MODULE 1

Clinical Workflows

Complete standard operating procedures for every clinical step — from medical screening to prosthesis delivery. Eliminate variability. Ensure excellence.

Use this interactive screening tool during the initial consultation. Each condition is flagged with a clear status to guide clinical decision-making.

Healthy bone density, good dexterity, motivated patient

PROCEED

Ideal candidate for implant-retained prosthetics. Proceed with treatment planning.

Controlled Type 2 Diabetes (HbA1c < 8%)

CAUTION

Proceed with caution. Ensure glucose is well-controlled. Consider delayed loading protocol. Vitamin D level should be 40-60 ng/ml.

Mild systemic issues, previous implant experience

CAUTION

Review previous implant history. Assess bone quality with CBCT. May need grafting consideration.

On blood thinners (Warfarin, Eliquis, Xarelto)

CAUTION

We ask about blood thinners because they can affect healing after surgery. Consult with physician. INR should be < 3.0 for surgical procedures.

Uncontrolled Diabetes (HbA1c > 8%)

STOP

HIGH RISK: Postpone until glucose is controlled. Refer to endocrinologist. Implant failure rate significantly elevated.

Heavy smoker (>10 cigarettes/day)

STOP

HIGH RISK: Initiate smoking cessation protocol. Smoking reduces blood flow and impairs osseointegration. Minimum 2-week cessation before surgery.

Recent bisphosphonate use (oral or IV)

STOP

MRONJ RISK: Complete bisphosphonate screening form. IV bisphosphonates = higher risk. Consult with prescribing physician. May require drug holiday.

Recent COVID-19 vaccine (within 90 days)

STOP

Postpone elective implant surgery. Patient should not have had a COVID-19 vaccine in the past 90 days prior to surgery.

Consultation

Complete medical/dental history review. Run Red Light/Green Light screening. Discuss expectations, timeline, and financial options. Present Good/Better/Best treatment tiers.

Impressions

Primary impressions with alginate or digital scan. Custom tray fabrication. Final impressions with polyvinyl siloxane or digital workflow.

Implant Placement

Surgical protocol per manufacturer specs. Minimum 2 implants for mandibular overdenture. Healing phase: 3-6 months for osseointegration. Vitamin D blood draw within 90 days of surgery (target: 40-60 ng/ml).

Uncovering & Abutment

Second-stage surgery if submerged protocol. LOCATOR abutment selection based on tissue height. Initial torque per Zest specifications. Retorque 10 minutes later. Final torque at definitive restoration (4-6 months).

Denture Fabrication

Lab communication with standardized Rx form. Try-in appointment for fit, esthetics, and occlusion. Processing: chairside pick-up or lab-processed housing placement.

Delivery

Housing pick-up with LOCATOR processing kit. Occlusion check and adjustment. Patient education on insertion/removal, cleaning, and maintenance schedule.

Follow-Up

1-week post-delivery check. Maintenance schedule established: every 6 months. OHI reinforcement. Insert replacement tracking initiated.

Pre-populated SOAP note templates with Zest-specific torque values and component IDs. Customize for each patient encounter. Built for legal defensibility.

subjective

Patient presents for [implant placement / uncovering / prosthesis delivery / maintenance visit]. Chief complaint: [describe]. Pain level: [0-10]. Current medications: [list]. Allergies: [list].

objective

Vital signs: BP [___], HR [___]. Intraoral exam: [findings]. Radiographic findings: [describe]. Implant stability: [ISQ value if available]. Tissue health: [describe color, texture, bleeding].

assessment

Diagnosis: [K08.1 Loss of teeth / K08.2 Atrophy of edentulous ridge / other]. Treatment phase: [surgical / prosthetic / maintenance]. Prognosis: [good / guarded / poor].

plan

Procedure performed: [describe with Zest component IDs]. Torque values: [Ncm]. Next appointment: [date and purpose]. Patient instructions: [post-op care]. Prescriptions: [if any]. Follow-up: [timeline].

Pain Management — The 1-2 Punch

Hour 0

Ibuprofen 600mg

Take with food, before numbness wears off

Hour 3

Acetaminophen 1,000mg

Alternate with ibuprofen

Hour 6

Ibuprofen 600mg

Continue alternating every 3 hours

Hour 9

Acetaminophen 1,000mg

Stay ahead of pain — don't wait for it

Key Message to Patients: Stay ahead of the pain. Don't wait until it hurts to take medication. This alternating schedule keeps a steady level of pain relief without exceeding safe doses of either medication.

