Dental Management of Children with Special Health Care Needs

(CSHCN)
Terminology:

 Defect (Impairment): any imperfection or disorder of body, intellect or

personality (abnormality of psychological, physiological or anatomical
structure or function) .
 Disability : A defect which results in some malfunctioning but does not
necessarily affect the individual’s normal life
 Handicap: Disability which retards ,distorts , or otherwise adversely affects
growth ,development or adjustment to life

Who is handicapped child?

A P H A: Children who have a mental, physical, developmental, behavioral, or

medical condition that prevents the child from achieving full potential when
compared to other children at the same age.

WHO: One who, over an appreciable time, is prevented by physical or mental

condition from full participation in the normal activities of his age group
including those of a social, recreational, educational and vocational nature.

Classification of handicapping conditions

Nowak’s classification (1976):

1. Physical: Cerebral Palsy, poliomyelitis.

2. Mental retardation: intellectual disability
3. Congenital defects: Congenital heart disease, Down’s syndrome, Cleft lip
and palate.
4. Metabolic and Systemic disorders: Renal diseases, Liver diseases,
Diabetes Mellitus, Respiratory disorders, Immunological disorders
5. Communication disorders :Childhood autism
6. Sensory disorders :Blindness and deafness
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 7. Hematological disorders : hemophilia
8. Neoplasia: leukemia
9. Osseous : rickets
Handicapping conditions can be also classified as:

1. Mental handicap: Down’s syndrome

2. Physical handicap: Cerebral palsy
3. Medical handicap: Hematological disorders
4. Dental handicap: Skeletal malocclusion, Amelogenesis imperfecta,
Dentinogenesis imperfecta, Cleft lip and palate

Mental Retardation (intellectual disability)

Definition:
A person whose intellectual development is significantly lowers than
that of normal persons and whose ability to adapt to the environment is
limited
Characteristics:

1- An IQ score less than 70

2-An accompanying impairment in adaptive behavior

3-A manifestation of both before the 18 years of age

Calcification:

Mild (Educable mental retardation) : IQ of 69 -55

Moderate (Trainable mental retardation): IQ of 54-40

Severe (Non trainable) :IQ of 39 -25

Profoundly retarded (Non trainable) : IQ<25

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Degree of Wechsler Communication Special considerations
Intellectual Intelligence for dental care
Disability Scale
Mild 69-55 able to speak ●Treat as normal child
well enough for most ●Mild sedation or N2O2
communication needs
Moderate 54-40 Has vocabulary and ●Mild to moderate
language skills such that sedation
child can communicate ●Restraints and positive
at a basic level Reinforcement
●GA may be indicated in
cases of severe,
generalized, dental decay
Sever/Profou 39 and Mute or communicates As moderate
nd below in grunts; little or no
communication skills

Intraoral findings Characteristics of Intellectual Disabled

Child Undergoing Dental Care

Increase the incidence of: 1. Short attention span

1. Poor oral hygiene 2. Restless
2. Untreated caries 3. Erratic emotional behavior
3. Ginigivitis
4. Malocclusion
5. In sever cases;
 Clenching
 Bruxism
 Drooling
 Missing teeth
 Self injurious behaviors

Dental management:
The dentist should assess the degree of mental disability by consulting the
patient's physician. The following procedures have proved beneficial in
establishing dentist-patient-parent-staff rapport and reducing the patient's anxiety
about dental care:
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 General considerations for children with mental impairments:

1. Give a brief tour of the office before starting treatment.

2. Speak slowly and use simple words.
3. Give only one instruction at a time.
4. Listen carefully to the patient and give him enough time.
5. Reward the patient with compliments after the successful completion of each
procedure

6. Invite the parent into the operatory for assistance and to aid in
communication
7. Keep the appointment short.
8. Schedule the patient early in the day.

Diseases associated with Mental impairments

 Down Syndrome

 Cerebral Palsy

 Autism

Downs’ Syndrome

A congenital autosomal anomaly characterized by generalized growth

deficiency and mental deficiency. 95% of Down syndrome cases have extra
chromosome 21 making the chromosome count 47 instead of 46. The other 5%
show other chromosomal abnormalities including translocation and mosaicism or
partial trisomy.

10% of mentally retarded patients suffer from Down syndrome.

