Medically Compromised Patients Flashcards
Cardiovascular Disorders
May be congenital/acquired
identify structural (ventricular septal defect)/ rhythm problem (supraventricular tachycardia)/ muscle tissue (cardiomyopathy)
8 in 1,000 live births CHD
4 in 1,000 adults with CHD
Structural defects
Acyanotic
- ASD/VSD/PDA
- Coarctation of aorta
- Aortic or pulmonary stenosis
Cyanotic
- Transposition of great arteries
- Tetralogy of Fallot (VSD/ pulmonary stenosis, overriding aorta, right ventricular hypertrophy)
Rhythm Defects/Arrhythmias
Supraventricular tachycardia in children
Atrial tachycardia/atrial fibrillation or long QT syndrome
LA with no adrenaline (Citanest)
Presence of anaesthetist/cardiologist
hospital tx
Cardiomyopathies
Dilated cardiomyopathy - enlarged heart, poor contraction
Hypertrophic cardiomyopathy - thickened muscle, thus difficult to fill
Restrictive cardiomyopathy - abnormal relaxation but good pumping
May need heart transplant
Hypertrophic Cardiomyopathy means increased IE risk and may have arrythmia
Infective Endocarditis
Infection of lining of heart
Rare condition
People with certain structural cardiac conditions at risk
Life threatening disease with mortality at 20%
NICE Guidelines on IE
Antibiotic prophylaxis is no longer offered routinely for the interventional procedures.
Prompt investigation and treatment of infection.
Benefits and risk of antibiotic prophylaxis and an explanation as to why antibiotic prophylaxis is no longer routinely recommended
Importance of maintaining good oh
Patients at risk of IE
Acquired valvular disease with stenosis or regurgitation
Hypertrophic cardiomyopathy
Previous IE
Structural CHD including surgically corrected or palliated structural conditions
Valve replacement
Patients requiring special consideration
Pts with prosthetic valves
Pts with previous IE
CHD (any type of cyanotic CHD/any type of CHD repaired with a prosthetic material, up to 6 months after procedure or lifelong residual shunt or valvular regurgitation remains.
Avulsed teeth in cardiac pts
reimplantation would cause bacteraemia
risk/benefits discussed
course of antibiotics
Haematological disorders
Bleeding disorders:
1.Inherited Coagulopathy
2. Acquired Coagulopathy
3. Platelet disorder
4. Vascular disorder
Inherited Coagulopathy
Haemophilia A (factor VIII deficiency)
Haemophilia B (factor IX deficiency)
Disorder of platelet function - von willebrand
Acquired Coagulopathy
Liver disease
Vitamin k deficiency
anticoagulant therapy eg warfarin/heparin
Platelet disorders
Primary - idiopathic thrombocytopenia purpura (ITP)
Secondary - systemic disease - leukaemia, drug induced
Vascular disorders
Hereditary Haemorrhagic Telangiectasia (HHT)
Extractions and IDB
Tx should be carried out in hospital
Extractions or IDB will require haematology cover (factor concentrates/DDAVP/Antifibrinolytics such as tranexamic acid)
If IDB block required - danger of haematoma/airway compromise
Extractions - consider local measures such as surgicel and sutures
Respiratory disorders
Asthma
Cystic Fibrosis
Asthma
Diffused obstructive lung disease
Leading cause of chronic illness in children
about 1/2 will be symptom free as adults
10% children at some time will have signs
Dental implications of asthma
Link between asthma and erosion
Inc likelihood of oral candidiasis
Dental implications of asthma
Oral candidiasis
Erosion link weak
Dental management implications of asthma
medications
LA and IHS may be used
Avoid GA if possible
Cystic Fibrosis
Hereditary disease affecting endocrine glands causing progressive multisystem failure
1 in 25 carry gene, autosomal recessive
Multisystem disorder: Lungs/GIT/Pancreas/Liver/GUT
Dental implications of CF
Hypoplasia
Hypomineralisation
Increased caries risk with diet high in carbohydrates (buffering effect of saliva increased, high intake of antibiotics)
Previous tetracycline staining
Erosion - inc risk due to GORD
Dental management implications in CF
High risk GA
Preventive advice and early tx for high risk pt
Consider IHS but liaise with physician
8% may have cirrhosis of liver so potential clotting defect
May have Vit K deficiency - coagulation defects
Endocrine Disorders
Diabetes
Diabetes
Most common endocrine disorder
Deficiency of insulin and abnormal metabolism of carbohydrate/protein/fat
Type 1 IDDM - 95% of childhood diabetes
Dental implications of Diabetes
Poorly controlled
- increased glucose in saliva
- decreased saliva (higher caries risk)
- altered response to healing
- increased susceptibility to infection esp Candida
- inc perio problems
Dental treatment of Diabetes
Well controlled dental tx
normal breakfast
normal insulin
Neurological disorders
Epilepsy
Epilepsy
Recurrent seizures
Causation - idiopathic (genetic predisposition)/secondary (neoplasm/cerebral malformation)
Dental implications of epilepsy
Drug side effects
Phenytoin - gingival overgrowth
Carbamazepine - oral ulceration, xerostomia
Sodium valproate (decreased platelets and possible clotting problems)
Drug interactions
Phenytoin - metronidazole/miconazole/NSAID
Carbamazepine and Sodium Valproate - erythromycin
Dental management of epilepsy
Prevention
Good OH to minimise gingival hypertrophy
Trauma may occur following seizures
Restorative - fixed prosthesis
Emergency management of epilepsy
Remove sharp objects
Protect from injury
Prolonged seizure (>3 mins) – ambulance
Oncology
1,200 cases of childhood cancer per year
90% paeds pts suffer oral complications
Dental implications of oncology
Chemotherapy
Bone marrow transplantation
Radiotherapy to head and neck
Aim to minimise mucositis/infection/haemorrhage
Effects of chemotherapy on developing dentition
Enamel defects (discolouration/hypoplasia)
Agenesis
Microdontia
Effects of chemo and radiotherapy
Enamel defects (discolouration/hypoplasia)
Agenesis
Microdontia
Arrested root development
Increased caries esp if xerostomia
Facial growth
TMJ
CLP
1 in 700 live births
fusion disorder affecting mid face skeleton
approx 40 cases born per year NI
30% associated with other syndromes
70% are non-syndromic - but still have a significantly inc risk of CHD
Different presentations:
- Lip only
- Palate only
- Complete unilateral
- Complete bilateral
- Submucous cleft
Dental implications of clp
inc caries risk
ortho issues (crowding/class II tendency/cross-bites)
fistula formation
Dental implications of clp: alveolus
inc caries risk
ortho - crowding/class III tendency
fistula
hypoplasia in teeth adjacent to cleft site
hypodontia/supernumerary teeth in region of cleft
lip tethering - difficult access and plaque retention
