CLINICAL PEDIATRIC DENTISTRY I DSV 441 CHAPTER 24 MANAGEMENT OF THE MEDICALLY COMPROMISED PATIENT: HEMATOLOGIC DISORDERS, CANCER, HEPATITIS, AND AIDS.

CLINICAL PEDIATRIC DENTISTRY I DSV 441

CHAPTER 24 MANAGEMENT OF THE MEDICALLY COMPROMISED

PATIENT: HEMATOLOGIC DISORDERS, CANCER, HEPATITIS, AND AIDS

(557-597)McDonald, Avery, Dean. Dentistry For The Child And Adolescent, 8th Ed.

22

Tuesday 31\3\2015

1:00 pm-2:00 pm

OTHMAN AL-AJLOUNI 1

LECTURE OUTLINE

HEMOPHILIA

VIRAL HEPATITIS

SICKLE CELL ANEMIA

ACQUIRED IMMUNODEFICIENCY SYNDROME

LEUKEMIA

BONE MARROW/STEM CELL TRANSPLANTATION

SOLID TUMORS

2

LEARNER OBJECTIVES

To list the more common medical conditions in children that place in a compromised state for dental treatment

Describe special concerns the dentist must address when preforming dental care with the patients.

Describe specific concerns for dental care and treatment and precautions must take in providing care for these patients.

PRVENTING DENTAL DISEASE SHUOLD BE THE MOST IMPORTANT PART OF A DENTAL PROGRAM FOR

MEDICALLY COMPROMISED CHILDREN

3

INTRODUCTION

To achieve optimal oral health for medically compromised patient, dentist and physician must establish a close working relationship.

To minimize the risk of possible complications that may affect the physical health of medically compromised patients, an aggressive prevention-oriented program is needed for such individuals.

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

Short life expectancy.

Advances in medicine.

Additional time.4

H E M O P H I L I A

Disorders of hemostasis resulting from a deficiency of a procoagulant.

Inherited bleeding disorder an X-linked recessive trait Therefore males are affected, females are carriers, and there is no male-to-male transmission.

Affecting approximately 1 in 7500 males.

Hemophilia A, or classic hemophilia, is a deficiency of factor VIII, also known as antihemophilic factor.

5

H E M O P H I L I A

The dentist should be prepared to discuss with the hematologist :

Type of anesthetic anticipated to be administered,

Invasiveness of the dental procedure,

Amount of bleeding anticipated,

Time involved in oral wound healing to help establish an appropriate treatment plan.

Antifibrinolytics are adjunctive therapeutic agents to help control oral bleeding. These agents include Eaminocaproic acid (Amicar*) and tranexamic acid (Cyklokapron})

Analgesics containing aspirin or antiinflammatory agents (e.g., ibuprofen) alter platelet function and should not be used

6

H E M O P H I L I A

DENTAL MANAGEMENT

Prevention of Dental Disease.

Toothbrushing,

flossing,

topical fluoride,

systemic fluoride administration,

proper diet and

professional examination at regular intervals

Rubber cup prophylaxis and

supragingival scaling may be safely performed without prior factor replacement therapy.

7

H E M O P H I L I A

RISKS TO DENTAL STAFF

The risk of acquiring hepatitis B virus infection following an accidental stick with a needle used by a hepatitis B virus carrier ranges from 6% to 30%, far higher than the risk of human immunodeficiency virus (HIV) infection (less than 1 %o) following a stick with a needle used by a patient infected with HIV.

Moreover, although HIV antibodies have been isolated in saliva and other body fluids, there is no evidence to suggest that the disease is easily transmitted through saliva alone. A study by Klein et al demonstrated a less than 0.5% occupational risk of HIV infection among dental

8

H E M O P H I L I A

DENTAL MANAGEMENT

Restorative Procedures.

Most restorative procedures on primary teeth can be successfully completed without replacement of deficient factor

Using PDL injections of local anesthesia or local infiltration, NO block anesthesia

Small lesions may be restored using nitrous oxide-oxygen inhalation analgesia alone.

The use of acetaminophen with codeine may also help to decrease discomfort in the child.

9

H E M O P H I L I A

DENTAL MANAGEMENT

Pulpal Therapy: A pulpotomy or pulpectomy is preferable to extraction. Most vital pulpotomy and pulpectomy procedures can be successfully completed using local infiltration anesthesia.

If the pulp of a vital tooth is exposed, an intrapulpal injection may be safely used to control pain.

Bleeding from the pulp chamber does not present a significant problem because it is readily controlled with pressure from cotton pledgets.

Similar to all suspected haemostasis disorders

10

VIRAL HEPATITIS

Viral hepatitis is an infection that produces inflammation of liver cells, which may lead to necrosis or cirrhosis of the liver.

Hepatitis B virus (HBV) transmission is of major concern to the dentist.

The capability of transmitting the disease to patients and dental staff members and family.

