Medically compromised patient

Dr. Jijo
Postgraduate
Department of pedodontics
Medical conditions

• Heart diseases
• Leukemia
• Diabetes Mellitus
• Respiratory Diseases
• Psychobehavioural Disorders
• AIDS
• Hematological Disorders
Introduction

A medically compromised condition is one in which the

patient suffers from a certain systemic condition which puts
him at risk from undergoing regular dental treatment

Due to this , the practioner has to take certain precautions to

enable the patient to go through the treatment without
complications.
Heart diseases
1. Congenital Acyanotic
Cyanotic

2. Acquired Rheumatic fever

Infective bacterial endocarditis
Acyanotic -
• Minimal or no cyanosis
• Two categories-
 Left to right shunting of blood- Atrial / ventricular septal defects (hole)
 Obstruction- Aortic stenosis (narrowing of valve) , Coarctation of aorta
(narrowing of aorta)

Clinical manifestations : congestive cardiac failure, pulmonary congestion,

Heart murmur, labored breathing

Cyanotic –
• Cyanosis on minimal exertion due to right to left shunting of blood within
heart
• Tetralogy of fallot- Pulmonary stenosis, thickened right ventricular wall,
Ventricular septal defect, aorta overrides septal defect (aorta positioned
over a ventricular septal defect, instead of over left ventricle

Clinical manifestations : Cyanosis, poor physical development, clubbing,

heart murmurs
Etiology :

• Multifactorial- interaction between genetic – environmental

factors
• Maternal rubella, maternal diabetes, drugs during pregnancy
• Inborn errors of metabolism – Downs syndrome, Williams
syndrome
Acquired heart disease:
Rheumatic fever
• Occur at any age but rare in infancy; Most common- 6-15 yrs
• Can be fatal in acute stage (or)
• Can lead to chronic RHD as a result of scarring of valves

Clinical manifestations : Jones criteria

2 major & 2 minor or 1 major & 2 minor following supportive evidence
Major manisfestation- Carditis, polyarthritis, chorea (involuntary abnormal movement
of limb, erythema marginatum (redness), subcutaneous nodules
Minor manisfestations- Fever, arthralgia, raised ESR, history of rheumatic fever,
prolonged PR interval
Supporting evidence of preceding streptococcal infection within last 45 days
Elevated anti steptolysin (antibody) or
+ve throat culture
Infective bacterial endocarditis

An inflammation or infection of the inner surface of the heart

(endocardium) by bacteria that enter the bloodstream and settle in the heart
lining, a heart valve or a blood vessel.

There are two forms of BE:

Acute BE — develops suddenly and may become life threatening within days;
caused by highly virulent streptococcus viridans & staphylococcus aureus
Subacute or Chronic BE — develops slowly over a period of weeks to several
months;
Caused in who already have an existing congenital cardiac/rheumatic
valvular lesions caused by strep viridans

Clinical symptoms- Low irregular fever, sweating. Malaise, anorexia,

weightloss, arthralgia
Transient bacteremia can also be a initiation factor
Dental management :
• Preventive dental programs
• Consult with cardiologist
• Antibiotic prophylaxis – scaling, minor surgeries, incision drainage,
intraligamentary injections
• Dental treatment to be completed with 3-4 weeks of planned surgery
• Pulp therapy of primary teeth contraindicated - extraction with space
maintainer
•Permanent dentition – endodontic therapy
• Extensive dental treatment - GA
Leukemia

• Malignant neoplasm of hematopoietic cells proliferate initially in bone

marrow before circulating to peripheral blood, spleen, lymph nodes &
other tissues
• Immature undifferentiated blast cells replace normal cells in bone
marrow
• 13 in 100,00 ppl per year

Classification : (According to morphology of white cells in bone marrow)

• Acute lymphocytic leukemia (Common in children)
• Acute non lymphocytic leukemia (common inadults)
 Acute Myelocytic Leukemia
 Acute Monocytic leukemia
 Erythroleukemia
 Megakaryocytic Leukemia
• Chronic myelocytic leukemia – Juvenile (Philadelphia chromosome (22) negative)
Adult (Philadelphia chromosome postive)
• Chronic lymphocytic leukemia
Etilogy :

