Dental treatment of children with

Disabilities

Medical disability

Key medical questions – ask about:• Respiratory/chest problems;

• Cardiovascular disorders;

• Bleeding disorders;

• Epilepsy;

• Hepatitis;

• Diabetes;

• Hospitalization for any reason;

• Previous general anesthetic experience;

• Allergies;

• Illness in other family members;

• Medication.

Respiratory diseases -

Asthma

• Asthma is a diffuse obstructive disease

of the airway caused by edema of the

mucous membranes, increased mucous

secretions, and spasm of smooth

muscle;

• Irritants are cold air, fumes, or dust;

• A dental procedure constitutes an acute

irritant to the airways of the asthmatic

child and may precipitate an attack.

Patients taking systemic

corticosteroids

• Should be treated with caution because

they are at higher risk of morbidity and

mortality;

• Sometimes, deferring the dental visit

until the patient`s asthma is controlled is

the best approach.

Patients who use

bronchodilators

• Should take as dose before their

appointment;

• They should bring their inhalers;

• Behavioral methods are employed to

reduce anxiety;

• Valium have been successful in

alleviating anxiety

Contraindication

• Barbiturates and narcotics are not

indicated because of their potential for

histamine release leading to

bronchospasm;

• Aspirin compounds and nonsteroidal

anti inflammatory agents are

contraindicated because about 4% of

patients experience wheezing after

taking these drugs.

Recomendations

• Acetominophen;

• Positioning a child in an upright for the

dental procedures.

• Avoid the potential for dental materials

and products to exacerbate the asthma.

Emergency treatment• Discontinuing the dental procedure;

• Reassuring the patient, and opening the

airway;

• Administer 100% oxygen while placing the

patient in an upright;

• Keeping the airway open, administer inhaler;

• If there is no improvement, administer

subcutaneous epinephrine (0,01 mg/kg of

1:1000 solution) and obtain medical

assistance immediately

Cardiovascular disorders

Heart disease

• Heart diseases are divided in two general

types:

– Congenital;

• Non cyanotic congenital heart disease;

• Cyanotic congenital heart disease;

– Acquired:

• Rheumatic fever – infection with group A streptococci;

• Infective Bacterial Endocarditis – infection with

Staphylococcus, group A Streptococcus, and

Pneumococcus.

Individuals with heart disease

require

• Special precautions during dental

treatment:

– Such as antibiotic coverage for prevention

of bacterial endocarditis;

• Dentist should closely evaluate the

medical histories of all patients to

ascertain their cardiovascular status.

Prophylaxis recommended

• Dental extractions;

• Periodontal procedures – surgery, scaling and

root planing, probing and recall maintenance;

• Reimplantation of avulsed teeth;

• Endodontic treatment only beyond the apex;

• Subgingival placement of antibiotic

fibers or strips initial placement of

orthodontic bands but not brecets;

• Intraligamentary local anesthetic

injections;

• Prophylactic cleaning of teeth where

bleeding is anticipated.

Prophylaxis not recommended

for:

• Restorative dentistry;

• Local anesthetic injections;

• Intracanal endodontic treatment; post

placement and build up;

• Postoperative suture removal;

• Placement of removal orthodontic

appliances;

• Creation of oral impressions;

• Fluoride treatment;

• Shedding of primary teeth.

Dental management• Before initiating the care, the dentist should

obtain a thorough medical and dental

history;

• Perform a physical examination;

• Formulate a complete treatment plan, and

discuss it with the child`s cardiologist;

• Cardiopulmonary resuscitation equipment

should be available.

Especially important:

• Pulp therapy is not recommended for

primary teeth with a poor prognosis;

• Extraction of such teeth with appropriate

fixed-space maintenance is preferred;

• Endodontic therapy in permanent teeth

usually be successfully if the treatment

is carefully selected and adequately

performed.

Antibiotic treatment

• Patients not allergic to penicillin –

Amoxicillin:

– <5 years: oral amoxicillin 750 mg 1 h

before the procedures;

– 5-10 years – 1,5 g 1 h before the

procedures;

– >10 years use adult dose – 3 g 1 h before

procedures;

Patients allergic to penicillin

• Oral Clindamycin:

– <5 years – 150 mg 1h before the

procedures;

– 5 – 10 years – 300 mg 1 h before;

– < 10 years use adult dose – 600 mg 1 h

before.

Or Azitromycin as a

suspension

• < 5 years – 200 mg 1 h before;

• 5 – 10 years – 300 mg 1 h before;

• <10 – use adult dose – 500 mg 1 h

before.

