Prosthodontic consideration in medically compromised cases.pptx

prosthodontic consderation for common systemic conditions

1. COMMON SYSTEMIC CONDITIONS AFFECTING PROSTHODONTIC TREATMENT

2. 2 CONTENTS Introduction Patient’s physical status classification General principles to follow Prosthodontic considerations of Cardiovascular disease Endocrine disorders Hematological disorders Pulmonary diseases Diseases of bone and joints Neurological disorders

3. Liver and Renal disorders Infectious diseases Oncological diseases Drug interactions Conclusion References 3

4. INTRODUCTION 🩺 Systemic disease → affects the entire body, not just one organ. Many systemic diseases manifest in oral mucosa, maxilla, and mandible. Medical evaluation = essential step before prosthodontic treatment. Prosthodontist must assess: 🔹 Risks of treating medically compromised patients 🔹 Impact of systemic condition on treatment outcome Factors to consider: Patient’s medical & dental history Medications (past & present) Treatment type, duration, invasiveness, urgency 4

5. 5 ASA Class Definition Clinical Significance ASA I Healthy patient no systemic disease → routine dental care safe (CD, RPD, implants) ASA II Mild systemic disease, no functional limitation Mild systemic disease (controlled) → dental care safe with precautions ASA III Severe systemic disease, not life-threatening Severe systemic disease (stable) → higher risk; needs stress reduction & short visits ASA IV Severe systemic disease, constant threat to life Recent MI/stroke (<3 months), severe CHF, advanced COPD/renal/liver failure → only emergency dental care in hospital setting ASA V Moribund, not expected to survive without surgery Advanced multisystem trauma, ruptured aneurysm, massive intracranial bleed → elective dentistry contraindicated ASA VI Brain-dead, organ donor Not relevant for dental treatment ASA Physical Status Classification

6. GENERAL PRINCIPLES TO FOLLOW 6

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8. CARDIOVASCULAR DISEASES

9. 1.HYPERTENSION A condition in which the force of the blood against the artery walls is too high . Essential / Primary / Idiopathic hypertension- doesn't have a known secondary cause. Secondary hypertension is high blood pressure that's caused by another medical condition. 9

10. RISK FACTORS FOR PRIMARY HYPERTENSION :- SECONDARY HYPERTENSION 10

11. PROSTHODONTIC CONSIDERATIONS ✅ General Protocols Stress-reduction protocol (short, relaxed appointments) Avoid sudden positional changes → prevents orthostatic hypotension Safer appointments in afternoon (BP lower) Monitor BP → defer elective procedures if >180/110 mmHg Cautious use of LA: Avoid / minimize vasoconstrictors in uncontrolled HTN 1–2 cartridges of 2% lidocaine + 1:100,000 epi usually safe Limit NSAIDs → short-term only 11

12. 12 🦷 Complete Dentures (CD) Trim & polish sharp edges → avoid mucosal trauma Extra care to prevent soft tissue abrasions Manage xerostomia → recommend artificial saliva lubricants 🦷 Fixed Partial Dentures (FPD) Prefer supragingival margins → ↓ gingival bleeding Avoid / minimize epinephrine in gingival retraction cords Do not use topical vasoconstrictors for hemostasis 🦷 Implants Stress reduction & strict BP monitoring pre-surgery Careful use of LA with epi Elective implant surgery contraindicated if BP uncontrolled (>180/110) Ensure good post-op control (avoid delayed healing / bleeding risk

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14. 2. ANGINA PECTORIS Chest pain that is a result due to reduced blood flow to cardiac tissue. CLASSICAL SYMPTOMS 14 Retrosternal pain during stress or exertion Radiates → shoulder, arm, neck, or mandible Duration → < 5 minutes Relief → rest or sublingual nitroglycerin

15. 15 Step Action 1 Stop dental procedure immediately 2 Position patient semi-upright/upright 3 Administer oxygen 4 Give 1 nitroglycerin (0.3–0.6 mg) SL 5 If no relief in 2–3 min , give 2nd dose ; prepare for emergency transfer 6 If still unresolved, give 3rd dose after 3 min ⚠️ Persistent pain after 3 doses = suspect MI → transfer to higher care facility Management of Angina Attack in Dental Chair Class Characteristics I No angina with ordinary activity; only with strenuous exertion II Angina with ordinary activity (e.g., walking uphill, climbing stairs quickly); mild limitation III Angina with low activity (walking 50–100 yards on level ground, 1 flight of stairs); marked limitation IV Angina at rest or with any activity Canadian Cardiovascular Society's classification of angina

16. PROSTHODONTIC MANAGEMENT IN ANGINA PECTORIS Angina Severity Complete Denture (CD) & FPD Implants Risk Zone Mild (≤1 attack/month) Routine care with vitals monitoring, nitroglycerin prescribed Postpone if possible; if required → nitrous oxide sedation, minimal adrenaline (0.004–0.005 mg) 🟢 Safe with precautions Moderate (≤1 attack/week) Short appointments, anxiety control, oxygen support Sublingual nitroglycerin before surgery + oxygen & stress management 🟡 Caution Unstable (Daily episodes) Only diagnostic/examination procedures ❌ Contraindicated (no elective treatment) 🔴 High Risk 16

17. 3. MYOCARDIAL INFARCTION (MI) Definition: Prolonged ischemia or hypoxia due to inadequate coronary blood supply → myocardial damage. Follow same protocol as angina pectoris . If on anticoagulants: Check INR on day of treatment . Proceed only if INR < 3.5 . Ensure adequate bleeding control during surgery. If on antiplatelet drugs: Employ additional hemostatic measures . 17

18. 18 Prosthesis MI Considerations Removable Dentures Safest; minimal risk; preferred option; lightweight, neutral zone, gradual adaptation Fixed Partial Dentures (FPD) Only after 6 months post-MI; short appointments; stress reduction; minimal LA with epi; avoid recent MI Risk Duration since MI Implant Procedures Mild > 12 months Implant possible; hospitalize if GA needed Moderate 6–12 months Postpone procedure Severe < 6 months Postpone procedure IMPLANT CONSIDERATIONS IN PATIENTS WITH MI BASED ON THE DURATION OF LAST MI ATTACK R. Resnik, Misch’s Contemporary Implant Dentistry , Elsevier,St Louis, MI, USA, 4th edition, 2020.

