Dental Management of Medially Compromised

Patients (1)Dr. Usama M. Madany

Prof. Oral Medicine, Periodontology, Diagnosis and Oral Radiology, Faculty of Dental Medicine, Al- Azhar

Univer. , Cairo, Egypt.

Hemolytic Anemias

Sickle cell disease

Sickle cell anemia (homozygous )

Sickle cell trait (heterozygous)

Thalassemia

Alpha thalssemia

Beta thalssemia

Thalsssemia major (homozygous thalassemi, Cooley’s anemia)

Thalssemia minor (heterozygous thalassemia, thlassemia trait)

Glucose 6 Phosphate Dehydrogenase Deficiency (G6PDD, Favism)

Sickle cell anemia is an inherited blood disorder caused by structurally abnormal haemoglobin (Hb S ) that causes a rigid distorted red blood cell (sickle cell)

Acute crises may occur spontaneously or precipitated by

Infection Dehydration Hypoxia Sedatives and local anaesthetics Cold

Hemolytic Anemia

Weakness

Splenomegaly

Heart failure

Increased viscosity and clumping of RBCs

Thrombosis Ischemia

Infarction

Dental AspectsOral Manifestations

-Pale and yellow oral mucosa -Maxillary overgrowth

Delayed eruption -Enamel hypoplasia-

Radiographic findings

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Hair on End appearance

•Susceptibility to infection

•Susceptibility to develop crisis

•Bleeding tendency

Problems

Dental considerations and management

Never

Anesthetize or operate on patients during crisis (except for the relief of pain and treatment of infection).

Use tourniquetUse GA in the clinic (GA must be carried out in a hospital with full anesthesia facilities and in close cooperation with a hematologist)

Prescribe drugs that can cause respiratory depression and hypoxia such as sedatives (Nitrous oxide can be used safely as long as oxygen conc. is <50%).

ExpectCerebral or cardiac hypoxia my result in these patients with minor procedure

Poor wound healing after minor surgery or extraction

Pulpal symptoms are common without obvious dental disease

Infarction of bone may result in osteomyelitis esp. in the mandible

Remember

-Patient’s physician should be consulted about the patients myocardial status.

-Preventive dental care is important.

-Dental infections should be treated vigorously, if facial cellulitis develops patient should be admitted to the hospital.

-Pain medications for patients with sickle cell disease include paracetamol, paracetamol with Codeine, NSAID’s and narcotics especially morphine. However, the use of Meperidine (Demerol) should be avoided as much as possible since one of its toxic metabolites (normeperidine) has a long plasma half-life and can cause seizures.

-Due to high risk of infection in such patients, prophylactic antibiotic regimen for prevention of endocarditis should be followed before any dental procedures that can cause transient bacteremia.

-After surgical procedures, antibiotics ( 500 mg penicillin VK 4 times/day or erythromycin, 250 mg 4 times/day, for penicillin-allergic patients) should be continued for 7-10 days postoperatively.

-Use of vasoconstrictor in local anesthesia is controversial, however, for short routine procedures lacking discomfort , the vasoconstrictor should not be used. If the procedure requires long profound anesthesia, 2% lidocaine with 1/100,000 adrenaline is the anesthetic of choice.

If general anesthesia is required, it is advisable to carry out comprehensive dental treatment, including any extraction or restoration that may be required, so as to avoid a second procedure.

Trait-60% of hemoglobin is HbS

-Patient is asymptomatic and lives normal life

-Sickle cell crisis can be precipitated by reduce oxygen tension

-Few problems in management

*General anesthesia better be performed in hospital with full oxygen supply

*Acute infections should be treated immediately

*Prophylactic antibiotic cover before surgery

Thalassemia

Group of congenital disorders characterized by deficient synthesis of either α or β chains of hemoglobin in Hb.

