Dental Problems of Children with Disabilities
C. Chavarria DDS - October 18, 2006
Children with Disabilities
The AAPD defines persons with special health care needs as individuals who:
“have a physical, developmental, mental, sensory, behavioral, cognitive,
or emotional impairment or limiting condition that requires medical
management, health care intervention, and/or use of specialized services
or programs.
Health care for the special needs patients is beyond that considered
routine and requires specialized knowledge, increased awareness,
attention and accommodation”
Currently, 56 million Americans have some type of disabling condition &
25 million Americans have a severe disability
Patients with Special Health Care Needs can face many obstacles (such as
financial resources, lack of preventive and therapeutic care, language
and/or cultural barriers) in order to obtain oral health care
Children with Disabilities Treatment Modification
1. Access to dental office
2. Radiographic examination
3. Preventive Dentistry
Dental Office
August 1984: Uniform Federal Accessibility Standards
(barrier-free facility access)
The Americans with Disabilities Act defines the dental office
as a place of public accommodation. Follow accessibility guidelines
(table 23.1) P. 567 (www.access-board.gov)
Special Health Care Needs patients will continue to grow in number due to
improvements in medical care. Many of the acute or fatal conditions have
become chronic and manageable problems
Mobility Problem
Maintain clear path for movement throughout the treatment setting
If you need to transfer your patient from a wheelchair to a dental chair,
ask the patient or care giver
Certain pts can’t be moved into dental chair, treat them in a wheelchair
Dental Examination
If a patient has a gagging problem, schedule an early morning appointment
before eating or drinking
Minimize the gag reflex by placing the patient’s chin in a neutral position
or downward position
If the patient has a swallowing problem, tilt the head slightly to one side
and place the body in a more upright position
Radiographic Examination
X-ray are necessary for diagnosis and treatment plan
Assistance from the parent, caretaker, dental assistant.
Stabilize the films (Snap a ray; Bitewing loop with dental floss)
Wear lead apron and/or gloves
Preventive Dentistry
Goal: Prevention of oral disease
Factors: a) patient’s needs
b) adequate communication
with the parent/child in order to implement
an appropriate preventive program for the patient
c) direct involvement of the care takers and/or patient
Home Dental Care
• Parents/ caretakers are responsible for establishing good oral hygiene
• Should begin during infancy
• Unsupervised oral hygiene procedures in children with disabilities can
have serious dental consequences
• Plaque control program is essential
• Brushing technique should be simple and effective
• Various toothbrush–handle modification
• Common positions of plaque removal: standing, upright wheelchair,
reclining on couch or in bed, “leg lock” position, reclining on floor
Diet and Nutrition
• Nutrition influence dental caries by affecting the type and the virulence
of the microorganisms in the dental plaque
• Diet analysis is based on medical condition
• Discontinuation of nursing bottle by 12 months of age
• Cessation of at-will breast-feeding after teeth erupt (6 months of age)
Fluoride Exposure
• Emphasis should be placed on adequate systemic fluoride for patients
with disabilities
• Water analysis recommended prior to the use of fluoride supplementation
• Professional topical fluoride treatments should be based on caries-risk
assessment (fluoride varnishes)
• Children at high risk for caries or children with active caries should
be considered for additional fluoride therapy
• Home fluoride programs using fluoride mouth rinses
or brush-on fluoride gels should be recommended for use by
children at high risk for caries
• If a patient at high risk for caries cannot or will not comply with home
fluoride therapy then frequent professional fluoride treatments may
be substituted
Preventive restorations
• Pit and fissure sealants have been effective on occlusal caries reduction.
• Stainless steel crowns are treatment of choice when a patient has
Interproximal caries or severe bruxism
• Recall visits may be required every 2, 3 or 4 months as indicated.
Treatment Immobilization
Mental Deficiency
(AAPD Standards of Care for Behavior Management)
Definition (American Association on Mental Deficiency):
“(1) significant sub-avg. general intellectual functioning existing
concurrently with (2) deficits in adaptive behavior
and manifested during the (3) developmental period”
Indications:
1. Lack of maturity
2. Mental or physical disability
3. Other behavior management techniques have failed
4. Safety
Contraindications:
1. Cooperative patient
2. Underlying medical condition (e.g. Osteogenesis imperfecta)
3. Should not be used as a punishment
Documentation includes
1. An informed consent
2. Indication of use
3. Type of immobilization used
4. Duration
Mechanical aids for:
Mouth opening:
1. Tongue blade
2. OPEN-WIDE®
3. Molt mouth prop
• Reverse scissor action
• Lip and/or palatal laceration
• Never rest on the anterior teeth
4. Rubber bite block
• Secured with dental floss
• 3 sizes: small-child, child and adult size
Body: Immobilization actually encourages relaxation and prevents
undesired reflexes by keeping the patient’s arms in the midline
of the body
1. Papoose Board
• Has the option of a head attachment
• A supporting pillow is needed
• May develop hyperthermia
2. Triangular wrap
3. Pedi-Wrap
• Does not have head support
• Mesh fabric permits better ventilation
4. Bean bag dental chair insert
5. Safety belt
6. Extra assistant
Extremities
1. Posey straps
2. Velcro straps
3. Towel and tape
4. Extra assistant
Head
1. Forearm-body support
2. Head position
3. Extra assistant
Attention Deficit Hyperactive Disorder (ADHD/ADD)
• Neurobehavioral syndrome described by significant levels of inattention,
impulsivity and overactivity
• Learning problems
• Poor peer relations and low self esteem
• Affect 3-5% of school age children
• Male >female = 4:1
• Onset 7 yrs old
• Etiology is unknown/ familial disorder
• Relation of maternal use of alcohol and tobacco during pregnancy
Treatment:
• Ritalin® (methylphenidate): stimulant, increase BP and HR
• Adderall®, Concerta®, Strattera®
• Counseling
• 40% have symptom as adult
Dental Management
• Morning appointment (child rested and medication maximal level)
• Avoid treatment during drug holiday
• Short appointment
• Simple instruction, repeat frequently
Epidemiology
• 1-3 % of US population has been identified as mentally disabled
• 80% mild mental retardation
Mental ”Disability”
• General term used when an individual’s intellectual development
is significantly lower than the average and his or her ability
to the environment is limited
• A diagnosis of Mental Disability is not made based on IQ alone
• Inadequate adaptive functioning and intellectual deficiency are required
to comply with a diagnosis of Mental Disability
1983 Classification (15 point intervals)
LEVEL
IQ
ABILITY
Borderline 68-83 Slow learner
Mild
52-67 Educable
Moderate
36-51 Trainable
Severe
20-35 Nontrainable
Profound
<20
Nontrainable
Functional Goals
LEVEL
GOAL
Mild
Independence and self support: employment, parenting
Moderate
Some support & Supervision:
academics of daily living, self-help, survival academics
Severe
Higher level or total support & supervision
Etiology
• Prenatal stage: single gene defects, chromosomal disorders,
complex syndromes, toxin exposures, congenital infections
• Perinatal stage: complications of prematurity, hypoxic-ischemic insults,
infection
• Postnatal stage: infection, toxins, metabolic disorders, trauma,
severe deprivation
Dental Management
• Comprehensive medical & dental history
• Assess patient’s behavior & cooperation
• Approach mental age of patient
• A brief tour of dental office
• Allow parent/caretaker to escort patient
• Be repetitive, speak slowly and in simple terms
• Positive reinforcement
• Modeling by parents, siblings
• Give one instruction at the time
• Actively listen to patient
• Keep appointments short
• Schedule patients early in the day
• Rigorous preventive oral hygiene regimen, diet counseling
• Fluoride, chlorhexidine
• Frequent recalls
• Premedication
• Physical restraints for aggressive patients
• Sedation, N2O, IV or general anesthesia
Dental Treatment according to Mental Disability Classification:
Mild
• Simple preventive & op. procedures usu. tolerated
Moderate
• May require sedation, restraints or IV/GA
Severe/Profound
• Usu. totally dependent & cannot cope
w/even simple tasks.
