Management of medically handicapped children

MANAGEMENT OF MEDICALLY
HANDICAPPED PATIENTS
Dr Susmita Shah
III MDS
Pediatric & Preventive Dentistry

Contents:
1. Introduction
2. Pre-appointment preparation
3. Establishment of Dental Home
4. Management of Cardiovascular
Diseases
5. Management of Pulmonary
Diseases
6. Management of Haematological
Disorders
7. Management of Endocrine
Disorders
8. Management of Neurological
Disorders
9. Management of Immunological
Disorders
10.Summary
11.Bibliography 2

1. Introduction
01
02
03
acquiring a thorough health history.
significance of the disease that may
be endorsed by the patient.
Each identified condition can affect dental care in a unique
manner.
American Academy of Pediatric Dentistry. Guideline
onrecord-keeping.
Pediatr Dent 2012;34(special issue):287-94.
3

American Academy of Pediatric Dentistry. Guideline onrecord-keeping.
Pre-appointment preparation
Obtain Medical
history records-
most complete
picture of the
child’s medical
conditions and/or
behavioral issues.
Consult with the
child’s primary
care physician-
underlying
medical conditions
affecting the heart,
lungs or other
internal systems
-taking
medications
- allergies to latex
4

American Academy of Pediatric Dentistry. Guideline onrecord-keeping.
 Assessment and Management Tools:
• Complete blood count (CBC) with Plat.
Count and white blood cells (WBC).
• BT/CT
• Liver function tests (LFTs)
• Hepatic Serology, Serum Creatinine.
• Fasting blood sugar test (FBS);
 Complete Health History:
• Date of Last Physical
Examination;
• Name, Address and Tel of
Specialists;
• List of Medical conditions being
treated;
• List of medications;
• Allergies and Medical
emergencies experienced;
• Hospitalizations.
5

At each
patient visit,
the history
should be
consulted and
updated.
An
individualized/
customized
treatment plan
should be
made.
Establishment
of Dental
Home
A caries-risk
assessment
should be
performed
periodically.
-American Academy of Pediatric Dentistry. Guideline oncaries-risk
assessment and management for infants, children and adolescents.
-AAPD Guidance on management of persons with
special health care needs. Revised 2012 6

MANAGEMENT OF
CARDIOVASCULAR
DISEASES
7

Acyanotic
left
to
right
shuntVentricular
septal defect
Atrial septal
defect
Patent ductus
arteriosus Cyanotic
obstructive
lesions
Pulmonary
stenosis
Coarctation of
the aorta
Aortic stenosis
Cyanotic
right
to
left
shunt
Tetralogy of
Fallot
Transposition
of the great
arteries
Truncus
arteriosus
1) Congenital Cardiac Conditions
McDonald RE, Avery DR, Dean JA. Dentistry for the child and adolescent. 9 ed.
USA: Mosby an affiliate of elsivier; 2004. 8

Acyanotic left to right shunt
Cyanotic right to left shunt
Cyanotic obstructive lesions
9

10
Oral and dental management in children with tetralogy of fallot
Dent. J. (Maj. Ked. Gigi), Vol. 40. No. 1 January-March 2007: 42–45

• Preventive treatments were carried out and topical fluoride
application.
• Curative treatments are extraction of the teeth with necrotic
pulp and glass ionomer cement fillings in hyperemia pulp teeth.
• To prevent bacterial endocarditis, patient was given a
prophylactic antibiotic 50mg/kg body weight one hour before
treatment.
• During the dental procedure, patient was monitored by pulse
oximetry to monitor the oxygen saturation and pulse.
• Patient also inhaled oxygen (Figure 2).

Cardiac
arrhythmias
•Cardiomyopathies
Cardiac
failure
Infectious
endocarditis
Rheumatic fever – carditis
and valvular damage
Stewart R E, Barber T K, Troutman K C, Wei S H. Pediatric Dentistry scientific foundation and clinical practice. Mosby
publishers 1942, First edition.
Oral Manifestations
1. Delayed eruption of teeth
2. Positional anomalies
3. Enamel hypoplasia
4. Teeth have bluish white skimmed milk appearance
and gross vasodilatation of pulps
5. Increased caries & Periodontal Disease
6. After cardiotomy, transient small white, non
ulcerated mucosal lesions of unknown etiology
may be seen.
2) Acquired Cardiac Conditions
12

Infective
Endocarditis
• An infrequent condition resulting from the
association of morphological alterations of
the heart and bacteremia of different origins.
• It has been estimated that 14-20% of all cases
of IE have a buccodental origin.
• Transient bacteremia is observed not only in
dental treatments such as tooth extractions
(51-85%) or periodontal surgery (36-88%), but
also during tooth brushing (26%) or when
chewing gum (17- 51%).
• Approximately 50% of all cases of infectious
endocarditis are caused by Streptococcus
viridians.
13
Stewart R E, Barber T K, Troutman K C, Wei S H. Pediatric Dentistry scientific foundation and clinical practice. Mosby publishers
1942, First edition.

• It is characterized by microbial infection of the heart valves/ endocardium in
proximity to congenital / acquired cardiac defects.
14
Infective
Endocarditis
Acute IE Chronic IE
Microorganisms of high pathogenicity
(staphylococcus, group A Streptococcus,
Pneumococcus) attack normal heart, causing
erosive destruction of valves.
Persons with preexisting
congenital cardiac conditions/
rheumatic valvular lesions.
Stewart R E, Barber T K, Troutman K C, Wei S H. Pediatric Dentistry scientific
foundation and clinical practice. Mosby publishers 1942, First edition.