19. 4. CONGESTIVE HEART FAILURE Abnormality in cardiac function, which causes failure of heart to pump adequate blood to the tissues. Many drugs that are used in management of HF result in dryness of mouth and oral lesions. Digitalis toxicity causes increased gag reflex and hypersalivation . So, as a dentist, we must be able to recognize these signs 19

20. 20 NYHA Class CD (Complete Dentures) FPD (Fixed Partial Dentures) Implants Class I No symptoms ✔ Routine care ✔ Trim & polish to avoid trauma ✔ Stress-free appointments ✔ Minimize bleeding risk ✔ Routine care, no consult usually needed Class II Mild symptoms, slight limitation ✔ Avoid gag-inducing designs ✔ Manage xerostomia with saliva substitutes ✔ Short appointments ✔ Avoid excessive retraction ✔ Routine implant therapy possible Class III Marked limitation, symptoms with less activity ✔ Careful stress reduction ✔ Avoid long procedures ✔ Short chair time ✔ Careful retraction ⚠ Medical consult mandatory for: - Ridge augmentation - Sinus grafting - Subperiosteal implants - Full-arch therapy Class IV Severe limitation, symptoms at rest ✔ Only urgent palliative care ✔ Avoid gag-inducing designs ✔ Avoid elective procedures ✔ Emergency care only ❌ Complex implants contraindicated ✔ Only after medical clearance

21. 5. INFECTIVE ENDOCARDITIS (IE) Infective Endocarditis Infective Endocarditis (IE) : Infection affecting the heart valves or the endothelial surfaces of the heart 21

22. PROSTHODONTIC MANAGEMENT IN IE Endocarditis prophylaxis is recommended in various dental procedures such as dental implants or subgingival cord placements in many cases, which includes prosthetic heart valves, past infective endocarditis, cyanotic congenital cardiac disease etc. 22

23. 23 Aspect Clinical Guidance When to Give Prophylaxis • Prosthetic heart valves • Previous IE • Cyanotic congenital heart disease • Procedures: implant placement, subgingival cord insertion When NOT Needed • Prosthesis insertion • Impression making Implant Suitability ❌ Avoid: poor oral hygiene, repeated IE history ✔ Prefer: endosseous implants with adequate attached gingiva

24. MOST FREQUENT CARDIOVASCULAR DRUGS & THEIR RELATED MANIFESTATIONS ACE inhibitors : - Erythema Multiforme , Xerostomia , Loss Of Taste, Pharyngitis, Burning Sensation & Ulcers. B-blockers: Xerostomia , Paresthesia . Calcium antagonists ( nifedipine ): Gingival Hyperplasia. Diuretics: Xerostomia , Parotid Gland Hypertrophy. Ibuprofen, indomethacin or naproxen - lowering their antihypertensive action. 24

25. ENDOCRINE DISORDERS 25

26. DIABETES MELLITUS Group of metabolic diseases characterized by increased blood glucose level and inability to produce and/or use insulin. 26 Type of Diabetes Mellitus Pathophysiology / Features Type 1 (Insulin-dependent DM) β-cell destruction with lack of insulin Type 2 (Non-insulin-dependent DM) Insulin resistance and relative insulin deficiency Gestational Diabetes Abnormal glucose tolerance during pregnancy Others Impaired fasting glucose / impaired glucose tolerance (ii) Abnormalities of fasting glucose / abnormal glucose tolerance (iii) Genetic defects of β- cell function, endocrinopathies, drug-induced diabetes, etc.

27. According to American diabetic association (ADA): Fasting blood sugar (FBS) > 126 mg/dl Post prandial blood sugar (PPBS) > 200mg/dl Impaired fasting glucose (IFG) when FBS is between 100 - 125 mg/dl. Impaired glucose tolerance (IGT) 2 hour glucose level after 75g oral glucose tolerance test is between 140-199 mg/dl. This distinction is important because individuals with IFG & IGT are at increased risk of developing atherosclerotic disease even though if they don't develop diabetes. 27 American Diabetes Association, “Diagnosis and classification of diabetes mellitus,” Diabetes Care , vol. 34, no. 1, pp. S62– S69, 2011.

28. HbA1C TEST – GYCOSYLATED HEMOGLOBIN 28

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30. 30 Oral Manifestations Xerostomia Periodontitis Burning mouth syndrome Delayed wound healing Alveolar bone resorption Candidiasis

31. 31 PROSTHODONTIC CONCERNS IN A DIABETIC PATIENT Complication Mechanism Clinical/Prosthodontic Considerations Salivary Hypofunction ↓ Saliva flow due to salivary gland changes Frequent mouth wetting during appointments - Sugar-free substitutes (tablets, gels, pastes, swabs) - Severe cases: Cholinergic agonists → Pilocarpine, Cevimeline Candidal Infection Altered oral pH, ↑ salivary glucose, impaired immunity Higher risk of oral candidiasis Regular antifungal prophylaxis if recurrent - Ensure good denture hygiene

32. 32 Delayed / Impaired Wound Healing - Poor blood supply (microvascular changes) → ↓ oxygen delivery - ↓ Collagen production + ↑ Collagenase activity Delayed healing after extractions/implant placement Compromised surgical outcomes - Stress on atraumatic techniques & prolonged follow-up

33. PROSTHODONTIC CONSIDERATIONS IN DM GENERAL Detailed medical history + assess glycemic control (glucometer if needed) Prefer morning appointments Stress reduction protocol Oral hygiene instructions + prophylaxis Antibiotics if infection Avoid NSAIDs in patients on sulfonylureas 33

34. REMOVABLE PROSTHESIS Impression:- Mucostatic technique with wax spacer covering tissues Rubber base for border molding Broad tissue coverage for better support Neutral Zone Technique Records muscle balance → enhances stability Lingualized or Monoplane occlusion - preferred 34

35. Teeth Arrangement Decrease buccolingual width Set teeth directly over ridge Use semi-anatomic or cusp-less teeth Avoid inclined planes Other Essentials Smooth, polished denture flanges, Good oral hygiene 35

36. FIXED PARTIAL DENTURE 36

37. IMPLANTS Implants / Implant-Supported Dentures Only after adequate glycemic control Pre/post-op antimicrobial coverage 37 Encourage smoking cessation + antiseptic rinses Monitor glucose peri- and post-op Not contraindicated if well controlled

38. HYPOGLYCEMIA 38 Hypoglycemia – Abnormally low blood glucose (<70 mg/dL) causing sweating, tremors, confusion, or unconsciousness

39. Prosthesis Hypoglycemia-related Considerations Complete Denture (CD) Ensure proper fit; maintain comfort to allow normal diet RPD Short appointments; balanced occlusion; design for efficient mastication FPD Quick, stress-free procedures; good occlusion to support normal diet; effective temporization Implants Contraindicated if uncontrolled diabetes; short surgeries after meals; hospital monitoring if high risk; prosthesis improves chewing → better glycemic control 39