• General anesthesia
Down Syndrome
• Most common cause of moderate to severe MR
• Trisomy 21 is the most common chromosomal aberration
• Incidence 1.5 per 1000; increases with maternal age
• Mortality rate increases when cardiac defects, leukemia (10 to 20 fold
greater incidence during infancy) & upper respiratory infections present
Facial Characteristics
• Mongoloid facies
• Slanted palpebral fissures
• Small, brachycephalic head
• Midface deficiency
• Broad & shortened hands, feet, digits
• Transverse palmar crease (Simian)
• Iris anomalies common
• Flat facies with hypertelorism
• Depressed nasal bridge
• Protrusion of the tongue
• Epicanthal folds
• Small and misshapen auricles and anomalies of the folds
• Wide gap between the first and second toes
Oral Manifestations
• Macroglossia, fissured tongue
• Abnormal tooth morphology
• Congenitally missing incisors
• Delayed eruption
• Caries~level of MR
• Midface deficiency gives Class III appearance
• Crowding of dentition
• Mouth breathers
• Dry, cracked lips
• Periodontal disease
• Gingival hyperplasia
Systemic Manifestations
• Cardiac (40%): Most of the patients experience mitral valve prolapse
• Gastrointestinal, sensory and infectious complications
• Hearing and visual loss
• Spine instability
• Onset of Alzheimer disease in adults during the third decade of life
• Onset of dementia during the fifth decade of life
• Increased rate of infections
• T-cell and B-cell deficiency
• Increased rate of Acute Lymphocytic Leukemia (ALL) during infancy
• Increased hepatitis rate
• Thyroid dysfunction
Dental Management
• Medical History (heart disease, ALL)
• Emphasize oral hygiene due to high incidence of rapid periodontal dz
• Poor vascularized gingival tissue
• T-cell maturation defect or PMN chemotactic defect
• May benefit from daily antimicrobial agents e.g. Chlorhexidine
• Many children with Down syndrome are affectionate and cooperative
• Some may require light sedation, immobilization or general anesthesia
Pervasive Developmental Disorders
Childhood Schizophrenia
Asperger Disorder (or syndrome):
Display some of the features of autism but may also possess
a level of skill in some areas well above the average for their peers.
Autism
• Difficult to diagnose and has no cure
• For many years, thought to be purely psychological w/o organic basis
• Search for a biological cause- defective structure in brain
• Closely associated with other clinical and medical conditions
Prevalence:
Earlier studies: 4 per 10,000
Recent studies: 10-15 per 10,000
• improved diagnosis
• changing definitions of autism
(milder forms now included)
• boy:girl ratio is 3- 4:1
• Autism distinctive feature: restricted & stereotyped behavior patterns
• Most children score below normal on IQ testing
& experience significant developmental delay
• The more severely affected express themselves minimally,
show a low level of interest in exploring objects, avoid sounds,
and engage in ritualistic behavior
Characteristics:
• Extreme aloneness
• Language disturbances
• Mutism
• Parrot like, repetitive speech
• Difficulty with the concept of “yes”
• Nystagmus
• Obsession with maintenance of sameness; routines
• Inability to evaluate own thoughts
• Unable to judge what others might be thinking
• Spinning of objects
• Sensitive to touch
Associated Conditions
• Maternal rubella
• Early injury to brain
• Infantile seizures
• Chromosomal abnormalities
• Mental Retardation
• Metabolic disorders (phenylketonuria)
• Fragile X syndrome
• Rett syndrome
• Williams syndrome
• Neurocutaneous disorders(neurofibromatosis,tuberous sclerosis)
Oral Manifestations
• Drooling
• Poor muscle tone
• Poor tongue coordination
• Pouch food instead of swallowing
• Increases caries rate due to sweet and soft diet
Dental Management
• Repeated visits may desensitize
• Use slow approach and quiet voice
• T-S-D
• Modeling by parents and siblings
• Home rehearsals
• Positive reinforcement with immediate reward
• Minimize movements as easily distracted
• Short visits, time out
• Physical restriction
• Sedation, N2O, GA
Cerebral Palsy
Definition:
1. There must be a difficulty in neuromotor control
2. A nonprogressive brain lesion
3. An injury to the brain that occurred before it was fully mature
4. Used only if static encephalopathy exists
5. Often associated with other symptoms
• An estimated 764,000 children and adults in the United States
manifest one or more of the symptoms of cerebral palsy.
• Currently, about 8,000 babies & infants diagnosed each year.
Incidence and Prevalence:
• Prevalence: 1.5 to 3 per 1000 live births
• There is a correlation between premature birth and incidence of CP
• All children with cerebral palsy are w/ brain damage,
but not all children with brain damages are with cerebral palsy.
Etiology
Brain insult may occur at the prenatal, perinatal or postnatal stage.
50% of time etiology is unknown
Multiple Classifications
1. Extremities involved
2. Type of motor disorder
3. Type of tone abnormalities
4. Characteristics of involuntary movements
5. Degree: mild, moderate, severe
Anatomic Involvement
• Monoplegia (one limb)
• Hemiplegia (arm and leg on same side)
Arm held in flexion
Internal rotation
Leg circumducted on involved side
• Paraplegia (both legs)
• Diplegia (both legs with minimal involvement of both arms)
• Quadriplegia (all four limbs)
Medical Management
• Enrollment in an early intervention program
-federal law mandates such a program in all states
• Must address motor dysfunction and associated nonmotor deficits.
