Special Needs Patients pt 1

Question 1

Diabetes Mellitus Type I

• Prevalence in pediatric population?
• Cause?
• Peak onset>
• Susceptibilty?

Answer 1

• Most common form of pediatric diabetes at 70%
• Chronic metabolic disorder caused by absolute deficiency of insulin due to absence or destruction of pancreatic beta cells
• Peak onset: 10-12 (girls) 12-14 yo (boys)
• Susceptibilty: genetics, environment, autoimmune factors

Question 2

Diabetes types I : twin studies demonstrate?

• coinfection? or environmental changes?
• Chromosomal anomalies with increased risk?
• Increased risk for what diseases?

Answer 2

60% chance if identitical of both having, not identical 8% share.

• Environment: viral infection, breastfed has a lower risk
• Downs, Turner, Klinefelter
• DM1 has increased risk for Celiac disease and hypo or hyperthyroid disease

Question 3

Signs and symptoms of Diabetes type I

Answer 3

Polyuria, polydipsia, polyphagia

• weigh tloss, FTT (gluconeogenesis)
• Ketoacidosis (15-40%): dehydration, ketone breath, acidotic breathing, abdominal pain
• Immune impairment: recurrent infection and candidiasis
• Symptoms develop over a short period of time

Question 4

Blood glucose fasting and random test values for diabetes type I?

Answer 4

fasting >120mg/dL

random >200mg/dL

Question 5

Type II DM :

• What is it?
• Prevalence in children?
• Risk factors?

Answer 5

Insulin resistance w/relative deficiency

• Characterized by hyperglycemia, vascular disease, and neuropathy (burning mouth syndrome)
• 30% of pediatric diabetes but increasing
• Risk factors: >10yo obesity family hx, ethnicity, physical inactivity, alcohol/drug use

Question 6

Physical symptoms of DM type II

Answer 6

Increased appetite/thirst

• Increased urination
• Fatigue
• Blurred vision
• Dry, itchy skin. Tingling or numb extremities
• non healing skin infections
• Candidiasis
• Acanthosis nigricans: cutaneous marker of insulin resistance

Question 7

Acanthosis Nigricans:

• what is it?
• Assoc w/?
• where is it found?

Answer 7

Acquired or inherited pigmentation skin

• assoc w/diabetes, obesity, other endocrine disorders malignancies,
• sites: flexural places (knees, neck, elbows), lips

Question 8

Metformin: what does it do?

Answer 8

Metformin reduces hepatic glucose production and increases insulin sensitivty

Question 9

Diabetes : oral manifestations?

Answer 9

• Increased risk for gingivitis, periodontitis
• Prolonged infections, candiasis
• Xerostomia, sialodenosis
• Delayed wound healing
• Altered sensation (burning mouth synd), taste issues
• Odontalgia (microangiopathy)–can increase toothaches because they have small blood vessels that can be occluded
• Lichen planus and acetone breath (DM 1)
• Benign migratory glossitis (geographic tongue)

Question 10

Localized Juvenile Spongiotic GIngival hyperplasia:

• what is it?
• Origin?
• Cause?
• Age/gender/race

Answer 10

Irritation in papilla at gingival margin
Site: sulcular/junctional epithelium especially anterior facial gingiva, esp maxilla
- Cause: unknown not strong bacterial plaque assoc
- Factors orthodontics (15%), tooth eruption, lip incompetence/mouthbreathing
- Do not see a lot of plaque on the teeth, does not necessarily respond to oral hygiene
Age/Gender/Race: 12 yo, F», white

Question 11

Periodontitis in children:

• Prevalence in the US?
• Risk factors?
• Relationship to DM 1 and 2?
• nutrition?

Answer 11

20% of 14-17 yo have attachment loss of >2mm in 1 or more sites

• Risk factors: teen who smokes, DM
• DM1 : 10-15% risk, DM2: increased risk
• Chronic vitamin C deficiency also risk

Question 12

GERD: prevalence? peak age? symptoms?

Answer 12

Malfunctioning/week lower esophageal sphincter that results in retrograde flow of gastic contents into esophagus

• Affects 5-7% of population; common in infants
• Peak age: 1-4 months; most resolve at 8-10 months, chronic reflux if still occur beyong 18 months

Question 13

Signs and symptoms of GERD

Answer 13

Chronic heartburn, acid regurgitation, vomiting, belching, painful swallowing, chronic sore throat, sour taste, wheezing, poor appetite, halitosis, oral ulcers/erosion, dental erosion

Question 14

Causes of GERD: physical? Meds? etc?

Answer 14

Anatomic factors, angle, hiatal hernia
- Medicines: theophylline, almotriptan- migraine meds, bisphosphosphonates), obesity, overeating, late night eating, greasy foods, etc

Question 15

Lifestyle treatments, medicines and foods to avoid for GERD, possible consequences of treatment?

