Week 3 Mani: Medically Compromised Patients Flashcards
What paeds pts often have congenital heart defects?
70% of children with Trisomy 21 (downs syndrome) are affected
What are examples of congenital heart defects?
Acyanotic and cyanotic defects
What are acquired cardiac problems?
- Cardiac arrythmias
- Infection endocarditis
- Cardiomyopathies
What are medical implications regarding cardiac issues?
- Other medical conditions/syndromes
- Risk of bacterial endocarditis
- Bleeding tendency (if on anticoagulants)
- Possibility of oxygenation issues
- Potential blood pressure issues
What is dental management for cardiac conditions?
- Liaise with cardiologist
- Is AB cover needed?
- Prevention- good OH, routine reviews
- Reduce risk of endocarditis
- Administer LA with vasoconstrictor with caution
- Pulp therapy in primary teeth contraindicated
Most important considerations: Drug hx, AB prophylaxis, Bleeding disorders, No pulp therapy in primary teeth
Why is pulp therapy in primary teeth contraindicated for cardiac paeds pts?
Exo is recommended instead. Want to eliminate source in infection to prevent secondary infection.
What are classic features of congenital heart conditions?
- Dyspnoea
- Cyanosis
- Clubbing of fingers
What are oral features of cardiac conditions?
Developmental enamel defects (esp primary dentition)
Inc risk of dental caries- meds, compliance, diet
What dental procedures require AB prophylaxis?
- Exo
- Raising flap
- Biopsies
- Subgingival procedures (ortho bands, scaling teeth, irrigation of pockets)
- Intraligamentary injections
- Reimplantation of avulsed teeth
- Incision and drainage of abscess
- Placement of dental implants
- During diagnostic phase of RCT if likely that file will pass through apex
Describe primary haemostasis
- Injury to blood vessels
- Vascular spasm (slows blood loss)
- Platelet plug formation. Platelets release chemicals to attract more platelets to site of injury, forming clot
- Secondary haemostasis (coagulation cascade)
What are quantitative vs qualitative platelet disorders?
- Quantitative: reduced platelet numbers (leukaemia, HIV, liver disease, drug induced)
- Qualitative: altered platelet function (von-willebrand, drug induced)
How do do NSAID’s cause increased bleeding?
NSAIDs inhibit COX which blocks production of thromboxane A2, which results in reduced platelet aggregation
What are dental implications of haematological disorders?
- Failure of initial clot formation
- Oral petechiae and purpura
- Spontaneous gingival bleeding
- Prolonged excessive bleeding
- Other associated medical conditions e.g. liver disease or malignancy
How can platelet disorders be managed?
- Management of platelet levels
- Avoid exos
- Good surgical technique and local measures to control bleeding
- AVOID block injections
Why avoid block injections on paeds pts with haemotological disorder?
Accidental injury to vessel may cause excessive/inadvertent bleeding
What are reasons for coagulation mechanism disorders?
- Haemophilia A, B, C
- Von Willebrand’s disease
- Anticoagulation therapy
- Bone marrow suppression
- Renal failure
- Liver disease
- Vit K deficiency
Why can haemophilia bleeds be delayed?
Can be delayed by several hours bc primary haemostasis not impaired
How can haematological disorders be managed dentally?
- Liaise with haematologist
- May need to coordinate dental tx with med tx (may need hospital setting)
- Avoid oral surgery/invasive procedures in general dental setting where risk is greater
- Preventative
- Gentle techniques
- Avoid prescription drugs that would exacerbate bleeding e.g. NSAIDs
- Appropriate local measures to control bleeding
- LA (use vasoconstrictor and IAN block requires haematological prophylaxis)
What vit deficiency can sore tongue and oral mucosa indicate?
Vit B12 deficiency
What are oral manifestations of deficiency anaemia?
Angular cheilitis, atrophic glossitis, soreness of tongue, recurrent ulcerations
What are oral features of immunodeficiency?
- Candidosis (opportunistic infections)
- Gingival and perio disease
- Recurrent aphthous ulcers
- Recurrent herpetic infections
- Premature tooth exfoliation (certain genetic conditions)
Describe dental management for immunodeficient pts
Preventative regime
Antibacterial, antifungal and antiviral agents
Exo of pulpally involved teeth (rather than RCT- want to remove any poss source of infection)
How can you treat oral candidiasis in neonates/children <2 years?
- Nystatin liquid 1mL topically (then swallowed) 4x daily after feeding for 7-14 days. Continue tx for 2-3 days after symptoms resolve
- 2% Miconazole gel 1.25mL topically (then swallowed) 4x daily after feeding for 7-14 days. Continue tx for at least 7 days after symptoms resolve
How can you treat oral candidiasis in adults/children _>_2 years?
- 2% Miconazole gel 2.5mL topically (then swallowed) 4x daily after food, for 7-14 days. Continue tx for at least 7 days after symptoms resolve
- Amphotericin B lozenge 10mg sucked 4x daily after food, for 7-14 days. Continue tx for 2-3 days after symptoms resolve
- Nystatin liquid 1mL topically (then swallowed) 4x daily for 7-14 days. Continue tx for 2-3 days after symptoms resolve
What are clinical features of oncology pts?
- Fatigue and weight loss
- Chronic infection
- Anaemia
- Skin purpura
- Febrile episodes
- Hepatosplenomegaly
- Bone pain
- Generally unwell
What are oral complications of chemo?
