Group 1 :LESIONS STRONGLY ASSOCIATED WITH HIV
INFECTIONS
 Candidiasis : Eythematous and Pseudomembranous
 Hairy leukoplakia
 Kaposi’s sarcoma
 Non- Hodgkin’s lymphoma
 Periodontal diseases :
Linear gingiva erythema
Necrotizing ulcerative gingivitis
Necrotizing ulcerative periodontitis

72. Group 2 LESIONS LESS COMMONLY ASSSOCIATED WITH
HIV
 Bacterial infections: M.avium – intracellulare M. tuberculosis
 Melanotic hyperpigmentation
 Necrotizing ulcerative stomatitis
Fungal lesions ( Candidiasis Histoplasmosis Cryptococcus
neoformans)
Viral lesions (Herpes simplex Herpes zoster Human papilloma
virus Cytomegalovirus Epstein-Barr Virus)

74. guIdelIneS for proSthodontIC management
of SuBjeCtS wIth hIv/aIdS
• The distinction should be made between asymptomatic HIV
positive patient and AIDS patient.
• General Measures:
1. Create safe and empathetic environment.
2. Maintain confidentiality of patients’ information.
3. Use standard precautions.
4. Provide unbiased treatment.
5. Advise regular dental visits.
6. Identify and manage oral manifestations of HIV/AIDS.

75. meaSureS In partICular to proSthodontICS:
 Evaluation of periodontal status of existing dentition during
construction of removable and fixed dentures.
 Evaluation and management of xerostomia.
 Increased maintenance of dentures for prevention of
candidiasis.
 Evaluation of temporomandibular joint disorders.
 Precautions during pre-prosthetic and implant surgeries.

76. optImIzIng human faCtorS In dentIStry
• Occupational health hazards among dental professionals are
on a continuous rise and they have a significant negative
overall impact on daily life.
• Risk factors among dentists are multifactorial, which can be
categorized into biomechanical and psychosocial.
• Dentistry faces a serious threat because of the poor
ergonomic practices.
• Musculoskeletal disorders can be reduced through proper
positioning of dental worker and patient, regular rest breaks,
general good health, using ergonomic equipment
• Musculoskeletal disorders (MSDs) are now increasingly
common, Owing to a mismatch between the physical
requirements of the job and the physical capacity of human
body

77. the preSent SCenarIo
• Among the dentist worldwide that low back problems are the
most common, followed by problems of the hand and wrist,
neck and shoulders with more than one-third requiring
medical care for MSDs
• Moreover, hand paresthesia is now becoming increasingly
common.
• WHY ARE DENTISTS AT RISK?
• risk factors include static and awkward postures
• repetition and force (more commonly related to hand and arm
conditions)
• poor lighting
• poor working conditions and instrument designs, individual
characteristics

78. Dentists are bound to limited range of motion (constrained
postures) resulting in isometric muscle contractions,
difficulties in direct visualization (which causes awkward
posture)
Head rotation, neck flexion, and the necessity of upper arm
abduction for mirror usage are common risk factors for upper
extremity disorders.
Cervicobrachial disorders are more common among dentists
who keep their head bent to the side and rotated.
Risk for trapezius pain may also be heightened from holding
the arm elevated for long periods, such as holding a mirror for
indirect visualization.
It is also noted that dentists often rotate their necks to the left
with side bending to the right for better visibility and this is
likely to strengthen the muscles on one side while weakening
the opposing muscles,

79. preventIon StrategIeS
• MSDs can be reduced through proper positioning of dental
worker and patient, regular rest breaks, general good health,
and exercises.
• A few Prevention Guidelines can be summed up:
 An adjustable ergonomic stool
with lumbar and arm support and
capability to rotate.
 Dentists sitting with feet flat on floor
and thighs parallel to the floor and
dental assistants 4-6” higher and
using a footrest on the stool

80.  Patients reclined fully with mouth at the dentist's elbow height for
maxillary arch tasks and lowered with a 20° incline (still with mouth at
dentist's elbow height) for mandibular arch tasks.
 Proper lighting and indirect mirror viewing.
 Using ×2 magnification, properly selected and positioned magnification
systems can help reduce forward posture, including keeping forward
flexion of the neck below 20°
 Regular resting from static postures particularly for the trapezius and
forearm muscles, and from repetitive motions of the forearm and hand
(minimum of 6 min per h and 10-15 min every 2-3 h).

81. ConCluSIon
• The successful management of patient begins right from
the medical history to the treatment plan.
• Consideration has to be given to the systemic status of
individual.
• The practitioner neglecting the systemic status in the
history will step into more serious complication at the
cost of individual life

82. referenCeS
• Burket's oral medicine 12th edition
• Shafer oral pathology 7th edition
• Neville oral pathology 4th edition
• Carranza's clinical periodontology 9th edition
• Harrison's principles of internal medicine 19th edition
• Davidson's principles and practice of medicine 21st edition
• Contemporary implant dentistry – Carl E. Misch
• Chzechze. (2011, December 30). Burning mouth syndrome.
Retrieved from http://www.intelligentdental.com/2011/12/30/burning-
mouth-syndrome/
• . Mayo Foundation for Medical Education and Research. (2010, July
17). Burning mouth syndrome. Retrieved from
http://www.mayoclinic.com/health/burning-mouth-syndrome/

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Indian Journal Of Stomato.2014; 2(4):263-66.
J Indian Prosthodont Soc (Oct-Dec 2013) 13(4):393–399
Michaeli E, Weinberg I, Nahlieli O. Dental implant in diabetic patients: Systemic
and rehabilitative consideration. Quintessence Int. 2009;40:639–45.
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JADA 1970, vol 80, pg 133.
JADA 1980, vol 100, pg 682.
JADA 1997, vol 128, pg 1109.
JADA 1995, vol 126, pg 1107