Alpha thalssemia Beta thalassemia

Imbalance in globin chain precipitation of these chains in RBCs ineffective erythropoiesis

+ hemolysis

Beta thalassemia

1-Homozygous thalassemia (Cooly’s anemia) no or few normal beta chains

2-Heterozygus thalassemia

Cooley’s anemia

Oral manifestations

Pale or/and oral mucosa

Painful swelling of salivary glands

Painful tongue

Teeth discoloration

Hyperplasia of bone marrow

Large head and mongoloid characters

Enlargement of premaxilla

Spacing of upper ant. teeth

Delayed sinuses’ pneumatization

b

a

Dental implications

1 -Expect poor wound healing

2 -Antibiotic is required to control infection without delay

3 -Avoid GA in dental clinic.

3 -Avoid excessive bleeding during surgery.

Glucose 6 Phosphate Dehydrogenase Deficiency (G6PDD)

Erythrocyte metabolic defect characterized by hemolysis due to denaturing of hemoglobin in presence of oxidant compounds.

Life span of RBCs is 2/3 the normal and this is compensated by liver and bone marrow

Diabetes

Infection

Oxidants compounds

General anesthesia

Dental management

1 -Avoid oxidant drugs eg asprin, phenacetin, sulphonamides, chloramphenicol, and vit .K

2-Infection should be treated without delay

Hemolysis

• Chronic renal failure/hemodialysis.

• Renal transplantation.

Renal Disorders

Problems

• Increased susceptibility to infection + immunosuppression

•Bleeding tendency.

•Decreased ability to excrete drugs.

•Existence of A-V shunt.

•Cross infection.

Renal Disorders

Dental Aspects and management

Chronic renal failureIt is generally preferable to treat patients before rather than after dialysis or transplantation

1-Consult patient’s physician

2-Monitor blood pressure

3-Check lab values, PTT, PT, platelet count, bleeding time, blood urea nitrogen (do not treat if less than 60 mg/100ml) and serum creatinine (do not treat if less than1.5 mg/100ml).

4. If medical parameters permits

Eliminate all foci of infection

Keep only the easily maintainable teeth

Try to keep good oral hygiene

Normal Lab ValuesNormalComfort Zone

PT12-14sec1.5x normal

PTT25-35sec1.5xnormal

Platelets150,000-450,000Min 50,000

HemoglobinMales: 13.5-17.5 g/dLFemales: 12-16 g/dL

10g/dL

HematocritMales: 39-49%Females: 35-45%

30%

BT3-9 min1.5x normal

5 -Avoid prescribing

Tetracyclines, streptomycin, Vancomycin, Gentamycin. Acyclovir

acetaminophen, phenacetine, NSAIDs, asprin, antihistamines, phenobarbitones

Decrease dose of

Cephalosporins, penicillins,, ampicillin, metronidazole, acyclovir, paracetamol, benzodiazpine

Normal dose

Cloxacillin, erythromycin, minocycline, codiene, diazepam, lidocaine

HemodialysisHigh incidence of serum hepatitis

High incidence of anemia

Significant incidence of secondary hyperparthyroidism

Uremic stomatitis may exist

Undergo heparinization during hemodialysis

Have arteriovenous shunt or fistula

a

Dental management

1-Screen for HBsAg and HBsAb

2-Antibiotic prophylaxis to prevent endartritis of arteriovenous fistula

3-Prevent hypoxia

4-Provide treatment on the day after hemodyalisis

5-Be careful to protect the fistula or shunt when patient on dental chair

6-Refer the patient to physician if uremic stomatitis is noted to develop

Renal transplant patientInfection in such patients is life –threatening

Before transplantation easily only maintained teeth should be determined by dental team approach

Teeth with furcation involvement, periodontal abscesses, or extensive surgical requirements should be extracted

Management1 -Emergency tx only for 1st 6 months

2 -HBsAg screening

3-Prophylactic antibiotics according to AHA recommendations

4- Erythromycin is contraindicated in patients on cyclosporins 5- Immunosuppressed pt requires supplemental corticosteroids