Genera l features:

1. Generalized growth deficiency and mental deficiency

2. Microcephaly of the head.

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 3. Upward and outward slanting of the eyes.
4. Flat under-developed nasal bridge.
Systemic problems:
1. High incidence of congenital heart diseases,
2. High incidence of upper respiratory tract infection
3. High incidence of leukemia
Dental findings:

1. Under-developed maxilla leads to open mouth.

2. Stair palate with “v” shaped high vault.
3. Macroglossia as a result of small oral cavity and tongue thrust.
4. Severe gingival or periodontal diseases.
5. Frequent malocclusion.
6. Bruxism

Teeth
 Oligodontia or supernumerary teeth
 Microdontia
 Conical teeth
 Small roots
 Delayed shedding and eruption (the first primary tooth may not appear until
2 years of age).

Dental management:

Usually these patients are very affectionate and friendly, but some present
behavioral problems:

Apprehensive patients give mild sedation. Resistant patients require treatment

under general anesthesia.
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Therefore Dental management could be summarized in the following points:
 Premedication

 First dental visit: introductory treatment

 Radiographs are difficult (gagging reflex) so film holder is used

 Prophylactic antibiotic is required in patients with systemic problems

 Strong and durable restorations

 Resorbable sutures after surgery

 Attach dental floss to instrument

Autism Spectrum Disorder (ASD)

ASD is a severely incapacitating disturbance of mental and emotional

development that causes problems in learning, communication and relating to
others.

ASD is a group of neurodevelopmental disabilities with a core set of defining

criteria that comprise:
1. Impaired social interaction (e.g. Lack of eye contact, Not respond to his
name)
2. Impaired communication (e.g. Delay or lack of langue development)
3. Restricted or repetitive behavioural stereotypes (behaviour, interest or
activity (e.g. Staring, flaping hands or interest with a specific object)

It manifests during the first 3 years of life, it is difficult to diagnose and has no
cure. American Psychiatric association listed autism as a neurological disorder.
It is believed to be caused by a physical disorder of the brain.

Autistic children have several medical and behavioral problems that make
dental treatment difficult.

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General findings
1. Poor muscle tone
2. Poor coordination
3. Drooling
4. Hyperactive knee jerk
5. Epilepsy (30%)

Behavioral problem:

1. Impaired social interaction:. Lack of eye contact, not respond to his name,
wants to be alone; he relates poorly to persons and relates well to objects. Has a
little or no attachment to their parents

2. Impaired communication: Delay or lack of langue development. His

language is impaired

3. Restricted or repetitive behavioural stereotypes: Staring, flaping hands or

interest with a specific object

Dental problems:

 They have high caries index as they prefer soft and sweetened food and they
pouch the food instead of swallowing due to the poor tongue coordination.

 Poor oral hygiene

Dental management:

1. They may need several dental visits to get acquainted with the dental
environment.

2. Require great patience and positive reinforcement to promote desirable

behavior.

3. The use of Pedi-Wrap or pre-appointment conscious sedation may be

necessary.

4. Extensive dental treatment preferably performed under GA

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 Cerebral palsy

Non progressive neuromuscular dysfunction resulting from brain lesion.

CP is not a specific disease entity but a group of movement disorders occurs by

damage of the developing brain

Several causes: may be due to:

• Congenital Cerebral defects.

• Traumatic brain injuries.
• Brain Anoxia.
• Severe infections.
• Unknown etiology.
Incidence of cerebral palsy is 1 - 3.5 per/1000

Classification

A-According to site of lesion

1) Spasticity

Site: cerebral cortex lesion

Characterized by hyperactive reflexes, stretch reflexes, and a general stiffness

in the affected parts.

2) Athetosis
Site: the basal ganglion
Characterized by purposeless involuntary movements
3) Ataxia
Site: the cerebellum
Characterized by lack of balance and an unsteady gait
4) Rigidity
Site: basal ganglion
Characterized by intentional or unintentional tremors

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 B-According to the limb involved:

1. Monoplegia
2. Hemiplegia
3. Paraplegia
4. Quadriplegia

General findings:
1. Intellectual disability (Approximately 60% of cases)
2. Seizure disorders (Approximately 30% to 50% of cases)
3. Sensory impairments: Impairment of hearing and eye
4. Speech disorders: More than half of cases
5. Joint contractures
Dental findings
1. High incidence of dental caries. However, there is debate regarding its
incidence compared to general population
2. High incidence of periodontal disease
3. High incidence of enamel hypoplasia (30% , Normal 6%)
4. High incidence of malocclusion
5. High incidence of traumatic injuries
6. Oral habits e.g bruxism
7. Self injurious behavior (Protective oral appliances).