• The final objective of CP management must be the socialization
of the child with his/her motor, speech, or cognitive difficulties,
which have to be checked and supported all thru his/her lifetime.
Oral manifestations of CP
• Periodontal disease due to poor oral hygiene and soft diet
• Gingival hyperplasia due to seizure meds
• Dental caries-conflicting data
• Malocclusion-twice as common
• Protrusion of max ant teeth, increase overbite/overjet, openbite
• Bruxism
• Trauma
Classification by neuromuscular dysfunction:
Spastic Cerebral Palsy: tense, contracted muscles (most common type)
• Affects 70 to 80 percent of patients,
muscles are stiff and permanently contracted.
• Often described according to the affected limbs
i.e. spastic diplegia (both legs) or left hemiparesis (left side of body).
• In some cases, spastic cerebral palsy follows
a period of poor muscle tone (hypotonia) in the young infant.
• Spastic Diplegia:
Scissoring of legs: excessive pull of hip adductors
and internal rotators
Toe walking
Note that child is crouched due to hamstring tightness
Athetoid or Dyskinetic: constant, uncontrolled motion of limbs, head, eyes
• Affects about 10 to 20% of Cerebral Palsy patients
• Characterized by uncontrolled, slow, writhing movements usually
affecting the hands, feet, arms, or legs and, in some cases,
the muscles of the face and tongue, causing grimacing or drooling.
• The movements often increase during periods of emotional stress
• Patients may also have problems coordinating the muscle movements
needed for speech, a condition known as dysarthria.
Ataxic Cerebral Palsy: poor sense of balance, falls & stumbles
• Affects an estimated 5 to 10% of Cerebral Palsy patients
• Affects the sense of balance and depth perception
• Affected persons often have poor coordination; walk unsteadily
with a widebased gait, placing their feet unusually far apart and
experience difficulty when attempting quick or precise movements.
Mixed
• Affects 10% of the Cerebral Palsy patients
• It is not unusual for patients to have symptoms of more than one form.
• The most common mixed form includes spasticity and athetoid
movements but other combinations are also possible.
Rigidity: tight muscles that resist effort to make them move
Tremor: uncontrollable shaking, interfering with coordination
Dental Management
• Thorough medical and dental history
• Consider treating in wheelchair
• Use 2 person lift if moving to dental chair
• Do not force limbs into unnatural positions
• Use rubber dam - protection from aspiration
• Consider physical restraints for protection
• Consider recommending mouthguard
• Patience
• Goal of treatment-comprehensive care
• Prevention- frequent visits, parental involvement in home care,
modifications to toothbrush, diet, fluoride
• Restorative care with rubber dam, bite block tied with floss
• Short appointments.
Spina Bifida
• Unknown etiology
• Spina bifida is the most common neural tube defect
• Affecting 1,500 to 2,000 babies each year (one in every 2,000 live births)
• Occurs at the end of the first month of pregnancy
• Evidence suggests that genes and/or environment may be involved
• Folic acid during the first 6 weeks of pregnancy
can prevent over 50% of neural tube defects
Occurs in different forms, each varying in severity.
• Spina Bifida Occulta (mildest form)
Also known as Closed Neural Tube Defect
Opening in one or more vertebrae w/o apparent damage to spinal cord
Asymptomatic with no neurologic problems
• Spina Bifida Manifesta:
• Meningocele
The meninges, or protective covering of the spinal cord,
is pushed out through the opening in the vertebrae
in a sac called the “meningocele”
Spinal cord remains intact
Can be repaired with little or no damage to the nerve pathways
• Myelomeningocele
The most severe form of spina bifida
A portion of the spinal cord protrudes through the back
Sacs can be covered by skin or tissue & nerves can be exposed
• A high percentage of children with Spina Bifida are allergic to latex,
possibly due to multiple genitourinary operations along with multiple
urinary catheterizations for neurologically impaired bladders
• Over 40,000 products contain latex rubber
• Latex is a natural rubber; a complex mixture of phospholipoproteins,
sugars, nucleic acids, lipids, minerals and proteins
• The proteins are responsible for the severe immediate (Type I)
anaphylactic reaction
• Reaction to latex:
Irritant contact dermatitis
Nonimmunologic inflammation of the skin
Erythema,dryness,fissuring, chapping, vesicle formation
Allergic contact dermatitis
Lesions appear 48-96 hrs post exposure
Pruritus, erythema, scales, crusts, scabs, vesicles
Immediate allergic reaction
Caused by exposure to proteins in the natural latex rubber
Immediate pruritus, erythema, edema
Dental Management
• Avoid all latex products: All equipment that comes in contact with the
patient should be made of non-latex substitutes
• Schedule dental appointments at the beginning of a working session
• Treat the patient in a controlled setting
• Emergency carts available at all times if an anaphylaxic rxn is present
• Children with neural tube defects are at a high risk of caries due to poor
oral hygiene, poor nutritional intake and long-term drug therapy
• Be alert to medical history (history of allergies to banana, avocado, kiwi,
pineapple, peach, nectarine, plum, cherry, potato, tomato, celery,
and chestnuts) which may sensitize allergic patients to latex exposure
• Pt. should wear a medical alert bracelet & carry an epi-pen at all times
• Must have a latex free cart to simplify management
• Patients with latex allergy need to be flagged, labeled and a latex allergy
sign be posted outside the treatment room
Treatment of latex anaphylactic reaction
Terminate treatment. Use a cardiopulmonary monitor and oximeter
Initiate basic life support:
• Remove latex exposure
• Discontinue IV or inhalation agents
• Administer 100% Oxygen
• Secure the airway with endotracheal tube if indicated (edema)
• Administer epinephrine
1:1000 IV, SQ or intralingual
0.125-0.25 ml (child)
5 ml (adult) every 5-15 minutes as necessary
• Administer diphenhydramine
1-2 mg/kg PO or IM,
max 50 mg
• Activate EMS
• Transport the child to an appropriate medical facility
Management of the Medically Compromised Patient
C. Chavarria DDS - October 19, 2006
Acquired Immunodeficiency Syndrome
• The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates
40 million people living with HIV or AIDS worldwide.
• In the U.S. approximately one million people have HIV or AIDS, and
40,000 Americans become newly infected with HIV each year.
• AIDS is threatening children as never before:
Children under 15 account for 1 in 6 global AIDS-related deaths
and 1 in 7 new global HIV infections.
