Dentistry Department

Al-iraqia University College

2019/2020

Research Title: Dental

management of medically
compromised children

Name of student: Ahmed Kamal Hashem

Grade: 5

Supervision by Dr. Bassam Al Sheikhly

Table of content

Items Page number

introduction 2
Common diseases that affect the 2
children
Cardiovascular disorder 3
Hematology disorder 4
Diabetes Mellitus 6
Respiratory system disorder 7
Genetic disorder 8
Conclusions 10
References 11
1.0 Introduction1

 One of dentist’s main roles is to coordinate the management of special needs

children.
 The term of special need refer to a child who has a medical condition that
affects dental treatment or shows specific oral and dental manifestations. Some
countries called these patients as medically compromised children.1
 A survey to special needs children who came to Special Care for Dentistry
Clinic Dr. Hasan Sadikin Hospital in Bandung showed that these children have
poor oral hygiene level.Many general medical conditions may directly affect
dental treatment and in several conditions are a consequence of dental disease,
or even a dental treatment may cause an implication that leads to life
threatening.
 Increase in number of children who survive from complex medical disorder
shows several abnormalities in their oral cavity.
 The remarkable decline in childhood mortality has led to increasing emphasis
on maintaining and enhancing the quality of the child’s life and ensuring that
children reach adult life as physically, intellectually, and emotionally healthy
as possible.
 Dental care can play an important part in enhancing this quality of life.2
 According to the data from Special Care for Dentistry Dr. Hasan Sadikin
Hospital Bandung, in 2003 there are under 10 new visits and increase to 81
new visits in July-December 2008.3
 There are many systemic diseases that show oral manifestation.4
 Dentist should be able to recognize the manifestation so diagnoses and
treatment plan can be done accurately.
 This paper discusses about several medical conditions in children and the
dentist’s role in the treatment of those patients in the hospital.

1.1 Common diseases that affect the children1, 2

1. Heart Diseases
2. Leukemia
3. Diabetes Mellitus
4. Asthma
5. Hemophilia
6. Renal Disorders
7. AIDS
1.2 Cardiovascular disorder
 Heart diseases can be divided into two main groups, congenital heart disease
and acquired heart disease.2
 Almost every heart disease in children occurs congenitally with the prevalence
of 8-10 in 1000 life birth.1,2,5
 Children with congenital heart disease are the most common medically
compromised children seen by the dentist.1
 They were refer from their pediatricians in order to have mouth preparation
before heart surgery.

 Etiology of congenital heart disease

 It is rarely known and may be the combination of genetic and environment
factors, including infection during the second month of pregnancy.
 Several chromosome disorders such as Down syndrome is related to a severe
congenital heart disease.2
 Generally, congenital heart disease include:
a- Ventricular Septal Defect (VSD)
b- Arterial Septal Defect (ASD)
c- patent ductus arteriosus (PDA)
d- tetralogy of fallot (ToF).1,2,5–7

 Acquired heart disease include myocarditis, infective endocarditis, and

rheumatic fever.
 All of these diseases may cause death in children.2,5

 Important consideration
The most important consideration in planning a dental treatment for children
with cardiovascular disorder is to prevent the occurrence of dental disease.
When a child is diagnosed having a heart disease, the child should immediately
refer to a dentist to get a proper dental treatment and preventive efforts which
include diet counseling, fluoridation, fissure sealant, and oral hygiene
instruction.
Regular checkup, clinically or radiographically for preventive efforts, is highly
recommended.2,5

 Treatment of active dental disease should be done before heart surgery. 2

 Invasive dental treatments, such as tooth extraction, scaling, and endodontic
treatment may cause bacteriemia.5
 Pulpotomy is contraindicated due to the possibility to cause bacteriemia. 1
 If a patient is going to be treated with a treatment that may cause bacteriemia,
antibiotic prophylaxis is needed to prevent the development of endocarditis. 2
  Dental Problems & Treatment
a- Prior to treatment, complete medical history should be elicited & consultation
with the child’s cardiologist is necessary to determine the child’s ability to
tolerate the planned treatment, complications that can arise & antibiotic
prophylaxis to be given.
b- Antibiotic prophylaxis may be recommended in infective endocarditis patients
for those dental procedures which are likely to induce gingival bleeding &
including orthodontic treatment.
c- Pulp therapy of the primary teeth is not recommended due to high risk of
chronic infection. Instead, extraction of the offending tooth & its replacement
with a space maintainer is advocated.
d- Oral sedation & nitrous oxide analgesia may be beneficial in reducing anxiety
& minimizing risk.
e- In patients who are on anticoagulant therapy hematological monitoring &
cessation of anticoagulation therapy are important before any dental surgery is
taken.
f- Children suffering from severe, debilitating heart disease requiring extensive
dental work-up should be treated in a hospital under general anesthesia.