Oral Manifestations
• Developmental defects of enamel (Particularly in primary dentition)
- Attributed to:
15
Stewart R E, Barber T K, Troutman K C, Wei S H. Pediatric Dentistry scientific foundation and clinical practice.
Mosby publishers 1942, First edition.
Relationship
between the
genetic basis of
the cardiac
condition and
development of
the dentition
Metabolic features
of the condition
Effect of treatment
of the cardiac
condition

• Increased risk of dental caries (Primary and
permanent dentition)
- Prevalent despite the finding that cardiac
children receive more dedicated oral health
care
- Attributed to:
• Medications
• Compliance
• Diet
• gingivitis
• Delayed tooth eruption
• Instrinsic tooth stains
Increased prevalence of periodontal disease
- Attributed to:
• Compliance
• Association with the syndromic patient; eg
Trisomy 21
Increased prevalence of malocclusion and crowding
- Attributed to association with the syndromic
patient; eg DiGeorge syndrome or Trisomy 21
Intra‐oral soft tissue cyanosis
16

Dental Management:
17
• Pre‐surgical 0.2% chlorhexidine mouth
wash
• Determine coagulation status
• Reduce stress with sedation or GA
• Monitor for respiratory distress
• Regular review
• Essential principles:
• Eliminate oral infection
• Reduce the risk of bacterial
endocarditis
• Maintain good oral health
• Consult patients cardiologist
• Vigilant preventive regimen

PLANNED PREVENTIVE DENTAL CARE
 Meticulous preventive oral health care
 To keep periodontal infection at the lowest
 If extractions are unavoidable, gingiva should be kept healthy to reduce bacteremia
 Smith and Adams in 1993- very high proportion have periodontal diseases.
Scaling - antibiotic prophylaxis
Pulp therapy is not recommended for primary teeth with a poor prognosis because of
high incidence of associated chronic infection.
Extraction of these teeth with appropriate fixed space maintainers is preferred.
18

 Rheumatic Fever
• Heart: carditis, scarring & deformity of valves
• joint
• skin
• CNS
• subcutaneous tissue
• prevalence of RHD to be about 2/1000 population,
• however survey conducted in school children in the age group of 5-
16 years by ICMR gives overall prevalence of 6/1000(range 1.8 to
11/1000).
National Health Portal Published Date : Nov 07, 2016 Published By : Zahid
19

General Management
S
S
P
A
Use of salicylates for arthritis
and penicillin if streptococcal
infection is still active
Prompt treatment ( 24 hours ) of a
streptococcal sore throat prevents
development of rheumatic fever
After an attack, continuous antibiotic
prophylaxis to prevent permanent cardiac
damage
Drug of choice -oral
phenoxymethyl penicillin 500 mg
daily until 20 years of age. If
allergic, sulphadimidine 500mg
daily 20

Dental Aspect of Rheumatic fever
• Emergency dental treatment may be necessary during an attack to relieve
toothache
• Consultation with physician
• LA is preferred
• GA avoided because of possibility of myocarditis
21
Stewart R E, Barber T K, Troutman K C, Wei S H. Pediatric Dentistry scientific foundation and clinical practice. Mosby publishers 1942, First edition.

Recommended Not Recommended
•Dental extraction
•Periodontal procedures including surgery,
scaling, root planing, probing
•Dental implant, reimplantation of avulsed
teeth.
•Endodontics or surgery beyond apex
•Subgingival antibiotics strip placement
•Orthodontic band placement
•Intraligamentary LA
•Prophylaxis of teeth/implants
•Restorations
•Non intraligamentary LA injections
• Intracanal endodontic treatment, post
placement
•Rubber dam placement
•Suture removal
•Removable appliances
•Impressions
•Fluoride treatment
•Orthodontic appliance adjustments
•Shedding of primary teeth
Antibiotic Prophylaxis Prior Dental
Treatment
22

AAPD Guidelines On Antibiotic Prophylaxis For Dental
Patients At Risk For Infection (2012)
Situation Agent Adult dose Children dose
Oral Amoxicillin 2g 50mg/kg
Unable to take oral
medication
Ampicillin
or
Cefazolin or ceftriaxone
2 g IM or IV
1 g IM or IV
50 mg/kg IM or IV
20 mg/kg IM or IV
Allergic to penicillins or
ampicillin—oral
Cephalexin
or
Clindamycin
or
Azithromycin or
clarithromycin
2 g
600 mg
500 mg
50 mg/kg
20 mg/kg
15 mg/kg
Allergic to penicillin or
ampicillin
and unable to take oral
medication
Cefazolin or ceftriaxone
or
Clindamycin
1 g IM or IV
600 mg IM or IV
50 mg/kg IM or IV
20 mg/kg IM or IV
23

MANAGEMENT OF
PULMONARY
DISEASES
24

• Chronic obstructive pulmonary disease (COPD) is a general term used in
reference to respiratory disorders characterized by not totally reversible chronic
pulmonary airway obstruction.
• Representative examples of COPD are chronic bronchitis and lung emphysema.
• Patients with COPD may experience worsening of respiratory function during
dental treatment; a number of precautions are therefore recommended.
1. Chronic Obstructive Pulmonary Disease
Claramunt Lozano A, Sarrión Perez MG, Gavaldá Esteve C. Dental considerations in patients with respiratory
problems. J Clin Exp Dent 2011; 3(3): 222-7.
25

Claramunt Lozano A, Sarrión Perez MG, Gavaldá Esteve
C. Dental considerations in patients with respiratory
Epidemiology
• 4th leading cause of death.
• More than 20 million people affected – 17 million with Chronic
bronchitis & 3 million with Emphysema.
• Prevalence, incidence and hospitalization increase with age.
• Most common cause of COPD in children – Second hand
smoking.
26

