medical conditions that can directly affect the provision of dental care and/or consequences of...

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Medical conditions that can directly affect the provision

of dental care and/or consequences of dental

treatment

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Outline

• Objectives • Introduction• Different medical conditions and

dental care• Conclusion • References

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Objectives

–To highlight the medical conditions that can directly affect the provision of dental care and/or consequences of dental treatment. –To address the conditions under:

cardiovascular disorders, disorders of the blood, respiratory disorders, metabolic and endocrine disorders, neurologic disorders, liver disease, renal disease

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Introduction• There are many medical

conditions that can directly affect the provision of dental care and some where the consequences of dental disease, or even dental treatment, can be life threatening.

Paediatric Dentistry, 3rd Edition, by Richard Welbury and Monty Duggal, 2005

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• The definition of a “medically compromised” patient is not precise and in this context, it is interpreted as the presence of a medical factor which may have implications for the provision of dental care.

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• To achieve optimal oral health for the medically compromised patient, the dentist and physician must work closely.

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• Because many of these medical conditions are so complex, additional treatment time may be needed to provide these services.

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• Each patient presents a unique set of challenges to the dentist, but achieving a successful outcome can be a rewarding experience.

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Medical conditions1. Cardiovascular disorders2. Disorders of the blood3. Respiratory disorders4. Metabolic and endocrine disorders5. Neurologic disorders6. Liver disease7. Renal disease

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Cardiovascular diseases• Main signs and symptoms–Chest pain–Dyspnea–Cyanosis–Palpitations– Syncope– Edema of ankles–Cold pale extremities–Clubbing fingers– Easy fatigue Paediatric Dentistry, 3rd Edition, by Richard

Welbury and Monty Duggal, 2005


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• Types–Congenital•Heart murmurs , ventricular septal

defects, atrial septal defects, pulmonary stenosis, patent ductus arteriosus, tetralogy of Fallot,

–Acquired •Rheumatic fever, diseases of the

myocardium and pericardium, secondary hypertension


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- Dental management of cardiovascular disorders- Prevent dental disease- OHI, diet

counselling, fluoride therapy, fissure sealants–Any active dental disease must be

treated before cardiac surgery


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–Treatment planning for cardiovascular patients-•Antibiotic prophylaxis given before invasive operative procedures• Ideally short appointments in children for maximal cooperation•Check patient’s platelet count and prothrombin time before tooth extraction


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•No child with symptomatic cardiac problems should have any routine dental procedures until details of the condition have been obtained and the patient’s physician consulted.


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• Endodontic treatment only for teeth with high probability of success like:–Permanent incisors–Straight canals–Closed apices–Single visit

–Consider potential drug interactions and remember some of these patients will be on anticoagulants.


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Blood disorders– Bleeding disorders• Hemophilia• Von Willebrand’s disease• Thrombocytopenia

– Blood dyscrasias• RBC disorders–Anemia -Iron deficiency anemia, Glucose 6-

Phosphate dehydrogenase deficiency, Sickle cell anemia,Thalassemia

• WBC disorders– leukemia


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• Dental management of bleeding disorders–Communicate with hematologist–Find out the diagnosis/aetiology–NSAIDS alter platelet function and

should not be used.


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–Acceptable analgesics•For acute pain – Acetaminophen, Propoxyphene hydrochloride•For severe pain – Narcotics – heroin, morphine, hydrocodone


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–Care taken while placing intraoral xrays–Local anaesthesia infiltrations or

intraligamentous injections unlikely to cause problems if given carefully–Regional anaesthesia (mandibular

block) contraindicated as bleeding in pterygomandibular region may cause asphyxia


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–Pulp therapy preferred to extractions–Dental extractions or surgery best

managed in hospital setting (use resorbable sutures if needed)–Antifibrinolytics – (e-aminocaproic

acid, tranexamic acid) Used as extra to the factor concentrate replacement to prevent or control oral bleeding


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• High speed vacuum and saliva ejectors used with caution so that sublingual hematomas don’t occur

• Periphery wax used on impression tray• Orthodontic treatment possible- be careful wires don’t

lacerate mucosa• Platelet transfusions are short-lived and if used

prophylactically must be given immediately prior to or during surgery.