Dental management

 Behavior management techniques.

1. Good rapport.
2. Gain cooperation.
3. A child with severe cognitive disability: repetition of commands and
requests.
4. A child with visual impairment: verbal description.
5. A child with hearing impairment: nonverbal techniques.

6. Sedation and GA may be considered in complex cases

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  Rubber dam is highly recommended

 Restraining devices: are essentials to control body movements

a) Control involuntary body and jaw movements
b) Head immobilizer ,papoose board ,safety belts
c) Mouth prop( Molt mouth prop , Mckesson rubber bite blocks )
Patient preference should weigh heavily, since a patient with cerebral palsy may be
very apprehensive about the ability to control swallowing. Such appliances may
also trigger the strong gag reflex that many of these patients possess

 Drug therapy:

a) Meprobamate for involuntary movements,

b) Chlorpromazine for anxiety ,

c) Librium decrease psychic tension and muscle spasm.

 Myofunctional therapy for young children who have orofacial and tongue
hypotonia to increase the muscle tone of the lips, and control tongue thrust.

 Myofunctional appliance: treatment of oral habits

Dental treatment

1. Consultation with patient’s physician

2. Early morning appointment
3. Evaluate each patient individually in term of medical history, symptoms and
behaviour
4. Maintain pt body in the middle of dental chair , with arms and legs close to
body, semi- setting position (difficulty in swallowing )

5. Back of the chair should be slightly elevated

6. Determine the patient's degree of comfort and assess the position of the
extremities (don’t force legs and arms in unusual position)

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7. To minimize startle reflex reactions, avoid presenting stimuli such as abrupt
movements, noises, and lights without forewarning the patient , avoid sudden
jerky movement

8. Children treated on their wheelchair and for young children the chair tipped
back
9. Speak slowly
10.Introduce intraoral stimuli slowly
11.Dental floss should be attached to small instrument ( delayed cough reflex)
12. Dental radiographs: The oblique plate radiographic technique or Buccal bite
wing technique
13. Select durable restorations

Preventive measures

1. Good oral hygiene practice.

2. Dietary counseling.
3. Fluoride
4. Preventive restorations
5. Regular dental visits

Home dental care

1. Choose a well-lit location.

2. Always support the head.

3. Give lots of praise while brushing your child's teeth.

4. Parents should help brush their children's teeth after every meal. Brush
the tongue to prevent halitosis.

5. Use an ADA-approved children's toothpaste.

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 Seizure disorders

Epilepsy:

Is a disease characterized by a chronic or recurrent form of seizures where

consciousness is lost either for an instant or for a period of minutes. This loss of
consciousness may or may not be accompanied by muscular contractions.

Etiology: There is still some argument about the exact cause ( genetic, injury,
disease or brain anomaly).

Types:

a) Petit mal : more common ,momentary loss of consciousness, no evidence

of muscle spasm

b) Grand mal : tonic and clonic phases of muscle spasm ,loss of

consciousness ,pt may be cyanotic during tonic phase, pt wake up with
headache & confusion

 Tonic : Contentious tension and contraction

 Clonic: Alternating contraction and partial relaxation

The phases of tonic and clonic seizures are prodromal, aura , ictal ,post-ictal

1. Prodromal: mode alteration, headache and myoclonic jerking that alter

some patients to an impending seizer hours before it occurs.

2. Aura (part of attack): epigastric discomfort (emotion) hallucination of

hearing, vision or smell. This is followed seconds to minutes later by
unconsciousness

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 3. Ictal : convulsion, jerky movement, tongue bitting

4. Post-ictal: headache ,confusion ,occaional temporary neurologic deficit

and deep sleep

Dental findings

1) Injuries caused by the seizure:

a) Laceration of the tongue or buccal mucosa.
b) Injuries to the face from falling.
c) Looseness of teeth.
d) Subluxation of TMJ.
2) Complications of treatment:

I. AEDs Side Effects

Phenytoin  Gingival hyperplasia
 Increased incidence of cleft lip/ palate in
children of mothers
Carbamazepine  Xerostomia
 Glossitis
 Stomatitis
Valproic acid Affect bleeding time

Dental Management:

A. Identification of patient history

1. Type of seizure
2. Age at time of onset
3. Cause of seizures (if known)
4. Medications
5. Frequency of seizures
6. Date of last seizure
7. Known precipitating factors
8. History of seizure-related injuries
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B. The appointment:
a. Early hours of the day and short appointment
1. Taken medicine: anticonvulsant
2. Premedication
3. Avoid sudden stimulants (e.g. shimmering bright lights and extreme noise)
4. Relaxed dental atmosphere
5. Rubber dam
If attack occurs, stop any procedures

Steps to minimize risk of injury during an epileptic seizure

Oral hygiene measures for children with physical impairments

 For infant:

Parent should clean the incisors with soft cloth or gauze

 For Child:

Teaching a correct tooth brushing method for the parents and some positions
that permit firm control of the child

Modified tooth brush for children with poor motor skills

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 Medically Compromised Patients

A-Heart Diseases

1. Congenital heart disease:

It occurs as result of embryonic development of a normal structure or the
failure of a structure to progress beyond an early stage of embryonic
development. Maternal rubella also interferes with cardiogenesis.
1. Cyanotic: cyanosis or cyanosis upon minimal exertion e.g. Fallot
tetralogy.
2. Acyanotic : minimal or no cyanosis
a) Shunts e.g. ventricular or atrial septal defects.
b) Obstructions e.g. pulmonary or aortic stenosis.
Oral Manifestations:

1. Cyanotic gingivitis, and Cyanotic glossitis

2. Delayed eruption of both dentitions.
3. High incidence of Caries and Periodontal disease
4. Increased frequency of enamel Hypoplasia.
5. Bluish – white or skimmed milk appearance of teeth

II-Acquired heart disease

i-Rheumatic heart disease
Inflammatory disease, sequlae to pharyngeal infection with group A
streptococci with a resultant damage to the heart valves.
Dental implication: prevention of sub acute bacterial endocarditis.
Transient bacteremia is an initiating factor. Prophylactic antibiotic is necessary
before dental procedures.

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 ii- Infective Bacterial Endocarditis
It is one of the most serious infections of humans. Characterized by microbial
infection of the heart valves or endocardium in proximity to congenital or
acquired cardiac defect. It may be acute or sub-acute.
 Acute: is a fulminating disease occurs as a result of microorganisms of high
pathogenicity attacking a normal heart causing erosive destruction of valves.
Microorganisms include: staphylococcus, group A Streptococcus and
Pneumococcus.
 Subacute bacterial endocarditis develops in persons with pre-existing
congenital heart disease or rheumatic valvular lesion caused by viridians
streptococci common to oral flora.
Main concern is prevention of subacute bacterial endocarditis.

Complications of bacterial endocarditis

1. Cardiac complication

a) Valvular insufficiency
b) Congestive heart failure
c) Myocardial abscesses
2.Embolic complication :

a) Cerebral embolic infarction

b) Renal infarction
c) Splenic infarction
3. Immune complex reaction
a) Arthritis
b) Glomerulonephritis

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 Dental Management
1. Consultation with patient’s physician
2. Antibiotic prophylaxis
3. Preoperative oral antiseptic mouth rinse
4. There is no contraindication to the use of vasoconstrictors in local
anesthetics’
5. Pulpotomy / endodontic treatment are not recommended ;poor prognosis or
any failure may results in to bacteremia.
6. Conscious sedation / GA
7. General anesthesia contraindicated in cases of heart failure.

Antibiotic prophylaxis

A. Patient treated under L.A

Standard regimen

Regimen: Single Dose 30 to 60 min Before Procedure

Situation Agent Adults Children
Oral Amoxicillin 2g 50 mg/kg

Unable to take oral Ampicillin OR 2 g IM or IV 50 mg/kg IM or IV

medication
Cefazolin or 1 g IM or IV 50 mg/kg IM or IV
ceftriaxone

Allergic to Cephalexin 2g 50 mg/kg

penicillins or OR Clindamycin 600 mg 20 mg/kg
ampicillin—oral OR Azithromycin or 500 mg 15 mg/kg
clarithromycin

Allergic to penicillin Cefazolin or 1 g IM or IV 50 mg/kg IM or IV

or ampicillin and ceftriaxone 600 mg IM or 20 mg/kg IM or IV
unable to take oral OR Clindamycin IV
medication

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Special regimen

Highly susceptible / G.A: the same protocol + Gentamycine 2 mg/kg

(maximum 80 mg)

Who is the highly susceptible person?

