Practical Procedures in Implant Dentistry. Группа авторов
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possible pathologic jaw fracture. The risk is increased in IV infusion therapy of these medications, other comorbidities, duration of medication usage, and the complexity of surgery.
In a postal survey, Mavrokokki et al. [11] estimated the risk of osteonecrosis of the jaw after dental extraction to be 0.09–0.34% with weekly oral alendronate (Fosamax) and 6.7–9.1% with IV formulations used for bone malignancy.
The American Association of Oral and Maxillofacial Surgeons updated position paper (2014) on bisphosphonate‐related osteonecrosis of the jaws listed additional risk factors of corticosteroid use, diabetes, smoking, poor oral hygiene, and chemotherapy [12]. Their recommendations are as follows:For individuals on oral bisphosphonate for less than four years with no clinical risk factors, no alteration or delay in the planned surgery is necessary. It is suggested that if dental implants are placed, informed consent should be provided related to possible long‐term implant failure and the low risk of developing osteonecrosis of the jaws if the patient continues to take an antiresorptive agent.For those patients who have taken an oral bisphosphonate for less than four years and have also taken corticosteroids or anti‐angiogenic medications concomitantly, the prescribing provider should be contacted to consider discontinuation of the oral bisphosphonate (drug holiday) for at least two months prior to oral surgery, if systemic conditions permit. The antiresorptive should not be restarted until osseous healing has occurred.For those patients who have taken an oral bisphosphonate for more than four years with or without any concomitant medical therapy, the prescribing provider should be contacted to consider discontinuation of the antiresorptive for two months prior to oral surgery, if systemic conditions permit. The bisphosphonate should not be restarted until osseous healing has occurred.
Current management is based on minimal evidence and expert opinion with an emphasis on prevention. Informed consent must be attained on possible risks and complications. Ongoing careful monitoring is essential when considering implant treatment for these patients.
2.1.7 Radiotherapy
Radiation treatment may lead to oral effects such as xerostomia, hypovascularity, mucositis, fibrosis, and osteoradionecrosis.
A systematic review by Colella et al. [13] reported similar failure rates for implants placed pre‐radiotherapy compared with those placed post‐radiotherapy: 3.2 and 5.4%, respectively. Implant failure rate was significantly higher in the maxilla (17.5%) compared with the mandible (4.4%), with all implant failures occurring within three years after radiotherapy and most within 1–12 months. No implant failures were reported when radiation dose was less than 45 Gy.
The adjunctive use of hyperbaric oxygen therapy (HBO) has been suggested in the treatment of irradiated patients. HBO increases the blood‐to‐tissue oxygen gradient, improving the healing capacity of irradiated tissue by stimulating capillary growth and osteogenesis. Treatment consists of breathing 100% pressurised oxygen for approximately 90 minutes for about 20 sessions pre‐surgery and 10 post‐surgery. Esposito et al. [14] in a Cochrane review of HBO and implant treatment failed to show any appreciable clinical benefits.
Ihde et al. [15] reported in a systematic review that implants placed in irradiated bone exhibited a two to three times greater failure rate compared with non‐irradiated bone, with doses above 50 Gy having a higher failure rate. No significant differences in failure rate were found with implants placed at various intervals, either before or after radiotherapy for a clinical recommendation to be made. However, implants placed in the maxilla were at least twice as likely to fail and no specific implant could be recommended based on survival data.
2.1.8 Dental History
Questioning on past history of dental treatment is helpful to understand the reason for tooth loss and to identify any risk factors that the patient may present with. The aetiology for tooth loss may be congenitally missing, periodontal disease, fractured or carious tooth beyond restoration, endodontic complications, along with other reasons. Patients that present with a history of periodontal disease may have lost significant amounts of alveolar bone, complicating implant treatment with the need for bony augmentation, as well as being in the higher risk category of peri‐implantitis. Questions about how the tooth was removed or if there was difficulty in removal of the tooth may provide useful information, as surgical removal of the tooth and difficulty in extraction resulting in bone removal may indicate a need for future hard or soft tissue augmentation. Valuable information is gathered in the history that may enlighten the clinician as to what progressed prior to their visit to the practice.
Determining the level of the patient's expectations is important to assess whether it will be possible to achieve the desired result, or whether they may need to be referred to a more experienced colleague for assistance. In cases of deficient soft tissue, it may be virtually impossible to recreate perfect soft tissue aesthetics with natural dental papilla, and discussions on the use of pink replacement with porcelain may be necessary.
Excellent patient compliance is necessary for long‐term success of dental implants, with regular dental attendance providing continual assessment, occlusal verification, and reinforcement of correct hygiene techniques. This provides the supportive care that a patient requires and at initial consultation it is necessary to advise the patient on the need for continual care. Regular oral hygiene with excellent plaque control will provide the environment for healthy peri‐implant tissues, and implant therapy should only be initiated once this has been achieved.
2.1.9 Social History
A social history may include aspects of the patient's developmental, family, and medical history, as well as relevant information about life events, social class, race, religion, and occupation.
Asking the patient about any environmental influences such as alcohol, tobacco (amounts and durations), and drug use (including illicit drugs), along with the frequency, will assist in a complete history.
2.2 Tips
A systematic and repeatable approach should be adopted, consulting with patients to ensure that a comprehensive history is taken.
Documents and checklists may be used to ensure that clinicians do not miss critical information when taking history and examining patients. These may provide prompts when questioning patients on relevant information required.
References
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