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1 - Medically Compromised Patients Flashcards

1
Q

What are the known risk factors associated with congenital heart disease?

A
  1. Maternal rubella
  2. Diabetes
  3. Alcoholism
  4. Irradiation
  5. Drugs such as thalidomide, phenytoin sodium (Dilantin) and warfarin sodium (Coumadin)
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2
Q

Describe the acyanotic and cyanotic heart lesions?

A
  1. Acyanotic lesions are characterized by a connection between the systemic and pulmonary circulations or stenosis of either circulation (left to right shunts).
  2. All cyanotic conditions exhibit right to left shunting of desaturated blood.
    - -Infants with mild cyanosis may be pink at rest but become very blue during crying or physical exertion.
    - -Children with cyanotic defects are at significant risk for desaturation during general anesthesia.
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3
Q

What are the most common acyanotic congenital heart diseases?

A
  1. Atrial septal defect (ASD)
  2. Ventricular septal defect (VSD)
  3. Patent ductus arteriosus (PDA) caused by failure of closure of the ductus connecting the pulmonary artery with the aorta (normally closes soon after birth)
  4. Coarctation of the aorta
  5. Aortic stenosis
  6. Pulmonary stenosis
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4
Q

What are the most common cyanotic congenital heart diseases?

A
  1. Tetralogy of Fallot - includes a VSD, pulmonary stenosis, overriding aorta and right ventricular hypertrophy
  2. Transposition of great vessels
  3. Tricuspid atresia
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5
Q

For a pt with a congenital heart disease, what information do you need from the cardiologist and hematologist?

A
  1. Nature of diagnosis (acyanotic or cyanotic)
  2. Current cardiac status - BP, RR, oxygen rate, pulmonary saturations, blood gases.
  3. Cardiac medications
  4. Current INR range (normal without anticoagulant therapy is -1; target range with therapy is -2 to 3)
  5. Previous surgical management
  6. Future surgical management
  7. Physical activity limitations
  8. Risk of infective endocarditis

This information is used to:

  1. Assess risk of cardiac complications under GA.
  2. Access risk of infective endocarditis and need for antibiotic prophylaxis before invasive dental procedures.
  3. Access risk of hemorrhage during dental surgery.
  4. Develop a perioperative anticoagulant management plan.
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6
Q

Describe the process of how bacteremia after a dental procedure can lead to infective endocarditis?

A
  1. Coronary heart disease and rheumatic heart disease can predispose the scarred internal lining of the heart to infective endocarditis.
  2. Bacteremia during or after an invasive dental procedure can lead to the formation of friable vegetations of blood cells and organisms on the scar tissue.
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7
Q

What is the most common bacteria in infective endocarditis?

A
  1. Streptococcus viridans is most frequently responsible for chronic infective endocarditis.
  2. Staphylococcus aureus is often implicated in the acute fulminating form.
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8
Q

Besides antibiotic prophylaxis, what else can you do to help prevent antibiotic prophylaxis?

A
  1. Pre-operative antiseptic mouthwash can reduce oral bacterial load.
  2. Focusing on good oral hygiene practices may be more important than antibiotic prophylaxis.
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9
Q

When are anticoagulants used for pts with congenital heart disease?

A

Anticoagulants are usually prescribed for children with valvular heart disease and prosthetic valves to reduce the risk of embolization.

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10
Q

What are the common anticoagulant drugs?

A
  1. Oral warfarin sodium (Coumadin) - a vitamin K antagonist depleting factors II, VII, IX and X.
  2. Heparin sodium (Heparin) - inhibits factors IX X and XII.
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11
Q

What are local hemostatic measures that can be done?

A
  1. Application of topical thrombin.
  2. Packing of the socket with microfibrillar collagen hemostat, oxidized regenerated cellulose.
  3. Suturing of attached gingivae.
  4. Splints or stomo-adhesive bandages may also be of benefit.
  5. There have been recent reports of the efficacy of a “fibrin sealant” (Tisseel Duo 500) in the management of coagulopathies, but its use on moist oral mucosa is limited.
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12
Q

What are the common changes in anticoagulant therapy that is done before dental treatment?