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Anemia


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Oral symptoms of anemia

–Oral discomfort and/or ulceration–Glossitis–Angular cheilitis.


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• Dental management of anemia–Tendency to bleed after invasive

dental procedures–Tests to be taken- Hb, Hematocrit,

WBC, Platelet cell count


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• Dental management of leukemia–Prevent dental caries as these children at high

risk because of difficulty in taking care of oral health due to mucositis.

–Oral surveillance–Topical fluoride therapy, toothbrushing

information–Chlorhexidine mouthwash 0.12%–Nystatin 500,000units ‘swish and swallow–Diet control–Relieve mucositis- Difflam mouthwash,

Quadragel, ice chips Paediatric Dentistry, 3rd Edition, by Richard Welbury and Monty Duggal, 2005


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–Unless dental emergency, no operative dental treatment carried out until child in remission

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• Once the leukemia is in remission, and after consulting child’s physician, routine dental care can be undertaken with following protocol:

1. Hematological information required to assess bleeding risks

2. Prophylactic antibiotics incase of depressed neutrophil count

3. Fungal infections treated with amphotericin B, nystatin, or fluconazole and herpetic infections with topical and/or systemic acyclovir

4. Regional block anaesthesia contraindicated



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Respiratory disorders- Clinical conditions –Asthma–Cystic fibrosis


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• Dental management of asthma–Dental treatment can cause emotional

stress -> attack–Child may take puff of their inhaler

before starting dental treatment–Use analgesics and sedatives with

caution; opioids and sedatives decrease respiratory drive.

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–Recently a study has been published linking dental erosion with asthma•Could be due to gastro-oesophageal reflux in asthmatics•Or acidic long term medication•Or to increased consumption of erosive beverages due to ‘drying’ of oral mucosa by inhalers

•Paediatric Dentistry, 3rd Edition, by Richard Welbury and Monty Duggal, 2005•Dental erosion in asthma: a case-control study from south east Queensland, Sivasithamparam K et al, Aust Dent J, 2002, Dec;47(4):298-303


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• Dental management of cystic fibrosis–These children suffer from delayed dental

development, more commonly have enamel opacities and are more prone to calculus–They need to have higher caloric intake

and may have frequent refined carbohydrate snacks – important priority group for dental health education and care



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–May also have cirrhosis of liver -> clotting defects -> haemorrhaging following surgical procedures–May be prescribed tetracycline to

prevent chest infections -> intrinsic dental staining–General anaesthesia should be

avoided


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Endocrine and metabolic disorders

• Diabetes mellitus• Adrenal insufficiency• Other – thyroid disease, renal

disorders


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• Dental management of diabetes–Preventive care–Uncontrolled ->• Increased glucose concentrations in saliva, decreased salivary flow -> dental caries•Periodontal problems and susceptibility to infections (Candida sp)


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–Dental appointments arranged at times when blood sugar levels well controlled; morning immediately after their insulin injection and a normal breakfast


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• General anaesthetics a problem due to the pre-anaesthetic fasting, so normally carried out on an in-patient basis to enable insulin and carbohydrate to be stabilized intravenously


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• Dental management of adrenal insufficiency–In children, the risks of taking

corticosteroids are greater than in adults and should only be used when specifically indicated, in minimal dosage and for the shortest time possible.


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–if child has adrenal insufficiency or on steroids, any infection or stress may lead to adrenal crisis–For routine restorative treatment

no additional steroids are necessary, but if extractions or other surgeries planned and/or the patient is very apprehensive, then the oral steroid dosage should be increased.


