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Case Selection and Diagnosis

Part A: Medical Consideration in Implant Dentistry

1 Commonly Ordered Blood Tests in Implant Dentistry1

Blood test Normal Clinical significance Hematocrit (Hct) Female: 36-46%
Male: 42-52% Low values: Anemia; monitor for fatigue, dyspnea, tachycardia, and tachypnea. Hemoglobin (Hgb) Female: 12-15 g/dl
Male: 14-17 g/dl Low values: Anemia; monitor for fatigue, dyspnea, tachycardia, and tachypnea. Red blood cell (RBC) count Female: 4-5.5 million/mm3
Male: 4.5-6.2 million/mm3 Low values: Anemia; monitor for fatigue, dyspnea, tachycardia, and tachypnea. High values: In chronic obstructive pulmonary disease (COPD), this may indicate polycythemia, a compensation for pulmonary dysfunction that makes blood thicker, increases risk of cerebrovascular accident (CVA). Total white blood cell (WBC) count 5000-10,000/mm3 >10,000 indicates systemic infection (more than just local colonization). Platelets and thrombocytes 200,000-500,000/mm3 30,000-50,000: Risk of internal hemorrhage. Erythrocyte sedimentation rate (ESR) Female: 1-25 mm/h
Male: 0-17 mm/h Bad if elevated. Used to diagnose, or follow the course of, inflammatory diseases (e.g., rheumatic conditions). Creatinine Female: 0.6-1.2 mg/dl
Male: 0.5-1.1 mg/dl Renal function measure: High values are bad. May indicate nephropathy, or end-stage renal disease. Potassium (K) 3.5-5.0 mEq/l Results of low K: Ventricular arrhythmias. Results of high K: Ventricular arrhythmias and asystole. Calcium (Ca) 8.2-10.2 mg/dl Results of low Ca: Osteoporosis, muscle spasms or tetany, calcium deposits in tissue, cardiac arrhythmia, and asystole.
Results of high Ca: thirst, polyuria, renal stones, decreased muscle tone, tachycardia, cardiac arrhythmia, and asystole. Sodium (Na) 136-145 mEq/l Results of low Na: postural hypotension, abdominal cramps, headache, fatigue, and weakness.
Results of high Na: edema and tachycardia. Fasting blood glucose (FBG) 70 to 99 mg/dL 100 to 125 mg/dL: Impaired fasting glucose (pre-diabetes).
>126 mg/dL: Diabetes. Serum c-telopeptide collagen Adult male
18-29 Years 87-1200 pg/mL
30-39 Years 70-780 pg/mL
40-49 Years 60-700 pg/mL
50-68 Years 87-345 pg/mL
Adult female
18-29 Years 60-640 pg/mL
30-39 Years 60-650 pg/mL
40-49 Years 40-465 pg/mL High in osteoporosis, osteopenia, and primary hyperthyroidism. Alkaline phosphates 30-120 IU/L High values: liver disease, osteoclastic activity, Paget's disease, bone cancer, and osteoporosis. Prothrombin time (PT) 1-18 sec Measures extrinsic clotting of blood.
Prolonged in liver disease, impaired vitamin K production, and surgical trauma with blood loss. Partial thromboplastin time (PTT) By laboratory control Measures intrinsic clotting of blood and congenital clotting disorders.
Prolonged in hemophilia A, B, and C. International Normalized Ratio (INR) Without anticoagulant therapy: 1
Anticoagulant therapy target range: 2-3 Measures extrinsic clotting function.
Increased with anticoagulant therapy. Bleeding time (BT) 1-6 min Measures quality of platelets.
Prolonged in thrombocytopenia.

A Recommendations

1. Low platelet count and abnormal clotting tests in addition to abnormal BT, PT, PTT, or INR value is a contraindication in implant surgery, especially in a sinus grafting procedure, due to the possibility of uncontrolled bleeding.
2. Abnormal c-telopeptide values related to the use of oral or systemic bisphosphonates should be considered prior to implant surgery.
3. Consult with a physician in writing regarding any abnormal values, and attach a copy of the blood test results.