The signs and symptoms of COPD
include
An ongoing cough
or a cough that
produces large
amounts of mucus
(often called smokers
cough)
Shortness of
breath, especially
with physical
activity.
Wheezing (a
whistling or
squeaky sound
when you breathe)
Chest tightness.
problems. J Clin Exp Dent 2011; 3(3): 222-7. 27

• It is advisable to treat the patient in the vertical position.
• Avoid use of rubber dam.
• Use pulse oximetry
• Specialized clinics are able to offer oxygen equipment and personnel trained in its use.
• Hypnotics, narcotics, antihistamines and anticholinergic agents are to be avoided.
•
• If the patient is receiving corticosteroids- supplements may be needed.
• In the case of individuals receiving theophylline- macrolide antibiotics (erythromycin, clarithromycin) are to be
avoided.
• Ambulatory general anaesthesia is totally contraindicated.
• The teeth and periodontium can serve as a reservoir for respiratory infections.
Dental Management:
Claramunt Lozano A, Sarrión Perez MG, Gavaldá Esteve C. Dental considerations in patients with respiratory problems. J Clin Exp Dent 2011; 3(3):
222-7.
28

Title Authors
Journal
LOE Aim Method Result Conclusion
The
association
between dental
health and
nutritional
status in
chronic
obstructive
pulmonary
disease
Takeshi
Terashima et al
Chronic
Respiratory
Disease 2017
3b The purpose of
this case-
control study
was to examine
our hypothesis
that COPD
patients have
poorer
periodontal
health and
poorer
nutritional
status than non-
COPD patients.
Periodontal status
was assessed
using bleeding on
probing (BOP),
pocket depth (PD),
and plaque–
control ratio
(PCR). Nutritional
status was
assessed using
body mass index,
lean body mass,
and serum
albumin levels.
All the specimens
showed marginal
adaptation and
discrepancy. The
lingual margin had
a significantly better
adaptation
(p < .0001) over the
other surfaces. The
buccal surface was
the only surface
that had an
appropriate supra-
CEJ level with a
significance
of p < .0001
The marginal
discrepancies
occur during
the trimming
procedure and
assessment of
the gingival
approximation
of the SSC
margin. The
inspection of
stainless steel
crown
adaptation and
discrepancy is
an essential
clinical step.
29

2. Asthma
Reactive airway disease
Characterized by a family
history of asthma, together
with an increase in serum IgE
titers.
Stimuli such as physical exercise, the
inhalation of cold air, emotions, exposure to
smoke, hypoxemia, stress,
gastroesophageal reflux, etc
Intrinsic Asthma
Asthma is a common condition,
typically affecting children and with a
prevalence of 5-6%.
Non-allergic Asthma
Allergic
Over half of all affected
individuals are between 5-
15 years of age
Asthma
30

• Patients with asthma can be sensitive to aspirin and nonsteroidal antiinflammatory
drugs (NSAIDs).
• The drugs used to treat asthma have been related to certain oral disorders such as
• xerostomia (dry mouth),
• oropharyngeal candidiasis and
• an increased prevalence of caries (due to the use of inhalatory β-agonists).
• The use of oral rinses after medication has been found to be of great help in preventing
oral mucosal alterations.
• Asthmatic patients can also suffer gingivitis, since they are often oral breathers -
contribute to increase gingival inflammation.
problems. J Clin Exp Dent 2011; 3(3): 222-7. 31

Drugs to be avoided in asthmatic patients:
Drugs containin
g aspirin (10-28
% of all asthma
tics may not tol
erate the latter)
Macrolide anti
biotics in patie
nts treated wit
h theophylline.
Opiates: these can
cause respiratory
depression and
histamine release.
Nonsteroidal
antiinflammatory drugs
(patients with intrinsic
asthma).
222-7.
Local anesthetics: use
solutions without adrenalin or
levonordefrin, due to the
sulfite preservative contents
Ask patient to bring medication
inhaler at ever appointment and
to keep it available
32

The critical moments of dental treatment in which
an asthma attack can be triggered
Immediately after local
anesthetic injection
Those maneuvers that cause
stress – such as extractions,
surgery, or dental pulp removal in
endodontic procedures.
Claramunt Lozano A, Sarrión Perez MG, Gavaldá Esteve C. Dental considerations in patients with respiratory problems. J Clin Exp Dent 2011; 3(3): 222-
7.
33

Management of Asthmatic Attack
Suspend the dental
procedure and raise the
patient to a comfortable
position.
Establish and keep the airways
free, and administer an
inhalatory β2 agonist
Administer oxygen with a mask. If no
improvement is observed or the symptoms
worsen, administer subcutaneous
epinephrine (1:1000 in solution, 0.01 mg/kg
body weight, with a maximum dose of 0.3
mg).
Claramunt Lozano A, Sarrión Perez MG, Gavaldá Esteve C. Dental considerations in patients with respiratory problems. J Clin Exp Dent 2011;
3(3): 222-7.
Notify the emergency
medical service.
Maintain adequate oxygen
levels until the patient breathes
regularly and/or medical help
arrives.
34