A
  1. Some practitioners cease warfarin 3 to 5 days prior to the surgery date, commence enoxaparin sodium once daily via Insulfon and admit the pt to the hospital on the day of the procedure.
    - -Recommencement of warfarin and weaning of enoxaparin sodium 24 hours after surgery is required to re-establish correct INR, PT and APTT.
  2. However, recent studies on adults who had multiple dental extractions without modification of their anticoagulant therapy showed few or no post-operative complications. ADA stated in 2003 that the scientific literature does not support routine discontinuation of oral anti-coagulation therapy for dental pts bc it can place them at unnecessary medical risk. Any changes in the anticoagulation therapy must be discussed with the pt’s physician.
  3. American College of Chest Physicians recommends that pts who are taking vitamin K antagonists and are about to undergo minor dental procedures continue with the therapy bc it does not confer an increase in clinically important major bleeding. It further states that it is reasonable to co-administer an oral pre-hemostatic agent at the time of the procedure until more adequately powered studies are done. In pts receiving aspirin, the College recommends continuing it around the time of the procedure.
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13
Q

What are some common medications to improve cardiac function and reduce congestive heart failure in children?

A

Oral elixirs including Digoxin and Furosemide, usually with sucrose or sorbitol base.

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14
Q

Why are children with congenital heart disease more likely to develop dental caries in primary teeth?

A
  1. Enamel is often hypoplastic and susceptible to early childhood caries.
  2. High-caloric diet.
  3. Use of sucrose-rich medications.
  4. Medications may induce xerostomia.
  5. Parental indulgence with sweets, juices, sodas, etc.
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15
Q

How would non-compliance with preventive advice alter treatment planning?

A

It may be necessary to extract all carious teeth, especially those with pulpal involvement, to reduce the risk of infection and infective endocarditis.

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16
Q

For a pt with cystic fibrosis what questions do you ask about the medical history?

A
  1. When was the diagnosis made?
  2. Who are the lead pediatrician and other pediatricians who are involve din the pt’s care and what are their addresses?
  3. What is the frequency of outpatient appointments?
  4. What is the frequency of admissions?
  5. What are the frequency and severity of chest infections?
  6. What is the microbiology of chest infections? (Infection by pseudomonas is an indication that lung function is severely compromised)
  7. What are the current medications?
  8. Is an indwelling catheter (central line) present?
  9. What is the pt’s experience with general anesthesia?
  10. Is there a possibility of future radical treatment? (Heart-lung transplant may be considered in pts with terminal respiratory failure)
  11. Are there any special dietary requirements/modifications?
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17
Q

What is the genetics of cystic fibrosis?

A

Basic defect is a failure to code for cystic fibrosis transmembrane regulator (CFTR) protein which regulates electrolyte and water transport across cell membranes.

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18
Q

What is the test for cystic fibrosis?

A

The optimal diagnostic test is the measurement of sweat electrolyte levels.

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19
Q

What is affected in cystic fibrosis?

A
  1. Respiratory issues:
    - -Viscous secretions accumulate in smaller airways which are prone to infection.
    - -Children are on long-term antibiotics to prevent chest infections, which must be treated aggressively.
    - -Healing occurs with scarring, further compromising the airway.
    - -Regular physiotehrapy is required to encourage physical removal of secretions.
    - -Many children have reversible airway obstructions treated by salbutamol and steroid inhalers.
  2. Gastrointestinal issues:
    - -Damage to pancreas results in pancreatic enzyme insufficiency, thus oral pancreatic supplements are required with all meals.
    - -Fat-soluble vitamin supplements are taken due to the pt’s reduced ability to absorb the vitamins.
    - -Incidence of celiac disease and Crohn’s disease seems to be increased in CF pts.
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20
Q

What are the long-term complications of cystic fibrosis?

A
  1. Diabetes
  2. Liver disease
  3. Pneumothroax
  4. Sinusitis
  5. Nasal polyps
  6. Osteopenia
  7. Failure to thrive
  8. Infertility
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21
Q

What is the management of cystic fibrosis?

A
  1. Proactive treatment of airway infection
  2. Encouragement of good nutrition
  3. Active lifestyle

-For pts in late respiratory failure, heart-lung transplants are an option but are available in only a minority of cases.

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22
Q

What are the oral manifestations in cystic fibrosis pts?

A
  1. Dental caries is lower than in healthy controls (despite a high-carbohydrate diet) - this is due to long-term antibiotic therapy, high salivary pH and raised salivary calcium levels
  2. Increased levels of calculus and lower gingival health - pts have altered amounts of calcium and phosphate in their saliva. Pancreatin may have a role in decreasing calculus formation and reducing dental caries in these pts.
  3. Higher prevalence of enamel defects - due to severe systemic upset in infancy, especially in cases in which pts are diagnosed late.
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23
Q

What is the dental treatment considerations for cystic fibrosis pts?