2 ASA Classifications

• ASA Physical Status 1: A normal healthy patient.
• ASA Physical Status 2: A patient with mild systemic disease.
• ASA Physical Status 3: A patient with severe systemic disease.
• ASA Physical Status 4: A patient with severe systemic disease that is a constant threat to life.
• ASA Physical Status 5: A moribund patient who is not expected to survive without the operation.
• ASA Physical Status 6: A declared brain-dead patient whose organs are being removed for donor purposes.

A Recommendations

• ASA Status 1 and 2 can be treated in a dental office.
• ASA Status 3 and 4 should be treated in an in-patient facility.

3 Medical Conditions1

A Scleroderma

1. A multisystem disorder characterized by inflammatory, vascular, and sclerotic changes of the skin and various internal organs, especially the lungs, heart, and gastrointestinal tract.
2. Typical clinical features in the facial region are a masklike appearance, thinning of the lips, microstomia, sclerosis of the sublingual ligament, and indurations of the tongue.
3. The symptoms cause the skin of the face and lips as well as the intraoral mucosa to become taut, thereby hindering dental treatment and complicating or even preventing the insertion of dental prostheses.
4. No controlled studies were found for scleroderma to demonstrate any positive or negative effects on the outcome of implant therapy.

B Oral Lichen Planus (OLP)

1. A common T-cell-mediated autoimmune disease of unknown cause that affects stratified squamous epithelium exclusively.
2. OLP has been considered a contraindication for the placement of dental implants possibly because of the altered capacity of the oral epithelium to adhere to the titanium surface.
3. OLP as a risk factor for implant surgery and long-term success cannot be properly assessed.

C Ectodermal Dysplasia (ED)

1. A hereditary disease characterized by congenital dysplasia of one or more ectodermal structures.
2. Common extra- and intraoral manifestations include defective hair follicles and eyebrows, frontal bossing, nasal bridge depression, protuberant lips, hypo- or anodontia, conical teeth, and generalized spacing.
3. Most search results for ED were case reports demonstrating treatment success with dental implants.
4. A few larger case series report survival and success rates of implants in such patients. All studies reported significantly lower survival and success rates in the maxilla than in the mandible.

D Sjögren's Syndrome (SS)

1. A chronic autoimmune disease affecting the exocrine glands, primarily the salivary and lacrimal glands. The etiology of SS is far from being under-stood.
2. The most common symptoms of SS are extreme tiredness, along with dry eyes (keratoconjunctivitis sicca) and dry mouth (xerostomia).
3. Xerostomia can eventually lead to difficulty in swallowing, severe and progressive tooth caries, or oral infections.
4. Currently, there is no cure for SS, and treatment is mainly palliative.
5. Literature on implant performance in patients with SS is scarce. There are no controlled studies available, and only one case series study with eight patients included was found. The eight patients in this study were all women receiving a total of 54 implants (18 in the maxilla and 36 in the mandible) with a machined surface. Seven of these implants (12.9%) were found not to be osseo-integrated at abutment connection. During the first year of function, two additional implants in the mandible were lost, resulting in an implant-based failure rate of 16.7% (the patient-based rate was 50%; four patients out of eight lost at least one implant).

E Crohn's Disease

1. An idiopathic chronic inflammatory disorder of the gastrointestinal tract that may also involve the oral cavity.
2. The disease process is characterized by recurrent exacerbations and remissions.
3. The literature regarding the performance of dental implants in patients with Crohn's disease is scarce. In a retrospective study with observation up to 1 week after second-stage surgery, two of three patients with Crohn's disease had implant failures (3 out of 10 inserted implants were lost). The authors speculated that the presence of antibody-antigen complexes might lead to autoimmune inflammatory processes in several parts of the body, including the bone-implant interface. However, in...