W3 - Medically Compromised Children - Mani Flashcards
Cardiac medical implications to consider in compromised children (6)
- Risk of bacterial endocarditis (valve defects, birth defects)
- Bleeding tendency - anticoagulants?
- Possibility of oxygenation issues
- Blood pressure issues
- Other medical conditions
- Medications
Clinical features / presentations of cardiac patients (5)
Dyspnoea - shortness of breath
Cyanosis
Clubbing of fingers
Heart sounds (murmurs)
Altered heart rate
Oral features of cardiac patients (2)
No direct effects, HOWEVER indirect effects due to meds, routine, etc
-
Developmental defects of enamel
- Hypoplasia in primary teeth
- Increased risk of caries
Dental management of cardiac patients (5)
- Liase with cardiologist
- AB cover indicated?
- Reduce risk of bacterial endocarditis
- Prevention - good OH and frequent check ups
- Careful with LA w/ vasoconstrictor (not contraindicated)
DO NOT LEAVE ANY SOURCE OF INFECTION IN MOUTH IN CARDIAC PT
Exo rather than pulp therapy
Why is pulp therapy (pulpectomy, pulpotomy) contraindicated in primary teeth in cardiac patients
Do not leave any source of infection in mouth of child with congenital cardiac disorders
- They will have increased risk of bacterial endocarditis
Extract instead
Primary vs secondary haemostasis
Primary: platelet adhesion (thrombocytes)
Secondary: coagulation cascade (clotting factors)
Ultimate goal is for fibrinogen to form fibrin clot
Additional info:
Thrombocytopoenia / platelet disorder is associated with PRIMARY haemostasis
Von Willebrands and Hemophilia is associated with SECONDARY haemostasis
How are platelet disorders classified (2) examples?
Quantitative - reduced # (thrombocytopoenia)
- can be inherited (many; rare) or acquired (infections like HIV)
Qualitative - altered function
- can be inherited (von willebrand) or acquired (aspirin or NSAID)
How does Aspirin and NSAID affect haemostasis?
Inhibits COX which blocks production of thromboxane A2
- Leads to reduced platelet aggregation
What are 4 dental implications that can occur if you treat a pt with a platelet disorder or coagulation mechanism disorders?
Failure to clot
Excessive bleeding
Spontaneous gingival bleeding
Purpura / petechiae
Dental management of pts with platelet disorders (4)
Management platelet levels (only tx once safe)
Avoid block injections
Avoid exo
Good surgical technique + local measures to control bleeding
Why should you avoid block injections (IAN) in pts with platelet disorders?
Accidental injury to vessel could cause inadvertant/excessive bleeding
Examples of inherited (2) and acquired (5) coagulation mechanism disorders
Inherited
- Hemophilia A (factor 8 def) and B (factor 9 def)
- Von Willebrands
Acquired
- Anti-coagulation therapy (warfarin)
- Vit K deficiency
- Liver disease
- Renal failure
- Bone marrow suppresion
What clotting factors are associated with Haemophilia A, B, and Von Willebrands
Hemophilia A (factor 8 def)
Hemophilia B (factor 9 def)
Von willebrands (factor 8 def)
Why may delayed bleeding occur in pts with hemophilia or von willibrands
They still have primary haemostasis to stop bleeding (formation of platelet plug)
Fibrin clot will not develop however and thus they will bleed later
How to manage patients with coagulation disorders (hemophilia/ von willibrands) (5)
- Liase with haematologist
- Avoid oral surgery / invasive procedure in general dentist setting (consider hospital setting)
- Avoid prescribing NSAID / Aspirin
- Local measures to control bleeding
- Nerve block (IAN) requires haematologic prophylaxis
Oral manifestations of Deficiency anemia (Fe, B12, folate) (4)
Angular cheilitis
Atrophic glossitis
Soreness of tongue
Recurrent ulcerations
Cause of hemolytic anemia (2) and consideration
- Extrinsic factors (malaria
- Defects with hemoglobin (thalassemia, sickle cell)
REQUIRE AB PROPHYLAXIS
Oral features of immunocompromised pts (5)
Candidosis (could be angular cheilitis)
gingivitis / perio
Recurrent aphthous ulceration
Recurrent herpetic infections
Premature tooth exfoliation
Dental management of immunodeficient patients (3)
- Preventive care
- Antibacterial / antifungal / antivirals
- Extraction of pulpally involved teeth
Treatment of candidiasis in children (2 ways) younger than 2 years
Nystatin liquid 100 000 units/mL 1 mL topically (then swallowed), 4xday after feeding for 7-14 days (or 2-3 days after symptoms resolve)
OR
Miconazole 2% gel 1.25mL topically (then swallowed), 4xday after feeding for 7-14 days (continue tx for 7 days after symptoms resolve)
