- Author: Hugh Devlin
- Clinical Goals of Patient Care and Clinic Management
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Our patient population is vast and diverse.
Author: Hugh Devlin
Any hospital service will draw patients from within the institution as well as from the community. The patients are varied both medically and socioeconomically. Over time we have become a center for small diameter implants, with regard to both their placement and their restoration. For the purposes of this chapter, we will focus on the medical and dental parameters of our patients. A multitude of our patients are referred from neighboring medical clinics. The use of hospital outpatient clinics for primary care medicine will benefit a patient because all of their primary care and specialty care is under one roof.
This allows and encourages better coordination of therapy and communication between the various medical and dental practitioners. Many of our regular patients will fall into the ASA 2 category. As we look at more complex medical histories in our patients, extensive surgical procedures such as might be needed in some cases for multiple conventional implant placement may put them at risk for greater postsurgical complications. The hospital dental clinic setting is a common place for referrals of patients seen for other services in the hospital.
Many patients have some form of cardiovascular disease. In some cases, these patients are treated with a combination of anticoagulant and antiplatelet therapies. They are at times poor candidates for large incisions and flap reflections. Due to the vascularity, cutting osteotomies into medullary bone causes bleeding. Increasing the diameter of the osteotomy opens more vasculature to increase bleeding. Wide full thickness mucoperiosteal flaps causes bleeding as well.
Both procedures can cause changes in crestal bone that can adversely affect implant healing. Because no flap is created, bleeding is minimal. The hole through the soft tissue made by the pilot drill is only 1.
The pilot hole is taken one-third the length of the implant in moderately dense bone and removed. The implant is then placed into the hole and engages bone. As the implant is progressed to full length, it is not removing bone as an osteotomy would, but rather compressing the bone around it. This tamponade stops medullary vessels from bleeding. This also contributes to its initial stabilization. This generally stops any bleeding from bone, and the procedure is completed with little or no postoperative bleeding.
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Another common referral to our dental clinic is from the departments of Medical and Radiation Oncology. These patients often present after surviving various forms of cancer and having had radiation and chemotherapy. The bone and soft tissue will be affected directly. The associated medical issues and compromised immune system place them in a fragile category in which conventional implant therapy to replace missing teeth or to stabilize a removable prosthesis is not an option.
Radiation therapy has much longer lasting consequences that chemotherapy. Patients who have had radiation therapy directly to the mandible or maxilla due to oral and head and neck cancers or metastasis to the head and neck region are particularly fragile.
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These patients are often faced with few options for improvement of quality of life in the area of their oral health, both in form and function. With the concurrent loss of stability, denture sores are common and heal poorly due to decreased tissue vascularity. The minimally invasive protocols for MDIs are again of great benefit in these cases. Using the MDI to stabilize complete upper and lower dentures gives these patients the ability to function with their dentures normally.
For patients who have received radiation therapy to the mandible or maxilla, conventional implants would not be an option. The process of healing relies on the formation of a stable clot from healthy bleeding bone. Higher doses of radiation therapy decreases the ability of bone to heal properly. Radiation therapy also results in compromised vascularity of the overlying, soft tissue.
Large, full thickness flaps show poor healing and are at risk for breakdown, exposing underlying bone. The margins of a surgical flap and the cut bone walls of a conventional osteotomy will have poor healing. The MDIs are placed into the pilot hole, and they are self threading and compress the bone as they engage it. After the pilot hole there is no cutting of bone when using the MDIs, and the compromised vascularity will not adversely affect the healing.
Many types of cancer are treated with a combination of radiation and chemotherapy.
Although radiation therapy may not affect the prospective implant surgical sites, if chemotherapy is used in conjunction to treat the cancer, the systemic effect is a concern. The severe neutropenia that accompanies chemotherapy places a patient at much greater risk for postoperative complications. The best option of course is to wait a prescribed amount of time before beginning any elective dental surgery. The healing of the soft tissue, response of bone to surgical trauma, and the risk for infection will benefit from waiting.
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In a large segment of the developmentally disabled population, the only treatment for advanced caries is extraction. As one would expect, this would leave a large portion of that population either partially or completely edentulous. To further complicate dental rehabilitation, there are often advanced medical conditions and multiple medications for both systemic disease and emotional or psychological support. The range of developmental disabilities is vast. In many cases these patients are treated in a routine dental setting for restorative procedures, but for any more invasive procedures such as oral surgery, soft tissue surgery, or even implants, general anesthesia is indicated.
Patients who cannot tolerate dental care in a routine setting will benefit from general anesthesia. In some cases, the outcomes will be better than if only conscious sedation is used. After these patients have any unrestorable teeth removed, they are left partially or completely edentulous. That leads to the next great challenge of restoring the patient to function with prosthetics. Often a sufficient impression for an acrylic removable prosthesis is all that is possible.
Fabrications of all-acrylic removable prostheses are therefore often easier for both the patient and practitioner. MDIs greatly increase the success of these prostheses by increasing retention and stability. Once again, the simple and minimally invasive nonsurgical protocol for MDIs makes them the solution of choice.
After the prosthesis is fabricated, a return to general anesthesia or sedation will allow the placement and attachment of the implants to the prosthesis.
This allows a patient immediate ability to function with the prosthesis, without waiting for surgical healing and a third visit under anesthesia. In this same vein, because there are fewer postoperative complications with these implants, the postoperative problems that are much harder to manage in these cases can be avoided. If a patient presents with a small edentulous area a greater number of implants can be placed and used to retain a fixed prosthesis.
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The nonsurgical protocol lends itself to the treatment of patients for whom a larger more invasive and longer implant surgery is not ideal. In these cases, a laboratory processed long-term provisional bridge is the restoration of choice. A processed temporary is serviceable for repair or modification, can be removed if needed for evaluation, and replaced at reasonable cost.
It is best to examine the clinical applications of small diameter implants by looking at their various applications separately. The remainder of the chapter will be looking first at removable applications in various types of patients, then the uses for fixed prosthetics, and finally salvage operations of fixed prosthetics. The place to begin in the review of the versatile uses of the small diameter MDI is with the most exciting solution for a patient with a complete lower denture: overdenture support.
As any lower denture wearer will willingly share with anyone who asks, a lower denture does not stay still during function. Even the best fitting, properly extended, and well maintained lower denture will move during function. Upper dentures are to some degree better in terms of retention due to the support of the full palatal coverage. During function, however, both dentures will dislodge and move. With the advance of implant dentistry, overdentures retained in place with various types of fixtures have become standard.
American Association of Public Health Dentistry. American College of Prosthodontists. American Society of Dentist Anesthesiologists.
[PDF] Complication rates and patient satisfaction with removable dentures - Semantic Scholar
Oral and Maxillofacial Surgeons. Dentists, All Other Specialists. Dentists, General. Bureau of Labor Statistics, U. Last Modified Date: Wednesday, September 4, The What They Do tab describes the typical duties and responsibilities of workers in the occupation, including what tools and equipment they use and how closely they are supervised. This tab also covers different types of occupational specialties. The Work Environment tab includes the number of jobs held in the occupation and describes the workplace, the level of physical activity expected, and typical hours worked.