 Patient with prosthetic cardiac valve or prosthetic material used for cardiac
valve repair
 Cardiac transplantation recipients who develop cardiac valvulopathy
 Congenital heart disease (CHD)
 Previous bacterial endocarditis
 Recent surgical repair of cardiovascular defects within 6 months
 Renal failure / renal dialysis

B-HEMOPHILIA

Congenital genetically transmitted disease of blood coagulation

characterized by deficiency of one of the clotting factor.

Types: A, B ,C, pseudo & Para Hemophilia

1. A : factor VIII (x-linked recessive )

2. B :factor IX (x- linked recessive )

3. C:factor XI (autosomal recessive )

4. Pseudo Hemophilia :factor VIII von W (autosomal dominant)

5. Para Hemophilia: factor V

Hemophilia A:

Types :

a) Severe : less than 1 % factor VIII

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 b) Moderate : 2-5 % factor VIII

c) Mild : 5- 25 % actor VIII

d) Subclinical : 25 -50 % factor VIII

Diagnosis: history, symptoms, lab investigation

1. Bleeding time is normal ( N: 1-3 min )

2. Coagulation time is prolonged (30 min)

3. APTT is elevated (N: 24-38 sec )

4. Deficient factor VIII ( N : 50-200 %)

Problems?

a) Increased Fibrinolytic activity

b) Bleeding is delayed

c) Carriers for HBV, HCV, HIV

d) 15% of the patients develop antibodies (inhibitors ) to factor VIII

Dental consedrations:

1. Carriers for HBV, HCV ,HIV

2. Premedication

a) Reduces stress (fibrinolytic activity )

b) Avoid IM sedative
Local anesthesia:

a) Infiltration: limit L.A. Injections to the gingival tissues above the

mucobuccal fold. No need for factor replacement unless injection in
highly vascular or loose C.T (replacement up to 30-40%)

b) Avoid mandibular block, may lead to hemorrhage into the lateral

pharyngeal spaces (Factor replacement at least 40%)
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 c) Intraligamentary; No need for factor replacement

d) All injections should be made with the finest gauge needles

Restorative procedures:

a) Use infiltration anesthesia or intra-ligamental injection

b) Caution with the use of rubber dam ,wedges & retainers

c) Careful placement of x-ray films

Pulp therapy:

Pulpotomy and endodontic treatment is preferable to extractions

Periodontal therapy:

Deep scaling; begin with supragingival then allow tissue healing for 7-14 days
then apply subgingival. Factor replacement should be weighted

Periodontal surgery; Factor replacement and hospitalization may required

Oral surgery

a) Replacement factor (Infusion of fresh plasma or whole blood)

b) Antifibrinolytic agents (Tranexmic acid or £- amino caproic acid)

c) Extraction :a traumatic , local haemostatic measures

d) The socket should be packed with hemostatic agents such as Gel foam ,
gelatin sponge & thrombin.

e) Suture should be avoided, if necessary use Resorbable one ,stent

f) A routine of 25 to 50 cc . of fresh plasma every 4 to 6 hours ( for 12 to

24 hours ) should be instituted to maintain a normal clotting time.

Postoperative care:

1. Antibiotic: in severe hemophilia (patient with joint replacement)

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 2. Diet: liquid diet for first 72 hours and soft pureed diet for other 7days.
During this time, the patient should not use straws or metal utensils, pacifiers,
or bottles
3. Analgesic: avoid aspirin and non-steroidal anti-inflammatory.
IM injection is contraindicated
Antifibrenolytics agents

a) Tranexmic acid (Cyklokapron) : 25mg/kg loading dose and 15-2omg /kg

3/day for 5-7days

b) £- amino caproic acid (Amicar):100mg/kg loading dose then30mg/kg

4/day for 7 days

Replacement factor

Hemophilia A

a) Severe : 100%
b) Mild :30-50% or DDAVP (0.3Mg/kg IV)
c) One unite of factor VIII c/kg will raise level by 2%
d) Replacement Factor may be F VIIIc or recombiant factor VIII
Factor replacement may be given on demand or as prophylactic 3times /week

Von Willebrand’s disease

Is AD coagulation disorder due to decrease or absence or absence of a vWF

which is a circulating plasma protein.
Type 1 vWD is the most common form, accounting for 75% of all cases of VWD.
In Type 1 vWD, the von Willebrand factor (vWF) works normally, but there is not
enough of it
Factor replacement:
a) Type I:DDVP

b) Type II,III: cryoprecipitate

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 LEUKEMIA
ACUTE LEUKEMIA

Malignant blood disease; characterized by uncontrolled proliferation of

abnormal leukocytes in the bone marrow and dissemination of these cells into
the peripheral blood. The abnormal cells replace the normal cells in the bone
marrow.