A child under 15 dies of an AIDS-related illness every minute of every day
A young person aged 15–24 contracts HIV every 15 seconds. (UNICEF)
Infants & children w/ AIDS have clinical findings similar to those in adults:
• Weight loss and failure to thrive,
• hepatomegaly or splenomegaly,
• generalized lymphadenopathy, and
• chronic diarrhea
• HIV infects cells of the immune system (lymphocytes and macrophages)
These white blood cells contain the greatest number of CD4 cell surface
receptors (glycoproteins) which permit attachment with viral surface
proteins and enhance host-cell invasion and infection
The viral genome is integrated into the host-cell genome and leads to
progressive and eventually irreversible immunosuppresion by
producing more virus and further killing the CD4 (T4) helper-inducer
lymphocytes that are important modulators of the immune system
• Immunodef’cy allows opportunistic infections, malignancies & autoimmune dz
Diagnosis is made by screening the serum for antibodies to HIV
& is confirmed by Western blot analysis
Ongoing management is guided by the patient’s CD4 cell count
• A person can receive a clinical diagnosis of AIDS,
as defined by the U.S. Centers for Disease Control and Prevention (CDC),
if he/she has tested positive for HIV & meets one or both of these conditions:
1) The presence of one or more AIDS-related infections or illnesses
2) A CD4 (T-cell) count that has
reached or fallen below 200 cells per cubic millimeter of blood
(CD4 count ranges from 450 to 1200 in healthy individuals)
• Treatment: Antiretroviral drugs target the virus at several steps:
1. The fusion of the virus at the host cell
2. The transcription of DNA from viral RNA by reverse transcriptase
3. The cleavage of viral proteins by the viral protease enzyme
4. The most effective treatment strategies use a combination of several drugs
to inhibit the virus at several steps
• Oral Manifestations of HIV Infection
Fungal infections
• Oral candidiasis:
1. Pseudo-membranous lesion: creamy white/yellow plaques
easily removed from mucosa leaving a red, bleeding surface
2. Hyperplastic lesion: white plaques that cannot be easily removed
3. Erythematous (atrophic) lesion: red or spotty areas on the mucosa
4. Angular cheilitis: fissures radiating from lip/mouth commissures
• Systemic treatment
1. Ketoconazole (Nizoral)
200-400 mg daily with food
2. Fluconazole (Diflucan)
100 mg daily
3. Amphotericin B or fluconazole IV
• Topical treatment (one to two weeks is usually effective)
1. Nystatin (Mycostatin) rinses (100,000 U, three to five times daily)
2. Clotrimazole (Mycelex) troches
Viral infection
• Herpes group viruses (HSV) can produce recurrent episodes of vesicles
(oral acyclovir –Zovirax)
• Herpes zoster (VZV) can produce oral ulcerations accompanied by
skin lesions restricted to one side of the face
(oral acyclovir)
• Oral hairy leukoplakia (HL) caused by Epstein-Barr virus,
white lesion that does not rub off located on lateral margins of tongue,
seen on HIV patients
(high doses of acyclovir)
Bacterial Infection
• Mycobacterium avian-intercellulare
• Klebsiella pneumoniae
Neoplasms
• Kaposi sarcoma most common malignancy seen in AIDS
• Occurs in 15 to 20% of AIDS patients
• May be red, blue, or purple, flat or raised and solitary or multiple
Kaposi sarcoma is a vascular, malignant tumor that can involve the skin,
mucous membranes, or internal organs. The palate is a common site of
oral involvement Lesions often are purple or brown in color, and can
be flat, raised, or nodular.
Idiopathic Processes/Lesions
• Ulcers of unknown etiology resemble apthous ulcers
• Salivary gland swelling
• HIV associated gingivitis and HIV associated periodontitis
(aggressive curettage, Peridex, and/or antibiotic treatment)
• Dental Management of AIDS
Consult with Physician
Emphasis on Preventive Care
Palliative treatment as needed
Asthma
Sickle Cell Anemia
• a diffuse obstructive lung disease
• Affecting 1:10 children (3/4 : mild)
• Prepubertal: boy>girl
• Adolescence/adulthood: male= female
• Characterized by inflammation and bronchial constriction
• Caused by: 1. edema of mucous membranes,
2. increased mucous secretion, and
3. spasm of smooth muscle
• Autosomal recessive hemolytic disorder
• Predominantly: African, Italian, Greek, Arabian and Indian descent
• Hemoglobin S-decreased oxygen-carrying capacity
Decreased oxygen tension causes sickling of the cells
• Radiographically: stepladder trabeculation, hair on end
• Painful crisis
Possible splenectomy
Progressive deterioration of cardiac, pulmonary and renal failure
• May need SBE
• Etiology:
Biochemical
Immunologic
Infectious
Endocrine
Psychological factor
• Precipitating Factors:
Acidosis
Dehydration
Hypoxia
Fever
Hypothermia
Infection
Hypotension
Hypovolemia
Stress
• Onset:
Acute (exposure to irritants)
Insidious (precipitated by viral infection)
• Dental Management
Short dental appointments
Aggressive preventive program
No dental treatment during a sickle cell crisis
Occasionally infarcts in the jaw
If GA for dental procedures, consult with hematologist and anesthesiologist
Patients with less than 7 g/dl and 20% hematocrit may require transfusion
• Signs and symptoms
Coughing
Wheezing on expiration
Chest tightness
Dyspnea (difficulty or labored breathing)
Severe asthma:
Dyspnea
Wheezing
Tachypnea
Profuse perspiration
Cyanosis
Hyperventilation
Tachycardia
Chest pain
• Medications used in asthma
Bronchodilators
ßeta-agonists:
Albuterol (Ventolin™, Proventil™),
Salmeterol (Serevent™)
Anticholinergic:
Ipratropium (Atrovent™)
Theophylline
Anti-inflammatory
Steroid: Beclomethasone (beclovent)
Other: Cromolyn (Intal™)
Cystic Fibrosis
• Autosomal recessive disorder predominantly affecting the exocrine glands
• Approximately 5% of the population is carriers & 1 in 2000 live births affected
• The most common lethal genetic disorder affecting Caucasians
• The abnormal gene has been located on the long arm of chromosome 7
• basic abnormality: elevation of viscosity of the mucous secretions
• pancreas: obstruction of secretory ducts, exocrine insufficiency & malabsorption
• extensive bronchi plugging: obstruction, infection, destruction of bronchial walls
• confirmation of CF: elevation of sweat concentration of Na & Cl > 60mEq/L
• Clinical manifestations vary, some pts are asymptomatic for long periods of time