40. THYROID DISORDERS 40 Hyperthyroidism → Overactive thyroid ⚡ Negative interaction with epinephrine Cardiac arrhythmias Congestive Heart Failure (CHF) Thyroid storm (triggered by infection/surgery) Hypothyroidism → Underactive thyroid ❄️ Increased sensitivity to sedatives/narcotics Risk of myxedematous coma ✅ Well-controlled patients: Standard vasoconstrictors safe ⚠️ Untreated hyperthyroid patients: Avoid epinephrine

41. Prosthesis Hyperthyroidism Hypothyroidism CD Tremors → difficulty in procedures; ↑ bone resorption → ↓ denture stability Macroglossia, edematous mucosa, fatigue; careful flange & relief design FPD Stress reduction, minimal LA with epi; avoid prolonged prep Delayed healing; simple design, stress-free occlusion Implants Risk of poor osseointegration due to ↑ bone turnover; avoid in uncontrolled cases Delayed healing/osseointegration; only in controlled cases; staged approach 41

42. DENTAL IMPLANT MANAGEMENT IN THYROID DISORDERS Risk Level Patient Profile Implant Management Low Risk Treated thyroid disease, symptom-free Implant surgery can be safely performed Moderate Risk Thyroid disorder, asymptomatic Standard protocol + stress reduction ; limit epinephrine in advanced procedures High Risk Active thyroid symptoms Only examination; postpone implants until medical control confirmed 42

43. ADRENAL GLAND DISORDER 43 Hypoadrenalism → Low adrenal hormone production Hyperadrenalism → Excess adrenal hormone production Stress or dental procedures can trigger complications Risk Level Patient Profile High Risk ≥20 mg cortisone (or equivalent) for ≥2 weeks within last 2 years Moderate Risk Steroid therapy >7 days within past year Low Risk Alternate-day steroid therapy ended ≥1 year before procedure

44. PROSTHODONTIC CONSIDERATIONS IN CASE OF ADRENAL GLAND DISORDERS. Risk Level Steroid Management Additional Measures High Risk Double dose day before surgery , return to normal day after Monitor closely Moderate Risk Double dose on day of surgery , reduce to 50% for 3 days post-op General anesthesia for anxious patients Low Risk Schedule procedure on steroid day, 50% dose on 2nd day , resume alternate-day schedule on 3rd day Sedation & antibiotics as needed 44

45. Hematologic Disorders 45

46. HEMATOLOGIC DISORDERS 🩸 Red blood cells : Polycythemia, Anemia (Pernicious, Thalassemia, Sickle cell, Iron deficiency, Plummer-Vinson) White blood cells: Leukocytosis, Leukopenia Platelets : Thrombocytopenia Malignancy: Leukemia 9/12/2025 46

47. LAB INVESTIGATIONS 47 Test Assesses Normal Range Clinical Significance Bleeding Time Platelet function 2–7 min Prolonged → platelet disorder or aspirin use aPTT (Activated Partial Thromboplastin Time) Intrinsic & common pathways 25 ± 10 sec Prolonged → hemophilia, heparin therapy INR (International Normalized Ratio) Extrinsic pathway ~1.0 (normal) 2–3 (therapeutic in anticoagulated pts) INR >3.0 → physician referral ; reducing anticoagulants ↑ thromboembolic risk Platelet Count Quantifies platelet number 150,000–450,000/μ L Thrombocytopenia → ↑ bleeding risk in dental procedures

48. ORAL MANIFESTATIONS 48 Disorder Key Oral Features Polycythemia Erythema of mucosa, glossitis, gingival bleeding, no ulceration Pernicious Anemia Beefy red tongue, atrophic papillae, glossopyrosis , xerostomia, aphthous-like ulcers Thalassemia Maxillary overgrowth, palor oral mucosa, chipmunk/rodent facies, occlusal & esthetic issues Sickle Cell Anemia Pallor mucosa, gingival enlargement, delayed eruption, enamel hypoplasia, osteomyelitis, step-ladder alveolar defects, malocclusion

49. Condition Key Oral Manifestations Iron Deficiency Anemia • Mucosal pallor • Angular cheilitis • Glossitis • Atrophic mucosa • Candida infections Plummer–Vinson Syndrome • Atrophic glossitis • Angular cheilitis • Hyperkeratotic lesions • Dysphagia • Pharyngoesophageal ulcerations Leukemia • Gingival hyperplasia • Spontaneous gingival bleeding • Mucosal pallor • Soft tissue infections 49

50. IMPLANT CONSIDERATION Disorder Implant Safety / Protocol Polycythemia Implants contraindicated Anemia Implants generally safe if Hb ≥10 mg/dL; antibiotic prophylaxis recommended; gradual loading; longer osseointegration due to poor bone maturation (25–40% trabecular reduction) Leukopenia / Leukocytosis Risk of infection, delayed healing → close monitoring, antibiotics if needed Thrombocytopenia Implants contraindicated if platelets <50,000/µL Leukemia Implants contraindicated ; use removable prostheses or FPD with digital impressions to minimize tissue trauma 50

51. 51 Bleeding Management in Patients on Oral Anticoagulants Thorough medical history Consult physician if patient is on warfarin / DOACs INR check (for warfarin): Safe if < 3.5 (WHO guideline) If higher → hospital setting Perform procedure early in the day & week → allows better monitoring & hemostasis Preoperative Considerations Misch CE. Dental Implant Prosthetics . 2nd ed. St. Louis: Mosby Elsevier; 2015. p. 703-712

52. 52 💉 Use local anesthetic with epinephrine (1:80,000 or 1:100,000) unless contraindicated ✂️ Atraumatic surgical technique → minimize trauma to bone & soft tissues 🩺 Prefer minimal flap elevation in implant placement / extraction 🛡️ Control bleeding with: 🩹 Oxidized cellulose ( Surgicel ) 🧽 Collagen sponge / gelatin sponge 🧪 Fibrin glue 🧵 Silk sutures (stabilize flaps & prevent dislodgement) Intra operative Measures Misch CE. Dental Implant Prosthetics . 2nd ed. St. Louis: Mosby Elsevier; 2015. p. 703-712

53. 53 🩹 Gauze pressure with saline / TXA–soaked gauze (4.8–5%) 🧴 TXA mouthwash : 5% solution, 4× daily for 2–7 days 🍲 Soft diet & avoid disturbing wound 🧵 Use resorbable sutures ; if non-resorbable → remove at 4–7 days 🚫 Avoid NSAIDs / COX-2 inhibitors → prefer acetaminophen/paracetamol 🩺 Postoperative Protocol Misch CE. Dental Implant Prosthetics . 2nd ed. St. Louis: Mosby Elsevier; 2015. p. 703-712