Answer 15

• Lifestyle: upright until meal digested, eat smaller meals/more often, restrict food choices, no exercise after meal, reduce body weight, elevate head of bed 30 degrees for children >2 yo, eliminate tobacco smoke exposure
• Foods that aggravate: caffiene, carbonated, chocolate, peppermint, spicy, acidic, fried/fatty, alcohol
• Meds: antacids, foaming agents (cover stomach contents), H2 receptor antagonist (inhibit acid production), proton pump inhibitors (total acid suppression - can lead to vit D/B deficiencies), prokinetics (strengthens sphincter)

Question 16

Surgical tx for GERD and inications for sx

Answer 16

Fundoplication: wrap fundus around distal part of esophagus, distended stomach compresses on esophagus, curative for 90% of pts
- Indications for sx: failed drug tx (12 wks), complications

Question 17

Dental considerations for GERD

Answer 17

1. Children w/ GERD have increased risk of erosion
2. Higher salivary micro-organism colonization in GERD children increases caries risk; INCREASED BACTERIAL LOAD
3. Consider evaluation for GERD when dental erosion is present in asymptomatic children
4. Do not brush after vomiting

Question 18

Prevalence of Anorexia, bulimia? ED-NOS?

Gender?

Answer 18

Anorexia : 1% Bulimia Nervosa 1-4%
50% of all teens w/ED
90% are female

Question 19

Oral signs/symptoms of eating disorders

Answer 19

• Sore throat, painful swallowing
• palatal erythema, ulcers, petechiae
• Angular cheilitis +/- xerostomia
• Dental erosion, tooth sensitivity, mucosal palor
• nutritional deficiencies, osteopenia, uni/bilateral parotid enlargement

Question 20

Russell’s Sign?

Answer 20

Chapped/calloused fingers from vomiting

Question 21

Anorexia nervosa: prevalence? genetics? Consequences? Most common cause of death? Prognosis? Mortality rate?

Answer 21

• 1%; 10:1 female:male ratio
• Genetic predisposition
• Amenorrhea, depression, cold hands/feet, headaches, lethargy, dry skin/hair loss, constipation, hypothyroidism, anemia, lekopenia, thrombocytopenia,
• cardiac disease most common cause of death
• Prognosis: 50% completely recover, 50% partially recover, w/20% having an ongoing problem.
• 10-20% morality rate

Question 22

Bulimia nervos: prevalence by gender? diagnostic criteria? prognosis? Major complications? Mortality rate?

Answer 22

4% of population. 3% of women and .1% of men
- At least 2x/week for 3 months
-50% recover totally
-30% partially recover
15-20% ongoing problem
-Major complications: depression, suicide, substance abuse, cardiac arrhythmias/arrest, esophageal tears, esophagitis, pancreatitis, seizures,
- up to 3% die of the disease

Question 23

Treatment for ED pharma?

Answer 23

• SSRI’s (fluoxetine)

- Sodium bicarbonate and water mouth rinse to neutralize gastric acids

Question 24

Gastric Feeding Tubes: population in need of them? oral findings?

Answer 24

Severe eating problems in 3-10% of children
- Oral findings: poor OH, gingivitis, increased calculus and plaque, increased salivary bacteria, reduced salivary flow, risk of aspiration pneumonia in some children, risk for GERD, delayed tooth eruption, eruption cyst/hemangioma, dental erosion, oral contact aversion, difficulty handling fluids and secretions, nutritional deficiencies

Question 25

Children w/HIV worldwide and in the US? Maternal transmission?

Answer 25

2. 5 million worldwide; 3,000 children | - HAART therapy has reduced maternal transmission to less than 1% in the US (6000 pregnant HIV+)

Question 26

HIV general info: virus type? targets? what occurs to the immune system?

Answer 26

Retrovirus : HIV-1 (US), HIV-2 (W Africa) - HIV targets cells w/CD4 receptor proteins - Primary affects CD4+ helper T lymphocytes - Greatly decreased cellular immunity - Decreased humoral immunity

Question 27

Pediatric HIV Sources and risk potential where applicable

Answer 27

Perinatal transmission (risk potential 25%) - postnatal transmission from breastfeeding and pre-mastication of foods - Blood products - IV drug abuse - Unprotected sexual activity - Child abuse