• More than 85% of affected children show evidence of malabsorption
• Median life expectancy is 31 years
• Death results f/ pneumonia & anoxia after long period of respiratory insufficiency
• Oral Findings:
High caries rate
Low salivary flow
High palatal vault
More posterior crossbite
Greater overjet
Increased facial height
Chronic mouth breather
• Questions to ask:
Age of onset
Frequency/severity
Triggering agent
Hospitalizations? ER visit
Last episode
Medications
Limitation of activities
• Dental Management
Evaluate the patient
MD consult
Well controlled asthmatic patients may be treated safely in the office
Poorly controlled asthmatic patients should postpone elective dental treatment
Severe asthmatic pts on steroids may need add’l steroids to cover the stress
of the procedure
Upright or semi upright position may be beneficial
Should have a bronchodilator available prior to treatment
Reduce anxiety
Nitrous Oxide,Vistaril or Valium help alleviate anxiety
Narcotics are contraindicated: Histamine release leads to bronchospasm
Aspirin and NSAIDs are contraindicated
Acetaminophen is recommended
• Emergency Treatment
Discontinue dental treatment
Reassure the patient, administer inhalant bronchodilator give 2-3 inhalations
Administer supplemental 0xygen
Keep airway open
Consider SQ epinephrine 1:1000, 0.25 cc or 0.01 mg/kg
Call medical assistance
• Oral Findings of CF:
Low incidence of caries
High incidence of tooth discoloration (systemic tetracycline during formation)
High incidence of mouth breathing / open bite (chronic nasal/sinus obstruction)
• Multidisciplinary Approach…
• Dental Management of CF:
need a high caloric intake, therefore preventive advice is essential
MD consultation
Patients may prefer upright position (clear secretions more easily)
Avoid sedatives that interfere with pulmonary function
Nitrous oxide is contraindicated on pts with history of severe emphysema
Endocarditis Prophylaxis (PO 1 hour before dental procedure)
Heart Disease
Congenital Heart Disease:
Ventricular septal defect
Patent ductus arteriosus
Tetralogy of Fallot
Transposition of the great vessels
Atrial septal defect
Pulmonary stenosis
Coarctation of the aorta
Aortic stenosis
Tricuspid atresia
All other
22%
17%
11%
8%
7%
7%
6%
5%
3%
14%
• Etiology
• Aberrant embryonic development of a normal structure
• Failure to progress beyond early stage of embryonic developm’t
• Maternal rubella
• Chronic maternal alcohol abuse
• Hereditary predisposition
• Acyanotic Congenital Heart Disease
Left to the right:
1. VSD
2. ASD
3. patent ductus arteriosus
Obstructive defect:
1.aortic stenosis
2. coarctation of the aorta
• Cyanotic Congenital Heart Disease
Right to left shunt:
1. Transposition of great vessels
2. pulmonary stenosis
3. tricuspid atresia
4. tetralogy of Fallot
Congestive heart failure
pulmonary congestion
heart murmur
labored breathing
cardiomegaly
Congestive heart failure
labored breathing
Cyanosis
hypoxia
poor physical development
heart murmur
clubbing of the fingers
Tetralogy of Fallot
1. VSD
2. aorta overriding
3. pulmonary stenosis
4. RV hypertrophy
Acquired Heart Disease:
• Rheumatic fever:
Heart Murmurs
Innocent (functional) murmurs = sounds from turbulence w/o
cardiac abnormality & do NOT require antibiotic prophylaxis
Organic murmurs = sounds from pathologic abnormality in the heart
& do require antibiotic prophylaxis
Rheumatic heart disease requires antibiotic prophylaxis
• Bacterial endocarditis: Microbial infection of heart valves
or endocardium in the area of a heart defect
Acute
Fulminating disease
Result from high pathogenic microorganism:
staphylococcus, group A streptococcus and pneumococcus
Normal heart suffers of erosion and destruction of the heart valves
Subacute (SBE)
Caused by viridians streptococci
Embolization is a characteristic feature of infective endocarditis
Microorganism→ Blood stream→
Endocardium/valvular heart defect→ Form vegetations
Symptoms:
Low irregular fever
Sweating
Malaise
Anorexia
Weight loss
Arthralgia
Heart murmur
Painful fingers and toes
Amoxicillin (standard regimen)
Clindamycin (‘cillin allergy)
Dosage forms:
Amoxicillin:
Clindamycin:
adults 2.0 g, children 50mg/kg
adults 600 mg, children 20mg/kg
125 or 250 mg/5ml or 250, 500 tabs
150, 300, 450, 600, 750, 900 mg/tab
Recommended for: (pts with high & moderate risk conditions)
Ext. (& reimplanting avulsed teeth)
Perio (surgery, prophy, S/RP, probing, recall, implants)
Endo (RCT or surgery only beyond the apex)
Subgingival fibers/strips
Initial placement of ortho bands but not brackets
Intraligamentary LA injections
When bleeding is expected
…
HIGH-RISK
Prosthetic valves
Previous bacterial endocarditis
Complex cyanotic congenital heart dz
Sugically constructed shunts/conduits
MODERATE-RISK
Most other congenital malformations
Acquired valve dysfunction (e.g., rheumatic heart dz)
Hypertrophic cardiomyopathy
MVP w/regurgitation &/or thickened leaflets
NOT Recommended for: (unless bleeding is expected)
Restorative (op & prosth) w/ or w/o cord
LA injections (non-intraligamentary)
Intracanal endo; post placement & buildup
Rubber dam placement
Post-op suture removal
Removable or ortho appliance placement
Taking impressions
Ortho adjustment
Shedding of primary teeth
…
NEGLIGIBLE-RISK (normal)
Isolated secundum ASD
Surgically repaired ASD, VSD, or PDA (after 6 months)
Previous coronary artery bypass graft surgery
MVP w/o regurgitation
Physiologic (functional, innocent) heart murmurs
Previous Kawasaki dz w/o valve dysfunction
Previous rheumatic fever w/o valve dysfunction
Cardiac pacemaker or implanted defibrillator
• Dental Management of Heart Disease
Update dental and medical history
Cardiology consultation
SBE prophylaxis
Behavior management techniques (sedation, general anesthesia)
CPR equipment
Pulp therapy in primary teeth is not recommended
Endo treatment in permanent teeth
Refer as needed
Definitive treatment is recommended
Once amoxicillin oral suspension is mixed with water, it will expire in a week
Wait 2-4 weeks between each visits to allow penicillin resistant organisms
to disappear from the oral flora and allow repopulation of the mouth
with antibiotic susceptible flora
If needed, the alternation of medication may be indicated
Consider hospital dentistry
Make the parent(s) aware that poor dental hygiene and periodontal or periapical
infections my produce bacteremia even in the absence of dental
procedures.