Disorders of hemostasis -

Hemophilia

• With recent advances in treatment,

most hemophilic patients can receive

outpatient dental care routinely;

• The dentist, in conjunction with the

hematologist, can make appropriate

decisions regarding treatment.

Use of antifibrinolytics

• Antifibrinolytics are adjunctive therapeutic

agents for dental management in bleeding

disorders to help control of oral bleeding;

• These agents include Amicar and

Cyklokapron;

• They prevent lysis of clots within the

oral cavity.

• They are used as an adjunct to factor

concentrate replacement to prevent or

control oral bleeding.

Dosages

• 100 to 200 mg/kg by mouth up to a total dose

of 10 g;

• Subsequently, 50 to 100 mg/kg per dose up

to 5g of amicar is administered orally every 6

hours for 5 to 7 days;

For Cyclokapron

• – 25 mg/kg given immediately before

dental treatment;

• The same dose is continued every 8

hours for 5 to 7 days.

Side effects

• Headache;

• Nausea;

• Dry mouth.

Local anesthesia

• In the absence of factor replacement,

periodontal ligament injections may be used;

• One must proceed with caution when

considering block anesthesia:

– A minimum of 40% factors correction is mandatory;

– The dentist must carefully aspirate to make certain

that the needle has not entered a blood vessel;

– In the event of bloody aspirate, further factor

replacement may be required, and the hematologist

should be notified immediately.

.

Dental management

• Prevention of dental diseases:

– If bleeding persist for several minutes, the

topical application of bovine thrombin,

microfibrillar collagen (Avitene) and local

fibrin glue (Tissel);

Periodontal therapy

• When necessary deep scaling – first

supra gingival scaling, after 7 to 14 days

– sub gingival scaling

• Replacement therapy may considered.

• When frenulum or other periodontal

surgery – both factor concentrate

replacement and antifibrinolytic therapy

are required before.

Restorative procedures

• Most restorative procedures on primary

teeth can be successfully completed

without factor concentrate replacement.

Pulpal therapy

• Bleeding from the pulp chamber does

not present a significant problem

because it is readily controlled with

pressure from cotton pledgets.

• It is important to treat closed

asymptomatic pulpitis with indirect pulp

capping.

Oral surgery

• The dentist should discuss with the

hematologist the surgical procedures

Antibiotic Prophylaxis

• Is required for patients with artificial

joints before invasive dental procedures

Dental emergencies

• In oral trauma;

• May require a combination of factors

replacement and antifibrinolytic therapy,

and treatment with local haemostatic

agents

Convulsive disorders -

epilepsy

• Epilepsy – a term applied to recurrent

seizures;

• Forms:

– Idiopathic epilepsy – unknown origin;

– Due to congenital brain lesions;

– Due to acquired lesions.

Dental management of

epilepsy • Any anti-epileptic medication should be sugar-

free;

• Sodium Valporate is not associated with

gingival enlargement;

• Phenytoin results in gingival enlargement in

about half of patients;

• In good control of seizures needs a minimum of

restrictions, although the possibility of an attack

occurring in the dental chair should be

considered.

Diabetes mellitus

• The well-controlled diabetic child with

no serious complications can have any

dental treatment;

• They should receive preventive care as

a priority.

Clinical manifestations

• Polydipsia – increased thirst;

• Polyuria – increased urination;

• Polyphagia – increased appetite;

• Weight loss;

• Hyperglycaemia in association with

glucosuria.

Uncontrolled diabetes

• Can result in varied problems, mainly

related to:

– fluid imbalance;

– Altered response to infection;

– Possible increased glucose concentrations

in saliva;

– Micro vascular changes;

– Decreased salivary flow;

– Increased incidence of dental caries;

– Increased periodontal problems;

– Susceptibility to infections, particularly with

Candida sp.

Dental treatment

• Appointment should be arranged at

times when the blood sugar levels are

well controlled;

• Usually a good time is in the morning

immediately following their insulin

injection and a normal breakfast;

One of major hazards of insulin

treatment is the development of

hypoglycemia

• For an acute episode a carbohydrate-

containing snack or drink should be

given.

Hepatitis

Viral hepatitis

• Hepatitis B transmission is of major

concern to the dentist;

• The availability of a safe, effective

hepatitis B vaccine affords the dentist

and staff additional protection;

• Procedures is three-dose injection

regimen – 0, 1, 6 months.

Hepatitis C

• Is of great concern to the dentist,

because it can be transmitted by needle

stick and no immunization is available.

• However, the use of universal

precautions should provide adequate

protection.

Adrenal insufficiency

There are a number of

syndromes

• Addison`s disease;

• Cushing`s syndrome;

The problems in the dental

management

• In children who are prescribed steroid

therapy for other medical conditions:

– In the suppression of inflammatory and

allergic disorders;

– Acute leukaemia;

– To prevent acute transplant rejection.