A
  1. General anesthesia is strongly contra-indicated bc of the compromised airway and increased incidence of post-operative chest infections.
  2. Consult with pediatrician to decide on which antibiotic to give for acute dental conditions. The choice of antibiotic should take into account the current regime and the types of antibiotics that may be required for future treatment.
  3. High priority for dental prevention bc the condition makes treatment of dental disease more difficult.
  4. Liver disease may be a feature of older children with CF, resulting in complications involving bleeding, infection and drug metabolism.
  5. Nitrous oxide sedation may be contra-indicated in these children and should only be carried out after consultation with the pediatrician to establish respiratory capacity. The procedure should be carried out in a hospital environment. Careful monitoring of oxygen saturation levels is essential.
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24
Q

What precautions are required for treatment under general anesthesia in cystic fibrosis pts?

A

The precautions for treatment under general anesthesia are:

  1. Avoid general anesthesia if possible.
  2. Make sure that there are no signs of pulmonary infection. May require sputum culture.
  3. Chest radiograph.
  4. Blood gases.
  5. Pulmonary function testing.
  6. Vigorous course of pre-op and post-op chest physiotherapy to clear as much of the secretions as possible.
  7. Check for diabetes (blood glucose) and liver disease (LFTs) pre-op.
  8. Check current antibiotic regimen.
  9. Peri-operative frequent suctioning and removal of secretions.
  10. Nasal polyps are a contra-indication to nasal intubation.
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25
Q

For a pt with hemophilia, what questions do you ask about the medical history?

A
  1. Type and severity of hemophilia
  2. Hemophilia team contact information
  3. Compliance with medications
  4. Frequency and management of bleeding episodes
  5. Inhibitor status
  6. History of blood borne disease such as HIV infection or hepatitis due to blood transfusions
  7. Limitations or restrictions on activities
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26
Q

Describe the heredity of hemophilia?

A
  1. Hemophilia A and hemophilia B are X-linked recessive traits.
  2. Hemophilia C is an autosomal recessive trait (most frequently presenting in Ashkenazi Jews).
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27
Q

Describe the effect effect on bleeding of hemophilia?

A

Hemophilia presents as impaired secondary hemostasis (stabilization of the platelet plug with fibrin) while primary hemostasis (platelet plug formation) is normal.

Hemophilia A - factor VIII deficiency
Hemophilia B - factor IX deficiency
Hemophilia C - factor XI deficiency

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28
Q

How is the severity of hemophilia classified?

A

Classified by level of factor activity:

  1. Normal: 55% to 100%
  2. Mild: >5%
  3. Moderate: 1% to 5%
  4. Severe:
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29
Q

What are the medications that can be used in hemophilia management?

A
  1. Antifibrinolytic medications - aminocaproic acid (AMICAR) or tranexamic acid (Cyklokapron).
  2. Desmopressin - increases plasma levels of factor VIII (may be useful in mild hemophilia A).
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30
Q

When should a hemophilia pt be treated under general anesthesia?

A
  1. Most pts can receive outpatient dental treatment.

2. Pts with extensive treatment needs, and moderate or severe hemophilia should be considered for treatment under GA.

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31
Q

For a hemophilia pt, what local anesthetic injections can be administered without factor replacement?

A

Buccal, intrapapillary and PDL infiltrations can be administered without factor replacement.

Intfiltrations into a highly vascularized area or into loose connective tissue and posterior superior alveolar and inferior alveolar nerve blocks.

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32
Q

If factor replacement is required for the local anesthetic injection for the hemophilia pt, what should be done?

A

Due to the risk of dissecting hematoma formation and potential airway compromise, factor replacement should be raised to 30% to 40% before infiltration into a highly vascular area or loose connective tissue as well as before PSA or IANB.

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33
Q

What alternative pain medications should be used for hemophilia pts?

A
  1. Don’t use aspirin and other NSAIDs - may aggravate bleeding.
  2. Codeine and acetaminophin are safe alternatives.
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34
Q

What lab test is affected by hemophilia?

A

The activated partial thromboplastin time is usually two to three times the upper limit of normal.

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35
Q

What is the significance of inhibitors in hemophilia?

A

Bleeding episodes continue despite appropriate factor replacement levels. Care for these pts may include use of a bypassing agent such as VIIa or activated prothrombin complex concentration.

