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
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LECTURE OUTLINE
 HEMOPHILIA
 VIRAL HEPATITIS
 SICKLE CELL ANEMIA
 ACQUIRED IMMUNODEFICIENCY SYNDROME
 LEUKEMIA
 BONE
MARROW/STEM
TRANSPLANTATION
CELL
 SOLID TUMORS
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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
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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.
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H E M O PH I LIA
 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.
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H E M O PH I LIA
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
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H E M O PH I LIA
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.
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H E M O PH I LIA
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
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H E M O PH I LIA
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.
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H E M O PH I LIA
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
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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.
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.
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
VIRAL HEPATITIS
Isolated environment
Filtration system
Sterilization of instruments after use
Tested and immune dentist
Limited dental chair
Surgical gowns
Gloves, face masks
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
SICKLE CELL ANEMIA
Radiographic 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
pathology
dental pain with absence of
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.
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
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
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.
ORAL MANIFESTATIONS OF HIV
INFECTION
Fungal Infection. Candida Albicans.
Viral Infection.
papillomaviruses
Herpes
group
viruses
and
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
LEUKEMIA
2nd to accidents leading cause of death in
children.
Acute leukemia is
malignancy in children
most
common
Leukemias
are
hematopoietic
malignancies proliferation of abnormal
leukocytes in bone marrow and
dissemination of these cells into
peripheral blood.
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
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
S O LI DTU M O RS
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.