it is the management of patients in whom dental treatment may need modifications according to their medical condition.

1. DENTAL
MANAGEMENT
OF
MEDICALLY COMPROMISED CHILDREN
ISHITASINGHAL
INTERN

2. INDEX
•Introduction
•Heart Diseases
•Leukemia
•Diabetes Mellitus
•Asthma
•Hemophilia
•Renal Disorders
•AIDS

3. Introduction

5. Heart Diseases

6. Diseases of heart can be divided into two general types:—
• Congenital Heart Defect is a problem with the heart structure & function that is present
at birth.
1. Acyanotic
2. Cyanotic
• Acquired Heart Defect is a heart disease that develops after birth.
1. Rheumatic Fever
2. Infective Bacterial Endocarditis

7. Acyanotic Congenital Heart Disease
• There is minimum or no cyanosis.
• It consists of 2 different categories-
1. Defects that cause left to right shunting of blood within the heart.
(Atrial Septal & Ventricular Septal Defects)
2. Defects that cause obstruction.
(Aortic Stenosis & Coarctation of the Aorta)

8. Cyanotic Congenital Heart Disease
• Cyanosis is seen on minimum exertion due to right to left shunting of blood within
the heart.
(Tetralogy of Fallot, Transposition of Great Vessels, Pulmonary Stenosis & Tricuspid
Atresia)

9. Etiology Of Congenital Heart Disease
• There is interaction between genetic & environmental factors.
• Maternal rubella, maternal diabetes & drugs during pregnancy.
• Children with inborn errors of metabolism & connective tissue disorders.

10. Rheumatic Fever
• It is a serious inflammatory disease.
• Can occur at any age.
• Rarely seen in infants.
• Commonly appears between 6 to 15 years of age.
• Condition can be fatal in acute stage or can lead to a chronic rheumatic heart disease
as a result of scarring of the valves.

11. Infective Bacterial Endocarditis
• It is a microbial infection of heart valves.
• It is of 2 forms-
1. Acute form-A fulminant disease occurs as a result or infection with highly virulent
organisms like staphylococcus, group A streptococcus & pneumococcus.
2. Sub-acute form-It develops in individuals who already have an existing congenital
cardiac disease or rheumatic valvular lesions caused by viridans streptococci.

12. Dental Problems & Treatment
• 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.
• Antibiotic prophylaxis may be recommended in infective endocarditis patients for
those dental procedures which are likely to induce gingival bleeding & including
orthodontic treatment.

13. • 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.
• Oral sedation & nitrous oxide analgesia may be beneficial in reducing anxiety &
minimizing risk.
• In patients who are on anticoagulant therapy hematological monitoring & cessation of
anticoagulation therapy are important before any dental surgery is taken.
• Children suffering from severe ,debilitating heart disease requiring extensive dental
work-up should be treated in a hospital under general anesthesia.

14. Leukemia

15. Leukemia is a hematopoietic malignancy in which there is a proliferation of abnormal
leukocytes in the bone marrow & dissemination of these cells into the peripheral blood.
The abnormal leukocytes (blast cells) replace normal cells in bone marrow & accumulate
in other tissues & organs of the body.

16. Etiology Of Leukemia
• Cause in most patients is unknown ,although both genetic & environmental factors
are important.
• Immunodeficiencies & prolonged immunosuppression may also lead to lymphoid
malignancies.

17. Dental Problems & Treatment
• The primary aim of dental treatment should be to prevent ,control & remove oral
infection ,inflammation & hemorrhage.
• Consult the child’s physician prior to any treatment & take a complete medical
history.
• Avoid prescribing drugs like aspirin that can alter platelet function.
• Pain from ulcerative lesions can be relieved by application of topical obtundents.

18. • For deep lesions that bleed spontaneously ,apply topical bovine thrombin.
• Pulp therapy on primary teeth is contraindicated.
• If platelets are less than 20,000/cubic mm dental treatment should not be undertaken
without prophylactic platelet transfusion.
• Avoid mouth brushing & substitute with moist gauze wipes containing chlorhexidine
if platelet count is low.
• Management of xerostomia by the use of sugarless sweets ,sorbitol based gums
,artificial saliva & topical fluoride may be done.

19. Diabetes Mellitus

20. 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
• Polyuria (frequent urination),
• Polydipsia (increased thirst) &
• Polyphagia (increased hunger).