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36
Q

What is the most common acute childhood leukemia?

A

ALL accounts for 80% to 85% of acute childhood leukemias with a peak incidence at four years of age.

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37
Q

How is ALL defined?

A

Defined by the presence of more than 25% lymphoblasts in the bone marrow.

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38
Q

How is ALL treated?

A

Therapy is tailored to the risk of relapse dependent on cytogenetic markers, and includes a combination of induction chemotherapy, central nervous system prophylaxis, and maintenance chemotherapy for 2.5 to 3.5 years.

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39
Q

How can cranial radiation be avoided in ALL treatment?

A

Intrathecal therapy (commonly methotrexate) has been used to replace cranial irradiation.

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40
Q

What is the cure rate for ALL?

A

Cure rates for standard risk ALL are now over 90% on current protocols. If relapse occurs, 40% to 50% can be cured with chemotherapy and/or hematopoietic stem cell transplantation, which is reserved for very-high-risk or relapse patients.

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41
Q

How is the prognosis of ALL determined?

A

Prognosis depends on age of onset, initial white cell count, cytogenetic abnormalities, and other features.

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42
Q

Why should you avoid alcohol products in pts with mucositis?

A

Avoid using alcohol-containing products when mucositis is present (it will sting and burn the mucosal tissues).

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43
Q

What antimicrobial therapy can you prescribe before dental treatment under general anesthesia?

A

Prescribe 0.2% chlorhexidine gel application four times daily prior to procedure.

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44
Q

How should the pt perform oral care during cancer treatment?

A
  1. Aggressive oral hygiene with a soft toothbrush or an electric brush should be done throughout treatment, regardless of the child’s hematological status.
  2. Ultrasonic brushes and flossing can be used if the patient is properly trained.
  3. Avoid using toothpicks and water irrigation devices during periods of immunosuppression.
  4. Patients should brush or at least rinse the mouth with water after taking oral medications or nutritional supplements.
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45
Q

What should you know about nystatin in cancer pts?

A

Nystatin is not effective for prevention and treatment of fungal infections in immunocompromised hosts.

46
Q

In a cancer pt, what dental procedures should be completed first?

A

Infections, extractions, scaling, and sources of tissue irritation should be taken care of first, followed by carious teeth, root canal therapy, and replacement of faulty restorations. The risk of pulpal infection and pain determines which carious lesions should be treated first.

47
Q

Below what ANC level is dental treatment delayed?

A
  1. Elective dental treatment should be delayed when ANC 500.

2. In emergency cases, discuss antibiotic prophylaxis with the pt’s physician before proceeding.

48
Q

For cancer pts, when do you extract teeth instead of doing pulp treatment?

A

Primary teeth in need of pulpal therapy during the induction and consolidation phase of chemotherapy should be considered for extraction due to possibility of failure of the pulp treatment, which will lead to an odontogenic infection.

49
Q

What is the risks of doing pulpal therapy on permanent teeth during cancer treatment?

A

Risk of bacteremia and potential septicemia.

50
Q

What orthodontic considerations should be given for cancer pts?

A
  1. Braces should be removed if the pt has poor oral hygiene or is at risk for the development of moderate/severe mucositis.
  2. Smooth, well-fitting appliances (e.g., band and loops) can be kept if the pt has good oral hygiene.
51
Q

What dental treatment should be completed before cancer treatment?

A

Root tips, teeth with periodontal pockets >6mm, teeth with acute infection, significant bone loss, involvement of furcation, symptomatic impacted teeth and non-restorable teeth should be removed at least 7-10 days prior to initiation of therapy.

52
Q

What considerations do you give for the platelet count in cancer pts?

A
  1. Platelet count >75,000/mm3 does not require additional support, but be prepared to treat prolonged bleeding with local measures after oral surgical procedures.
  2. Platelet count
53
Q

What considerations do you give for a cancer pt in full remission?

A

Children in full remission can be treated routinely, although a CBC is prudent if an invasive procedure is planned.

54
Q

Do you give antibiotic prophylaxis for a cancer pt with central venous catheter?

A

There is no evidence to support the administration of antibiotic prophylaxis to prevent catheter-related infections associated with an invasive oral procedure in patients with chronic indwelling central venous catheters.

55
Q

What is the definition of neutropenia?

A

Neutropenia is defined as

56
Q

What can chemotherapeutic agents do to the oral mucosa?