Question 28

``` Age 1-5 : - Category 1 CD4 count - Category 2 CD4 count - Category 3 CD4 count Age 6-12 : - Category 1 CD4 count - Category 2 CD4 count - Category 3 CD4 count ```

Answer 28

Age 1-5 : - Category 1 CD4 count: 1000 cells/uL (>25%) - Category 2 CD4 count: 500-999 (15-24%) - Category 3 CD4 count: 500 (>25%) - Category 2 CD4 count: 200-499 (15-4%) - Category 3 CD4 count: <15%)

Question 29

When to treat HIV?

Answer 29

Asymptomatic or mild symptoms and CD4 350 and viral load of >100,000 copies/uL

Question 30

Pediatric HIV Oral disease: oral lesions- prevalence? significant for? typical etiology?

Answer 30

- Most symptomatic children have at least 1 oral lesion (up to 80%) - Oral lesions signal decreased immunity and advancing disease - infection disease are very common - Most neoplasms are EBV driven: lymphoma, leiomyoma, and leiomyosarcoma - Immunologic disorders are common

Question 31

Dental considerations : Cell counts?

Answer 31

Neutropenia : 10% in asymptomatic kids, 50% w/AIDS Anemia : 20-80% during course of disease Thrombocytopenia: 10% during course of disease

Question 32

Oral manifestations of HIV infection in children?

Answer 32

Cervical lymphadenopathy and tonsillar hyperplasia Candidiasis Angular chelitis Salivary gland disease: parotitis, xerostomia Lingear gingival erythema Necrotizing periodontal disease/stomatitis (2-5%) Recurrent HSV/apthous ulcers Varicella zoster infection Orofacial warts

Question 33

Linear gingival erythema

Answer 33

- Form of atypical gingivitis that is an immunologic response to the virus and w/a secondary candidiasis (looks like primary herpetic gingivostomatits w/lesions primary on the attached gingiva) - Not responsive to OH, redness is disproportionate to the amount of plaque

Question 34

Hairy Leukoplakia: looks like? occurs w/? due to? mortality?

Answer 34

White patches on the lateral border of the tongue which does not wipe off. - occurs w/HIV, topical steroids, lupus and other autoimmune disease - Due to expression of latent Epstein-Barr Virus - NOT precancerous

Question 35

Apthous stomatitis : prevalence? Cause? factors? site?

Answer 35

Pediatric prevalence: up to 15% - Cause localized immune dysfunction - Factors: trauma, drugs, hematologic disorders, nutritional deficiencies, xerostomia - Variants: minor/major/herpetiform - Site: primarily affects nonkeratinized oropharyngeal mucosa, esophagus

Question 36

Treatment for apthous ulcers?

Answer 36

Pain mgmt : topical anesthetics - Ulcer mgmt: triamcinolone .1% paste Fluocinonide .05% gel clobetasol, dexamethasone, beclomethasone, prednisone, thalidomide

Question 37

An oral disease that has increased with HAART and improvement in HIV symptoms?

Answer 37

Oral and Perioral Warts - related to immune reconstitution syndrome - drug induced side effect: increase in CD4 count and decrease in HIV viral load (when they are getting better they develop these infections) - Often has a florid and refractory presentation

Question 38

Molluscum Contagiosum

Answer 38

Common viral infection for HIV/immunocompromised patients that mimics warts

Question 39

Cancer in Children w/HIV

Answer 39

Prevalence 2% of HIV infected children - Viral associated causes: EBV, HHV-8, HPV - Types: Non-Hodgkin's Lymphoma, leiomyosarcomas, leiomyomas, leukemia, lymphoblastic and myeloid, Kaposi's sarcoma, Hodgkin's lymphoma, vaginal carcinoma

Question 40

Lyphoma in Children w/HIV: prevalence? what are they usually? causes? site? oral site? Tx?

Answer 40

- Prevalence: s lymphoma - Cause: EBV, HHV-8 and immunosuppression - Site: 80% are extranodal; GI and CNS - Oral site: tonsils, palate, and gingiva - Tx: multiagent chemo +/- radiation

Question 41

Kaposi's Sarcoma : pediatric prevalence? Causes? Oral site? Tx?

Answer 41

- Pediatric prevalence--rare except for Africa - Cause: HHV-I and immune suppression - Rare vertical transmission, except Africa - Red to purple macule or nodule; single or multiple, usually asymptomatic - TX: HAART, chemo

Question 42

Prevalence of children w/ the criteria for special health care needs? Causes of disability?

Answer 42

13-20% of all US children, | Causes: congenital disorder, acquired disorders (accidents, disease); extreme pre-term birth (<26 weeks)

Question 43

Asthma: prevalence, leading causes, other influences (meds, physical condition)

Answer 43

7-10% of children have asthma - Leading cause of hospitalizations in children - Other influences: Meds like NSAIDS/aspirin; products w/sulfites; obesity: increases risk of asthma, severity and difficulty in controlling ashtma

Question 44

Pathogenesis of asthma?

Answer 44

- Exposure to trigger, - Mast cell degranulation to bronchoconstriction (takes 30 min) - Decrease in expiratory airflow - Progressive shortness of breath - Airway inflammation (late phase 8-12 hr later) - Bronchial hyper-responsiveness (ultra-late phase days to weeks later)

Question 45

Mild vs Moderate vs Severe asthma

Answer 45

Mild (no night, tolerates exercise, wheeze <2 day/wk Mod (some night, limited exercise, wheeze 2-5 d/week Severe (frequent night, poor exercise, wheezy erryday