Individuals who are at risk for developing bacterial endocarditis should
establish and maintain the best possible oral health to reduce potential
sources of bacterial seeding
Ventricular Septal Defects (VSD)
• The most common of cardiac malformations
• Small defects can be asymptomatic
• May be found during routine physical examination
• Large defects with extensive pulmonary flow are responsible for
breathlessness, feeding difficulties and poor growth
• 30-50% of the small defects close spontaneously within the first year of life
• Larger defects are usually closed surgically in the second year of life,
• Defects involving other cardiac structures may require complex surgery
or even transplantation
Tetralogy of Fallot
• Consists of a combination of:
1. An obstruction to the right ventricular outflow ( pulmonary stenosis)
2. VSD
3. Dextroposition of the aorta
4. Right ventricular hypertrophy
• Cyanosis is one of the most obvious sign as the child grows,
the obstruction of blood is further exaggerated
• Oral mucous membranes, nail-beds show signs of cyanosis
• Growth and development may be markedly delayed
Atrial Septal Defects (ASD)
• Not as common as VSD in children
• More significantly on adult
• Even an extremely large ASD rarely produces heart failure in children
• Symptoms usually appear in the third decade
Acquired cardiovascular disease: Rheumatic fever
• Group A streptococcal infection of the upper respiratory tract
• Usually between 5 -15 years
• Higher among lower socioeconomic groups
• Clinical onset is usually acute and occurs 2-3 weeks after a sore throat
• Joint pains
• Carditis is the most serious manifestation
• Fever (low grade) is usually present
• Most of the carditis resolves except the lesions on the cusps of the heart valves
which become fibrosed and stenotic; may affect mitral, aortic, tricuspid, and
pulmonary valves
Pulmonary stenosis
• Mild to moderate stenosis of the pulmonary valve usually present no symptoms
• Severe stenosis may cause exercise intolerance and cyanosis
Disease of the myocardium and pericardium
Bacterial infections such as : diphtheria and typhoid; fungal and parasitic infections:
rheumatoid arthritis: systemic lupus erythematosus; uraemia, thalasemia,
hyperthyroidism, neuromuscular diseases, such as muscular dystrophy and
glycogen storage diseases
Viral hepatitis
Viral hepatitis is an infection that results in the inflammation of the liver cells,
leading to necrosis or cirrhosis of the liver
Hepatitis A virus (HAV)
Hepatitis B virus (HBV)
Hepatitis delta virus (HDV)
Non-A, non-B hepatitis virus (NANB) or Hepatitis C (HCV)
- parenterally transmitted
Patent ductus arteriosus (PDA)
• During fetal life most of the
pulmonary arterial blood is shunted
through the ductus arteriosus
into the aorta, bypassing the lungs.
• Functional closure of the ductus arteriosus
usually occurs at birth
NANB or hepatitis E virus
- enterically transmitted
Leukemia
• Hematopoietic malignancy: proliferation of abnormal leukocytes in bone marrow
and dissemination of these cells into peripheral blood, tissue and organs
• Second to accidents as the leading cause of death in children
• Affects 5 in 10,000 children in the US (Peak incidence 2 and 5 years of age)
• Our primary objective should be prevention, control and
eradication of oral inflammation, hemorrhage and infection
• Physically debilitated patients with ulcerative lesions require close attention,
in order to avoid the potential of a fatal viral, fungal or bacterial infection •
• Infection = 1º cause of death in approx. 80% of children w/ leukemia
• Bleeding is the second most common cause
• Candida infection is common in leukemia patients
(debilitated, immunosuppressed, poor OH, prolonged antibiotic therapy)
• Nystatin is recommended
• Etiology:
Unknown
Ionizing radiation
Chemical agents
Genetic factors
• Classified according to:
1. Morphology of predominant abnormal white blood cells in the bone marrow
2. Clinical course (acute or chronic)
3. Degree of differentiation or maturation
• Signs and Symptoms
History at presentation:
Irritability, lethargy, persistent fever, vague bone pain, easy bruising
Common findings on physical examination:
Parlor, fever, adenopathy, hepatosplenomegaly, petechiae,
cutaneous bruises, gingival bleeding, and evidence of infection
Clinical manifestation of acute leukemia:
anemia, thrombocytopenia and granulocytopenia
• Once diagnosed, the patient is stabilized and prepared for chemotherapy
Treatment for ALL is prolonged (2.5 to 3.5 years)
The treatment regimen depends on the prognosis and parameters evaluated
• Phases of Treatment:
1. Induction (use of antileukemic drugs 4 week regimen)
2. Consolidation (intensify prophylactic CNS treatment)
3. Interim maintenance (combo of relatively non toxic agents, monthly visits)
4. Delayed intensification (intensify antileukemic therapy)
tends to improve survival rate in patients with ALL
5. Maintenance phase (two years for girls and three years for boys)
• Oral Manifestation:
Regional lymphadenopathy
Mucous membrane petechiae
Gingival bleeding ( due to anemia, granulocytopenia and thrombocytopenia)
Gingival hypertrophy (due to direct infiltrate of leukemic cells)
Pallor
Nonspecific ulcerations
• Evidence of skeletal lesions is visible on dental radiographs
in up to 63% of children, although not pathognomonic,
we should be alert of the following changes:
1. Generalized loss of trabeculation
2. Destruction of the crypts of developing teeth
3. Loss of lamina dura
4. Widening of the periodontal ligament space
5. Displacement of teeth and tooth buds
• Dental Management:
Pulp therapy on primary teeth is contraindicated
Avoid the use of drugs that may alter platelet function (salicylates)
The pt’s hematologist & oncologist or 1° care physician should be consulted
Primary medical diagnosis
Anticipated clinical course and prognosis
Present and future therapeutic modalities
Present general state of health
Present hematologic status
Blood cell profile and platelet count
Platelet Count
150,000-400,000
50,000-100,000
20,000-50,000
<20,000
normal
bleeding time prolonged,
most routine procedures OK
moderate risk of bleeding;
Defer elective surgical procedures
significant risk for bleeding;
Defer elective dental procedures
100,000/mm³ is adequate for most dental procedures
< 20,000/mm³ can cause spontaneous bleeding
(all intraoral mucosal tissues hemorrhaging)
Absolute neutrophil count (ANC)
>1500
normal
500-1,000
some risk of infection (bacteremia)
Defer some elective procedures
200-500
pt. should be admitted to hospital;
moderate risk of sepsis;
defer all elective dental procedures
<200
Significant risk of sepsis
ANC=(% of neutrophils+ % of bands) x total white count ÷ 100
Indicates the host’s ability to suppress or eliminate infection
< 1,000/mm³ defer elective dental treatment
Management of the Medically Compromised Patient ( II )
Carmen Chavarria DDS - October 25, 2006
Hearing Loss
• Affects 1.8 million people
• 1 in 600 neonates has a congenital hearing loss
• 14 million hearing-impaired individuals in the US
• Table 23-3 of your textbook demonstrates how speech and psychological
problems relate to various degrees of hearing loss
• Early identification and correction of hearing loss is essential for normal
development of communication skills
• Hearing impairment = problem with or damage to one or more parts of the ear.