54. Pulmonary Diseases

55. PULMONARY DISEASES General precautions that must be followed while managing patients with pulmonary diseases are as follows: Position the patient in upright position Avoid drugs causing respiratory depression like narcotics and sedatives Avoid bilateral mandibular block anesthesia Avoid ultrasonic instrumentation Prosthodontic procedures should not be done until emergency, i.e., in case of active fungal or bacterial respiratory disease 55

56. CHRONIC OBSTRUCTIVE PULMONARY DISEASES (COPD) Additional considerations If the patient is under systemic corticosteroids, supplementation dose is required for major surgical procedures because of adrenal suppression. Avoid the use of macrolide antibiotics in the patient taking theophylline 56

57. Prosthodontic Considerations in COPD Prosthesis Prosthodontic Considerations Complete Denture (CD) Lightweight; minimal palatal coverage; avoid bulky flanges; short appointments Removable Partial Denture (RPD) Lightweight framework; reduced palatal coverage; balanced occlusion; avoid complex designs Implants Contraindicated in uncontrolled COPD; hospital setting for surgery; implant overdentures (reduced palatal coverage → easier breathing) 57

58. ASTHMA Schedule late morning appointments . Keep patient’s inhaler accessible . Avoid aspirin, NSAIDs, barbiturates . Use local anesthesia without epinephrine/levonordefrin in moderate-severe asthma. Prophylactic bronchodilator inhalation at appointment start. Use methyl methacrylate-free prosthetic materials ; ensure optimal curing. 58

59. NSAIDs in Asthma Category Examples Effect in Asthma Recommendation 🔴 Unsafe (COX-1 inhibitors) Aspirin, Ibuprofen, Naproxen, Diclofenac, Indomethacin Inhibit COX-1 → ↓ PGE2 (protective) + ↑ leukotrienes → bronchospasm, nasal congestion, asthma attacks ❌ Avoid in asthmatic patients, especially if history of NSAID sensitivity 🟢 Safer options Paracetamol (Acetaminophen) Minimal COX-1 inhibition; rare bronchospasm at high doses ✅ First-line analgesic/antipyretic in asthma 🟡 Conditional / Safer NSAIDs COX-2 selective inhibitors (Celecoxib, Etoricoxib) Little/no COX-1 inhibition → lower risk of bronchospasm ✅ Can be used if NSAID is essential, but monitor patient 59

60. Prosthodontic Considerations in Asthma Prosthesis Considerations Complete Denture (CD) Lightweight; minimal palatal coverage; avoid residual monomer; duplicate dentures Removable Partial Denture (RPD) Lightweight, minimal coverage; stress-free short appointments; avoid irritant materials Implants Avoid elective surgery in uncontrolled asthma; use plain LA/minimal epi; implant overdentures reduce palatal coverage → better comfort 60

61. TUBERCULOSIS 61 Provide emergency care only for active TB patients. TB spreads via aerosolized droplets . Minimize use of high-speed handpieces . Ensure operatory air is properly vented . Treatment duration: ≥18 months with post-treatment follow-up. Standard infection control precautions are mandatory.

62. Prosthesis Considerations Complete Denture (CD) Contraindicated in active TB; after control → lightweight, well-fitting dentures to improve nutrition Removable Partial Denture (RPD) Avoid in active TB; after treatment → simple, hygienic design, minimal coverage, strict disinfection Implants Contraindicated in active TB; possible after complete treatment & clearance; risk if bone involvement; hospital-based surgery advised 62

63. ALLERGIC REACTIONS IMPRESSION MATERIALS Alginate : Alternative dust free alginate Polyether ACRYLIC RESINS Allergy to methyl methacrylate Alternative: Monomer free resins like acetal resin, Polyamide, Styrene, Vinyl, Polycarbonate, PEEK, Epoxy Latex in gloves and rubber dam : Nitrile gloves and latex free rubber dams Titanium allergy Nickel allergy: Use of Co-Cr alloys for prosthesis Local anesthetics: If allergic to esters, use amides and vice-versa. 63

64. DISEASES OF BONE AND JOINTS 64

65. OSTEOPOROSIS Osteoporosis is defined by low bone mass, increase microstructural deterioration, and bone fragility. 🔹 Effects on Jaws Generalized ↓ bone mineral density (BMD) in maxilla & mandible Porous bone, trabecular deterioration, ↓ cortical thickness 65

66. Removable Prosthesis 🦷 Preservation of Underlying Tissues in Complete Denture Design Use mucostatic & open-mouth impression techniques ( impression plaster, light body elastomers) ↓ Occlusal load: Narrow occlusal table Reduce number of posterior teeth Neutralize cuspal inclines Soft liners → cushioning effect, prevent fractures 66

67. Implant Considerations Implant Design 67 Bone Characteristics Osteoporotic bone ≈ Type 4 ( Lekholm & Zarb) Thin cortical layer + weak trabeculae Higher risk of failure ❌ but not contraindicated ✔️ 📏 Large width & long length → ↑ bone contact 🦴 Surface-treated / bioactive (e.g., HA coating) → better anchorage ⏳ Allow longer osseointegration ⚡ Progressive loading (not immediate)

68. OSTEOARTHRITIS OF TMJ 68 M. Kalladka , S. Quek , G. Heir, E. Eliav , M. Mupparapu , and A. Viswanath , “ Temporomandibular joint osteoarthritis: diagnosis and long-term conservative management: a topic review,” Journal of Indian Prosthodontic Society , vol. 14, no. 1, pp. 6–15, 2014 Breakdown of the articular cartilage, architectural changes in bone, and degeneration of the synovial tissues causing pain and/or dysfunction in functional movements of the jaw. RADIOGRAPHIC FEATURES Characterized by PAIN, RESTRICTION IN JOINT FUNCTION AND JOINT SOUNDS

69. PROSTHODONTIC CONSIDERATION Painful mandibular movement. Difficulty in Construction of dentures. Special impression tray to accommodate reduced mouth opening. (FLEXIBLE TRAY, SECTIONAL TRAY WITH MAGNETS AND 3D WORKFLOW) Difficulty in recording jaw relations. Occlusal corrections have to be made often. 69

70. FPD in Osteoarthritis Patients 70

71. Jaw Relation in Osteoarthritis Patients 71 Kantor ME, Silverman SI, Garfinkel L. Centric-relation recording techniques—a comparative investigation. The Journal of prosthetic dentistry. 1972 Dec 1;28(6):593-600.

