Medically Compromised Pa-

tients in Prosthodontics
Resource Faculties:

Prof. Dr. Pramita Suwal

Dr. Prakash Parajuli
Dr. Arati Sharma
Dr. Indra Limbu
Dr. Bishal Babu Basnet
Presented by :
Dr. Meena Singh
Sayana Sunuwar
Dr. Ankita Rai
Roll no - 818
 TABLE OF CONTENTS

01 INTRODUCTION Summary 03
02 Medical conditions
consideration
References
04
Introduction

 General health factors and systemic conditions has

a great impact on prosthodontic treatment plan-
ning.

 A detailed history including medical history and

medication taken by patients should be recorded
thoroughly.
Pulmonary Diseases
Asthma
 Take proper history of the patient
 Position the patient in upright position
 Schedule late morning appointment
 patient’s inhaler should be available during each visit
 Aspirin, NSAIDs, and barbiturates are avoided)
 Optimal curing of acrylic prostheses is recommended, and mate-
rial free of methyl methacrylate is preferred

COPD
 If the patient is under systemic corticosteroids, supplementation
dose is required for major surgical procedures because of adrenal
suppression
 Cardiovascular diseases
For all the patients with cardiovascular diseases, the general
stress reduction protocol should be followed

I. Adequate counseling to decrease fears and anxiety

II. Shorter morning appointment
III. Preoperative sedation and Intraoperative sedation
IV. Profound local anesthesia
V. Adequate postoperative analgesia
 Hypertension
Oral manifestations of hypertension result not directly due to
HTN itself but occur as a side effect of antihypertensive drugs.
They include xerostomia caused by diuretics like

 lichenoid mucosal lesions, burning mouth

 loss of taste sensation (angiotensin-converting enzyme in-
hibitors)
 and gingival hyperplasia (calcium channel blockers).
(i) Stress reduction protocol
(ii) Avoid abrupt change in
body position
(iii) Afternoon appointments
(iv) NSAIDs for short term use

(i) Sharp edges of dentures should be well trimmed and

polished
(ii) Utmost care should be provided to avoid soft tissue
abrasion during denture fabrication
(iii) Artificial salivary lubricants
(iv) Supragingival margin
(v) Careful with epinephrine containing gingival retraction
cord
Angina pectoris
Angina pectoris is defined as the chest pain that is a result due to
reduced blood flow to cardiac tissue.
Mild angina
 can undergo most nonsurgical dental Unstable angina
procedures with normal protocol. limited to examination procedures
 Vitals should be monitored contraindication for elective dental
 Extensive treatment like implant surgery like placement of implants.
surgery should be done under nitrous
oxide sedation
Moderate angina
 Sublingual dose of nitroglycerin prior to
extensive treatment like implant surgery.
 Adequate anxiolytic and oxygen supple-
mentation
Myocardial infraction

Dental management of MI is same as that of angina pectoris.

if the patient is under anticoagulants, the international normal-

ized ratio (INR) should be determined on the day of treatment,
and treatment should be provided within the recommended lim-
its, i.e., <3.5 with adequate bleeding control for surgery.
Infective endocarditis
Prophylaxis is recommended in various dental procedures such as
dental implants or subgingival cord placements in many cases, which
includes prosthetic heart valves, past infective endocarditis, cyanotic
congenital cardiac disease etc.

In the instances when implants are necessary, endo-osseous implants

with an adequate width of attached gingiva are preferred
Anticoagulant therapy
Normal INR <1
For patient taking anti-coagulant between 2-3

 consultation to physician is recommended

 No adjustments in oral anticoagulant are indicated, if invasive
procedures or minor oral surgery is planned and the INR is be-
tween 2 -3.5
 Use of oxidized cellulose or collagen sponges and sutures may
decrease the risk of bleeding in patients who are using oral anti-
coagulants. Consideration for the use of mouthwash with 5%
tranexamic acid 4x a day for two days can also be done.
 NSAIDs and COX-2 inhibitors should not be prescribed in pa-
tients taking warfarin as analgesics following dental surgery
Diabetes Mellitus
Oral manifestations in uncontrolled DM include xerostomia, periodonti-
tis, burning mouth syndrome, delayed wound healing, alveolar bone
resorption, and candidiasis.
Usually dental therapy is deferred in cases with uncontrolled DM. If
suspected, physician consultation is recommended.