It is classified according to morphology of predominant abnormal WBCs then

further classified as acute or chronic
Leukemia accounts for about one third of all childhood malignancies; of these,
approximately 75% are lymphocytic (acute lymphocytic leukemia, or ALL).
Chronic leukemia in children is rare, accounting for less than 2% of all cases

ALL 1-9 years, peak age (3-6 years)

AML Old children/adolescents

• Myelocytic Infant/young children
• Monocytic,Myelomonocytic Old children
• Promyleocytic Very rare
• Erythroleukemia Very rare
• Megakaryocytic
CML Infants and toddlers
• Juvenile, Philadelphia Old children/adolescents
• Adult, Philadelphia
CLL Not occur in children

Etiology
The cause is unknown but ionizing radiation, certain chemical agents and
genetic factors have been implicated.
Problems:

a) Anemia ,Thrombocytopenia ,Neutropenia

b) Radiation & chemotherapy complications
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Clinical features

Oral features
1. Primary complications: occur due to the disease itself, gingiva and bone is
effected e.g. leukemic gingival enlargement
2. Secondary complications: usually allied with direct effect of radiation or
chemotherapy, e.g. bleeding in the oral cavity, ulcers
3. Tertiary complications: due to a complex interplay of the therapy itself and
its side effect, e.g. mucositis, taste alteration, xerostomia
Oral manifestation:

1. Loose teeth & odontalgia

2. Stomatitis & sore mouth
3. Petechia & ecchymosis in mucous membrane
4. Gingival hyperplasia
5. Bacterial & fungal infection
6. Spontaneous abscess formation
7. Complications of chemotherapy and radiotherapy
Effect of Radiation:

1. Radiation mucosits

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 2. Candidal infection
3. Recurrent secondary infection
4. Rootless teeth and tooth agenesis
5. Xerostomia
6. Radiation caries
Effect of Chemotherapy

1. Ulceration & mucosal atrophy

2. Recurrent infection
Dental Management

1. Supportive therapy.

2. Routine preventive, restorative and surgical procedures can be provided for

patients in complete remission period yet undergoing a chemotherapeutic
regimen

3. Pulp therapy is contraindicated.

4. Endodontic treatment for permanent teeth is not recommended, an area of
chronic inflammation may remain in the periapical region.
5. Extraction of carious teeth with poor prognosis before cancer therapy.

6. Meticulous oral hygiene: must be maintained with the use of ultra soft
nylon tooth brush. In case of low level platelet count (less than 20,000
mm3) substitute the toothbrush with moist gauze wipes and frequent
saline rinses.
7. Chlorhexidine 0.2 % mouthwashes.

8. Topical xylocaine ( Xylocaine viscous 2 %).

9. Topical and systemic antifungals.

10.Prophylactic antibiotics.
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 11.Saliva substitutes

12.Preventive measures to control dental caries

Extraction

a-Before cancer therapy: Consult Oncologist and extract teeth with poor
prognosis

b-During cancer therapy: Consultation and you can extract with precautions
including:

i. Platelet replacement if the count < 40,000 (150,000 -450,000/L)

ii. Antibiotic if granulocyte < 2000/mm3
A complete blood count and platelet count should be done on day of treatment
to confirm that the patient is not at risk of hemorrhage or infection. Platelet
count 100,000 mm3 is adequate for dental procedures

c- After cancer therapy:

Avoid extractions as it may cause Osteioradionecrosis

Bronchial asthma

Is a chronic airway disease characterized by inflammation and bronchial

constriction

Oral findings:
1. Increased prevalence in caries in children with moderate to severe asthma
2. Chronic rhinitis and mouth breathing and found that they presented with an
increased upper anterior and total anterior facial height, higher palatal vaults,
greater over jets, and higher prevalence of posterior cross bites
3. Inhaled steroids with moderate asthma, inhaled steroid therapy has potential
side effects including
 adrenal suppression,
 growth impairment,
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  throat irritation,
 dryness of the mouth,
 oropharyngeal candidiasis,
 rarely, tongue enlargement
Management:

a) History : frequency & severity of attach, triggering factors

b) Medication given:

