- Email: [email protected]
Implant placement in infected sites
follow oral hygiene care instructions, or comply with medication regimens. Management.—Some patients have difficulty coping with patient-controlled sedation, so it must be used judiciously in older individuals. Each case must be analyzed individually. When sedation is needed the clinician anticipates an increased risk of respiratory suppression, confusion, or falls, among other problems, and whether provision for inpatient treatment is required. Efforts must be made to avoid covert age discrimination in management decisions. This includes avoiding the assumption that the patient will not live much longer and therefore will not benefit much from some interventions; avoiding underprovision of services or giving younger patients priority status; and making it inconvenient or limiting access to care for frail or disabled persons who require assistance and transportation. Provisions are needed so that all patients can access care and understand the existence of helping services. Similarly, the clinician should provide information to older patients in a way they can comprehend. Most older patients can make appropriate choices and give valid consent when provided with accurate information that is clearly and completely explained. Older patients are at higher risk for drug interactions. In addition, impaired homeostasis and multiple comorbid conditions can cause problems. In addition to an accurate accounting of the drugs the patient is taking, clinicians must be aware that older patients may have increased sensitivity to drug actions. For example, renal function and liver function deterioration reduce drug excretion. Older people absorb drugs much the same as other patients, but because of the altered excretion they will need lower doses, especially for drugs with a narrow therapeutic window. Local anesthetics are required in lower doses. Older patients have a more rapid onset of local anesthesia than younger patients, and a longer duration of pulpal anesthesia. Most antibiotics can be prescribed in regular doses, but longterm use of amoxicillin and metronidazole can change
clotting ability. Tetracycline absorption can be impaired by the concomitant use of iron or calcium preparations, which are commonly used by older patients. In addition, nonsteroidal anti-inflammatory drugs (NSAIDs) can cause problems in patients with dyspepsia, renal disease or heart conditions being treated with angiotensin converting enzyme (ACE) inhibitors, and those taking anticoagulants. Older patients are more likely to suffer the side effects of drugs that act on the central nervous system, causing confusion, drowsiness, and falls. Impaired vision, mental function, or dexterity combined with the use of multiple medications can produce poor compliance, so the clinician should employ means to help the patient take medications correctly. Liquid medications can be difficult for the older patient to measure into a spoon, but plastic syringes can help with such drug dosing. Dosing boxes can be used to organize medications into their proper time and day of administration. Caregivers or pharmacists may help set these up.
Clinical Significance.—Older patients require dental care more often than younger patients. Clinicians may be challenged by patients who are elderly, disabled, and dealing with multiple medical problems. Dental practitioners should join with these patients’ medical practitioners and caregivers to ensure that the care delivered is appropriate, thorough, and geared to the elderly patients’ capabilities.
Greenwood M, Jay RH, Meechan JG: General medicine and surgery for dental practitioners. Part 1 – the older patient. Br Dent J 208:339-342, 2010 Reprints available from M Greenwood, Oral and Maxillofacial Surgery, School of Dental Sciences, Newcastle Univ, Framlington Pl, Newcastle upon Tyne, NE2 4BW; e-mail: mark.greenwood@ newcastle.ac.uk
Implants Implant placement in infected sites Background.—Various studies have found that immediately placing an implant into a site with periapical or periodontal infection may be a recipe for failure, causing higher rates of implant failure or retrograde periimplantitis. However, recent studies have found successful
outcomes with this immediate placement. The advantages of placing an implant immediately into an infected site include less treatment time, fewer procedures, and the ability to place the implant in an ideal axial position. Published data were reviewed systematically to determine whether
Volume 55
Issue 6
2010
305
Table 1.—Periapical Pathology of Teeth That Present With Radiolucency Pathology
Clinical Features
Histologic Features
Periapical granuloma (also known as chronic apical periodontitis)
Associated with non-vital teeth. May arise after quiescence of a periapical abscess and can transform into a periapical cyst. Usually asymptomatic.
Periapical abscess
Associated with non-vital teeth. Symptomatic or asymptomatic.
Periapical cyst (also known as a radicular cyst and apical periodontal cyst)
Usually asymptomatic unless acute exacerbation or cyst reaches a large size. Associated tooth is non-vital.
