reader with information that allows their practice of implant dentistry to be successful and predictable, ultimately improving a patient's quality of life. The book has been formatted to ensure that the reader has access to relevant information in a recognisable format under the headings ‘Principles, Procedures, and Tips’. This will give practising clinicians accessible information to learn new skills, and provides a continual reference for revision prior to performing procedures. We hope this will ensure that the clinician undertakes best practice within their dental office in the field of implant dentistry.
References
1 1 Brånemark, P.‐I., Hansson, B.O., Adell, R. et al. (1977). Osseointegrated Implants in the Treatment of the Edentulous Jaw, 132. Stockholm: Almqvist and Wiksell.
2 2 Linkevicius, T., Apse, P., Grybauskas, S., and Puisys, A. (2009). The influence of soft tissue thickness on crestal bone changes around implants: a 1‐year prospective controlled clinical trial. Int. J. Oral Maxillofac. Implants 24 (4): 712–719.
3 3 Tomasi, C., Tessarolo, F., Caola, I. et al. (2014). Morphogenesis of peri‐implant mucosa revisited: an experimental study in humans. Clin. Oral Implants Res. 25 (9): 997–1003.
2 Patient Assessment and History Taking
Christopher C.K. Ho
2.1 Principles
Careful patient selection, evaluation, and treatment planning are fundamental to the success of implant therapy and will help to avoid future complications or failures. Since Brånemark et al. [1] published research documenting successful osseointegration on endosseous titanium implants in 1969, the use of osseointegrated dental implants has increasingly become the treatment option for the replacement of missing teeth. Despite the predictability of dental implants, a small but significant number of patients continue to experience implant failure, and it is important to understand the risk factors involved. Informed consent is the process of communication between a clinician and a patient whereby a patient grants permission for the proposed treatment based on understanding the nature of the problem, the risks, and the benefits of the procedure and treatment alternatives, including no treatment.
The first objective is to gather all relevant information to plan treatment. It is essential to obtain appropriate information about the patient's dental and medical history, and to conduct a comprehensive examination in conjunction with diagnosis from radiographic imaging and study casts.
2.1.1 Medical History
The general health status of a patient should always be assessed prior to any surgical procedure. Although there is minimal association between general health status and implant survival [2], there are certain situations where implant procedures may risk the health of a patient or possibly be associated with higher failure rates of osseointegration.
Medical questionnaires are routinely used and, in addition, it is best practice to verbally ask specific questions about the health of patients. There are two basic questions that a clinician should ask prior to implant surgical procedures:
1 Is the patient fit medically to have the procedure done?
2 Is there anything in their history that would interfere with healing and the normal osseointegrative process?
These two simple questions should form the basis of your questioning as to whether patients are able to undergo a surgical procedure and determine any risk factors with the healing process. There are very few absolute contraindications to implant surgery, however there are certain conditions which may increase the risk of complications with the surgical procedure or wound healing. The conditions listed in Table 2.1 have been suggested as possible contraindications to implant treatment and should be carefully managed.
Table 2.1 Relative contraindications to implant surgery.
| Diabetes |
| Tobacco use |
| Uncontrolled cardiovascular disease/hypertension |
| Cancer/leukaemia |
| Renal/liver problems |
| Bisphosphonate medications |
| Blood disorders/anticoagulant therapy |
| HIV/immunosuppression |
| Alcohol abuse |
| Psychological disorders |
| Pregnancy |
| Irradiation |
2.1.2 Medications and Allergies
A list of medications (including any herbal preparations or medications taken on as‐needed basis) along with the dosage and indications for the medication should be recorded. Patients should be asked whether they take any over‐the‐counter medications such as aspirin on a regular basis as they often forget to mention this when recording medications prescribed. Any allergies should be documented to preclude any reaction.
2.1.3 Past Medical History
Several conditions are discussed below, however further investigation is required if there is any uncertainty as to the prognosis.
2.1.3.1 Cardiovascular Disorders
Uncontrolled hypertension (blood pressure above 160/90 mmHg) places the patient at greater risk of stroke, heart failure, myocardial infarction, and renal failure. Implant surgery may therefore pose a risk to potential adverse cerebrovascular and cardiovascular events.
Patients who have had a cardiac infarction within the previous six months should not undergo surgery, and patients with a history of angina should have glyceryl trinitrate tablets/sublingual sprays available when undergoing implant surgery.
The use of antibiotic prophylaxis may be required for patients with a history of prosthetic valves, infective endocarditis, or rheumatic fever.
Anticoagulant therapy may cause extended bleeding post‐operatively, and patients taking warfarin or heparin should have an International Normalised Ratio (INR) of less than 2.5 prior to the surgical procedure. Consultation with the patient's physician is recommended to determine whether the patient should cease anticoagulant therapy such as aspirin.
2.1.3.2 Diabetes Mellitus
Diabetes mellitus is a common endocrine disorder affecting the metabolism of glucose. Patients with diabetes may experience increased susceptibility to wound‐healing complications and increased inflammatory destruction. Furthermore, they possess altered bone and mineral metabolism which may interfere with bone metabolism [3]. A prospective study of 89 patients with well‐controlled type 2 diabetes found an early failure rate of 2.2% in implants placed in edentulous mandibles. This increased to 7.3% after one year when the implants were loaded with overdentures [4]. The five‐year results of this study revealed