72. Non-surgical modalities such as Control of contributory factors Pharmacological interventions as well as Physiotherapy. Occlusal appliances Surgical treatment options include Intra-articular injections Arthrocentesis (lavage of the joint) as well as attempts at repair or replacement of portions of the TMJ. 72

73. RHEUMATOID ARTHRITIS 🔹 Etiology (Unknown cause): Triggered by immune dysregulation T-cell influx → Cytokine storm (IL-1, TNF- α) Attracts macrophages & fibroblasts → joint inflammation 🔹 Key Characteristics : Synovitis (hallmark) Targets small joints (hands, feet) Systemic: fatigue, anorexia, weakness, vague musculoskeletal pain 73 Chronic inflammatory disease characterized by synovial inflammation that destroys the articular cartilage and underlying bone, and causes erosions.

74. Treatment of Rheumatoid Arthritis (GENERAL) 🎯 Goal : Relieve pain, ↓ inflammation, prevent joint damage ⏱️ Early treatment (<2 months) → best prognosis 💊 NSAIDs – first line 💊 Corticosteroids – anti-inflammatory + immunosuppressive 💊 DMARDs – gold, sulfasalazine, hydroxychloroquine, leflunomide, azathioprine Methotrexate – drug of choice Surgery – arthroplasty/joint replacement (severe cases) 74 Grover H. S., Gaba N., Gupta A., Marya C. M. Rheumatoid arthritis: a review and dental care considerations. Nepal Medical College Journal: NMCJ . 2011;13:74–76.

75. 🦷 PROSTHODONTIC CONSIDERATIONS ✋ Reduced dexterity → Removable prosthesis difficult → consider fixed prosthesis 💉 Prosthetic joints → may need antibiotic prophylaxis before implant surgery TMJ involvement → occlusal changes, hard to record jaw relations 🔹 Use unloading appliances/ provisionals before final rehab ⏳ RA = fluctuating disease → postpone definitive treatment until stable 75 Yadav A, Beohar G, Kumar P, Verma B, Mankar N, Ali SS. Comprehensive Overview of Management of Medically Compromised Prosthodontic Patients: A Review.

76. Osteogenesis Imperfecta Hereditary connective tissue disorder caused by defective collagen (type I). Clinical features: B rittle bones, frequent fractures, dentinogenesis imperfecta (DI), blue sclera, joint laxity, hearing loss. 76

77. ORAL FINDINGS : 77 Feature Cause / Consequence ✨ Opalescent teeth Altered dentin structure affecting translucency 🦷 Enamel fracture Weak dentin support under enamel ⏳ Rapid tooth wear Loss of enamel + exposed weak dentin ❌ Tooth loss Progressive wear and fracture of teeth 😬 Malocclusion Secondary to early tooth loss & abnormal eruption 📉 Class III skeletal pattern Maxillary hypoplasia

78. Aspect Considerations Removable Prostheses Preferred in poor tooth quality Flexible/lightweight bases for comfort Monoplane or balanced occlusion to reduce stress Overdentures (if roots retained) → proprioception, bone preservation Fixed Prostheses Limited use (fragile dentin, weak abutments) Prefer minimal prep, adhesive/fiber-reinforced restorations Avoid heavy occlusal loading Implant Therapy Primary stability & osseointegration = main challenge Immediate loading if torque >35 Ncm Bone grafting (autogenous/synthetic, “tent-pole” technique) may be needed Survival rates 93–100% Bisphosphonates may impair success 78 Prabhu SS, Fortier K, May MC, Reebye UN. Implant therapy for a patient with osteogenesis imperfecta type I: review of literature with a case report. Int J Implant Dent. 2018 Nov 23;4(1):36.

79. Multiple Myeloma 79 M alignant plasma cell disorder → ~10% of hematologic cancers 30% of MM patients develop osteolytic jaw lesions , especially posterior mandible Bisphosphonates (Pamidronate, Zoledronic acid) used to prevent skeletal events Major complication: Bisphosphonate-Related Osteonecrosis of the Jaw (BRONJ) Introduction:   Junquera L, Gallego L, Pelaz A. Multiple myeloma and bisphosphonate‐related osteonecrosis of the mandible associated with dental implants. Case Reports Dent. 2011;2011:568246.

80. Prosthodontic Consideration 80 Prosthesis Considerations Complete Denture (CD) • Preferred option (non-invasive, no surgery) • Good for edentulous patients • Minimize trauma to mucosa (risk of ulceration & infection) • Regular follow-up for sore spots & tissue health Removable Partial Denture (RPD) • Acceptable if abutments are healthy • Minimal tooth prep (fragile dentin) • Use light-weight/flexible design to reduce stress • Careful clasp design → avoid overloading abutments & bone Fixed Partial Denture (FPD) • Generally not preferred (reduced bone quality & abutment support) • Risk of devitalization of abutment teeth • If required → conservative adhesive restorations / fiber-reinforced prosthesis Implants • Contraindicated with IV bisphosphonate therapy (high BRONJ risk) • Healing compromised in MM → implant failure risk • Only consider if no bisphosphonate use & stable systemic condition

81. NEUROLOGICAL DISORDERS 81

82. PARKINSON’S DISEASE Parkinson’s disease is a neurodegenerative disorder characterized by tremors, rigidity, bradykinesia , and postural instability. It is caused due to depletion of neurotransmitters—dopamine 82 General Prosthodontic Considerations Pharmacological Effect : Schedule appointments when medications are at peak effect Patient Positioning: Semi-reclined (~45°) reduces choking & drooling Dental Chair Adjustment: Move slowly; allow upright sitting before rising Orthostatic Hypotension: Monitor BP; rise gradually

83. COMPLETE DENTURE 83

84. Fixed Dental Prosthesis (FDP) Supragingival / equigingival margins recommended Gingival retraction: expanding vinyl polysiloxane Full-coverage restorations preferred Resin cements → reduce microleakage Implant Surgery Considerations Local anesthetics with epinephrine → use cautiously (<0.05 mg safe) Implant-supported prostheses → improve oral/general health & masticatory efficiency 84

85. EPILEPSY A neurological disorder characterized by seizures, including: Altered perception, behavior, and mental activity Involuntary muscle contractions Temporary loss of consciousness Chronic neurological changes from abnormal brain electrical activity 85