• Unknown
• Genetic + environmental factors
• In combination with syndromes - Downs, Blooms, Klinefelter, etc
• Ionization radiation, chemicals like benzene, aromatic
hydrocarbons

Clinical manifestations :

Anaemia, thrombocytopenia (↓ platelets), ↑ WBC, tachychardia,

adenopathy, gingival bleeding, fever, hepatosplenomegaly, etc
Oral manifestations :

• Regional lymphadenopathy
• Gingival abnormalities
• Ulceration
• Palor (paleness)
• Loss of lamina dura, widening of periodontal
space, loss of trabeculation
• Rapid loosening of teeth
• Cranial nerve palsies
• Lip paraesthesia
Dental management

• Primary aim- prevent/control oral infection, inflammation,

hemorrhage
• Consult child’s physician
• Complete medical history
• Postpone elective dental procedures
• Drugs like aspirin which alter platelet function contraindicated
• Candidiasis- Topical /systemic antifungal drugs
• Pain from ulcerations- Topical obtundents to relieve pain
• Deep lesions that bleed spontaneously - topical bovine thrombin
• Pulp therapy/endodontic treatment- contraindicated
• Platelets less than 20,000 /cm3 – dental Rx not undertaken without
prophylactic platelet transfusion
• Absolute granulocyte count less than 1000/cubic mm – delay
treatment
Diabetes mellitus
Associated with inadequate supply of insulin to meet physiological needs
of the body at cellular level

Type I – Insulin dependant diabetes mellitus

Type II – Non insulin dependent diabetes

Type I- Deficient insulin production due to destruction of beta cells of

islets of langerhans
• Juvenile onset diabetes

• Interaction of genetic, environmental, immunologic factors

• Sudden onset

• 5-15 % of cases
Type II

• Non insulin dependent diabetes

• Maturity onset diabetes

• Rare in infancy

• Seen in school age children

• Impaired insulin function rather than deficiency

• Later in disease insulin supplementation may become necessary

• Obesity common in type II

• 80- 93 % of cases
Signs & symptoms:
Early features:
• Polyuria, polydipsia
• Pruritus (itching), weakness
• Recent weight loss
• Constipation
• Mental confusion
• Acetone breath (fruity smell, nail polish remover breath)

Late features:
• Vomiting, nausea
• Abdominal pain
• Hyperventilation (rapid/deep breathing)
• Dehydration
• Hypovolemia (liquid portion of blood plasma is too low)
• Shock
• Coma
• Paresthesia of extremities
Oral manifestations :

• Reduced salivary flow

• Burning tongue
• Candidiasis
• Altered taste
• Progressive periodontitis
• Dental caries
• Oral neuropathies
• Parotid enlargement
• Sialosis
• Delayed wound healing
• Increased glucose content in GCF
Dental management

• Comprehensive medical history

• Short, stress free dental appointments, atraumatic

• Early morning appointments after breakfast

• Conscious sedation

• Vital pulp therapy is better than extraction

• Prophylactic antibiotics

• Vasoconstrictor drugs with LA

Medical Treatment

Type I - Insulin administration

• Short acting, intermediate acting (24 hrs)
• Long acting upto 36 hours
• Insulin administered at meal times
• High fiber balanced nutritious diet

Type II – Oral hypoglycemic drugs used to stimulate insulin production

Management of Hypoglycemic shock

Due to stress, insulin overdose, poor dietary control or glucose levels

below 40 mg/dl

Signs and symptoms

Mood changes , irritability , disorientation , blurred vision , loss of

consciousness, lethargy , nausea , stomach ache , hunger, increased
gastric motility,hypothermia
Management

Oral carbohydrates – orange juice, soft drinks & candy

No recovery in 2-5 minutes = IV dextrose 50 ml in 5 % Concentration

(Unconscious) IM Glucagon 1mg
IM epinephrine 0.5 mg 1:1000 concentration

Patient takes 5-10 min to recover; if stable give oral glucose when conscious
to prevent hypoglycemia from recurring