StellaLife VEGA Oral Care Protocol

Apply VEGA Oral Care Gel directly to surgical site 3-4 times daily

Use VEGA Oral Rinse (alcohol-free) twice daily — morning and evening

Begin use 3 days before surgery for optimal tissue preparation

Continue for 2 weeks post-surgery or until fully healed

Reduces swelling, speeds healing, and significantly reduces the need for narcotic pain medication. Clinically proven to improve patient comfort.

Antibiotic Stewardship Guidelines

When to Prescribe

Complex bone grafting procedures

History of infection at surgical site

Immunocompromised patients

Patients with specific cardiac conditions (per AHA 2021 guidelines)

Active infection with systemic involvement (fever, lymphadenopathy, cellulitis)

When NOT to Prescribe

Routine single-implant placement in healthy patients

Simple extractions in healthy patients

Prophylactic use without clinical indication

Prosthetic joint patients (per ADA 2015 & AAOS 2024 guidelines)

FDA BLACK BOX WARNING — Clindamycin

"Because [clindamycin] therapy has been associated with severe colitis which may end fatally, it should be reserved for serious infections where less toxic antimicrobial agents are inappropriate." — FDA Prescribing Information

Clindamycin is NO LONGER recommended by the ADA or AHA for dental antibiotic prophylaxis (removed in 2021 AHA Scientific Statement)

17-fold increased risk of C. difficile infection above baseline — highest of any antibiotic class

Single 600mg dose: 13 fatal and 149 non-fatal adverse reactions per million prescriptions

In contrast, single 2g amoxicillin dose: ZERO fatal reactions per 3 million prescriptions

6-fold higher C. difficile risk than penicillins, 3-fold higher than cephalosporins

Recommended Alternatives (AHA 2021)

Drug & Dose	Indication	Timing
Amoxicillin 2g PO	First-line for IE prophylaxis (non-allergic patients)	30-60 min before procedure
Cephalexin 2g PO	Penicillin-allergic (no anaphylaxis history)	30-60 min before procedure
Azithromycin 500mg PO	Penicillin-allergic alternative	30-60 min before procedure
Doxycycline 100mg PO	Penicillin-allergic alternative	30-60 min before procedure
Cefazolin or Ceftriaxone 1g IM/IV	Unable to take oral medication	30-60 min before procedure

Joint Replacement Patients — Updated ADA/AAOS/AAHKS Guidelines (November 2024)

"Routine use of a systemic prophylactic antibiotic before a dental procedure in patients with a hip or knee replacement MAY NOT reduce the risk of a subsequent periprosthetic joint infection (PJI)." — AAOS/AAHKS Evidence-Based Clinical Practice Guideline, November 18, 2024

Routine antibiotic prophylaxis is NOT indicated for dental procedures in joint replacement patients (Limited-strength recommendation)

No study found that administering antibiotics before a dental procedure changed a patient's risk of getting a periprosthetic joint infection

For patients with a history of complications from joint replacement surgery undergoing gingival manipulation or mucosal incision: prophylactic antibiotics should only be considered after consultation with the patient AND orthopedic surgeon

When antibiotics are deemed necessary, the orthopedic surgeon should recommend the appropriate regimen and, when reasonable, write the prescription

Replaces the previous 2012 guideline — jointly developed by AAOS, AAHKS, with contributions from IDSA, MSIS, and ADA

Source Reference

The Prevention of Total Hip and Knee Arthroplasty Periprosthetic Joint Infection in Patients Undergoing Dental Procedures

American Academy of Orthopaedic Surgeons (AAOS) / American Association of Hip and Knee Surgeons (AAHKS)

Co-Chairs: Yale Fillingham, MD, FAAOS & Charles Hannon, MD, FAAOS

Endorsed by: Musculoskeletal Infection Society (MSIS) & Infectious Diseases Society of America (IDSA)

Published: November 18, 2024

View Full Guideline (PDF)

AAOS/AAHKS. Prevention of Total Hip and Knee Arthroplasty Periprosthetic Joint Infection in Patients Undergoing Dental Procedures Evidence-Based Clinical Practice Guideline. aaos.org/dentalppxcpg. Published 11/18/24.

Benefits of Antibiotic Stewardship

Reduces societal costs and healthcare expenditures

Promotes antimicrobial stewardship and responsible prescribing

Decreases selection of antibiotic-resistant bacteria

Reduces Clostridioides difficile infection risk

Minimizes allergic reactions and adverse drug events