1.3 Hematology disorder

 In early childhood, many bleeding disorders have genetic background.
 Common hematology disorders in children are thallasemia and leukemia.2
 Thallasemia is a blood disorder with the absence or lack of one of the globin
chain from hemoglobin complex.
 Normally, blood from a healthy adult contain hemoglobin A that include two
chain of globin (HbA, α2β2) and a minor amount of hemoglobin A2 (HbA2,
α2γ2).
 Children also develop fetal hemoglobin (HbF,α2δ2).1 Dental implication of
thallasemia is malformation of jaws. This was due to overgrowth in the maxilla
and zygoma.
 Class II division 1 maloclusion is a common jaw disorder in thallasemia
children.
 Treatments for thallasemia are regular blood transfusion and the administration
of desferrioxamine-an iron-chelating agent.
 Blood transfusion may cause gingival discoloration (hemosiderosis) resulted
from ferrum accumulation.1
 Bone involvement is the commonest clinical manifestation of thallasemia.
 These include the involvement of alveolar bone.9
 Dental treatment for patient with thallasemia needs an adequate medical history
evaluation.
 Consultation with child’s pediatrician or hematologist before initiating dental
treatment is important.
 Treatment that is highly recommended for those patients is preventive treatment
and regular dental checkup.
 Dental treatment is preferable to be carried out after blood transfusion.
 The treatment is postponed if patient’s hemoglobin level is below 100 g/L. 2

 Dental Problems & Treatment

a- The primary aim of dental treatment should be to prevent, control &
remove oral infection, inflammation & hemorrhage.
b- Consult the child’s physician prior to any treatment & take a complete
medical history.
c- Avoid prescribing drugs like aspirin that can alter platelet function.
d- Pain from ulcerative lesions can be relieved by application of topical
obtundents.
e- For deep lesions that bleed spontaneously, apply topical bovine thrombin.
f- Pulp therapy on primary teeth is contraindicated.
g- If platelets are less than 20,000/cubic mm dental treatment should not be
undertaken without prophylactic platelet transfusion.
h- Avoid mouth brushing & substitute with moist gauze wipes containing
chlorhexidine if platelet count is low.
i- Management of xerostomia by the use of sugarless sweets, sorbitol based
gums, artificial saliva & topical fluoride may be done.
1.4 Diabetes Mellitus
 It is a condition in which a person has high blood sugar levels because either
the body does not produce sufficient amount of insulin or the patient does not
respond to the insulin that is produced.
 This high blood sugar levels are classically manifested as
a- Polyuria (frequent urination),
b- Polydipsia (increased thirst)
c- Polyphagia (increased hunger).

 Dental Management
a- Dental appointments should be short, stress free, as atraumatic as possible.
b- Early morning appointments are preferred and the patient should eat a
normal breakfast before the appointment to prevent hypoglycemia.
c- Use of pulp capping and pulpotomy procedures is questionable in the child
with uncontrolled diabetes.
d- Vital pulp therapy may be preferred to a stressed extraction procedure under
local anesthesia.
e- Prophylactic antibiotic may be recommended in use of surgical procedures.
 1.5 Respiratory system disorder
 Respiratory system disorder that commonly occurs in children is asthma.
 Asthma is a diffuse obstructive lungs disease that may cause short winded,
cough, and wheezing.
 This is related to hyperactivity of airway to any stimuli.2
 Children with asthma commonly receive medication with steroids.
 These drugs may cause extrinsic discoloration in tooth surface due to oral flora
changes which results in a candidiasis.
 Corticosteroid can also change oral cavity pH and reduces salivary flow
resulting an increase in the possibility of dental erosion.
 Children with asthma breathe through mouth, may lead to the development of
gingivitis and gingival enlargement in anterior part.1
 Dental treatment may cause emotional stress which can develop asthmatic
attack. Dental extraction or other treatments that need local anesthesia usually
do not cause any trouble.2
 Generally, dental treatment for children with asthma is regular dental
prophylaxis.
 Child is ordered to wash their mouth after using steroid inhaler or other
medication.1
  Dental Problems & Treatment (specially of asthma )
1- Complete medical history should be elicited.
2- Seat the patient in upright position for dental procedures.
3- Treat child soon after a dose of medication is given, and if the child is using
an inhaler it should be brought along for the dental appointment in case of
an attack.
4- Sedation, local anesthesia and general anesthesia can be given, if indicated.
5- Patients who are receiving corticosteroid therapy are at a risk from stress.
Therefore, double or triple the steroid dosage and adjust the time of
appointment to ensure that the patient is seen shortly, after medication has
been administered.
6- Use of aspirin, NSAID and penicillin is contraindicated.
7- Use of nitrous oxide-oxygen sedation is more desirable in such patients.
8- In case of an asthmatic attack in emergency, administer 100% oxygen with
the patient in a sitting position, leaning forward, and subcutaneous
administration of 0.3 ml of 1:1000 epinephrine.