11

VIRAL HEPATITIS

HBV is transmitted from person to person by parenteral, percutaneous, or mucous membrane inoculation.

It can be transmitted by the percutaneous introduction of blood, administration of certain blood products, or direct contact with secretions contaminated with blood containing HBV.

Infection may also result from inoculation of mucous membranes, including sexual transmission.

Wound exudate contains HBV, and open-wound- to-open-wound contact can transmit infection.

There can also be vertical transmission from an infected mother to her baby, and this almost always leads to chronic infection.

12

VIRAL HEPATITIS

A medical history is unreliable in identifying patients who have actually had HBV infection, because approximately 80% of all HBV infections are undiagnosed.

However, the medical history is useful in indicating groups of patients who are at higher risk of being undiagnosed carriers

13

VIRAL HEPATITIS

Isolated environment

Filtration system

Sterilization of instruments after use

Tested and immune dentist

Limited dental chair

Surgical gowns

Gloves, face masks

14

SICKLE CELL ANEMIA

An autosomal recessive hemolytic disorder

Hemoglobin S instead of the normal hemoglobin A. Hemoglobin S has a decreased oxygen-carrying capacity. Decreased oxygen tension causes the sickling of cells.

Susceptible to recurrent acute infections

15

SICKLE CELL ANEMIARadiographic changes :

Generalized radiolucency

Loss of trabeculae

Prominent lamina dura

Bone growth may be decreased in the mandible, resulting in retrusion

Teeth may be hypomineralized.

Occasionally, infarcts in the jaw, which may be mistaken for a toothache or osteomyelitis.

The patients experience dental pain with absence of pathology

16

SICKLE CELL ANEMIA

Appointments should be short to reduce potential stress on the patient.

Aggressive preventive program,

Dental treatment should not be initiated during a sickle cell crisis. If emergency treatment is necessary during a crisis, only treatment that will make the patient more comfortable should be provided.

Skeletal changes that make orthodontic treatment beneficial.

17

SICKLE CELL ANEMIA

Use of LA with a vasoconstrictor, Prilocaine (Citanest) not advised due to formation of methaemoglobin.

Nitrous oxide is not contraindicated in these patients

GA should be avoided

Pulpectomy in a nonvital tooth is reasonable if remain noninfected. If the tooth is likely to persist as a focus of infection, then extraction is indicated.

Prophylactic ABs are NOT necessary for routine dental procedures

18

SICKLE CELL ANEMIA

Schedule dental treatment shortly after blood transfusions and provide antibiotic prophylaxis

Sickling and occlusion of the vessels in dental pulp may account for dental pain in caries-free, normal teeth.

Ortho. Will move quickly through bone and relapse will most likely occur

19

ACQUIRED IMMUNODEFICIENCY SYNDROME

AIDS is caused by infection with HIV type 1 or, much less commonly, type 2.

The incubation period from the time of infection to the appearance of symptoms of AIDS is approximately 11 years in adults. Therefore HIV-infected individuals can unknowingly spread the virus

HIV infects cells of the immune system, specifically lymphocytes and macrophages.

20

ORAL MANIFESTATIONS OF HIV INFECTION

Fungal Infection. Candida Albicans.

Viral Infection. Herpes group viruses and papillomaviruses

Bacterial Infection. Bacteria causing oral lesions may include Mycobacterium avian-intracellulare and Klebsiella pneumoniae.

Neoplasms. Kaposi sarcoma is the most common malignancy.

Idiopathic Lesions. Oral ulcers of unknown etiology

21

LEUKEMIA

2nd to accidents leading cause of death in children.

Acute leukemia is most common malignancy in children

Leukemias are hematopoietic malignancies proliferation of abnormal leukocytes in bone marrow and dissemination of these cells into peripheral blood.

22

LEUKEMIA

Oral manifestations

Lymphadenopathy,

Petechiae and ecchymoses,

Gingival bleeding,

Gingival hypertrophy,

Pallor of mucous membranes,

Oral ulcers

Radiographic changes in jawbones

Toothache

Tooth mobility

xerostomia

23

DENTAL MANAGEMENT OF PATIENTS WITH LEUKEMIA

Child's hematologist and oncologist physician should be consulted

Pulp therapy on primary teeth is contraindicated in any patient with a history of leukemia.

Routine preventive and restorative treatment, including nonblock injections, may be considered when the platelet count is at least 50,000/mm'

Good OH must be maintained

The use of a soft nylon toothbrush for the removal of plaque is recommended

24

S O L I D T U M O R S

Half of the cases of childhood malignancy.

The most common tumors include brain tumors, lymphoma, neuroblastoma, Wilms tumor, osteosarcoma, and rhabdomyosarcoma.

Treatment with chemotherapy and radiation can suppress marrow function, many of the complications seen in acute leukemia are also seen with these patients.

Bleeding and infection are the most medical complications.

In general, the dental management of patients with solid tumors is similar to that of patients with acute leukemia.

25