No response after 5 min - emergency procedures to be initiated

Hyperglycemia
Blood glucose levels greater than 11.1 mmol/L

Signs :
Weak pulse, rapid deep breathing, dry skin, acetone breath , increased
frequency of micturition (urination), thirst, loss of consciousness

Management :
• Maintain airway

• Admin 100 % O2 + intravenous fluids to prevent vascular collapse

• Finger stick blood glucose test

• Administer insulin under controlled conditions

Respiratory diseases:
Cystic fibrosis

• Monogenetic autosomal recessive disorder involving the excocrine

glands like pancreas, sweat glands and glands in liver

Features:
• Chronic obstruction, airway infection, maldigestion, other abnormalities
of digestive tract

• Delayed sexual development; failure to thrive

• Defective secretions causes abnormal water and electrolyte transport

across epithelial cells resulting in chronic respiratory & GI disease

• Over retention of mucous takes place in lungs

• Incidence 1 in 2000 births

Oral manifestations

• Discoloration of teeth due to tetracycline therapy

• Enamel hypoplasia

• Low incidence of dental caries due to intake of antibiotics

• Increased pH, buffer capacity of saliva + calcium phosphorus levels

• High incidence of mouth breathing, open bite with chronic nasal/sinus

obstruction

• Delayed eruption/development of teeth

• Oral ulcerations
Management :

• Complete medical history

• Consultation with child’s physician

• Treat patents in upright positions to clear secretions

• Anterior teeth discoloration – composite veneers

• Sedation – respiratory depression

• Strict oral hygiene program + regular dental care

• Dietary advice with sugar free liquid with antibiotic coverage

Asthma

• Disease of the airways characterized by increased responsiveness of

the tracheobronchial tree due to multiplicity of stimuli
• Manifested by widespread narrowing of air passages

Clinically – paroxysms of dyspnea, cough, wheezing

Episodic - attacks short lived & recovers

10 % of children affected

2:1 male predilection

Etiology: Allergy- foreign substances like dust, chocolate

Respiratory infections, emotional disturbances, exhaustion,
change of climate
Dental management
• Complete medical history
• Upright position
• Inhaler if used should be brought for dental appointments
• Sedation / GA
• Nitrous oxide /02 most preferred
• Use of aspirin, NSAID, penicillin contraindicated

Asthmatic attack in emergency– 100% O2 in sitting position leaning

forward &
Subcutaneous administration of 0.3 ml of 1:1000 epinephrine
Pyschobehavioural disorders
Autism
• Incapacitating disturbance of mental and emotional
development- problems in learning, communication and relating
to others.

• 5 in 10,000 births; 4:1 predilection for men

Etiology
• Organic brain damage /dysfunction
• Lack of environmental stimulation of psychosocial factors
• Defective metabolic processes
Clinical Manifestations
• Poor muscle tone , poor co-ordination, drooling, hyperactive knee
jerk, epilepsy

• They have strict routines & prefer more soft sweetened foods-
increased caries susceptibility

• Extreme resistance to being held, show tantrums (outburst of anger),

destructive behavior

• Extreme loneliness, language disturbance, mutism, parrot like

repetitious speech, difficulty with the concept of yes

• Eating disturbances

• Mental retardation is seen in 1/2 to 1/3rd of autistic children

• Seizure disorders
Management :

• Phenytoin therapy – gingival enlargement

• Positive reinforement + tell show do

• Pre operative sedation with muscle relaxants + nitrous oxide

analgesia

• Psychotherapy + family counselling

• Use of papoose board or pedi wrap

• GA – when there is extensive treatment

AIDS can be defined as presence of antibodies to HIV and opportunistic
infections

Etiology-
• Human immune deficiency virus a human RNA retro virus
• 4 recognized belong to 2 groups: human T lymphotropic retrovirus- HTL V I
& HTL V III & human immune deficiency viruses- HIV I & HIV II
• Most common cause of AIDS- HIV I

Modes of transmission
• Parenteral - health care workers, needle sharing among IV drug abusers, blood
transfusion who tested negative to HIV but in window period, organs transplant from
HIV donors
• Perinatal – before during or shortly after birth
 Prenatal & neonatal tranfer from HIV mother to baby during 8-12 weeks of gestation
 Unsafe sex during pregnancy/feeding
 During cesarean delivery
• Sexual transmission
• Body fluids- Blood, semen, breast milk, vaginal/cervical secretions
WHO defines pediatric AIDS as an infant or child presenting with at
least a major criteria along with 2 minor criteria in the absence of any
immunosuppression