A

Direct stoma-toxicity is caused by the cytotoxic action of the chemotherapeutic agents on oral mucosal cells leading to inflammation, thinning, and ulceration of the mucosa (mucositis).

57
Q

What is the most common side effect of chemotherapy and how can the incidence be reduced?

A

Mucositis is the most common and painful side effect of chemotherapy. It may be reduced with the concomitant administration of granulocyte colony stimulating factor (G-CSF) during chemotherapy.

58
Q

What are the acute side effects of chemotherapy on the craniofacial complex?

A
  1. Oral sepsis (predisposed by neutropenia)
  2. Mucositis
  3. Secondary infections/opportunistic infections
  4. Oral bleeding
  5. Salivary dysfunction
  6. Neurotoxicity
59
Q

What are dental developmental effects that can occur?

A

Children younger than 10 years of age who receive chemotherapy and/or radiotherapy (total body irradiation or localized radiotherapy to the head and neck) may present dental developmental defects:

  1. Tooth agenesis
  2. Short, tapered roots
  3. Early apical closure
  4. Crown disturbances in size and shape
  5. Microdontia
  6. Enlarged pulp chambers
  7. Dentin and enamel opacities and defects
60
Q

For a pt with ALL, what questions do you ask about the medical history?

A
  1. Underlying disease
  2. Time of diagnosis
  3. Modalities of treatment the pt has received since the diagnosis
  4. Planned treatment, surgeries, complications, prognosis
  5. Current hematological status, allergies and medications
61
Q

For a cancer pt, how would non-compliance with preventive advice alter treatment planning?

A

Non-compliance with preventive measures such as daily oral hygiene would indicate a poor prognosis for minimizing adverse long-term oro-dental effect such as enamel demineralization and high caries rates.

62
Q

For a cancer pt, how would management differ if the child had a poor medical prognosis?

A

Management of children with a poor prognosis is generally palliative or symptomatic relief of pain and oral discomfort.

63
Q

What are some important functions of the liver?

A
  1. Metabolism of carbohydrates, lipids and proteins.
  2. Metabolism of drugs (detoxification) prior to excretion.
  3. Synthesis of plasma protein (albumin) and clotting factors.
  4. Storage organ for glycogen, vitamin B12 and iron.
  5. Breaks down hemoglobin; bilirubin and biliverdin are added to bile as pigment.
64
Q

What are the most common indications for pediatric liver transplantation?

A
  1. Chronic liver disease
    - -Biliary atresia (most common reason for pediatric liver transplantation)
    - -Alpha-1 antitrypsin deficiency
    - -Autoimmune hepatitis
  2. Metabolic liver disease with extra-hepatic complications
    - -Crigler-Najjar syndrome
    - -Urea cycle defects
  3. Acute liver failure
  4. Hepatic tumors
65
Q

What are the dental treatment considerations in a child with liver disease?

A
  1. Decreased metabolism (detoxification) of many drugs including lidocaine: administer less than maximum recommended dose of local anesthetic.
  2. Decreased metabolism (detoxification) of general anesthetic and sedative agents: except for nitrous oxide/oxygen analgesia/anxiolysis. The use of sedation or general anesthesia should be restricted to specialist home units.
  3. Decreased production of vitamin-K-dependent blood clotting factors (II, VII, IX, X): increased potential for post-extraction bleeding.
  4. Enlargement of spleen may cause platelet sequestration with associated low platelet count: increased potential for post-extraction bleeding.
  5. Varices (enlarged blood vessels) at base of esophagus due to obstruction of blood flow to diseased liver: chronic gastrointestinal hemorrhage may result in anemia.
  6. Greenish discoloration of teeth due to incorporation of unconjugated bile pigments, especially biliverdin, during the period of calcification of teeth.
  7. Yellow discoloration of skin and mucosa (jaundice) due to presence of unconjugated bilirubin in the tissues,
66
Q

What should you do regarding post-op bleeding in patients with liver disease?

A
  1. Local measures to control post-extraction bleeding include the use of oxidized regenerated cellulose (Surgicel or Gelfoam) and the use of resorbable sutures.
  2. Need a minimum of platelet count of 75,000/mm3 for dental extractions. Hematology consult if platelet count
67
Q

What are some common complications in pts with liver disease?

A
  1. Distal shoe appliance relatively contraindicated in view of immunosuppression.
  2. Long-term complications of steroid and immunosuppression agents: gingival overgrowth, high blood pressure, osteoporosis, etc.
68
Q

What is the dental management of a child before liver transplantation?