86. 86 Karolyhazy K , Kivovics P, Fejerdy P, Aranyi Z. Prosthodontic status and recommended care of patients with epilepsy. J Prosthet Dent . 2005 Feb;93(2):177–82 Aspect Key Points Risks During Dental Procedures • Seizures → aspiration, trauma, falls • Triggers: stress, bright light, anesthetic toxicity Oral Manifestations • Phenytoin → gingival hyperplasia • Xerostomia → poor denture retention • Seizure trauma → broken teeth, fractured prostheses, soft tissue injuries Prosthesis Design • Prefer fixed prostheses (safer) • Avoid ceramic inlays; use metal–ceramic crowns • RPDs → large/reinforced metal base, well-fitting, smooth edges, lightweight, secure clasps/attachments • Dentures → metal/reinforced bases to prevent fracture/aspiration

87. PROSTHODONTIC CONSIDERATIONS Prefer metal temporaries / implant-supported bridges ; avoid fragile restorations. Rubber dam essential → prevents aspiration/injury. Good denture fit & oral hygiene → lowers phenytoin-induced gingival overgrowth 87

88. Bell’s Palsy Acute, unilateral facial nerve paresis or paralysis of unknown cause, with onset within 72 hours . 88 Etiology: Exact cause unknown viral reactivation (HSV, VZV) Pathology: inflammation and edema of the facial nerve within the narrow bony canal → compression and ischemia. Clinical Features: Sudden unilateral facial weakness (drooping of mouth, inability to close eye). Loss of forehead wrinkles on affected side. May have ear pain, taste disturbance, hyperacusis, dry eye/mouth.

89. 89 Prognosis Management Most recover fully in 3–4 months History & exam → rule out other causes ~70% with complete paralysis → full recovery Electrodiagnostic testing → optional in complete paralysis only Up to 94% with incomplete paralysis → full recovery Oral corticosteroids within 72 hrs → ✅ strongly recommended ~30% may have incomplete recovery → facial asymmetry, synkinesis Steroid + antiviral combo → optional (within 72 hrs ) Follow-up at 3 months if no recovery or new neuro/ocular issues Baugh RF, Basura GJ, Ishii LE, Schwartz SR, Drumheller CM, Burkholder R, et al. Clinical practice guideline: Bell’s palsy. Otolaryngol Head Neck Surg. 2013;149(3 Suppl):S1–27.

90. Category Problem Prosthodontic Solution 🎭 Esthetics Facial asymmetry, drooping lip Tooth arrangement, flange contouring, esthetic characterization Speech & esthetics concerns Esthetic tooth setup, improved lip support 🦷 Function Poor denture stability (loss of muscle tone) Neutral zone impression technique, implants, adhesives Cheek/lip biting Soft liners, cheek/lip shields Food stagnation RPD design modification, smooth contours 💬 Psychological Social/psychological impact Counseling, esthetic rehabilitation 90 Rathee M, Jain P, Chahal S, Singh S. Prosthodontic implications of Nerves of orofacial region-A review. Asia Pacific Dental Journal. 2021 Nov 1;8(3):20-5.

91. Trigeminal Neuralgia Triggers: Touching the face, chewing, speaking, brushing teeth, prosthesis irritation. Pathophysiology : Often due to vascular compression of trigeminal root → demyelination → ectopic nerve firing. Course: Periods of remission and relapse. 91 Chronic neuropathic pain disorder of the trigeminal nerve → recurrent, sudden, unilateral, sharp, stabbing or electric-shock-like facial pain .

92. Clinical Features 🔹 Pain pattern → sudden, sharp, “electric-shock” pain; ends abruptly, recurs unpredictably. 🔹 Intervals → irregular pain-free periods between attacks. 🔹 Age group → mostly middle-aged & elderly patients. 🔹 Misdiagnosis risk → may be mistaken for dental pain. 92 Rathee M, Jain P, Chahal S, Singh S. Prosthodontic implications of Nerves of orofacial region-A review. Asia Pacific Dental Journal. 2021 Nov 1;8(3):20-5.

93. 93 Stage Problems / Challenges Prosthodontic Modifications & Management During Prosthodontic Procedures • Trigger zones activated during: – Impression making – Jaw relation recording – Occlusal adjustments • Pain with old ill-fitting dentures (overclosure) • Long-time denture wearers with ridge resorption • Avoid overextended borders near trigger zones • Pressure-free / mucostatic impressions • Lightweight dentures with smooth, rounded borders • Balanced occlusion with light, even contacts Adjunctive Measures • Pain intolerance with dentures • Fear/anxiety of prosthesis use • Soft liners if denture wear is intolerable • Reassure and educate patient on insertion/removal • Counseling for compliance • Laser therapy – ↑ blood flow, oxygenation, analgesia Rathee M, Jain P, Chahal S, Singh S. Prosthodontic implications of Nerves of orofacial region-A review. Asia Pacific Dental Journal. 2021 Nov 1;8(3):20-5.

94. 94 Special Prosthetic Designs • Difficulty maintaining occlusion and vertical dimension • Neuromuscular imbalance due to pain • Temporary dentures with sliding plates – restore vertical dimension & deprogram muscles • Acrylic bite plane in lower denture – flat surface for stable occlusion until pain subsides • Interocclusal splints – neuromuscular training & pain relief • Custom trays/stents with topical anesthetics for immediate relief When Pain Persists • Uncontrolled neuralgia despite prosthetic modifications • Postpone new dentures until pain is medically controlled • Refer to neurologist (Carbamazepine = drug of choice) • Defer elective RPD/FPD/implant placement until stabilized Rathee M, Jain P, Chahal S, Singh S. Prosthodontic implications of Nerves of orofacial region-A review. Asia Pacific Dental Journal. 2021 Nov 1;8(3):20-5.

95. LIVER AND RENAL DISORDERS 95

96. LIVER DISEASES 96 In liver disease, clotting factor synthesis and drug detoxification are impaired → requiring strict hemostasis management . structural or functional impairment of the liver , leading to reduced metabolism, detoxification, clotting factor synthesis, and bile production . Common causes: hepatitis, alcohol, fatty liver, cirrhosis, drugs . Clinical impact: bleeding risk, drug toxicity, jaundice, delayed healing .

97. 97

98. 98 Eremin OV, Lepilin AV, Eremin AV. APPROACHES TO PROSTHETICS OF DEFECTS TOOTH AT PATIENTS WITH CHRONIC ILLNESSES OF A LIVER.  Russian Journal of Dentistry . 2012;16(4):18-21.

99. RENAL DISEASES 99 Definition: structural or functional impairment of the kidneys , causing reduced ability to filter blood, regulate fluid–electrolyte balance, and excrete waste products . Common Causes: Diabetes mellitus (diabetic nephropathy), Hypertension Glomerulonephritis , Polycystic kidney disease Pyelonephritis (chronic infections) Types: Acute Kidney Injury (AKI ): Sudden decline in function, often reversible. Chronic Kidney Disease (CKD): Progressive, irreversible loss of kidney function (stages 1–5).