Title Authors
Journal
LOE Aim Method Result Conclusi
on
Dental
caries
status and
salivary
properties
of asthmatic
children and
adolescents
MÔNICA
PAGANI
NI et al
Internatio
nal
Journal
of
Pediatric
Dentistry,
2011
3b This
study
aimed
to
investig
ate the
dental
caries
status
and
salivary
properti
es in 3‐
to
15‐year
‐old
children
/adoles
cents.
The sample was split in
two groups: asthma group
(AG), composed of 65
patients who attended
Public Health Service;
asthma‐free group (AFG),
composed of 65
nonasthmatic
children/adolescents
recruited in two public
schools. Stimulated
salivary samples were
collected for 3 min.
Buffering capacity and pH
were ascertained in each
salivary sample. A single
trained and calibrated
examiner (kappa =
0.98) performed the dental
caries examination
according to WHO criteria.
The AFG showed salivary flow
rate (1.10 ± 0.63 mL/min)
higher (P = 0.002) than AG
(0.80 ± 0.50 mL/min). An
inverse relationship was observed
between asthma severity and
salivary flow rate (Phi coefficient,
rφ: 0.79, P = 0.0001). Children
with moderate or severe asthma
showed an increased risk for
reduced salivary flow rate (OR:
17.15, P < 0.001). No
association was observed
between drug use frequency (P
> 0.05) and drug type (P >
0.05) with salivary flow rate.
Buffering capacity was similar in
both groups. No significant
differences were encountered in
dental caries experience between
AFG and AG groups.
Although
asthma
can cause
reduction
in flow
rate, the
illness did
not seem
to
influence
dental
caries
experienc
e in
children
with
access to
proper
dental
care.
35

similar to that of
squamous cell carcinoma
Irregular ulceration with
polygonal margins,
possible peripheral
induration and a dirty
appearing base
with the Koch bacillus
Later stages: tuberculous
follicle or granuloma
Primary Infection
Mandibular bone, tongue, Lower lip,
Palatine Tonsils, Posterior Pharyngeal
Wall, Parotid Glands
Location
Appearance
Ulceration
Bacteria
Involved
Oral
Manifestations
222-7.
36
3. Pulmonary Tuberculosis
• Tuberculosis can affect any body organ, though the lungs are the most common location.
Age
common in
young
children

https://www.tbfacts.org/tb-statistics-india

Dental Management:
5. Maintenance of proper hand
hygiene, personal protective
equipment's like eye shields,
facemasks, head caps, gloves and
surgical gowns.
4. Provide dental
operatories with fresh,
non recirculated outdoor
air to dilute the
contaminated operating
air.
1. Limit the use of
ultrasonic scalers and
highspeed handpieces in
actively infected patients
2. High volume suction
is mandatory Avoid- In case patient
has productive cough
3. Use of Rubber Dam
222-7.
CDC Guidelines (2003)
6. Effective air
evacuation
exhausted or HEPA-
filtered if re circulation is
necessary
7. Anti
bacterial
sprays may
be used.
8. Regular fumigation of
dental operatories. Cleaning
and disinfecting critical and
semi critical contact surfaces
like Dental chair and
accessories.
38

MANAGEMENT OF
HAEMATOLOGICAL
DISEASES
39

Introduction
• Hemostasis General
Sequence-
• vascular,
• platelet and
• coagulation phases.
• Laboratory Test-
- Bleeding time
-partial thromboplastin time
- Platelet count
Gupta et al. Bleeding Disorders of
Importance in Dental Care and
Related Patient Management. JCDA,
2007; 30(1),
40

Common bleeding disorders
Among the congenital
coagulation defects, hemophilia
A, hemophilia B (Christmas
disease) and von Willebrand’s
disease are the most common.
41

1. Haemophilia A
Hemophilia A is due to a deficiency of clotting factor VIII or antihemophilic
factor.
It is an inherited X-linked recessive trait found in males.
Symptoms may include
delayed bleeding,
ecchymosis,
deep hematomas,
epistaxis,
spontaneous gingival bleeding and
hemarthrosis.
Gupta et al. Bleeding Disorders of Importance in Dental Care and Related Patient Management. JCDA, 2007; 30(1)
B. Neville, D. Damm, C. Allem, and J. Bouquot, “Hematologic disorders,” in Oral and Maxillofacial Pathology, pp. 573–613, Elsevier, 3rd edition, 2009
42

43
Kar A, Phadnis D, Nakhale J. Epidemiology & social costs of haemophilia in India, 2014
Gupta et al. Bleeding Disorders of Importance in Dental Care and Related Patient Management. JCDA, 2007; 30(1),
Inhibiting
fibrinolysis -
Epsilon-
aminocaproic
acid and
tranexamic
acid
Management of
hemophilia A
Replacing
factor VIII -
factor VIII
concentrates,
fresh frozen
plasma and
cryoprecipitate
Management of
hemophilia A
Increasing
factor VIII
levels -
desmopressin
Management of
hemophilia A
Incidence of 1
per 5,000 male
births.
That is around
20 per 1,00,000
population
Epidemiology

46
2. Haemophilia B
• Hemophilia B is the result of factor IX deficiency.
• It is managed by replacement therapy with highly purified, virally
inactivated factor IX concentrates.
• Prothrombin complex concentrates can also be used for factor IX
replacement.

47
3. Von Willebrand’s Disease
• Von Willebrand’s disease is the most common hereditary coagulation
disorder with an incidence of 1 in 10,000.
• It is not sex linked.
• It is classified as Type I to Type IV and may vary in severity.
• For mild conditions, use of DDAVP (1-deamino-8-D-arginine vasopressin)
may be sufficient, but severe disease warrants factor VIII replacement.