 Bronchodilator :give before appointment & bring inhaler

 Corticosteroid : double the dose

Behavior management: Try to alleviate anxiety

a) Be calm and confident
b) Use sedation (e.g. Hydroxyzine a, benzodiazepines are recommended while
barbiturates and narcotics are not recommended they lead to histamine
release and bronchoconstriction))
c) N2O can be used in mild and moderate cases while in severe cases is not

If attach occur during treatment:

a) Stop treatment
b) Reassure the patient
c) Patient in upright position
d) Keep airway patent
e) Give inhaler
 If no improvement, give 0.01 mg /kg of 1/1000 Epinephrine

Analgesics: Aspirin and acetaminophen usually is recommended for these children

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 Diabetes mellitus

Symptoms:

a) Polydipsia, polyuria, weight loss with polyphagia

b) Recurrent infections and candidasis

c) Glycosuria and ketoacidosis may be present

d) Insulin dependent

Problems:

a) Imbalance between collagen removal and deposition with impaired recovery

b) Deposition of mucopolysaccharide in B.V. walls that leads to their

narrowing thus interfere with tissue oxygenation and waste exchange

c) Defective polymorphneuclear leucocytes chemotasis and phagocytosis

Management

1. Early morning appointment

2. Sedative
3. Antibiotic
4. LA contain vasoconstrictor may be used to ensure profound anesthesia ( not
exceed 1/100000 )
Emergency treatment

1) Hypoglycemia :

Symptoms: Mental confusion, tachycardia, nausea , cold skin ,hypotension

,loss of consciousness

Management:
a) Oral sugar, juice, chocolate
b) IV dextrose or IM Glucagon + epinephrine
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 2) Hyperglycemia:

Symptoms: Breathing rapid & deep , hypotension , dry hot skin, acetone smell &
loss of consciousness

Management: Insulin

Chronic renal Disease

CRF is a progressive and irreversible decline in the total number of functioning

nephrons, which causes a decline in the glomerular filtration rate

Problems:

1. Hypocalcaemia (P retention & impaired Ca absorption)

2. Secondary hyperparathyroidism
3. Anticoagulant therapy ……….. prolonged C.T
Oral findings:

1. Pallor of the oral mucosa related to anaemia

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 2. Red-orange discoloration of the cheeks and mucosa caused by pruritus and
deposition of carotene-like pigments occurs when renal filtration is decreased

3. Salivary flow may be diminished, resulting in xerostomia and parotid

infections

4. Candidiasis

5. Ammonia-like odour that results from a high urea content

6. Uremic stomatitis may be present, characterized early by red, burning mucosa

and ulceration

7. White patches called uremic frost caused by urea crystal deposition are more
common on the skin but may be seen on the oral mucosa

8. Petechiae and ecchymoses on the labial and buccal mucosa, soft palate, and
margins of the tongue, as is gingival bleeding

9. Oral lesions; ulcers, lichen planus (or lichenoid-like) lesions, hairy tongue,
and pyogenic granulomas

10.Enamel hypoplasia, red-brown discoloration and delayed or altered eruption

11. localized radiolucent jaw lesions (central giant cell granulomas; “brown
tumor”)

12. In general, patients with chronic renal failure exhibit increased susceptibility
to gingivitis and periodontal disease

13. Low caries incidence

Dental management
 If the patient is in the advanced stages of failure or has another systemic
disease common to renal failure (e.g., diabetes mellitus, hypertension, systemic
lupus erythematosus)

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 One of the major problems associated with treating a patient with ESRD
involves drug therapy. Of concern are drugs that are excreted primarily by
the kidney or that are nephrotoxic

 Nephrotoxic drugs such as acyclovir, aminoglycosides, aspirin, nonsteroidal

anti-infl ammatory drugs, and tetracycline require special dosage
adjustments.
 Acetaminophen also is nephrotoxic and may cause renal tubular necrosis at
high doses, but it is probably safer than aspirin in these patients because it
is metabolized in the liver

 Extraction should be performed a day after dialysis,the patient should take

1. DDAVP 0.3μg /kg (capillary fragility)
2. Antibiotic prophylaxis: Clindamycin 20 mg/kg one hour before extraction

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