Clinical Scenario

An 80‐year‐old male presents for an assessment appointment at your dental clinic. He is dissatisfied with his full upper denture, as he finds it unstable, particularly on eating. The patient requests implant‐supported prosthetic rehabilitation and reports that other dentists have declined to provide this due to his history of heart disease.

Structured Learning

1. What factors may be contributing to the patient’s dissatisfaction with his upper denture?
   • The denture is over 10 years old
   • The residual ridge (denture‐bearing mucosa, submucosa and periosteum, and underlying residual alveolar bone) will have resorbed/changed shape significantly over this period, contributing to a deteriorating fit of the denture
   • The patient has a complete upper denture opposing natural teeth – this predisposes to tipping of the denture and generation of lateral forces which can result in compression of the periosteum, disruption of vasculature and an accelerated resorptive remodelling response
     

     

   • With increasing age as is the case for this patient, resorptive processes predominate over new bone formation
   • Hyposalivation leading to reduced tolerance and retention of the removable denture because of thin dry atrophic mucosa and lack of a saliva film

2. What is the most likely aetiology of the hyposalivation observed in this patient?
   • Salivary dysfunction in older age is mainly a consequence of systemic diseases and medications although it also reflects reduced functional reserve and reduced fluid consumption
   • For this patient, drug‐induced xerostomia is the most likely cause as the patient is taking several medications associated with this side‐effect:
     • Beta‐blocker (bisoprolol)
     • Angiotensin‐converting enzyme inhibitor (ramipril)
     • Diuretic (furosemide)
     • Alpha‐1 blocker (doxazosin)
3. Is the patient’s heart disease a contraindication for prosthetic rehabilitation with dental implants?
   • Pacemakers do not represent a contraindication for inserting dental implants
   • In carriers of coronary stents, the placement of dental implants is also not contraindicated
   • However, it is advisable to liaise with the cardiologist to ensure that the patient is stable and necessary adaptations are in place prior to proceeding
4. What factors are considered important in assessing the risk of managing this patient?
   • Social
     • Elderly patient with comorbidities – although there is no apparent change in cognition, it is known that coronary heart disease/MI are associated with an increased risk of cognitive impairment or dementia
     • Informed consent must be adapted to specify the possible complications and factors that could affect the prognosis of the implants should the patient’s health/cognition decline
   • Medical
     • Risk of pacemaker interference generated by electronic dental devices
     • Risk of hypertensive crisis and orthostatic hypotension episodes (see Chapter 8.1)
     • Tendency to bleed due to the antithrombotic drugs (see Chapters 8.6. and 10.5)
     • Drug selection determined by the prostatic disease and duodenal ulceration
     • Drug interactions
   • Dental
     • Reduced quality/quantity of jaw bone
     • Presence of dental/periodontal disease can contribute to dental implant failure; hence periodontal and conservative treatment is required first to stabilise the patient’s oral health (may include endodontic treatment, i.e. #45)
     • History of irregular dental attendance – patient may be lost to follow‐up
5. What are the considerations for performing calculus removal on the remaining teeth?
   • The patient carries a modern bipolar pacemaker (DDD)
   • This will probably be resistant to the interference generated by electronic devices
   • In the event of uncertainty, consult the cardiology team; if no conclusive information is obtained, it is be prudent to use manual instrumentation

6. What antibiotic prophylaxis regimen for bacterial endocarditis would you recommend for this patient?
   • Neither having a pacemaker nor having a coronary stent is considered an indication for endocarditis prophylaxis
7. What are the considerations for prescribing an analgesic to this patient?
   • A number of non‐steroidal anti‐inflammatory drugs can reduce the antihypertensive effect of beta‐blockers (e.g. bisoprolol) and angiotensin‐converting enzyme inhibitors (e.g. ramipril)
   • Non‐steroidal anti‐inflammatory drugs should also be administered with caution to patients with a history of gastroduodenal ulceration; the risk of recurrence and gastrointestinal haemorrhage is greater when these drugs are administered concomitantly with acetylsalicylic acid
   • Metamizole can reduce the antithrombotic effect of acetylsalicylic acid
   • Codeine and other opioid agonists should be avoided in patients with prostatic disease, because they can cause urinary retention and oliguria

General Dental Considerations