23. Dental Management
• Dental appointments should be short, stress free, as atraumatic as possible.
• Early morning appointments are preferred and the patient should eat a normal
breakfast before the appointment to prevent hypoglycemia.
• Use of pulp capping and pulpotomy procedures is questionable in the child with
uncontrolled diabetes.
• Vital pulp therapy may be preferred to a stressed extraction procedure under local
anesthesia.
• Prophylactic antibiotic may be recommended in use of surgical procedures.

24. Asthma

25. It is an episodic disease of airways wherein the attacks are short lived and the patient
seems to recover from them completely clinically and is characterized by an increased
responsiveness of the tracheobronchial tree to a multiplicity of stimuli.
It is manifested by a wide-spread narrowing of the air passages and clinically by
paroxysms of dyspnea ,cough and wheezing.

27. Dental Problems & Treatment
• Complete medical history should be elicited.
• Seat the patient in upright position for dental procedures.
• 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.
• Sedation ,local anesthesia and general anesthesia can be given ,if indicated.

28. • 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.
• Use of aspirin ,NSAID and penicillin is contraindicated.
• Use of nitrous oxide-oxygen sedation is more desirable in such patients.
• 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.

29. Hemophilia

30. It is a group of hereditary genetic disorders that impair the body’s ability to control blood
clotting or coagulation.

33. Dental Problems & Treatment
• 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.
• When general anesthesia is considered ,oral intubation is preferred over nasal
intubation.
• Intramuscular injections should be avoided.
• For patients who require deep scaling ,initially do supragingivally and then repeat
after 7-14 days after proper healing.

34. • Factor replacement is required before frenectomy and other periodontal surgeries.
• Electro surgery is done because of the possibility of continued bleeding.
• Small carious lesions are restored without a factor concentrate replacement.
• Use wedges and matrices for a proximal box.
• Use retraction cords during crown preparation.
• Antibiotic prophylaxis should be carried out before extraction.
• Instrumentation and filling beyond the apex should be avoided.
• Fixed appliances are preferred than removable.

35. Chronic Renal Failure

36. It an be defined as a progressive and irreversible decline in the total number of
functioning nephrons ,with concomitant decline in the glomerular filtration rate.
They may be acute ,chronic ,acquired or congenital.

40. Dental & Medical Treatment
• Consultation with the patients physician or nephrologist is usually required.
• Prevention of fluid and electrolyte imbalance ,limitations of uremic symptoms through
restriction in protein intake ,correction of hypocalcemia and hyperphosphatemia and
the control of anemia and hypertension.
• Artificial filtration in the form of either peritoneal dialysis or hemodialysis.
• Optimal treatment timing is 1 day after dialysis when blood is free of wastes and
heparin levels are waning.

41. • Renal transplantation in end-stage renal disease.
• Acute renal disease stage-only emergency care is indicated.
• When surgical procedures are considered ,assess the bleeding time.
• Avoid hypertension medications.
• Fluid balance should be maintained by managing oral diseases like herpetic stomatitis
,severe caries ,cellulitis ,etc.
• Increased need for oral prophylaxis due to increase in calculus formation.
• Antibiotic prophylaxis before dental treatment is to prevent bacteremia.

42. AIDS

43. Acquired Immune Deficiency Syndrome
• AIDS is the condition diagnosed when there are a group of related symptoms that are
caused by severe HIV infection.

45. Dental Management
• Barrier techniques
• Proper sterilization
– HIV is sensitive to autoclaving at 121°C for 15 min at 1 atmospheric pressure
– Dry heat of instruments up to 170°C
– Virus can be inactivated by heating lyophilized factor at 68°C for 72 hours.

46. • Disinfectants for innate objects:
– Calcium hypochlorite
– 0.2% sodium hypochlorite
– 6% hydrogen peroxide for more than 30mins
– 2% glutaraldehyde and 6% hydrogen peroxide
– Sodium dichloroisocyanate
– HIV is inactivated by treatment for 10 mins at room temperature with 10% household
bleach, 50% ethanol and 3% hydrogen peroxide
– Gloves may be disinfected by immersing them in boiling water for 20 mins and
alternatively overnight soaking in 1% sodium hypochlorite.

47. • Acyclovir 1 to 2 gm daily orally or IV
• Zidovudine (AZ7), which attacks the virus through the enzyme reverse transcriptase
• Three other inhibitors are also in market, namely Dideoxycytosine (ddc),
Dideoxyinosis (dd I), Stavudine (d4 T)
• Use of protease inhibitors like saquinavir, indinavir and ritonavir.