Conductive: problem with the outer or middle ear,
including the ear canal, eardrum, or ossicles.
• Usu. can be corrected with medications or surgery.
Sensorineural: damage to the inner ear (cochlea) or the auditory nerve.
trouble hearing clearly, understanding speech, & interpreting sounds.
• Hearing loss is permanent.
• Treated with hearing aids or, in severe cases, a cochlear implant.
Mixed both conductive and sensorineural hearing problems.
• Etiology:
Prenatal Factors:
1. Viral infections
2. ototoxic drugs (aspirin, streptomycin, neomycin, kanamycin)
3. Congenital syphilis
4. Hereditary disorders
Perinatal Factors:
1. Toxemia late in pregnancy
2. Prematurity
3. Birth injury
4. Anoxia
5. Erythroblastosis fetalis
Postnatal Factors:
1. Viral infections (mumps, measles, chickenpox, flu, &/or meningitis)
2. Injuries
3. Ototoxic drugs (aspirin, streptomycin, neomycin, kanamycin)
• Management
Prepare the pt & parent before the first visit with a welcome letter
Let the pt & parent determine how the patient desires to communicate
Assess speech, language ability and degree of hearing impairment
Identify the age of onset, type, degree and cause of hearing loss
Make sure the patient understands what the dental equipment is
What is going to happen, and how it will feel
Reassure the patient with physical contact
Allow extra time for all appointments
Avoid blocking the patient’s visual field
Adjust the hearing aid before the handpiece is in operation
(hearing aid amplifies all sounds
Use of an interpreter is extremely helpful
Visual impairment
• Total visual impairment affects more than 30 million people
• A person is considered to be affected by blindness
If visual acuity doesn’t exceed 20/200 in the better eye w/ corrective lenses OR
If acuity greater than 20/200 but w/ a visual field of no greater than 20 degrees
• Etiology
Prenatal Factors:
Optic atrophy, microphthalmos, cataracts,
colobomas, dermoid and other tumors,
toxoplasmosis, syphilis, rubella, tuberculous meningitis,
developmental abnormalities of the orbit
Postnatal causes:
Trauma, retrolental fibroplasias, hypertension, premature birth,
polycythemia vera, hemorrhagic disorders, leukemia,
diabetes mellitus, glaucoma
• The capabilities of a child with blindness are difficult to assess,
therefore an affected child could be misdiagnosed as developmentally delayed
• Children with blindness may exhibit self-stimulating activities,
such as eye pressing, finger flicking, rocking or head banging
• Listening, touching, tasting, and smelling are extremely important for the affected
children in helping to learn coping behavior
• Dental management:
Determine the degree of visual impairment
Establish rapport
Do not grab, move or stop the patient without verbal warning,
encourage the parent to accompany the child
Paint a picture in the mind of the visually impaired child
by describing the office setting and treatment
Introduce the office personal
When making physical contact, do so reassuring
Allow the patient to ask questions
Protect the patient’s eyes with eyeglasses
Use the touch, taste, or smell approach
A patient may reject strong tastes, use small quantities of dental materials
Use audio & Braille dental pamphlets explaining specific dental procedures
Ideally, limit providers of the patient’s dental care to one dentist
Maintain a relaxed atmosphere
Von Willebrand disease
• Hereditary bleeding disorder
• Abnormality of von Willebrand Factor (VWF)
• found in plasma, platelets, megakaryocytes and endothelial cells
• Circulates as carrier protein for factor VIII
• Important in platelet adhesion to the sub endothelium via collagen
and formation of the primary platelet plug;
• impairment may result in bleeding from skin and mucosa, bruising,
and prolonged bleeding after surgical procedures
Hemophilia
• sex-linked genetic disorder
Inherited bleeding disorder affects 1 in 7500 males
• def’cy or absence of one of the clotting proteins in plasma.
results in delayed clotting, bleeding involves muscle and joints
• There is no cure for hemophilia, the goals of treatment are early recognition of
bleeding episodes and appropriate intervention to prevent complications.
Factor VIII deficiency (Hemophilia A or Classic Hemophilia)
• VIII = antihemophilic factor
• X-linked recessive trait (Males affected, females carriers)
• It accounts for about 85% of all hemophilias (most common)
• joint and muscle hemorrhages, easy bruising prolonged
& potentially fatal hemorrhage after minor cuts or abrasions
• If joint hemorrhages go untreated, severe limitation of motion occurs
Factor IX deficiency (Hemophilia B or Christmas Disease)
• IX = plasma thromboplastin component
• X- linked recessive trait disorder
• One fourth as prevalent as factor VIII
• Factor XI = plasma thromboplastin antecedent def’cy
Inherited as an autosomal recessive trait
Male and female offspring equally affected
Most frequently observed in those of Ashkenazi Jewish descent
• Degrees of severity of Hemophilia A and B: (normal levels: 55-100%)
Mild
Pro-coagulant levels greater than or equal to 5%
Bleed infrequently and only in association with surgery or injury
May never have a bleeding problem
Rarely have joint problems
Diagnosis of mild deficiency is found during presurgical evaluation
or when bleeding occurs in association with surgery or trauma
Moderate
1%-5% factor activity levels
Can bleed with slight injury
May bleed 4-6 times/yr depending on activity level & stage of
May have joint problems if not treated
Develop a target joint (repeated episodes at same joint)
• Hemophilia A & vWD:
Hemophilia A
Normal
↑↑
↓↓
Normal
Normal
Normal
vWD
Normal
↑↑/ Normal
↓
↓
↑
Abnormal
• Physical Exam and Medical/Family History:
Documentation of presenting symptoms
Family history including bleeding history
Pt's bleeding Hx, including previous injuries, trauma response, prior surgeries.
(If female, menstrual history including detailed assessment of duration,
frequency, & amount of bleeding during cycle)
• Positive Indications for Potential Bleeding Disorder:
Excessive bleeding
Swelling to soft tissues, muscles or joints
Frequent mucosal bleeds (nosebleeds, oral bleeds)
Excessive bleeding after trauma or surgery
History of laboratory coagulopathy
Hematomas noted after IM injections and/or venipunctures
PT represents the extrinsic pathwayif abnormal, may be due to deficiency in FI, II, V, VII, X.