Periodontal abscess
Zone of gingival enlargement along the lateral aspect of a tooth. Erythema and edema are often present. Lesion is often characterized by throbbing pain, purulence, lymphadenopathy, and gingival sensitivity. Often treated with systemic antibiotics when fever is present.
Inflamed granulation tissue Surrounded by a connective tissue wall. Tissue contains lymphocytic infiltrate that may be intermixed with neutrophils, plasma cells, and histiocytes. Acute inflammation with the presence of neutrophils often mixed with inflammatory exudate, necrotic material, and bacteria. Lined by a stratified squamous epithelium. Lumen filled with fluid and cellular debris. May contain dystrophic calcification, red blood cells, cholesterol defts, multinudeated giant cells, and hemosiderin. Tissue characterized by features of periodontitis along with acute inflammation with the presence of neutrophils.
(Courtesy of Waasdrop JA, Evian CI, Mandracchia M: Immediate placement of implants into infected sites: A systematic review of the literature. J Periodontol 81:801-808, 2010.)
the presence of infection compromises osseointegration or implant success and whether certain protocols contribute to a better outcome. Methods.—A systematic search of MEDLINE/PubMed articles in English covered the period from 1982 until November 2009. Data were culled from both human and animal studies, but excluded all animal studies lacking a pristine control group and all human case reports and case series whose follow-up period was less than 1 year. Twelve articles were eventually selected, which included four animal studies and eight human studies. Results.—Most of the studies focused on sites with chronic periapical infections, although the actual classification was often unclear (Table 1). The animal studies indicated high levels of implant survival. However, the boneto-implant contact was greater in control groups than in test groups. High implant survival in sites with periodontal and periapical infection was also noted in the human studies, although few patients were actually studied overall. Protocols that were followed throughout included complete and thorough debridement of the socket and the aggressive use of systematic antibiotics. Discussion.—The outcomes for immediate placement of implants in periodontally or periapically involved sites were comparable with those for implants that were delayed until the infection had cleared. No differences were noted
306
Dental Abstracts
in implant stability quotient values, gingival esthetics, periapical cultures, or radiographic parameters. A protocol of complete debridement and systematic antibiotics was used for all cases, perhaps contributing to the good clinical outcome.
Clinical Significance.—Immediate placement of an implant in a site where the patient has periapical or periodontal infection used to be contraindicated, but we are finding that the outcomes can be quite good despite the presence of infection initially. Some studies have shown that the aggressive use of antibiotics is perhaps not needed; this point remains controversial. Additional research should relate antibiotic use to the type of infection present and investigate whether debridement and/or peripheral ostectomy may be sufficient.
Waasdrop JA, Evian CI, Mandracchia M: Immediate placement of implants into infected sites: A systematic review of the literature. J Periodontol 81:801-808, 2010 Reprints available from JA Waasdrop, MS 10112, Valley Forge Cir, King of Prussia, PA 19406; fax: 610/783-7829; e-mail: [email protected]
clotting ability. Tetracycline absorption can be impaired by the concomitant use of iron or calcium preparations, which are commonly used by older patients. In addition, nonsteroidal anti-inflammatory drugs (NSAIDs) can cause problems in patients with dyspepsia, renal disease or heart conditions being treated with angiotensin converting enzyme (ACE) inhibitors, and those taking anticoagulants. Older patients are more likely to suffer the side effects of drugs that act on the central nervous system, causing confusion, drowsiness, and falls. Impaired vision, mental function, or dexterity combined with the use of multiple medications can produce poor compliance, so the clinician should employ means to help the patient take medications correctly. Liquid medications can be difficult for the older patient to measure into a spoon, but plastic syringes can help with such drug dosing. Dosing boxes can be used to organize medications into their proper time and day of administration. Caregivers or pharmacists may help set these up.
Clinical Significance.—Older patients require dental care more often than younger patients. Clinicians may be challenged by patients who are elderly, disabled, and dealing with multiple medical problems. Dental practitioners should join with these patients’ medical practitioners and caregivers to ensure that the care delivered is appropriate, thorough, and geared to the elderly patients’ capabilities.