 . Dental Management:
• The management depends on the severity of the condition and the invasiveness of
the planned dental procedure.
• If the procedure has limited invasiveness and the patient has a mild bleeding
disorder, only slight or no modification will be required.
• In patients with severe bleeding disorders, the goal is to minimize the challenge to
the patient by restoring the hemostatic system to acceptable levels and maintaining
hemostasis by local and adjunctive methods.
• The patient’s physicians’ consultation before invasive treatment
49

50
1. Pain Control
• Coagulopathis- Nerve blocks
contraindicated
• Infiltration
• Sedation- diazepam/ nitrous
oxide
• Severe- Factor replacement &
may be treated under GA
2. Oral Surgery
• Hematologist Consultation
• Local Hemostatic agents-
pressure, sutures, surgical packs
or stents
• Caution use of Vasoconstrictors-
chances of rebound vasodilatation
• Antiplatelet drug- Clopidorgel &
Dipyridamole- continued
3. Periodontal
Surgeries
• Periodontal probing &
Supragingival scaling can be
done
• Factor replacement required
for subgingival scaling & root
planning
• Chlorhexidine mouth wash-
reduce severity before deep
scaling

4. Restorative & Endodontic
Procedures
• Rubber dam- Avoid Injury to
gingiva
• Saliva ejectors & High-speed
suctions can injure mucosa
• Endodontic procedure
preferred over extractions
• Endodontic surgical
procedures- Factor
replacement
5. Prosthodontic Procedures
• Considerably less risk of bleeding
• Avoid trauma post denture
insertion adjustments
• Delicate handling of oral tissues –
during fabrication procedures
6. Orthodontic
Procedures
• can be carried out without
bleeding complications
• appliances should not
impinge on soft tissues and
emphasis should be put on
excellent, atraumatic oral
hygiene

52
Gingival enlargement in von Willebrand disease: A case report
Journal of Indian Society of Periodontology, Year : 2014 | Volume : 18 | Issue : 3 | Page : 390-394
A 29-year-old female patient, resident of Nishat, Srinagar, reported to the Department of Periodontics
and Oral Implantology, Government Dental College, Srinagar with the complaints of recurrent bleeding
and swelling of gums. Medical history revealed that she was a known case of vWD. She had a history
of cholecystectomy and right ovarian cystectomy 9 years back. The patient was previously on oral
contraceptives as medication for menorrhagia. She underwent diagnostic hysteroscopy with
endometrial ablation with roller ball to cure menorrhagia 5 years back, and since then, she has had no
menstrual bleeding. The patient was hypertensive for the last 5 years and was on medication for that.
The patient also complained of frequent urinary tract infections.
Pedigree analysis of the family revealed that the patient's father, mother, maternal and paternal uncles,
and one of her three brothers were also suffering from vWD.

54
4. Anaemia
• McDonald RE, Avery DR, Dean JA. Dentistry for the child and adolescent. 9 ed. USA: Mosby an affiliate of
elsivier; 2004.
• Haemoglobin level lower than what is normal for
the age and gender.
Prepubertal Hb < 11 g/dl
Adult female < 11.5 g/dl
Adult male < 13.5 g/dl
• Anaemia impairs the oxygen carrying capacity of
the blood, it is not a disease but a manifestation of
many diseases.

55
Dental Management:
• Local anaesthesia is sufficient for pain control.
• Conscious sedation should be used only when oxygen is available to supplement. Deep sedation
carries the risk of hypoxia.
• Avoid Nitrous oxide (N2O) if vitamin B12 deficiency is suspected. N2O can interfere with B12
metabolism and neurologic function if administered for more than 12 hours.
• Elective surgery under GA should not be carried out if the Hb is less than 10 g/dl.
• The myocardium may not be able to respond to increased demands for oxygen if adequate
oxygenation is not ensured.
• In an emergency, blood transfusion can be used to correct the anaemia.
• Diuretics should be administered to prevent volume overload.
• McDonald RE, Avery DR, Dean JA. Dentistry for the child and adolescent. 9 ed. USA: Mosby an affiliate of
elsivier; 2004.

Dental Management of Sickle Cell Anaemia
• McDonald RE, Avery DR, Dean JA. Dentistry for the child and adolescent. 9 ed. USA: Mosby an affiliate of elsivier; 2004.
B. Neville, D. Damm, C. Allem, and J. Bouquot, “Hematologic disorders,” in Oral and Maxillofacial Pathology, pp. 573–613, Elsevier,
3rd edition, 2009.
-local
anaesthesia
(LA) is
preferred.
-Avoid
prilocaine
(may cause
methaemogl
obinaemia
-Avoid
Aspirin-
large doses
may cause
acidosis
-Conscious
sedation and
relative analgesia
are safe, avoid
benzodiazepines
which can depress
respiration.
-For treatment
under general
anaesthesia
(GA), correct
anaemia
preoperatively.
-Prophylactic
antibiotics
should be
given for
surgical
procedures

5. Leukemia
• Leukemia is a malignant disease of the blood, where the uncontrolled
proliferation of immature blood cells that originate from hematopoietic stem
cell mutation occurs.
• Eventually these aberrant cells compete with normal cells for space in the
bone marrow, causing bone marrow failure and death.
• The most common leukemias are generally classified as
(1) acute lymphocytic,
(2) acute myeloid,
(3) chronic lymphocytic, and
(4) chronic myeloid.