Major signs :
• Chronic diarrhoea for more than a month
• Prolonged fever for more than a month
• Weight loss

Minor signs :
• Oro phrayngeal conditions
• Repeated cough for more than a month
• Generalized lymphadenopathy
• Generalized Dermatitis
• Maternal HIV
Typical pediatric findings (Rubenstein, 1986)

• Pulmonary lymphoid hyperplasia

• Salivary gland enlargement
• Pyogenic bacterial infection like otitis media
• Developmental craniofacial features
• Chronic recurrent Diarrhoea
• Hepatosplenomegaly
• Chronic pneumonitis
• Failure to thrive
• Progressive encephalopathy
Oral findings
• Fungal infections- Candidiasis - Angular cheilitis
Hyperplastic
• Bacterial infections – localized or pyogenic
• Viral infections - Herpes Zoster
Herpes Simplex
Hairy leukoplakia
Herpetic stomatitis
• Parotid enlargement with xerostomia
• Apthous stomatitis
• Linear gingival erythema
• Cervical Lympadenopathy
• Gingival and periodontal lesions like ANUG
• Oral ulcerations
Management :
Antifungal drugs
• Topical – nystatin – 1-2 mol to the affected area tds or qds
• Amphotericin suspension– 1ml to be applied to affected area after food

Viral drugs
• Systemic doses of acyclovir 1-2 g orally or IV

Treatment of NUP
• Aggressive currettage
• Peridex mouth rinse 3 timed daily
• Antibiotic treatment

Treatment of oral ulceration –

• Fluconamide ointment (0.5%)
• Orabase 3-6 times /day
• Dexamethasone 0.5 mg /ml
Precautions in the dental field
• Proper sterilization
 Autoclaving at 121°C for 15 min at 1
• Proper medical history atmospheric pressure
 Dry heating at 170°C

• Barrier techniques like

• Disinfection
 Eye protection in terms of eye
glasses  0.2 % sodium hypochlorite
 Calcium hypochlorite
 Mouth mask
 6 % hydrogen peroxide for more than 30
 Disposable needles minutes
 Double gloves
 Change of cloths • Disinfectants for living tissue
 Povidone
 2% propanol
 Ethanol
Hematological disorders :
1. Red cell disorders
2. White cell disorders
3. Disorders of homeostasis including platelet and coagulation factors

Red cell disorders

Anaemia - reduction in the volume of red blood cells or in the
concentration of Hb in peripheral venous blood.

Types:
 Iron deficiency anemia
 Vitamin B-12 deficiency anemia
 Folate deficiency anemia
 Pernicious anemia
 Hemolytic anemia
 Aplastic anemia
Iron Deficiency Anaemia
• Microcytic, hypochromic anemia

• Causes:
 Early introduction of bovine milk, more milk, less solid
 Prolonged bottle feeders
 Chronic blood loss in teenaged girls

• Oral manifestations:
Painful atrophic tongue, decreased healing response, pale mucosa,
angular cheilitis, ginigivitis, periodontitis

• Management :
 Maintenance of oral hygiene
 Symptomatic treatment
 Supplementation as per requirement
Vitamin B 12 deficiency
• Macrocytic anemia
• Unusual in children
• Associated with Crohn’s disease or strict vegans with inadequate
diet

• Oral :
 Angular Cheilitis
 Stomatitis
 Pharyngitis
 Glossitis
 Glossopyrosis
 Neurologic dysfuntion

Treatment:
 Symptomatic dental therapy
 Supplementation according to individual needs
Folate deficiency Anaemia
• Macrocytic anaemia

• Causes:
 Found in patients with coeliac and Crohn’s disease
 Renal dialysis patients
 Epileptic patients with phenytoin therapy
 Lack of folic acid instrinsic factor

• Oral:
 Angular cheilitis
 Stomatitis
 Pharyngitis
 GIT dysfunction
Pernicious Anaemia
• Causes:
 Lack of vitamin B12 intrinsic factor