A
  1. Prevention: educate child and caretakers on importance of optimal oral care.
  2. Treat/stabilize active dental decay so that the teeth will not be a potential source of infection at the time of transplantation and for the following three to six months.
  3. Extract extensively decayed teeth and teeth with pulp or potential pulp pathology.
  4. Consult pediatric gastroenterology team and seek advice on coagulation status and ensure a platelet count of >75,000/ml3 before extracting teeth.
69
Q

What is the dental management of a child after liver transplantation?

A
  1. Regular dental visits for preventive and ongoing care from six months following treatment.
  2. Cyclosporine with/without antihypertensive drug nifedipine may cause gingival hyperplasia and delayed eruption of teeth. No gingival problems with tacrolimus, which is an alternative to cyclosporine.
  3. Caution with use of NSAIDs for analgesia bc these may increase the nephrotoxicity of cyclosporine and tacrolimus.
  4. Glucocorticoids may be used in low dosages as immunosuppressant: additional dosage not usually required for dental treatment unless treatment provided under general anesthesia.
  5. Azathioprine and mycophenolate mofetil are other immunosuppressant drugs that may be used following solid organ transplantation. They have no specific oral or dental side effects.
70
Q

At what ANC levels can dental procedures be performed?

A

1,500 to 8,000 cells/mm3 is normal
500 to 1,500 is safe (no restrictions)
500 or less is low (restrictions apply)

71
Q

At what ANC level is severe neutropenia?

A
  1. Severe neutropenia occurs at ANC
72
Q

What is the cause of neutropenias present at birth?

A
  1. Severe congenital neutropenia (Kostmann syndrome) with associated severe periodontitis.
  2. Cyclic neutropenia - primary cyclic (every 21 days) decrease in maturation of precursor cells in bone marrow with recurring fever, skin infections, oropharyneal disease and periodontitis.
  3. Neutropenia in association with metabolic disorder (Shwachmann-Diamond syndrome and Glycogen-storage disease type 1b).
  4. Neutropenia as part of certain syndromes - pancytopenia in Fanconi’s anemia, dyskeratosis congenital with progressive marrow failure.
73
Q

What is the cause of neutropenias acquired during life?

A
  1. Idiopathic neutropenia
  2. Autoimmune neutropenia
  3. Chronic benign neutropenia
  4. Hematologic dysplasias and malignancies
  5. Solid tumor invasion of bone marrow
  6. Cancer chemotherapy and radiotherapy
  7. Drug toxicity
  8. Viral infections
74
Q

What is the primary goal for medical management of neutropenia?

A

The primary goal is to prevent infection with:

  1. Prophylactic antibiotics
  2. Granulocyte-Colony Stimulating Factor (G-CSF)
  3. Interferon gamma (IFN-g)
  4. Hematopoietic stem cell transplant
  5. Immunoglobulin and steroid therapy
75
Q

What are the typical oral manifestations of neutropenia or disorders of neutrophil function?

A
  1. Gingivitis
  2. Periodontitis
  3. Oral ulceration
76
Q

What is associated with molar-incisor-hypomineralization?

A

History of illness during infancy or early childhood, such as pneumonia, otitis media, and fever or there may not be any relevant past medical history.

77
Q

What changes in treatment consideration do you give a pt who has neutropenia?

A
  1. Avoid use of SSC restorations bc of anticipated exaggerated gingival response in association with medical history of neutropenia.
  2. Extract pulpally involved teeth.
  3. Extract teeth with severe periodontal disease.
  4. Use antibiotic prophylaxis for surgical dental treatment (consult with pt’s physician).
  5. Follow-up visit after dental treatment to check that healing is satisfactory and any infection is resolved.
78
Q

What considerations should you be aware of for orthodontic treatment of a pt with neutropenia?

A

An exacerbation of gingivitis may be anticipated during fixed orthodontic appliance treatment and the orthodontist should be informed of this.

79
Q

What are the predominant types of pathogens likely to cause infection in a child with neutropenia?

A

Bacteria and fungi.

80
Q

What is the etiology of asthma?

A

The etiology is not fully understood. Precipitating factors include pollens, mold spores, house dust, viral infections, cigarette smoke, cold air, extreme emotional arousal, exercise and anti-inflammatory medication.

81
Q

What are the classifications of asthma?