1.6 Genetic disorder

 Child with genetic disorder usually visit a dentist with specific dental anomalies
that is related to their condition or a medical problem that complicate dental
treatment.
 Not every child having genetic disorder come to the dentist. History taking can
be simplified by making a simple family pedigree.1
 Generally, dental treatment for a child with genetic disorder is to overcome the
oral complication and manifestation that related to the disorder.
 However, it is important for a dentist to recommend the parents or patient’s
relative for genetic counseling.
 This is a process to make diagnostic assessment, information, and support to the
family or individual who have the risk in developing genetic disorder.1
 Genetic disorder discussed in this paper is Apert syndrome, which is a rare
genetic disorder and characterized by specific abnormality of craniofacial and
extremities structures.
 Oral manifestations are prominent mandible, decline edge of mouth, cleft
palate, dental malposition, crowding, delayed tooth eruption, thickened alveolar
ridge, malocclusion and hard palate deformity termed Byzantine arch
deformity.10,11
 Apert syndrome is characterized by midface hypoplasia, syndactyly of the
hands and feet, proptosis of eyes, steep and flat frontal bones, and premature
union of cranial sutures.
 Maxillary hypoplasia, deep palatal vault, anterior open bite, crowding of the
dental arch, severely delayed tooth eruption, and dental malocclusion are the
main oral manifestations of this syndrome.12
 Management of children with Apert syndrome needs team approach that consist
of craniofacial surgeon, neurosurgeon, oral surgeon TNT specialist, audiologist,
speech pathologist, psychology, ophthalmologist, pedodontist, dan
orthodontist.2,9
 The main treatment method is surgery that is needed to correct craniofacial
abnormalities and fused fingers and toes. Beside surgery, the treatment also
termed to correct upper respiratory tract, eyes deformities, or abnormalities in
dental area.11

 Dental Problems & Treatment

1- If the patient’s apprehension is significant, sedation or nitrous oxide-oxygen
inhalation analgesia is considered and also using acetaminophen,
propoxyphene hydrochloride, narcotic analgesics is required.
2- When general anesthesia is considered, oral intubation is preferred over nasal
intubation.
3- Intramuscular injections should be avoided.
4- For patients who require deep scaling, initially do supragingivally and then
repeat after 7-14 days after proper healing.
5- Factor replacement is required before frenectomy and other periodontal
surgeries.
6- Electro surgery is done because of the possibility of continued bleeding.
7- Small carious lesions are restored without a factor concentrate replacement.
8- Use wedges and matrices for a proximal box.
9- Use retraction cords during crown preparation.
10- Antibiotic prophylaxis should be carried out before extraction.
11- Instrumentation and filling beyond the apex should be avoided.
12- Fixed appliances are preferred than removable.
2.0 Conclusion
 Many medical disorders may directly affect dental treatment and in several
conditions it is a consequence of dental disease, thus it may leads to life
threatening. Children with medically compromised condition sometimes have
to be treated in hospital.
 These may lead to a lack of dental care that resulted in complex oral
manifestations. Lack of knowledge from their parents about the importance
of maintaining oral health may exacerbate the existing medical conditions.
 Early professional’s intervention is very important in carrying examination,
risk assessment, and giving information and tutorial, thus oral diseases can be
prevented.5
 Congenital heart disease is more common occur in children than acquired
heart diseases. Many heart diseases need antibiotic prophylaxis before
undergoing invasive dental treatment.
 Another important aspect to be carried out is patient’s monitoring during
dental treatment. These includes oxygen administration and observation of
pulse and oxygen saturation with pulse oxymetri.2
 Child with bleeding disorders, such as hemophilia, thrombocytopenia, and
Von Willebrand’s disease, have to be checked their hematological status
before carrying out dental treatment.
 Hematologic replacement therapy may be needed before operative treatment.
 Bleeding disorder in form of anemia is in a risk of dental treatment under
general anesthesia.2
 The importance of adequate dental plaque control techniques in order to
prevent inflammation, potential bleeding and infection in these patients is
emphasized.
 The pediatric dentist must be aware of the clinical appearance of bleeding
disorder in order to recognize the condition and successfully manage the
patient.14
 Child with genetic disorder needs a special attention in their oral and dental
care especially due to the complexity of the abnormalities in oral cavity.
These include the abnormality of dentocraniofacial complex.9,10
 Dental treatment of these patient usually needs specific team approach
consists of pedodontist, pediatrician, TNT specialist, anesthesiologist, and
surgeon.11
 Increased number of children who survive from complex medical problem
may be due to the increase of the advanced medical treatment and the
management of oral manifestation and complication through oral and dental
prophylaxis.
 Role of the dentist in managing these patients is giving preventive efforts and
dental treatments that may be improve patient’s quality of life.
 Nevertheless, cooperation from the dentist and other professional is needed
in treating these patients.
  In conclusion managing children with congenital heart disease, dentist may
make intervention as early as possible after a child being diagnosed having a
heart disease.
 With preventive efforts, the child will have a good oral conditions so they
can undergo heart surgery.
 Children with hematology disorder, such as thallasemia, have dental
implication due to malformation of the jaw which lead to class II division I
malocclusion.
 The role of the dentist is to minimize this malocclusion so the child may have
a “normal” appearance.
 These is also due to children with genetic disorder.
 The dentist’s role is to correct the abnormalities in dental area.
 Children with respiratory system disorder have dental implication due to the
drugs they used to treat their conditions.
 The role of the dentist in this children is to minimize the side effect of the
drugs to their oral environment.

2.0 References
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