Oral Manifestations
• Gingival hyperplasia- interdental papilla and marginal gingiva
• Pallor of the mucosa
• Soft tissue infections
• Generalized lymphadenopathy
• Opportunistic infections with Candida albicans and Herpes viruses are
common
• Ulcers can also result from impaired immune defence

Dental Management
Dental treatment in such patients is divided
as follows
A. Prechemotherapy phase
B. Transchemotherapy phase
C.Postchemotherapy phase
American Academy of Pediatric Dentistry, “Guideline on dental management of pediatric patients receiving chemotherapy, hematopoietic cell transplantation, and/or
radiation,” Journal of Pediatric Dentistry, vol. 35, no. 5, pp. E185–E193, 2013

Transchemotherapy phase

Postchemotherapy phase

MANAGEMENT OF
ENDOCRINE
DISORDERS
69

Introduction
• Endocrine system is responsible for hormonal secretion and is closely related to the
central nervous system, as it diversifies its functions through the hypothalamus and
pituitary.
• It controls physiological processes and maintains homeostasis.
• The neuroendocrine system is responsible for adaptation to environmental changes.
• This is especially important in dentistry because many of the patients attending the
dental clinics face stressful situations.
70

1. Hyperthyroidism
• Hyperthyroidism or thyrotoxicosis is defined by a decrease in thyroid hormone
production and thyroid gland function.
• Caused by-
Ectopic thyroid tissue,
Toxic thyroid adenoma,
Toxic multinodular goiter,
Subacute thyroiditis,
Factitious thyrotoxicosis and
Graves’ disease
71

Oral Manifestations
• Accelerated dental eruption in children
• Maxillary or mandibular osteoporosis
• Enlargement of extraglandular thyroid tissue (mainly in lateral posterior tongue)
• Increased susceptibility to caries and periodontal disease (possibly because these patients feel the need to
consume higher quantities of sugar to meet their physical requirements)
• Burning mouth syndrome
• Development of connective tissue diseases such as sjögren’s syndrome or systemic lupus erythematosus.
72

Dental Management
• In controlled patients, should carry out the same dental management as in healthy patients and avoid
severe stress situations and the spread of infectious foci.
• In uncontrolled cases
• restrict the use of epinephrine or other pressor amines in local anesthetics- myocardium sensitive
to adrenaline
• avoid surgical procedures because surgery, presence of acute oral infection and severe stress
may precipitate thyroid storm crisis
• Treatment should be discontinued if signs or symptoms of a thyrotoxic crisis develop
• These patients are susceptible to central nervous system depressant drugs such as barbiturates.
• analgesia is indicated and nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin should be used
with caution. 73

2. Hypothyroidism
• Hypothyroidism is defined by a deficiency of the thyroid hormone.
• It can be acquired or by congenital defects.
• When it is present in infancy – cretinism
• If it occurs in adults (especially in middle-aged women) - myxedema
75

Oral Manifestations
• Delayed tooth eruption
• Enamel hypoplasia in both dentitions,
being less intense in the permanent
dentition
• Micrognathia,
• Open bite due to lack of condylar and
mandibular growth,
• Macroglossia,
• Thick lips
• Dysgeusia, mouth breathing.
76

Dental Management
• prevention of caries with periodic reviews, advice regarding diet and oral hygiene
instructions.
• Before performing dental treatment, serum calcium levels should be determined.
• They must be above 8mg/100ml to prevent cardiac arrhythmias, seizures,
laryngospasms or bronchospasms.

A 13-year-old female patient came to the out-patient Department
of Oral Medicine and Radiology with chief complaint of malaligned
teeth. The girl was the first child of non-consanguineous healthy
parents. Prenatal and post-natal histories were insignificant. She
was overweight and of short stature [Figure 1]. She gained
abnormal weight after 9 years of age. She was having hoarseness of
voice. Extraoral examination revealed that she had dry and cool
skin; stubby hands [Figure 2]; poor muscle tone; puffy face [Figure
3]; a broad, flat nose and thick lips [Figures 3 and 4].
78

1. Diabetes Insipidus
• Results from autoimmune destruction of the insulin producing beta cells of
pancreas. It most commonly presents in childhood.
• The incidence in children <14 years ranging from 0.1/100,000 per year.
• Children with type 1 diabetes often present with diabetic ketoacidosis
(hyperglycemia and ketoacidosis).
Nirmala SVSG, Saikrishna D (2016) Dental Care and Treatment of Children with Diabetes Mellitus- An Overview. J Pediatr Neonatal
Care 4(2): 00134. DOI: 10.15406/jpnc.2016.04.00134
79

Oral Manifestations
Oral candidiasis
80
Nirmala SVSG, Saikrishna D (2016) Dental Care and Treatment of Children with Diabetes Mellitus- An Overview. J Pediatr Neonatal Care 4(2): 00134. DOI:
10.15406/jpnc.2016.04.00134
Xerosomia
Burning
Sensation
Gingivitis &
Periodontitis
Dental caries
Bacterial, viral,
and fungal
infections
Periapical
abscesses
Taste dysfunction

Dental Management:
• In general morning appointments are advisable since endogenous cortisol levels are generally
higher at this time.
• For patients receiving insulin therapy, appointments should be scheduled so that they do not
coincide with the peaks of insulin activity
• Since that is the period of maximal risk of developing hypoglycemia.
• It is important for clinicians to ensure that the patient has eaten normally and taken
medications as usual.
81
Nirmala SVSG, Saikrishna D (2016) Dental Care and Treatment of Children with Diabetes Mellitus- An Overview. J Pediatr Neonatal
Care 4(2): 00134. DOI: 10.15406/jpnc.2016.04.00134

• Local anesthesia can be used normally.
• Septic teeth which cannot easily be restored to a non-septic condition and non-
vital teeth which cannot be properly supervised are better removed.
• In Children, even where there is as yet no evidence of periodontal disease,
preventive measures are important.
• Instructions in correct tooth - brushing and gum massage whenever necessary,
the grinding of points of traumatic occlusion will assist the postponement of
gingival diseases.
• There is no contraindication to orthodontic treatment
83
Nirmala SVSG, Saikrishna D (2016) Dental Care and Treatment of Children with Diabetes Mellitus- An Overview. J Pediatr Neonatal Care 4(2): 00134. DOI:

A 12-year-old South Indian boy presented with the complaint of pain and swelling in the left maxillary
posterior region since 4 days to the Department of Pedodontics and Preventive Dentistry, Narayana
Dental College and Hospital. Pain was reported since 4 months, and it was moderate in nature and
aggravated on bending the head and chewing food.

