36 Dental implant complications
also causes less respiratory change and fewer neuro-
vascular effects. The efficacy and safety of parenteral
sedation, which is used not only during implant surgery
(221) but also during other oral and maxillofacial surgical
procedures (222, 223) in combination with other seda-
tives such as propofol (224) or fentanyl (225), have been
demonstrated previously.
According to Heckmann et al. (192), dental implants
can provide great benefits to severely handicapped PD
patients, including improvements in both chewing and
predigestion capacity. The use of regional anesthesia in
combination with intravenous midazolam is the treat-
ment of choice for patients with systemic disease under-
going implant surgery.
Pharmacologic considerations
Corticosteroids
For those taking corticosteroids for systemic disease,
contact between the clinician and the physician is imper-
ative. The range of treatment options and their advan-
tages and disadvantages should be carefully weighted in
relation to the patients need and wishes. An excellent
standard of oral hygiene is essential to minimize the pos-
sibility of infection.
Despite all precautions, an acute adrenal crisis may
occur and the dentist needs to be prepared to manage
the condition. Signs and symptoms of crisis include
hypotension, weakness, nausea, vomiting, diarrhea,
dehydration, abdominal cramping, irritability, headache,
and fever. Acute adrenal crisis is life threatening and
immediate treatment consists of 100 mg of hydrocorti-
sone administered intravenously or intramuscularly.
The patient should be transferred to a hospital facility as
soon as possible (226).
Bisphosphonates
The AAOMS (102) uses the following staging categories
for patients who develop or have been diagnosed with
bisphosphonate-related osteonecrosis of the jaw:
Stage I: Exposed/necrotic bone in patients who are
asymptomatic and have no evidence of infection.
Stage II: Exposed/necrotic bone in patients with pain
and clinical evidence of infection.
Stage III: Exposed/necrotic bone in patients with
pain, infection and one or more of the following:
pathologic fracture, extraoral fistula, or osteolysis
extending to the inferior border.
Treatment strategies are as follows (102):
Stage I: No surgical treatment is indicated. Patients
benefit from oral antimicrobial rinses, such as
chlorhexidine 0.12%, and do well with this type of
conservative treatment. Patients should be followed
up every 34 months (93)
Stage II: Patients benefit from oral antimicrobial rins-
es in combination with antibiotic therapy. Most of the
isolated microbes have been sensitive to the penicillin
group of antibiotics. For those with a penicillin aller-
gy, quinolones, metronidazole, clindamycin, doxycy-
cline, and erythromycin can be dispensed. Microbial
cultures should also be analyzed for the presence of
Actinomyces species of bacteria. If the microbe is iso-
lated, then the antibiotic regimen can be adjusted. In
some refractory cases, patients may require combina-
tion antibiotic therapy, long-term antibiotic mainte-
nance, or a course of intravenous antibiotic therapy.
Pain control may also be indicated.
Stage III: Patients typically have pain that may impact
quality of life. Surgical dbridement/resection in
combination with antibiotic therapy may offer long-
term palliation with resolution of acute infection and
pain.
Regardless of the stage of the disease, mobile segments
of bony sequestrum should be removed without expos-
ing the uninvolved bone. The extraction of symptomatic
teeth within exposed, necrotic bone should be consid-
ered because it is unlikely that the extraction will worsen
the necrotic process (102).
The risks and benefits of continued bisphosphonate
therapy should be decided in consultation with the treat-
ing physician and the patient to determine whether
modification or cessation of the therapy is possible.
Anticoagulants
During the past few years, new evidence has accumu-
lated that indicates an increased risk of thrombotic out-
comes with the discontinuance of low-dose aspirin
therapy (166, 227, 228). The continuation of aspirin dur-
ing more extensive procedures (e.g. complicated extrac-
tions, bony impactions, implant placement, osteotomies)
and the use of other antiplatelet medications have not
been thoroughly investigated with respect to postopera-
tive bleeding complications, but the same concerns with
the loss of antithrombotic benefit of antiplatelet medica-
tions must be carefully considered before discontinua-
tion of these medications (166).
Bleeding postextraction and dental implant placement
can be controlled by standard local hemostatic measures
including suturing and direct packing with gauze,
resorbable gelatin sponge, oxidized cellulose or micro-
fibrillar collagen (166). Fibrin glue or a mouthwash with
tranexamic acid also gives satisfactory hemostasis (103).
If bleeding is controlled after surgery, the patient
should be dismissed and given a 7-day follow-up
appointment and the telephone number of the office
with instructions to call if bleeding occurs (229). The
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