If PT alone is abnormal indicative of FVII deficiency.
PTT represents the intrinsic pathway
if abnormal, may be due to deficiency of FI, II, V, VIII, IX, XI, XII.
If PTT only is abnormal may indicate FVIII, IX, XI or XII.
Normal Factor Activity levels usually range from 50%-150% or 60%-200%
depending on specific laboratory parameters.
• Treatment:
Use of either purified concentrate made from pooled plasma
or factor produced through recombinant technology; one-time correction
of procoagulant to approx. 40% will achieve hemostasis
Factor concentrates are generally accessible, easy to handle and store,
virally inactivated, and lead to a more consistent hemostatic result
The level necessary for hemostasis is the same for Factor IX as for Factor VIII
for Hemophilia A:
Factor VIII concentrate
DDAVP (1- deamino-8-Darginine vasopressin) used for
mild factor VIII-deficient hemophilia (minor hemorrhagic episodes)
peak level one hour after post administer
The half- life of Factor VIII is approximately 12 hours
for Hemophilia B :
Purified coagulation factor IX concentrate
The half-life of Factor IX is approximately 24 hours
for von Willebrand disease:
DDAVP
• Complications:
Inhibitors are antibodies that may develop:
…in approximately 28% of patients with severe factor VIII deficiency
…in 3% to 5% of patients with severe factor IX deficiency
Hemophilic patients with inhibitors should be managed
only in conjunction with a hemophilia center
Patients with inhibitors:
High responders
Low responders
Arthritis: Degenerative joint disease secondary to recurrent bleeding
Blood borne viral infections (transmitted via blood used for therapy)
dev’pment
Severe
< 1% factor activity level
Can bleed with no injury (spontaneous)
May bleed two to four times/month
Common sites of bleeding include joints, muscles and skin
Hemarthoses (joint bleeding): pain, stiffness, limited movement)
Chronic musculoskeletal problems
Pseudotumor (hemorrhagic pseudocyst) of the jaw
PT
PTT
Factor VIII
vWF
BT
PLT aggregation
• Abnormal Test Results:
• Dental Management prior to treatment
1. Be aware of the patient’s specific type of bleeding disorder
2. Severity
3. Frequency of bleeding
4. Inhibitor status
5. Consult with hematologist in regards to the extent & invasiveness of the
dental procedures, anticipated bleeding & anesthetic technique to be used
• Dental Management
1. Prevention of dental disease (home dental care information, use of
systemic or topical fluorides, routine dental exams)
2. Periodontal therapy
3. Restorative procedures (rubber dam, high-speed vacuum & saliva ejectors
must be used with caution)
4. Pulpal therapy
5. Oral Surgery
6. Surgical complications
7. Antibiotic Prophylaxis
8. Orthodontic treatment
9. Dental Emergencies
• Antifibrinolytics: control oral bleeding (prevent lysis of clots w/in oral cavity)
Amicar (epsilon aminocaproic acid)
Cyklokapron (tranexamic acid) can be used in mucous membrane bleeding
Bone Marrow Transplantation
• A bone marrow transplant (BMT), also called a stem cell transplant, is a procedure
in which diseased or damaged bone marrow cells are replaced. This procedure
is performed after a patient had high-dose chemotherapy or radiation treatment
for conditions that did not respond to standard doses.
• There are three types of bone marrow transplants:
1. Allogeneic — from a donor who may or may not be a relative.
2. Autologous — The patient receives his or her own stem cells
that were collected and frozen before the high-dose
chemotherapy or radiation treatment.
3. Syngeneic – stem cells from a healthy identical twin
• Transplant Conditioning
• goal is to destroy abnormal cells or cancer cells throughout the patient's body.
• based on the type of disease, previous treatment, & clinical trial participation.
• may consist of chemotherapy, radiation therapy or both.
Radiation may be given before the transplant as part of the conditioning
or it may be given following recovery from transplant.
• During and after hemopoietic stem cell transplantation, the most common cause of
serious morbidity and mortality is infection (endogenous opportunistic
organisms are usually the cause of life-threatening infections)
• Oral Complications:
Ulcerations
Mucositis
Transient salivary gland dysfunction
Thrombocytopenic gingival bleeding
• Graft-Versus-Host Disease:
• interaction of donor cells & recipient cells that display disparate antigens
Acute form: involves the lymphoid system, skin, liver and GI tract
Chronic form: involves cutaneous and oral mucosal involvement
(mucosal erythema, lichenoid eruptions, ulcerations)
• Hematopoietic Cell Transplantation (HCT) Phases:
I. Pre-transplantation
In HCT, the patient receives all the chemotherapy and /or total body
irradiation in just a few days before the transplant
There will be prolonged immunosuppresion following the transplant
Elective dentistry will need to be postponed
until immunological recovery occurs (9-12 months after HCT)
II. Conditioning/neutropenia
Oral complications are related to conditioning regimen / medical therapies
Mucositis, xerostomia, oral pain, oral bleeding, opportunistic infections
and taste dysfunction
III. Initial engraftment to hematopoietic reconstitution
Intensity and severity of complications begin to decrease normally
after 3 to 4 wks after transplantation. Emphasis on Oral hygiene and
topical fluoride applications.
Invasive dental procedures should be done only if authorized
by the HCT team because of the patient’s immunosuppression
IV. Immune reconstitution/ late post-transplantation
After day 100 post-HCT, oral complications are related to the chronic
toxicity associated with the conditioning regimen,
including salivary dysfunction, late viral infections,
oral chronic GVHD
Invasive dental treatment should be avoid in patients
with profound impairment of immune function
• Dental treatment guidelines
Consult with oncologist
Definitive dental care before chemotherapy/ radiation
or at intervals between chemo cycles
Restore all carious teeth or source of irritation and/or active infection
Institute periodontal therapy and oral hygiene instructions
Establish a diagnosis for all oral lesions
Institute appropriate fluoride treatment
Remove orthodontic and other appliances that may cause irritation
Only minimum care during active phases of myelosuppression
• Medical Guidelines
Each patient should be considered individually
Elective dental procedures when:
ANC > 1000 / mm³
Platelet count >40,000 / mm³
Prophylactic antibiotic coverage according to current AHA
if ANC < 1000 / mm³ OR patient has a central venous catheter
Educate patients / parents about possible long-term sequelae of chemo
or radiation therapy
Place the patient on a 3 to 6 month recall schedule to monitor dental condition
and detect long- term complications