MANAGEMENT OF
NEUROLOGICAL
DISORDERS
85

86
Epilepsy
• The word “epilepsy” is derived from the Greek word “epilambanein” meaning to take or
to seize.
• Epilepsy is a brain disorder characterized by excessive neuronal discharge that can
produce seizures, unusual body movements, and loss or changes in consciousness.
• Transient episodes of motor, sensory, or psychic dysfunction, with or without
unconsciousness or convulsive movements may be present.

87
CONVULSIONS
SEIZURES
EPILEPSY
Neurological
condition in
which a
person
experiences
recurrent
seizures (fits).
Epilepsy is
diagnosed in
people who
have
experienced
two or more
episodes of
unprovoked
seizures.
A brief
episode of
abnormal
electrical
activity in the
brain that
causes a
variety of
signs and
symptoms.
A seizure may
or may not be
of epileptic
origin
A condition in
which the
muscles of the
body rapidly
contract and
relax.

88
Prevalence
• Epilepsy affects 0.5% to 1% of children and is the most frequent
chronic neurologic condition in childhood.
• The incidence rate of epilepsy is 144 per 100 000 person-years in the
first year of life and 58 per 100 000 for ages 1 to 10 years.
• Approximately 1 out of 150 children is diagnosed with epilepsy during
the first 10 years of life, with the highest incidence rate observed during
infancy.
Amudhan S, Gururaj G, Satishchandra P. Epilepsy in India I: Epidemiology and public health. Ann Indian Acad
Neurol. 2015;18(3):263–277. doi:10.4103/0972-2327.160093

89
Etiology
AGE AT ONSET CAUSES
Young Child Birth Trauma, Fevers, Metabolic Diseases,
Congenital Diseases Or Idiopathic
Adolescent Idiopathic Or Traumatic
Young Adult Traumatic, Alcoholism Neoplastic, AIDS Or Drug
Abuse
Middle Age Cerebrovascular Diseases, Neoplastic,
Traumatic, Drug Abuse And AIDS .
Elderly Cerebrovascular Diseases Or Neoplasm.

91
• Febrile Convulsions-
Children with high fever (38.8 degree celcius or more)
Age: 6months- 3 years
Infection not associated with CNS

Oral Manifestations
• Increased risk for dental caries
• Increased risk for oral trauma
• Medication-induced gingival hyperplasia, bleeding gums, and delayed
healing
• Child may be on a specially controlled diet – Ketogenic diet (high-fat,
low-carbohydrate)
92

Sequelae of Epilepsy
Injuries :
 Laceration Of Tongue
Buccal Mucosa Injury
Injuries On Face – Hematomas ,
Fractures
Fractures, Devitalisation,
Subluxation, Loss of Teeth.
93
Treatment complications :
 Phenytoin – Gingival Hyperplasia
 Folate Deficieny, Megaloblastic Anemia
 Recurrent Aphthae
 Cervical Lymphadenopahty
 Phenobarbitone- Bullous Erythema
multiforme.

Dental Management
• Obtain thorough medical history-including seizure triggers and seizure frequency/level
of control.
• Monitor child for anti-epileptic medication induced gingival hyperplasia.
• Meticulous oral hygiene is the best prevention.
• Powered toothbrushes may be too stimulating for some children and should be
recommended only after determining if the child will tolerate one.
94

• Schedule appointment during time of day when seizures are less likely to occur.
• Minimize seizure triggers.
• Reduce stress and anxiety by explaining procedures before starting.
• Keep bright light out of child’s eyes or allow child to wear dark glasses.
• If prosthetic restorations are considered, insure they are appropriate for the rate, level
and frequency of seizures, and they are resistant to damage or displacement during an
epileptic attack to reduce choking hazards.
• Determine if mouth guard is necessary for children with uncontrolled epilepsy.
95

Seizure Management During Dental Treatment:
• Remove all dental instruments from the mouth.
• Clear the area around the dental chair.
• Stay with the child and turn child to one side.
• Monitor airway to reduce risk of aspiration.
• Note time seizure begins: if seizure continues >3 min call EMS – Danger of Status
Epilepticus (potentially life threatening).
96

Contemporary Clinical Dentistry | Volume 9 | Issue 3 | July-September 2018

MANAGEMENT OF
IMMUNOLOGICAL
DISORDERS
99

1. AIDS, HIV & Related Conditions
• HIV can be spread to babies born to, or breastfed by, mothers infected with the virus.
• Persistent or severe symptoms may not surface for 10 years or more after HIV first enters
the body in adults, or within 2 years in children born with an HIV infection.
• This "asymptomatic" period of the infection is highly variable from person to person.
• But, during the asymptomatic period, HIV is actively infecting and killing cells of the immune
system.
100
Management of Dental Patients Who Are HIV Positive. Summary, Evidence Report/Technology
Assessment: Number 37.