100. DIALYSIS 100

101. Prosthesis Key Effects in CKD Clinical Management Complete Denture (CD) Fragile mucosa, xerostomia, delayed healing • Avoid overextension • Use tissue conditioners if sore spots • Short appointments, preferably day after dialysis Removable Partial Denture (RPD) Abutments may be mobile (renal osteodystrophy, periodontitis) Higher bleeding & infection risk • Careful abutment selection • Gentle impressions, avoid trauma • Emphasize strict oral hygiene & frequent recalls Implants Poor bone quality (renal osteodystrophy) → ↓ osseointegration ESRD/transplant patients: delayed healing, gingival overgrowth, infection risk • Only in stable, medically cleared cases • Physician consultation mandatory • Atraumatic/flapless surgery, strict asepsis • Avoid nephrotoxic drugs, adjust doses • Antibiotic prophylaxis often required 101 Swapna DM, Bathini PK. Guidelines for the Management of Chronic Kidney Disease Patients in Dental Setup.

102. INFECTIOUS DISEASES 102

103. ACQUIRED IMMUNODEFICIENCY SYNDROME 🔹 Introduction : HIV (Human Immunodeficiency Virus): A lentivirus causing AIDS → immune system failure → life-threatening opportunistic infections. Transmission: Blood, semen, vaginal fluid, pre-ejaculate, breast milk. 🔹 General Measures : Create a safe and empathetic environment . Maintain confidentiality of patient information. Follow standard infection control precautions . Provide unbiased treatment . Advise regular dental visits . 103

104. MEASURES IN PARTICULAR TO PROSTHODONTICS 104

105. 105 Use protective barriers: gloves, mask, eye protection, gown . Follow strict sharps & body fluid handling precautions . Report needle-stick injuries immediately to HIV centers. Post-exposure prophylaxis (PEP): Anti-retroviral therapy after risk assessment + counselling. 🔹 Infection Control for Health Care Workers

106. 106 🔹 Prosthesis & Material Disinfection Rinse materials under running water to remove debris. Disinfect prosthesis: spraying or immersion techniques; UV light also possible. Heat-stable items (face bows, pliers, metal trays) → sterilize with heat. Impressions: Alginate → 0.5% Sodium hypochlorite Elastomers → 2% Glutaraldehyde Consider autoclavable impression materials .

107. 107 Singla N, Yadav B, Shetty DC, Urs AB, Singh HP, Juneja S. Prosthodontic management of HIV-positive patients: A review. Indian J Dent Sci. 2018;10(3):183-9.

108. POST EXPOSURE PROPHYLAXIS 108

109. HEPATITIS B VIRUS (HBV) 109

110. Prosthesis Key Concerns Management Considerations Complete Denture (CD) • Fragile mucosa, easy bruising • Poor healing if advanced disease • Atraumatic borders, relieve sore spots • Ensure strict denture hygiene • Frequent follow-up to check tissue health Removable Partial Denture (RPD) • Gingival bleeding during impressions • Altered healing around abutments • Gentle impression techniques • Minimize gingival trauma • Simple, hygienic designs with minimal tissue coverage Fixed Prosthesis (FPD) • Periodontal fragility • Prolonged bleeding risk • Use supragingival margins for easy cleaning • Confirm periodontal health before treatment Implants • High bleeding risk during surgery • Poor osseointegration if advanced disease • Risk of infection (immunosuppression, cirrhosis) • Contraindicated in uncontrolled hepatitis/liver failure • Consider only in stable cases with physician clearance • Perform with strict asepsis and hemostatic measures 110

111. Oncologic Disease 111

112. 112 🔹 Before Therapy Oral evaluation of dentition & edentulous regions Impressions for surgical obturators Maintain oral health prior to cancer treatment 🔹 During Therapy Possible interventions: extractions, maxillary obturator, primary implant placement, preprosthetic procedures In radiation therapy (RT): Use temporary restorations if needed Defer cosmetic/prosthetic work Monitor for complications → mucositis, xerostomia, trismus, taste changes, infections, radiation caries, osteoradionecrosis 🔹 After Therapy No dentures for first 6 months post-RT Replace ill-fitting dentures with new ones For chronic xerostomia → apply petrolatum to denture surface Implants : Consider after 12–18 months post-RT Assess irradiation field, healing, vascularity Higher risk in posterior mandible vs. maxilla/anterior mandible Prosthodontic Considerations in Oral Cancer Over 90% of oral cancers are squamous cell carcinoma, usually treated with surgery and radiation therapy.

113. OSTEORADIONECROSIS Cause: Failure of bone healing after high-dose radiation , due to hypocellularity, hypovascularity , and hypoxia . Risk: Mandible > Maxilla . Presentation: Often begins with soft tissue necrosis → progresses to bone involvement. 113

114. PROTOCOLS FOR REDUCING THE RISK OF OSTEORADIONECROSIS ARE AS FOLLOWS 🔹 Prevention Protocols Prefer endodontic treatment over extraction. Use local anesthesia with low/no epinephrine . Follow atraumatic surgical techniques . Give prophylactic antibiotics & continue during healing. Consider Hyperbaric Oxygen Therapy (HBOT) before invasive procedures. 114

115. RADIOTHERAPY 🔹 Management of Established ORN Conservative first: Irrigate exposed bone with saline/antibiotic solution. Remove bony sequestrum . Prescribe broad-spectrum antibiotics (ampicillin, amoxicillin-clavulanate, doxycycline) if swelling/suppuration present. If conservative fails → Surgical resection of affected bone. 115 Singh A, Rosen EB, Randazzo JD, Estilo CL, Gelblum DY, Huryn JM. Intraoral radiation stents-Primer for clinical use in head and neck cancer therapy. Head Neck. 2021 Dec;43(12):4010-4017.