In children, the risk of taking

corticosteroids

• Are greater than in adults;

• They should only be used when

specifically indicated;

• In minimal dosage;

• And for the shortest possible time.

In children with adrenal

insufficiency or receiving steroids

therapy any infection or stress may

precipitate an adrenal crisis.

For routine restorative

treatment

• No additional steroid supplementation is

usually necessary;

Extractions or more extensive

procedures

• The oral steroid dosage should be

increased;

• General anesthesia should not be

carried out on an out-patient basis;

• Consultation with the child`s physician

is necessary before prescribing

steroids;

• Anesthetics must be aware of such

medication in order to avoid a

precipitous fall in blood pressure during

anesthesia or in immediate

postoperative period.

Organ transplantation

• Kidney;

• Heart;

• Bone marrow;

• Liver;

• Pancreas.

Organ transplantation

Pre transplant treatment planning

• Dental evaluation;

• Active dental diseases should be

treated before transplantation;

• Children undergoing bone marrow

transplantation are prone to infection,

bleeding, and delayed healing du to

leukopenia and thrombocytopenia;

• Consultation with medical doctors;

• Prophylactic antibiotics will be required

in patients with cardiac diseases.

Immediate post-transplant period• Children in this period may be even more prone

to infections and hemorrhage then before;

• Full supportive dental care is required and

children complain of nausea and may develop

sever oral ulceration;

• Routine oral hygiene procedures can become

difficult but the use of chlor hexidine as a

mouthwash, spray, or on a disposable sponge,

together with local anesthetic preparations is

helpful.

Stable post-transplant period

• Routine dental treatment can be

undertaken;

• Steroid therapy may be prolonged;

• Antifungal prophylaxis;

• Dental problems – delayed eruption and

exfoliation of primary teeth, ectopic

eruption of permanent teeth;

• Oral ulcerations;

• Gingival enlargement.

Key points

• Transplant immunosuppression :

– Leucopenia;

– Thrombocytopenia;

– Gingival enlargement.

Other disorders

Thyroid disease

• May present in early adolescence;

• More common in adults;

• Dental treatment should present no

problems if thyrotoxic patients are

medically well controlled;

• Consultation with physician is important

Renal disorders

• Nephrotic syndrome – protein leaks

from the blood into urine via the

glomeruli of the kidney;

• The result is:

– Hypoproteinemia;

– Generalized oedema.

Left untreated

• Suffers would die of infections;

• Fortunately the majority respond to

treatment using corticosteroids, usually

prednisolone.

Developmental problems of

kidney

• Congenital anomalies:

– Polycysticdisease;

– Unilocular cysts.

Acute pyelonephritis

• More common when there is a

congenital abnormality;

• The children with renal problems are

under specialist medical care.

From a dental viewpoint

• The children need extra consideration

when prescribing drugs;

• They may fail to excrete a drug or its

metabolites;

• Be more sensitive to the drug`s effect;

• Be less tolerant of a side effects;

• Some drugs may even be less effective.

Important drugs for dentists

• Midazolam and other bbenzodiazepins;

• Chloral hydrate;

• Fluconazole;

• Co-trimoxazde.

Acquired immunodeficiency

syndrom

AIDS

• Is a clinical defined condition caused by

infection with HIV type 1 or, much less

commonly, type 2;

• HIV infects cells of the immun system,

specifically lymphocytes and

macrophages.

Infants and children with AIDS

• Have clinical findings similar to those in

adults;

• Early manifestations of HIV infection:

– Interctitial pneumonitis;

– Weight loss;

– Failure to trive;

– Hepatomegaly or splenomegaly;

– Generalized lymphadenopathy;

– Chronic diarhea.

In pediatric patients with HIV

infection

Recurrent and sever bacterial

infections are common.

Oral manifestations of HIV

infection

• Fungal infection;

• Viral infecion;

• Bacterial infection;

• Neoplasms;

• Idiopatic lesions;

• HIV-associated gingivitis and HIV-

associated periodontitis.

Oral candidiasis in HIV-

infection

• There are 4 majger types of oral

candidiasis:

– Psudomembranous;

– Hyperplastic;

– Erythematous or atrophyc;

– Angular cheilotic.

Pseudomembranous lesions

• Presence of creamy white or yellow

plaques that can easily be remouved

from mucosa, leaving a red, bleeding

surface;

• Locations – palate, buccal and labial

mucosa, and dorsum of the tongue.

