MS2 - Medically Compromised Children

Question 1

What should you consider when making definitive treatment plans for medically compromised children?

Answer 1

-History / condition
-risk assessment
-Diagnosis
-prevention
-conjunction with specialist and child’s doctor
-is hospital admission required for dental tx?

Question 2

How many children with Down Syndrome have a congenital heart defect (CHD)?

Answer 2

70%

Question 3

what is the most common type of heart condition in paediatric pts?

Answer 3

CHDs
(80% of heart conditions in paeds pts, 10% of these are part of other syndromes/chromosomal abnormalities)

Question 4

*what may be some medical implications to consider in a child with CHD?

Answer 4

-risk of bacterial endocarditis (especially with any valve defects)
-anticoagulant therapy -> bleeding tendency
- other medical conditions / syndromes
- possibility of oxygenation issues
- possibility of blood pressure issues

Question 5

What are the clinical features of a cardiac conditons?

Answer 5

-Dyspnoea - SOB
-Cyanosis
-Clubbing of fingers
-Heart murmurs, clicks or thrills
-Heart rate affected

Question 6

what possible oral features can present in children with CHDs? (2)

Answer 6

-enamel developmental defects
-Increased risk of caries (medications, compliance, diet)

Question 7

What oral feature in primary dentition would lead you believe there may be an underlying genetic issue?

Answer 7

Generalised enamel hypoplasia

Question 8

If a child with cardiac conditions presents with any pulpal infection in a primary tooth, how should you treat this and why?

Answer 8

Extraction
Avoid pulp therapy in primary teeth in pts with cardiac conditions - reduce risk of bacterial endocarditis

Question 9

Can you use LA with adrenaline in a child with cardiac conditions?

Answer 9

Yes, provided it is administered carefully (aspirate)

Question 10

What are the indications for Antibiotic Prophylaxis?

Answer 10

-Prosthetic heart valve
-History of IE
-RHD in low socio-economic group
-Congenital heart disease with unrepaired cyanotic defect
-congenital heart disease with residual defects at/adjacent to a prosthetic device
-uncontrolled Immunodepression (eg. transplant, HIV, etc)

Question 11

Explain the 3 basic steps of clotting cascade after there is injury to a blood vessel

Answer 11

1. vascular spasm
2. Platelet plug formation
3. coagulation

Question 12

Is a pt is taking NSAIDs/aspirin, what would it tell you about the management of that pt?

Answer 12

-would cause an acquired qualitative platelet disorder
-> may have failure of initial clot formation

Question 13

If a patient has platelet disorders, how should you manage the patient?

Answer 13

-Management of platelet levels - refer to GP for blood test
-Avoid nerve blocks (avoid injury to blood vessel in case excessive bleeding occurs)
-Avoid extractions - consult GP
-good surgical technique and local haemostatic measures

Question 14

What are some examples of acquired coagulation disorders?

Answer 14

-Haemophilia A, B and C
-Vik K deficiency
-Renal failure
-Liver disease
-Bone marrow suppression

Question 15

When considering an invasive dental procedure in a patient with haemophilia, what should you warm them of?

Answer 15

In haemophiliac pts, bleeding can be delayed by several hours (as primary haemostasis is not impaired)

Question 16

*What are dental management strategies / consideration for pts with coagulation disorders?

Answer 16

-Liaise with haematologist
-Avoid oral surgery / invasive procedures in the general dental setting
-Avoid prescription of drugs that exacerbate bleeding (eg. NSAIDs)
-For LA
* Use vasoconstrictor
* Nerve blocks require haematological prophylaxis
-appropriate local haemorrhage control

Question 17

Is it safe to use LA in pts with anaemia?

Answer 17

Yes

Question 18

*What are the oral manifestations of anaemia?

Answer 18

-*soreness of the tongue and oral mucosa
-recurrent ulcerations
-angular cheilitis
-atrophic glossitis

Question 19

What should you consider when treating a pt with haemolytic anaemia?

Answer 19

Consult doctor whether abx prohylaxis is required

Question 20

what are some oral features of pts with immunodeficiencies?

Answer 20

-candidiasis
-recurrent aphthous ulcers
-recurrent herpetic infections
-gingival and periodontal disease
-premature primary tooth exfoliation

Question 21

how should you manage pulpally involved teeth in a pt with immunodeficiency?

Answer 21

primary tooth -> always extract
Permanent tooth -> weigh risks and benefits of treatment and condition

Question 22

How should you treat oral candidiases in Newborns and children younger than 2? (2)

Answer 22

either
1. Nystatin liquid (100,000 units/mL) - 1mL topically at the tip of the tongue then swallow - 4x daily after feeding for 7-10 days (continue 2-3 days after symptoms resolve)
or
2. Miconazole 2% gel - 1.25mL topically then swallowed - 4x daily after feeding for 7-10 days, continue for 10 days after feeding

Question 23

How do you treat oral candidiasis for children over 2 years old? (3)

Answer 23

1. Nystatin liquid (100,000 units/mL) - 1mL topically (then swallowed) - 4x daily after food, continue for 2-3 days after symptoms resolve
   or
2. Miconazole 2% gel - 2.5mL topically then swallowed - 4x daily after food, continue for 2-3 days after symptoms relieve
   or
3. Amphotericin B - 10mg lozenge sucked then swallowed - 4x dialy after food for 7-10 days, continue 2-3 days after symptoms resolve

Question 24

*Oral signs / symptoms of cancer?

Answer 24

-non-healing ulcer >2 weeks
-unexplained pain in the mouth
-displacement of teeth
-bony expansion
-trismus
-numbness
-lymph node involvement
-change in voice/sore throat

Question 25

What drugs should you NOT prescribe a pt with renal conditions?

Answer 25

Nephrotoxic drugs - eg. Paracetamol, Penicillin, Tetracyclines

Question 26

What are important considerations when treating a pt with liver disease? (2)

Answer 26

-Altered coagulation (Vit K deficiency)
-Immunodepression -> consult specialist about abx prophylaxis

Question 27

What should be done prior to tx in a pt with endocrine disorders?

Answer 27

• Liase with endocrinologist about appropriateness of steroid prophylaxis

Question 28

What is a dental manifestation of Hypothyroidism?

Answer 28

• delayed eruption of teeth -> primary teeth may be over-retained

Question 29

What is a dental manifestation of hyperthyroidism?

Answer 29

Premature eruption of teeth

Question 30

If you see a premolar tooth in a 5 year old pt, what may you suspect?

Answer 30

May be Hyperthyroidism -> refer to GP/ specilaist

Question 31

What considerations should you take when treating a pt with respiratory conditions eg. asthma?

Answer 31

• Avoid NSAIDs
• Avoid rubber dam to avoid triggers
• avoid long appts
• avoid potential alergens - eg. strong odours, stress

Question 32

What is the dose of epinephrine for children in case of anaphylaxis and where to inject?

Answer 32

300ug into antero-lateral aspect of thigh

Question 33

what is the epinephrine dose for adults undergoing anaphylaxis?

Answer 33

500ug

Question 34

Can you do pulp therapy in pts with down syndrome who have cardiac conditions?

Answer 34

NO

Question 35

*what are the dental and orofacial features of a pt with Down Syndrome?

Answer 35

• macgroglossia
• Class III - concave look
• AOB
• Underdeloped mis 1/3 of face
• periodontal disease
• Supernumerary or missing teeth
• Delayed eruption
• high palatal arch
• bifid uvula
• Low set ears
• short neck
• depressed nasal septum

Question 36

What do you need to consider when treating a pt with down syndrome for invasive treatment?

Answer 36

Abx prophylaxis - especially if they have CHD