 following proper medical history ,levels of glycemic control

early in the treatment process and query about the diet taken
by the patient
 morning schedule and stress reduction protocol
 Oral hygiene instructions, regular prophylaxis, and monitoring
of periodontal health is advised
 Use of antibiotics is recommended in case of infection
 RPD
1. Maintenance of good oral hygiene must be accom-
plished first
CD
2. All components of RPD should be well adapted to
1. Muco-static impression technique is suggested
the underlying tissues
2. Neutral zone technique is advised
3. Utmost oral and prosthesis care instructions should
3. Denture flanges should be smooth and pol-
be delivered
ished
4. Proper oral hygiene instructions should be given
along with regular follow-up visits
5. If patient has less salivation, proper therapy for
maintenance of wet environment (e.g. water sip-
ping, sugarless gum)
6. Frequent evaluation of denture is necessary
 FPD
1. Avoid traumatization of soft tissues during tooth
preparation
2. Supragingival finish line is better
implants or implant-supported denture
3. Chamfer margin is considered a better choice for peri-
1. Surgical procedure is started only after adequate control
odontally compromised teeth
of diabetic state
4. Proper flossing is advised to maintain the oral hygiene
2. Pre and post implant surgery, antimicrobial cover is rec-
5. Hygienic pontic is preferred for the ease of cleansing
ommended
3. Smoking cessation, proper oral hygiene, and antiseptic
mouth rinses is recommended
4. Implant is not contraindicated in most diabetic patients;
however, their medical care should be controlled
Thyroid disorder

(i) Patients with no symptoms (moderate risk patients )are managed

with normal protocol along with stress reduction protocol. Use of ep-
inephrine should be limited in moderate to advanced implant proce-
dures.

(ii) Patients with symptoms (high risk patients) should have only ex-
amination procedures performed, and all other treatment should be
deferred until control of the condition after adequate medical or
laboratory confirmation.
Hematologic Disorders
Trauma to the tissues should be minimized
Handling the oral tissues delicately in all the steps is beneficial
to reduce chances of ecchymosis
In case of polycythemia, dental implants are contraindicated

In majority of patients with anemia, implant procedures can safely

be carried out, but the minimum baseline recommended is 10
mg/dl especially for implant surgery. However, antibiotic cover is
recommended before and after the surgery

in Leukopenia and Leukocytosis. Most common complications that

can compromise the success of implant are infection and delayed
healing. these may further increase the risk of secondary infection
Bone Disorders

osteoporosis
 Preservation of underlying tissue structure should be attained with
proper design of complete denture
 Mucostatic or open mouth impression technique is recommended
 Use of non- or semi-anatomic acrylic teeth with narrow buccolin-
gual width is advised
 Optimal use of soft liners may be considered
 Frequent relining of dentures is often required
 The design of implant should be such that it provides greater bone
contact and density.
 In addition, patients are advised to have adequate dietary calcium
intake and healthy lifestyle

Osteitis Deformans
 Supporting area such as maxillary tuberosities may have contin-
uous enlargement so adjusting dentures frequently
 Oral implants are contraindicated in the affected regions

Fibrous Dysplasia
 In an active lesion area, it is absolutely contraindicated
Arthritis

Due to the difficulty in opening mouth, special impression trays to

make impression are often necessary.

CD construction since the mandibular movements are painful.

 It is difficult to record and repeat jaw relation records.
 Because of subsequent changes in the joint, occlusal
correction must often be made.

FPD - During tooth preparation appointments should be kept

short. Longer appointments can be segmented into shorter ones
since there is difficulty for opening mouth for a longer period
 Liver disease
Patients with elevated PT <1.5 times the control value or slightly af-
fected bilirubin fall under moderate risk. Physician consultation
should be done in such cases. Bleeding should be controlled ade-
quately.
 If elevated PT is >1.5 times the control value, they fall under high
risk for which elective dental procedures are contraindicated

Renal disease
Dental treatment should be provided on the day after hemodialysis.
Major surgical procedures should be performed on the day after the
end of the week of hemodialysis. If dental treatment is necessary on
the day of hemodialysis, protamine sulfate is administered by the
physician to block anticoagulant effects of heparin.
REFERENCES
1) Textbook of Prosthodontics- Deepak Nallaswamy
2) Management of Medically Compromised Prosthodontic Patients. Int J Dent. 2022
Jan 11;2022:7510578. doi: 10.1155/2022/7510578. PMID: 35069742; PMCID:
PMC8767402.
3) Findler M, Chackartchi T, Regev E. Dental implants in patients at high risk for infec-
tive endocarditis: a preliminary study. Int J Oral Maxillofac Surg. 2014
Oct;43(10):1282-5. doi: 10.1016/j.ijom.2014.04.015. Epub 2014 Jun 2. PMID:
24893765.
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