Hyperplastic lesion

• White plaques that cannot easely

removed;

• The most common location is the buccal

mucosa;

Erythematous lesions

Red appearance of lesions;

Common locations are palate and dorsum

of the tongue;

The lesion may also appear as spotty

areas on the buccal mucosa.

Angular cheilitis

• Is characterized by fissures radiating

from commissures of the mouth, often

associated with small, white plaques.

Viral infections

• Oral warts with human papillomavirus

as the etiologic agents;

• Herpes simplex virus – painful lesions

on the palate or on the tongue;

• Varicella-zoster virus, the chickenpox

virus – oral lesions and skin lesions;

• Oral hairy leucoplakia – white lesions

that does not rub off, located on the

lateral margins of the tongue.

Bacterial infections

• Mycobacterium avian-intracellulre;

• Klebsiella pneumoniae;

• They are known diseases that either

follow an atypical course or that show

an unusual response to treatment.

HIV-associated gingivitis and

periodontitis

• Progressive and premature periodontal

diseases;

• They may even be the first sign of HIV infection;

• Do not respond effectively to standart

periodontal treatment;

• Rapid progression from gingivitis do advanced,

painful, spontaneously bleeding periodontal

diseases in a few months.

Treatment includes

• Aggressive curettage, peridex (0,12%

chlorhexidin digluconate) rinss three

times daily, and possibly antibiotic

treatment.

Neoplastic disorders

Key points

• Children with cancer need the combined

care of primary and specialist dental

services;

• There are immediate and long-term

effect of cancer treatment;

• Disease prevention is vital.

Oral problems

Mucositis

• Acute inflammation of the mucosa;

• White/yellow fibrous slough, often with

ulceration;

• Painful to eat, speak and swallow;

• Portal for microbial entry.

Blood changes

• Spontaneous gingival and mucosal

bleeding;

• Crusting of lips.

immunosuppression

• Non-vital primary teeth can become a

medical emergency;

• Acute herpetic gingivo stoamatitis and

candida can rapidly progress to

systemic involvement in children

Changes in saliva

• Saliva becomes thick, viscous, and

acidic;

• Acute ascending sialadenitis can occur

as a complication;

• Loss or alteration of taste – may be

difficult to persuade the child to eat so

enticed by sugary snacks;

• Dysphagia – difficulty in swallowing.

Changes in oral flora

• Increase in cariogenic organisms;

• Increased susceptibility to candidal

infection;

• Rapid progression of periodontal

disease.

Dental pain and trismus

• Leukemic infiltration of dental pulp

tissue or direct infiltration of jaws;

• Jaw pain and trismus as a direct

complication of drug therapy or fibrosis

following radiotherapy.

summary

• 1. An increasing number of children with

complex medical problems now survive

due to improvements in medical care,

and present difficulties in oral

management.

• 2. An accurate, detailed medical history

must be obtained before any dental

treatment is undertaken.

• 3. An aggressive preventive regimen is

required for all children with significant

medical problems;

• This must encompass dietary

counselling, suitable fluoride therapy,

fissure sealant applications, and oral

hygiene instruction.

• 4. Congenital heart disease is more

common in children than acquired

conditions;

• Many of these malformations require

prophylactic antibiotics prior to carrying

out any invasive dental procedures.

• 5. Children with bleeding disorders,

such as hemophilia, thrombocytopenic

purpura, and Von Willebrand`s disease,

must be haematologically investigated

prior to dental treatment;

• Haematological replacement therapy

may be required before operative

treatment.

• 6. Children with anemia, whether from

deficiency or from such inherited

conditions as sickle-cell anemia or

thalassemia, represent general

anesthetic risks in particular.

• 7. Leukaemia is the most common from

of childhood cancer and the first

disseminated cancer to respond

completely to chemotherapy in a

significant number of children;

• Dental management of affected children

needs to consider their hematological

status as well as their

immunocompromised condition.

• 8. Asthma is a leading cause of chronic

illness in childhood;

• Severe asthmatics may be on systemic

steroid therapy, which has implication

for dental care.

• 9. Convulsions are common in children,

occuring in approximately 5%, but many

of these are associated with episodes of

high fever in the child and not with

spilepsy.

• 10. Diabetes mellitus is the most

common endocrine or metabolic

disorder of childhood;

• If there is good control of blood sugar

levels with insulin therapy and

nutritional management, then diabetic

complications are minimized and dental

care should be routine.

• 11. Organ transplantaion in children is

now being increasingly undertaken;

• There are many side effects of drug

control of immunosuppression that

affect treatment planning and oral care.

• 12. The participation of dental team in

the overall management of children with

medical problems can significantly help

to enhance the quality of life;

• Preventive care should be the

cornerstone of dental management.