116. 116

117. 117

118. 118

119. SALIVARY DYSFUNCTION This leads to xerostomia or dry mouth . The complaints of xerostomia necessitates the search for an underlying systemic disease. May induce oral alteration and discomfort with the removable prosthesis . Xerostomia is a subjective symptom associated with change in quantity and quality of saliva 9/12/2025 119

120. SIGNS AND SYMPTOMS Dry and cracked lips Increased plaque, dental decay, PDL degeneration. Trouble swallowing, speaking, tasting Thick and stringy saliva, oral malodour Infection prone Burning sensation Poor retention of denture Soreness of denture bearing area 120

121. PROSTHETIC MODIFICATION Maxillary and Mandibular salivary reservoir denture. Systemic stimulation of salivary function can be obtained by - Pilocarpine 5 mg three times a day 121

122. POTENTIAL DRUG RELATED ORAL HEALTH/MANAGEMENT COMPLICATIONS. 122 The Journal of Contemporary Dental Practice, Volume 6, No. 4, November 15, 2005

123. CONCLUSION The successful management of patient begins from taking the adequate medical history to making the proper treatment plan. Many of the aged patients are already diagnosed with some medical condition before they present for prosthodontics treatment. The prosthodontic procedures are delayed until the medical conditions are evaluated. The drugs taken by the patient for their systemic condition should be known since they have an impact on treatment outcome along with the drug interactions. Systemic evaluation, as well as the physician consultation should be an integral part of prosthodontic treatment plan. 123

124. REFERENCES S. F. Malamed, Handbook of Local Anesthesia, Elsevier, St. Louis, MI, USA, 6th edition, 2004. R. D. Phoenix, D. R. Cagna, C. F. DeFreest, and K. L. Stewart, Stewart’s Clinical Removable Partial Prosthodontics , Quintessence, Chicago, IL, USA, 4th edition, 2008 H. T. Shilligburg , D. A. Sather, E. L. Wilson et al., Fundamentals of Fixed Prosthodontics, Quintessence, Chichago , IL, USA, 4th edition, 2012. G. Zarb, J. A. Hobkirk, S. E. Eckert, and R. F. Jacob, Prosthodontic Treatment for Edentulous Patients, Elsevier, St.Louis , MI, USA, 13th edition, 2013. Misch CE. Dental Implant Prosthetics . 2nd ed. St. Louis: Mosby Elsevier; 2015. p. 703-712 R. Resnik, Misch’s Contemporary Implant Dentistry, Elsevier, St Louis, MI, USA, 4th edition, 2020. Kantor ME, Silverman SI, Garfinkel L. Centric-relation recording techniques—a comparative investigation. The Journal of prosthetic dentistry. 1972 Dec 1;28(6):593-600 Szczeklik A, Nizankowska E. Aspirin-induced asthma: Advances in pathogenesis and management. Allergy. 2000;55 Suppl 61:43-4 M. Z. Marder, “Medical conditions affecting the success of dental implants,” Compendium of Continuing Education in Dentistry (Jamesburg, N.J.: 1995), vol. 25, pp. 739–795, 2004. 124

125. Karolyhazy K, Kivovics P, Fejerdy P, Aranyi Z. Prosthodontic status and recommended care of patients with epilepsy. J Prosthet Dent . 2005 Feb;93(2):177–82 American Diabetes Association, “Diagnosis and classification of diabetes mellitus,” Diabetes Care, vol. 34, no. 1, pp. S62– S69, 2011.  Junquera L, Gallego L, Pelaz A. Multiple myeloma and bisphosphonate‐related osteonecrosis of the mandible associated with dental implants. Case Reports Dent. 2011;2011:568246 Grover H. S., Gaba N., Gupta A., Marya C. M. Rheumatoid arthritis: a review and dental care considerations. Nepal Medical College Journal: NMCJ . 2011;13:74–76. Eremin OV, Lepilin AV, Eremin AV. APPROACHES TO PROSTHETICS OF DEFECTS TOOTH AT PATIENTS WITH CHRONIC ILLNESSES OF A LIVER. Russian Journal of Dentistry. 2012;16(4):18-21. Eremin OV, Lepilin AV, Eremin AV. APPROACHES TO PROSTHETICS OF DEFECTS TOOTH AT PATIENTS WITH CHRONIC ILLNESSES OF A LIVER. Russian Journal of Dentistry. 2012;16(4):18-21. Baugh RF, Basura GJ, Ishii LE, Schwartz SR, Drumheller CM, Burkholder R, et al. Clinical practice guideline: Bell’s palsy. Otolaryngol Head Neck Surg. 2013;149(3 Suppl):S1–27. M. Kalladka , S. Quek, G. Heir, E. Eliav, M. Mupparapu , and A. Viswanath, “Temporomandibular joint osteoarthritis: diagnosis and long-term conservative management: a topic review,” Journal of Indian Prosthodontic Society, vol. 14, no. 1, pp. 6–15, 2014 N. Singh, “Systemic diseases of concern to prosthodontist,” International Journal of Oral Health and Medical Research, vol. 2, pp. 89–93, 2015 125

126. 126 Kumar KA, Bhat V, Nair KC, Suresh R. Preliminary impression techniques for microstomia patients. J Indian Prosthodont Soc 2016;16:229-33. Singla N, Yadav B, Shetty DC, Urs AB, Singh HP, Juneja S. Prosthodontic management of HIV-positive patients: A review. Indian J Dent Sci. 2018;10(3):183-9. Swapna DM, Bathini PK. Guidelines for the Management of Chronic Kidney Disease Patients in Dental Setup Prabhu SS, Fortier K, May MC, Reebye UN. Implant therapy for a patient with osteogenesis imperfecta type I: review of literature with a case report. Int J Implant Dent. 2018 Nov 23;4(1):36. Yadav A, Beohar G, Kumar P, Verma B, Mankar N, Ali SS. Comprehensive Overview of Management of Medically Compromised Prosthodontic Patients: A Review. J. Little, C. Miller, and R. Nelson, Little and Falace’s Dental Management of the Medically Compromised Patient, Elsevier, St. Louis, MI, USA, 9th edition, 2018. Soliman S, Meyer- Marcotty P, Hahn B, Halbleib K, Krastl G. Treatment of an adolescent patient with dentinogenesis imperfecta using indirect composite restorations – a case report and literature review. J Adhes Dent . 2018;20(4):345-54. Kowalski ML, et al. Diagnosis and management of NSAID-exacerbated respiratory disease (AERD): EAACI position paper. Allergy. 2019;74(1):28–39

127. 127 Rathee M, Jain P, Chahal S, Singh S. Prosthodontic implications of Nerves of orofacial region-A review. Asia Pacific Dental Journal. 2021 Nov 1;8(3):20-5 Singh A, Rosen EB, Randazzo JD, Estilo CL, Gelblum DY, Huryn JM. Intraoral radiation stents-Primer for clinical use in head and neck cancer therapy. Head Neck. 2021 Dec;43(12):4010-4017. Kunusoth R, Colvenkar S, Thotapalli S, et al. (September 21, 2022) Custom Sectional Impression Tray With Sectional Handle for Microstomia Patients. Cureus 14(9): e29433. Peskersoy , C.; Acar, G. In Vitro Evaluation of the Mechanical Properties of Posterior Adhesive Restorations Fabricated Using Three Different Techniques. Polymers 2025, 17, 1340.

128. THANK YOU!!! 128