Greenwood M, Jay RH, Meechan JG: General medicine and surgery for dental practitioners. Part 1 – the older patient. Br Dent J 208:339-342, 2010 Reprints available from M Greenwood, Oral and Maxillofacial Surgery, School of Dental Sciences, Newcastle Univ, Framlington Pl, Newcastle upon Tyne, NE2 4BW; e-mail: mark.greenwood@ newcastle.ac.uk
Implants Implant placement in infected sites Background.—Various studies have found that immediately placing an implant into a site with periapical or periodontal infection may be a recipe for failure, causing higher rates of implant failure or retrograde periimplantitis. However, recent studies have found successful
outcomes with this immediate placement. The advantages of placing an implant immediately into an infected site include less treatment time, fewer procedures, and the ability to place the implant in an ideal axial position. Published data were reviewed systematically to determine whether
Volume 55
Issue 6
2010
305
Table 1.—Periapical Pathology of Teeth That Present With Radiolucency Pathology
Clinical Features
Histologic Features
Periapical granuloma (also known as chronic apical periodontitis)
Associated with non-vital teeth. May arise after quiescence of a periapical abscess and can transform into a periapical cyst. Usually asymptomatic.
Periapical abscess
Associated with non-vital teeth. Symptomatic or asymptomatic.
Periapical cyst (also known as a radicular cyst and apical periodontal cyst)
Usually asymptomatic unless acute exacerbation or cyst reaches a large size. Associated tooth is non-vital.
Periodontal abscess
Zone of gingival enlargement along the lateral aspect of a tooth. Erythema and edema are often present. Lesion is often characterized by throbbing pain, purulence, lymphadenopathy, and gingival sensitivity. Often treated with systemic antibiotics when fever is present.
Inflamed granulation tissue Surrounded by a connective tissue wall. Tissue contains lymphocytic infiltrate that may be intermixed with neutrophils, plasma cells, and histiocytes. Acute inflammation with the presence of neutrophils often mixed with inflammatory exudate, necrotic material, and bacteria. Lined by a stratified squamous epithelium. Lumen filled with fluid and cellular debris. May contain dystrophic calcification, red blood cells, cholesterol defts, multinudeated giant cells, and hemosiderin. Tissue characterized by features of periodontitis along with acute inflammation with the presence of neutrophils.
(Courtesy of Waasdrop JA, Evian CI, Mandracchia M: Immediate placement of implants into infected sites: A systematic review of the literature. J Periodontol 81:801-808, 2010.)
the presence of infection compromises osseointegration or implant success and whether certain protocols contribute to a better outcome. Methods.—A systematic search of MEDLINE/PubMed articles in English covered the period from 1982 until November 2009. Data were culled from both human and animal studies, but excluded all animal studies lacking a pristine control group and all human case reports and case series whose follow-up period was less than 1 year. Twelve articles were eventually selected, which included four animal studies and eight human studies. Results.—Most of the studies focused on sites with chronic periapical infections, although the actual classification was often unclear (Table 1). The animal studies indicated high levels of implant survival. However, the boneto-implant contact was greater in control groups than in test groups. High implant survival in sites with periodontal and periapical infection was also noted in the human studies, although few patients were actually studied overall. Protocols that were followed throughout included complete and thorough debridement of the socket and the aggressive use of systematic antibiotics. Discussion.—The outcomes for immediate placement of implants in periodontally or periapically involved sites were comparable with those for implants that were delayed until the infection had cleared. No differences were noted
306
Dental Abstracts
in implant stability quotient values, gingival esthetics, periapical cultures, or radiographic parameters. A protocol of complete debridement and systematic antibiotics was used for all cases, perhaps contributing to the good clinical outcome.
Clinical Significance.—Immediate placement of an implant in a site where the patient has periapical or periodontal infection used to be contraindicated, but we are finding that the outcomes can be quite good despite the presence of infection initially. Some studies have shown that the aggressive use of antibiotics is perhaps not needed; this point remains controversial. Additional research should relate antibiotic use to the type of infection present and investigate whether debridement and/or peripheral ostectomy may be sufficient.
Waasdrop JA, Evian CI, Mandracchia M: Immediate placement of implants into infected sites: A systematic review of the literature. J Periodontol 81:801-808, 2010 Reprints available from JA Waasdrop, MS 10112, Valley Forge Cir, King of Prussia, PA 19406; fax: 610/783-7829; e-mail: [email protected]