• Oral manifestation:
 Same as vit B12 def
 Painful glossy tongue
 Beefy red coloured tongue
 Apthous ulcers
 Atrophy of filiform papillae
 Hunter glossitis

• Management :
Supportive therapy by blood transfusion
Hydroxycobalamine 1000 mg IM
(Daily for 1 week followed by 100 mg once in 3 months as maintenance dose)
Hemolytic anaemia
Premature destruction of RBC’s due to intracorpuscular defects
in erythrocytes which can be
• Congenital
• Acquired
 Hereditary sphercytosis
 Sickle cell anaemia
 Thalassemia

• Extracorpuscular factors
Infectious agents, cardiac valvular prostheses , hyperspleenism
RH factor incompatibility, Chronic liver disease

• Management :
Splenectomy, folic acid therpy, Prophylactic antibiotics, Vaccination
against infection, Antibiotic coverage before dental procedures
Sickle cell anaemia
• Autosomal recessive disorder
• Due to an abnormal hemoglobin known as hemoglobin S
• Lose their oxygen with a distortion of these erythrocytes into
a sickled shape
• Sickling phenomenon occurs only in reduced oxygen tension
• Causes chronic & compensated hemolytic anemia and vaso-
occlusive crisis
• Results in pain & tissue damage caused by infarction
Management:
• Use of LA with vasoconstrictor
• Conservative approach
• Prophylactic/post operative antibiotics before surgical procedures
• Inhalation sedation is safe provided that 100 % O2 for atleast 4 – 5
minutes
• At end of the procedure to avoid diffusion hypoxia airway should
be maintained with N2O- O2
• If GA not avoidable, maintenance of atleast 30% oxygen is
mandatory, fluid maintenance is necessary & preoperative
exchange transfusions may be needed
• Minimize stress
 Haemophilia
• Heredity blood disorder characterized by a deficiency of plasma proteins
needed for normal clotting
•Lab finding- Normal platelet count, normal bleeding time, normal
prothrombin time, prolonged partial thromboplatin time
•X linked recessive trait- males affected, females carriers
•Clinical features- spontaneous hemorrhage, chronic musculoskeletal
problems or muscle hemorrhage, easy bruising, deep hematomas &
hematuria
Hemophilia A
•Most common type (85%)
•Prevalence 1: 7500 males
•Factor VIII deficiency
Hemophilia B
•Factot IX deficency
Management
Hemophilia A
• Replacement of the missing clotting factor is achieved with porcine factor
VIII or recombinant factor VIII.
• Minor hemorrhage- 40% level of factor VIII
• Severe bleeding/major surgery- an initial level of 80-100% of factor VIII
followed by a maintenance level
• Mild-moderate- 1-deamino-8-D-orginine vasopression (DDAVP) can be
used to raise factor VIII to heostatic level

Hemophila B
• Replacement with plasma product 40 % high in factor IX
• With prothrobomin complex concentrates (PCC)
• Fresh frozen plasma (FFP) is an emergency alternative
The bleeding tendency can be aggravated by
 NSAIDs
 Liver damage after hepatitis
 HIV disease
 Thrombocytopenia.

Paracetamol, codeine and COX-2 inhibitors are safer

Local Anesthesia:
• When factor concentration maintained above 30% infiltration
preferable than regional blocks.
• Intraligamentary is safer.

Conservative Dentistry:
• Local Anesthesia – Intraligamentary Bands to prevent gingival
laceration
• Rubber dam to prevent trauma
• Saliva Ejectors can cause hemorrhage so placed above gauze swab
Endodontic Therapy:
• Avoid instrumenting through the tooth apex
• Topical application of 10% cocaine to the exposed pulp is
recommended for vital pulp extirpation.
Periodontal Surgery:
• Factor Replacement to level of 50 – 75%,
• Scaling can be carried out under antifibrinolytc cover
That’s all folks….
Thank you
References

• Shobha Tandon Textbook of Pedodontics 2nd edition

• Harrison’s Principle of Internal Medicine; 18th edition

• Shafers Oral Pathology, 6th edition