Epidemiology
• India has an estimated 2.2 million children infected by HIV/AIDS.
• As of July 2016, about 1,850 children were receiving ART in India.
• Over 35% of AIDS cases reported are below 25 years of age and 50%
of new infections are between 15 and 24 years old.
101
HIV/AIDS in India | UNICEF
unicef.in/Story/601/HIVAIDS-in-India

Symptoms
• Infants - HIV status may be difficult to determine in the first year of life.
• Failure to thrive. Delayed physical and developmental growth as
evidenced by poor weight gain and bone growth.
• Swollen abdomen. This is due to swelling of the liver and spleen.
• Swollen lymph nodes
• Pneumonia
• Oral thrush
102

Dental Management
• Consult patient’s physician to establish current status.
• Render only more immediately needed treatment.
• Provide dental procedures in accordance with patient’s wants and
needs.
103
Management of Dental Patients Who Are HIV Positive. Summary,
Evidence Report/Technology Assessment: Number 37.

Universal blood and body-fluid precautions" or "universal precautions,"
• use appropriate barrier precautions to prevent skin and mucous-membrane exposure when contact with
blood or other body fluids of any patient is anticipated.
• Gloves should be worn for touching blood and body fluids, mucous membranes, or non-intact skin of all
patients, for handling items or surfaces soiled with blood or body fluids, and for performing venipuncture
and other vascular access procedures.
• Gloves should be changed after contact with each patient.
• Masks and protective eyewear or face shields should be worn during procedures that are likely to
generate droplets of blood or other body fluids to prevent exposure of mucous membranes of the mouth,
nose, and eyes.
• Gowns or aprons should be worn during procedures that are likely to generate splashes of blood or other
body fluids.
• Hands and other skin surfaces should be washed immediately and thoroughly.
Updated (2013) U.S. Public Health Service Guidelines for the Management of Occupational
Exposures to Human Immunodeficiency Virus and Recommendations for Postexposure
Prophylaxis

• Handpieces that cannot be sterilized should at least be flushed, the outside surface cleaned and
wiped with a suitable chemical germicide
• light handles or X-ray-unit heads and that may become contaminated should be wrapped with
impervious-backed paper, aluminum foil, or clear plastic wrap.
• The coverings should be removed and discarded, and clean coverings should be put in
place after use with each patient
• All health-care workers should take precautions to prevent injuries caused by needles,
scalpels, and other sharp instruments or devices during procedures; when cleaning used
instruments; during disposal of used needles; and when handling sharp instruments after
procedures
• Health-care workers who have exudative lesions or weeping dermatitis should refrain from all
direct patient care and from handling patient-care equipment until the condition resolves.
Updated (2013) U.S. Public Health Service Guidelines for the Management of Occupational
Exposures to Human Immunodeficiency Virus and Recommendations for Postexposure
Prophylaxis

Summary
There is a real risk that adverse interactions between medical conditions and dental
treatment may occur--on some occasions, even fatal ones.
It is not possible for any one individual to know the details of all medical conditions,
their treatment and the possible interactions with dental treatment.
However, by the application of some sound general principles the risks of any
potential interactions can be evaluated.
The essential steps are: knowledge of the medical history of all patients; knowledge
of the potential interactions; and knowledge of the management of medical
emergencies.
106

Bibliography
• American Academy of Pediatric Dentistry. Guideline on record-keeping. Pediatr
Dent 2012;34(special issue):287-94.
• McDonald RE, Avery DR, Dean JA. Dentistry for the child and adolescent. 9 ed.
USA: Mosby an affiliate of elsivier; 2004.
• Stewart R E, Barber T K, Troutman K C, Wei S H. Pediatric Dentistry scientific
• Claramunt Lozano A, Sarrión Perez MG, Gavaldá Esteve C. Dental considerations
in patients with respiratory problems. J Clin Exp Dent 2011; 3(3): 222-7.
• Gupta et al. Bleeding Disorders of Importance in Dental Care and Related Patient
Management. JCDA, 2007; 30(1).
107

Bibliography
• B. Neville, D. Damm, C. Allem, and J. Bouquot, “Hematologic disorders,” in Oral
and Maxillofacial Pathology, pp. 573–613, Elsevier, 3rd edition, 2009.
• American Academy of Pediatric Dentistry, “Guideline on dental management of
pediatric patients receiving chemotherapy, hematopoietic cell transplantation,
and/or radiation,” Journal of Pediatric Dentistry, vol. 35, no. 5, pp. E185–E193,
2013
• Amudhan S, Gururaj G, Satishchandra P. Epilepsy in India I: Epidemiology and
public health. Ann Indian Acad Neurol. 2015;18(3):263–277. doi:10.4103/0972-
2327.160093
• Management of Dental Patients Who Are HIV Positive. Summary, Evidence
Report/Technology Assessment: Number 37.
108

• Skamagas, M., Breen, T.L., LeRoith, D. (2008) Update on diabetes mellitus: prevention, treatment,
and association with oral diseases. Oral Dis, 14(2):105-114.
• Oral and dental management in children with tetralogy of fallot Dent. J. (Maj. Ked. Gigi), Vol. 40.
No. 1 January-March 2007: 42–45.
• Skamagas, M., Breen, T.L., LeRoith, D. (2008) Update on diabetes mellitus: prevention, treatment,
and association with oral diseases. Oral Dis, 14(2):105-114.
• Vernillo, AT. (2003) Dental considerations for the treatment of patients with diabetes mellitus. J Am
Dent Assoc, 134: 245-335.
Bibliography

Management of medically handicapped children

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Management of medically handicapped children

Similar to Management of medically handicapped children (20)

More from DrSusmita Shah

More from DrSusmita Shah (9)

Recently uploaded

Recently uploaded (20)

Management of medically handicapped children

Editor's Notes