A
  1. Based on etiology
    - -Extrinsic: allergic
    - -Intrinsic (specific triggers, e.g., exercise)
  2. Based on severity
    - -Intermittent
    - -Persistent: mild, moderate, severe
82
Q

What questions do you ask about the medical history for a pt with asthma?

A
  1. Type and severity of asthma
  2. Level of asthma control
  3. Frequency of asthmatic attacks
  4. Precipitating factors
  5. Last acute episode and hospital admission
  6. Symptoms associated with sports/exercise
  7. Type of medication used regularly and during an acute episode
83
Q

What type of asthma pts do you need a medical consult with the pediatrician?

A

Consult with pediatrician in uncontrolled or severe cases. No need to contact pediatrician if the asthma is generally well controlled.

84
Q

What can you do for the management of oral candidiasis in an asthma pt?

A
  1. Prevention
    - -Consider use of aerosol holding chamber
    - -Rinse with water following exposure to inhaled corticosteroids
  2. Treatment
    - -Rinse with chlorhexidine mouthwash daily while candidiasis is present
    - -Consider topical antifungal drug therapy in more persistent cases
85
Q

What are the long-term control medication for asthma and what are the adverse effects?

A
  1. Long term medications:
    - -First choice: Inhaled corticosteroid (e.g., Beclomethasone)
    - -Inhaled long-acting beta2-agonist
    - -Leukotriene receptor antagonist
    - -Systemic corticosteroids
    - -Immunomodulators
  2. Long-term use of ICS (inhaled corticosteroid) within labeled doses is safe for children in terms of growth, bone mineral density and adrenal function.
  3. Low to medium dose ICS are not associated with the development of cataracts or glaucoma in children.
86
Q

What oral mucosal changes occur in asthma?

A
  1. Gingivitis (associated with mouth breathing)
  2. Oral candidiasis (associated with use of inhaled corticosteroids)
  3. Dryness of mouth (associated with use of inhaled corticosteroids)
87
Q

Describe the effect of asthma on dental caries?

A
  1. There is insufficient evidence to confirm the increased risk of dental caries and/or erosion in pts with asthma.
  2. Lactose is the carrier for many devices; it gives taste so pt knows that a dose was dispensed.
  3. Inhalers do not taste good; thus, pts increase consumption of flavored beverages.
88
Q

For asthma pts, what are Beta2 agonist medications associated with?

A
  1. Decrease in salivary flow
  2. Decrease in plaque pH
  3. Muscle relaxation with subsequent gastroesophageal reflux and associated acid reflux
89
Q

For asthma pts, when would you consider not doing the treatment in the office?

A

If wheezing, severe or poorly controlled asthma: reappoint/medical consult/consider a hospital setting.

90
Q

What should asthma pts do the day of the dental apt?

A
  1. Asthma medication should be taken as normal on day of dental treatment.
  2. Bronchodilator should be brought along to the dental appointments.
  3. For pts taking long-term oral corticosteroids, steroid supplementation is necessary in anticipation of a stressful situation such as dental extractions or during general anesthesia.
91
Q

What allergy should you be aware of in asthma pts?

A

NSAIDs should be used with caution in all children with asthma: 4% of asthmatics are allergic to aspirin and other NSAIDs. Use acetaminophen instead.

92
Q

What considerations for nitrous oxide should be given to asthma pts?

A

Nitrous oxide is contraindicated in severe asthmatics: consult physician.

93
Q

What dental materials can trigger an asthma attack?

A
  1. Sealants
  2. Enamel dust
  3. Cotton rolls
  4. Sulfites
  5. Dentifrices
  6. Methyl methacrylate
94
Q

What conscious sedation medications should be used with pts with asthma?

A
  1. Oral: benzodiazepines (e.g., midazolam 0.5mg/kg) in pts with mild/moderate asthma
  2. Inhalation sedation (e.g., nitrous oxide) in pts with mild/moderate asthma
  3. Intravenous: use extreme caution in pts with asthma (consult pediatrician and anesthesiologist)
95
Q

What precautions should you have for asthma pts for procedures under general anesthesia?

A

Pre-anesthetic review for children with severe or uncontrolled asthma. Non-urgent dental treatment should be postponed until asthma is controlled.

96
Q

What can trigger an asthma attack?

A
  1. Pollens
  2. Mold spores
  3. House dust
  4. Viral infections
  5. Cigarette smoke
  6. Cold air
  7. Extreme emotional arousal
  8. Exercise
  9. Certain anti-inflammatory medications
97
Q

What are the subclassifications of inflammatory bowel diseases (IBD)?