How to treat oral candidiasis in adults and children >2 years
3 ways
“favourite exam question .. oral manifestation and treatment of fungal disorders”
Miconazole 2% gel 2.5mL topically (then swallowed), 4xday after food for 7-14 days (continue tx for 7 days after symptoms resolve)
OR
Nystatin liquid 100 000 units/mL 1mL topically (then swallowed) 4xday after food, for 7-14 days (or 2-3 days after symptoms resolve)
OR
Amphotericin B 10mg lozenge, 4xday after food, for 7-14 days (continue tx for 2-3 days after symptoms resolve)
Oral complications of chemotherapy (5)
Mucositis
Infection (due to neutropenia)
Haemostasis problems
Hyposalivation
Affect development of teeth
Oral complications of radiotherapy (5)
Salivary gland atrophy
Demin / Caries
Altered tooth development
Microdontia
Osteoradionecrosis
Oral complications of Bone Marrow Transplant (for cancer pts)
Mucositis
Mucosal sloughing
Xerostomia
Loss of taste
Acidic saliva (low pH)
How to manage pts who are about to go for cancer therapy (5)
- Pre tx exam
- Liase with oncologist
- Radical dental care to eliminate / stabilise oral infection
- Avoid active dental tx during acute stage - emergency tx only
- Focus on preventive therapy
Oral features of renal conditions in kids (3)
Developmental defects of enamel
Intrinsic discolouration of enamel
Gingival hyperplasia
What drugs should be avoided in pts with renal conditions (kidney)
Nephrotoxic drugs
- Paracetamol
- Penicillin
- Tetracycline
How to dentally manage kids with renal conditions (5)
Haemostatic prophylaxis
AB prophylaxis
Aggressive mgmt of infection
Exo pulpally involved teeth
Don’t prescribe drugs without contacting GP (esp nephrotoxic drugs)
What is the main consideration with pts with liver disorders when providing dental tx
Bleeding issues
- problems with coagulation
Dental implications of bleeding disorders (systemic, how does it affect oral tissues) (5)
Problems with coagulation
Immunosuppression
Enamel development defects
Enamel staining
Gingival hyperplasia
Dental managment of paeds pts with liver disorders (3)
Liase with gastroenterologist / haematologist
Radical mgmt of teeth (remove infection)
AB prophylaxis
Dental management of organ transplant pts (4)
These pts likely have reduced immune function
- Eliminate sources of infection (Caries)
- Preventive regime
- Gingivectomy (bc cyclosporin)
- AB prophylaxis
oral features of graft vs host disease
Erythema
Desquamative gingivitis
Angular cheilitis
Loss of lingual papillae
Xerostomia
In oral conditions that present with desquamative manifestations, what is the likely cause?
issues with host immune response /
Immunomodulatory issues /
autoimmune disorders
Dental management of gastroenterology pts (4)
liase with gastroenterologist
Definitive tx
Preventive regimen to remin
active monitoring
Common examples of endocrine disorders (4)
Diabetes
Pituitary
Thyroid
Parathyroid disorders
Medical implications of paeds pts with diabetes/endocrine disorders (6)
Altered growth/development
Hyperglycemia (diabetes)
Hypertension
Poor wound healing
Inability to tolerate stress
Skeletal anomalies
Dental mangement of endocrinology/diabetic patients (5)
Liase with endocrinologist
Steroid prophylaxis as required
Definitive resto and perio care
Preventive regimen
Emergency care only during acute phase
Oral features of diabetes / endocrinology disorder pts (5)
- Developmental enamel & dentine defects
- Altered tooth development
- Perio
- Xerostomia
- “Spontaneous abscess”
Features of hyperthyroidism (3)
Precocious eruption of teeth
- Early loss of deciduous
- Early eruption of primary
Accelerated growth
Osteoporosis
Features of Hypothyroidism (3)
Delayed eruption
- Primary teeth overretained
- Delayed permanent eruption
Mentally retarded
Generalised body edema
Dental management of pts with resp conditions / asthma (5)
Advise to bring puffer
Avoid rubber dam when possible
Avoid NSAIDs (give COX2 inhib nsaids or para instead)
Steroid prophylaxis as indicated
Avoid long appts
What drug should be avoided in asthma / resp patients? Alternative?
NSAIDs - cause bronchospasm / restriction (Ibuprofen, aspirin, naproxen)
Use selective COX2 inhibitor nsaids (celecoxib) or paracetamol instead
Oral features of pt having allergies (6)
Pallor / cyanosis
Blushing
Oedema of lips
Paraesthesia
Metallic taste
Contact stomatitis
Dose of adrenaline in epipens (adults and kids)
300 microgram - kids
500 microgram - adults
AB prophylaxis MUST KNOWS (4)
Prosthetic heart valves
Previous history of infective endocardidits
Congenital Heart Disease
Cardiac transplant recipients with valve issues