- Mucositis
- Infection risk due to neutropenia and thrombocytopenia (secondary to bone marrow suppression)
- Haemostasis problems
- Dry mouth (inc caries risk)
- Affect development of teeth
What are oral complications of radiotherapy?
- Salivary gland atrophy
- Enamel caries/demin
- Arrested and/or altered crown/root development
- Microdontia, agenesis
- ORN
What are oral complications of bone marrow therapy?
- Mucositis
- Mucosal sloughing
- Xerostomia
- Loss of taste sensation
- Inc saliva acidity
Describe dental management for oncology pts
- Pre-tx exam to ensure dentally fit
- Liaise with oncologist
- Radical dental care to ensure elimination of stabilisation of potential oral infection
- Timing of tx (avoid dental tx during acute stage- emergency only)
- Preventative regime
What are clinical features of renal conditions?
- Bleeding tendency
- Growth retardation
- Progressive hypertension
- Fluid retention
- Metabolite retention
What are oral features of renal conditions?
- Chronological developmental defects of enamel
- Intrinsic discolouration
- Gingival hyperplasia
- Gingival bleeding
What is the dental management for renal conditions?
- Liaise with specialist
- AB and Haemostatic prophylaxis prior to surgery
- Intolerance to nephrotoxic drugs e.g. paracetemol, penicillin, tetracycline
- Exo of pulpally involved teeth
- Aggressive management on infection
- Effective prevention and regular review
What are considerations for liver disease?
- Inc bleeding (vit K deficiency)
- Immunosuppression
- Staining and developmental defects of enamel
- Hyperplasia of gingivae
What is the dental management for liver disease?
- Liaise with gastroenterologist/haematologist
- Radical management of teeth with removal of potential source of infection
- AB prophylaxis
What is the dental management for pts with organ transplants?
- Need to eliminate potential source of infection
- Preventative regime
- Gingivectomy (if they have GO from cyclosporine A)
- AB prophylaxis
What are oral manifestations of graft vs host disease?
- Oral mucosal erythema
- Desquamative gingivitis
- Angular cheilitis
- Loss of lingual papillae
- Xerostomia
What are gastroenterology diseases?
- Reflux
- Inflammatory bowel disease (Crohns)
- Coeliac disease
What are characteristics of reflux?
- Often asymptomatic
- Indigestion/heart burn
- Bad taste in mouth in morning
- Enamel erosion
- Restorations often “high”
- Halitosis
- Frothy saliva
What are medical implications for endocrine diseases?
- Altered general growth/development
- Hyperglycaemia
- Hypertension
- Skeletal anomalies
- Poor wound healing
- Inability to tolerate stress (if issues with cortisol may need prophylactic steroids before tx. Consult endocrinologist)
What are clinical features of endocrinology?
- Growth alterations
- Altered physical activity
- Neuromuscular excitability
- Cardiovascular dysfunction
- Gastrointestinal disturbances
- Polyuria
What are oral features of endocrine disorders?
- Altered oro-facial and dental development
- Developmental defects of enamel and dentine
- Spontaneous abscesses
- Periodontal disease
- Xerostomia
Describe dental management for pts with endocrine disorder
- Liaise with endocrinologist
- Emergency care only during acute phase
- Steroid prophylaxis as required
- Definitive restorative and perio care
- Preventative regime
What are features of hyperthyroidism?*
- Accelerated growth
- Premature eruption of teeth
- Early exfoliation of primary teeth
- Osteoporosis
- Excessive sweating
- Inc appetite & weight loss
- Thin sparse hair
- Short attention span
- Diarrhoea
What are features of hypothyroidism?
- Eruption rate delayed
- Delayed growth
- Mentally retarded
- Generalised edema
What are oral features of respiratory conditions (asthma, cystic fibrosis)?
- Developmental defects of enamel
- High caries risk
What are medical implications for respiratory disease?
- Restricted lung function
- Dyspnoea
- Risk of acute respiratory distress
- Chronic hypoxaemia
What are triggers for asthma?
Allergens, exercise, cold air, GORD, tobacco smoke, strong odours, pollutants, sinusitis, stress
Describe dental management for patients with respiratory conditions?
- Avoid long appts
- Advise pts to bring inhalers to appt
- Avoid rubber dam
- Steroid prophylaxis as indicated
- Preventative regimen
- Use of RA or GA must be discussed with physician (inc risk)
- Avoid NSAIDs (can cause severe bronchoconstriction)
- Can give selective COX-2 inhibitors or paracetemol
- Can develop oral candidiasis secondary to use of inhaled contricosteroids
What is the dose of adrenaline for adults and children?
Adult: 500micrograms
Children: 300micrograms
What are the features of anaphylaxis?
- Prodrome (coughing, choking sensation)
- Cutaneous (urticaria, angio-oedema)
- CV (tachycardia, hypotension)
- Respiratory (bronchospasm)
What are oral features of allergic reaction
- Metallic taste
- Pallor/cyanosis
- Paraesthesia
- Angio-oedema of lips
- Contact stomatitis
- Facial blushing
When is antibiotic prophylaxis indicated?
- Prev hx is endocarditis
- Prosthetic cardiac valve
- Congenital heart disease
- Cardiac transplantation recipients who develop cardiac valvopathy