A
  1. Ulcerative colitis (UC)
  2. Crohn’s disease (CD)
  3. Indeterminate colitis - the term used when unable to clearly discriminate between UC and CD
98
Q

What is Crohn’s disease?

A

Chronic granulomatous infammatory disorder of unknown etiology, likely the result of an inappropriate inflammatory response in a genetically susceptible individual to an environmental stimulus.

99
Q

Where does Crohn’s disease affect?

A

May affect any part of the GI tract from the mouth to the anus. Typically involves the terminal segment of the small intestine (ileum) and first segment of the large intestine (colon).

100
Q

What is the peak incidence of Crohn’s disease?

A

Second and third decades of life with up to 1/3 of cases occurring before 20 years of age.

101
Q

What gene is the susceptible gene for Crohn’s disease?

A

NOD2 is the best characterized susceptibility gene, mutations of which confer increased risk for CD.
–The gene encodes for a protein that is involved in recognizing pathogens and intracellular signaling of the innate immune response.

102
Q

What is the treatment for Crohn’s disease?

A
  1. Medical induction and maintenance of remission of intestinal inflammation.
    - -Nutritional support may require nasogastric infusion of formulated food in severe cases with malnourishment and growth retardation, to increase caloric intake.
  2. Medical treatment of relapses/acute exacerbations.
    - -Surgical intervention if there are intractable symptoms despite medical therapy or if there are intestinal complications such as obstruction, infection, fistula, perforation or hemorrhage.
103
Q

What is the presentation of Crohn’s disease in children?

A
  1. Abdominal pain
  2. Diarrhea +/- blood in stools
  3. Poor appetite
  4. Weight loss
  5. Impaired growth and pubertal delay
  6. Anemia due to malabsorption and blood loss
  7. Erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) and high platelet count are indicative of an inflammatory process
  8. Low albumin due to protein losing enteropathy oral soft tissue manifestations
104
Q

What is the oral manifestations of Crohn’s disease?

A

Up to 40% of children may have one or more of the following oral manifestations of CD at initial presentation:

  1. Lip and/or cheek swelling
  2. Angular cheilitis
  3. Mucogingivitis (inflammation of marginal and attached gingiva), most commonly in the anterior region
  4. Irregular nodular swelling or “cobblestoning” of buccal mucosa
  5. Long, deep ulcers in mandibular buccal sulcus
  6. Mucosal tags
  7. Multiple aphthous ulcers
105
Q

What does the biopsy of the oral lesion of Crohn’s disease show?

A

A non-necrotizing granuloma is a key histopathological finding in Crohn’s disease.
–It consists of an aggregate of epithelioid macrophages (“epithelioid”: lots of pink cytoplasm similar to squamous epithelial cells) and multinucleate giant cells.

106
Q

Should you do a biopsy for an oral lesion of Crohn’s disease?

A
  1. Biopsy of a gingival or mucosal tag lesion, if present, is recommended bc non-necrotizing granulomas should be found in a biopsy from these sites.
  2. Biopsy of the lower lip is not recommended bc there is a risk of damage to the labial branches of the mental nerve. Furthermore, granulomas in an extensively edematous lip will be sparse and scattered and may not be captured in a biopsy specimen.
107
Q

What is orofacial granulomatosis?

A

A condition characterized by orofacial swelling with biopsy-positive non-necrotizing granulomas in a pt without Crohn’s disease or other systemic disease.

108
Q

What is orofacial granulomatsis associated with?

A

May be associated with a hypersensitivity to certain food and drink additives such as benzoates, cinnamon and tartrazine.

109
Q

What is the relationship between Orofacial granulomatosis and Crohn’s disease?

A
  1. A child with OFG may not have overt symptoms or signs of CD but may subsequently develop intestinal CD.
  2. A child with OFG should be referred to a specialist in oral medicine. Review by a pediatric gastroenterologist may also be required bc OFG may precede the development of CD.
110
Q

How should you approach the dental treatment of a pt with Crohn’s disease?

A
  1. Delay treatment in the dental office until medical improvement in CD.
111
Q

What categories of drugs may be used in the management of Crohn’s disease in children?

A
  1. Ati-inflammatories (glucocorticoids, enteral nutrition, aminosalicylates)
  2. Immunomodulators
  3. Biologics
  4. Antibiotics

Moursi (9 decks)

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