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–General anaesthesia should be carried out on an in patient basis–Consult child’s physician before

prescribing steroids–Anaesthesists must be aware of

such meds in order to avoid fall in blood pressure during anaesthesia or in the immediate post op period.


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• Dental management of thyroid disease–Patient should present no

problems if the as long as they are medically well controlled, however contact with the physician is important


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Neurologic disorder• Febrile convulsions• Epilepsy: most common neurogenic

disorder faced by dentist

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• Dental management of epilepsy–Sugar free liquid anti-epileptic

medication–The possibility of an attack

occurring in dental chair should be considered



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–Phenytoin -> gingival enlargement in about ½ of patients–A very high standard of oral hygiene

required to minimize the development of gingival enlargement–Gingival surgery should never be

contemplated unless oral hygiene is good


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–Trauma to anterior teeth usually encountered–Reimplantation of avulsed teeth usually

contraindicated in those with severe learning difficulties–If prostheses are required then they

should be well retained with clasps and unlikely to break or be inhaled during attacks


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Liver disorders• Acute liver failure• Alagille syndrome• Alpha-1 antitrypsin

deficiency (AATD)• Autoimmune

hepatitis• Beckwith-Wiedemann

syndrome• Bile acid synthesis

defect• Biliary atresia• Budd-Chiari

Syndrome• Caroli’s disease

• Cirrhosis/chronic liver failure

• Crigler-Najjar syndrome

• Cystic fibrosis liver disease

• Glycogen storage disease (GSD)

• Hemochromatosis• Hepatoblastoma• Hypercholesterolemia• Metabolic diseases• Nonalcoholic fatty

liver disease

• Organic acidemias• Primary hyperoxaluria• Primary sclerosing

cholangitis• Progressive familial

intrahepatic cholestasis

• Tyrosinemia• Urea cycle defects• Viral Hepatitis• Wilson disease


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• Dental management of liver disorders –Preventive measures –Strict cross-infection control–Consult patient’s physician to establish a safe and

adequate treatment plan– If invasive procedures to be done then prior

coagulation, antibiotic prophylaxis and hemostasis tests required–Be cautious when administering drugs (consult the

BNF/DPF) and with administering local analgesia as liver disease alters with drug metabolism–Do not administer general anaesthesia


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Renal disease• Posterior urethral

valve obstruction• Fetal hydronephrosis• Polycystic kidney

disease• Multicystic kidney

disease• Renal tubular acidosis• Wilms tumor

• Glomerulonephritis• Nephrotic syndrome• Urinary tract problems• Hypertension• Nephritis• Kidney stones (mostly

in adults)• UTI


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• Signs and symptoms of renal disorders–Fever–Edema–Dysuria–Increased frequency of urination–Urine incontinence–Hematuria–High blood pressure


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• Dental management of renal disorders–Prevent dental diseases- OHI and

education–Strict cross-infection control–Consult patient’s physician before

performing dental treatment–Monitor BP pre-op and post-op–Treat all infections aggressively and

consider prophylaxis–Use additional hemostatic measures


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–Be cautious with prescribing drugs–Never subject these patients to out-

patient general anaesthesia–Remember veins are precious–Poor bone density -> frequent

denture adjustments–Try to perform dental treatment just

after dialysis if possible

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Conclusion• Medical conditions have an effect on not only

general health but also oral health. As dental practitioners it is our sole duty to know the medical conditions and how to provide dental care to patients who are suffering from these medical conditions.

• Oral care is important in enhancing quality of life, emphasis being put on preventive care.

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References • Oxford Handbook of Clinical Dentistry, by

Mitchell, chapter 11 ‘Medicine relevant to dentistry’.

• Paediatric Dentistry, 3rd Edition, by Richard Welbury and Monty Duggal, 2005

• Dental erosion in asthma: a case-control study from south east Queensland, Sivasithamparam K et al, Aust Dent J, 2002, Dec;47(4):298-303

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