Medically Compromised Patients

Question 1

Cardiovascular Disorders

Answer 1

May be congenital/acquired
identify structural (ventricular septal defect)/ rhythm problem (supraventricular tachycardia)/ muscle tissue (cardiomyopathy)
8 in 1,000 live births CHD
4 in 1,000 adults with CHD

Question 2

Structural defects

Answer 2

Acyanotic
- ASD/VSD/PDA
- Coarctation of aorta
- Aortic or pulmonary stenosis

Cyanotic
- Transposition of great arteries
- Tetralogy of Fallot (VSD/ pulmonary stenosis, overriding aorta, right ventricular hypertrophy)

Question 3

Rhythm Defects/Arrhythmias

Answer 3

Supraventricular tachycardia in children
Atrial tachycardia/atrial fibrillation or long QT syndrome
LA with no adrenaline (Citanest)
Presence of anaesthetist/cardiologist
hospital tx

Question 4

Cardiomyopathies

Answer 4

Dilated cardiomyopathy - enlarged heart, poor contraction

Hypertrophic cardiomyopathy - thickened muscle, thus difficult to fill

Restrictive cardiomyopathy - abnormal relaxation but good pumping

May need heart transplant
Hypertrophic Cardiomyopathy means increased IE risk and may have arrythmia

Question 5

Infective Endocarditis

Answer 5

Infection of lining of heart
Rare condition
People with certain structural cardiac conditions at risk
Life threatening disease with mortality at 20%

Question 6

NICE Guidelines on IE

Answer 6

Antibiotic prophylaxis is no longer offered routinely for the interventional procedures.

Prompt investigation and treatment of infection.

Benefits and risk of antibiotic prophylaxis and an explanation as to why antibiotic prophylaxis is no longer routinely recommended

Importance of maintaining good oh

Question 7

Patients at risk of IE

Answer 7

Acquired valvular disease with stenosis or regurgitation
Hypertrophic cardiomyopathy
Previous IE
Structural CHD including surgically corrected or palliated structural conditions
Valve replacement

Question 8

Patients requiring special consideration

Answer 8

Pts with prosthetic valves
Pts with previous IE
CHD (any type of cyanotic CHD/any type of CHD repaired with a prosthetic material, up to 6 months after procedure or lifelong residual shunt or valvular regurgitation remains.

Question 9

Avulsed teeth in cardiac pts

Answer 9

reimplantation would cause bacteraemia
risk/benefits discussed
course of antibiotics

Question 10

Haematological disorders

Answer 10

Bleeding disorders:
1.Inherited Coagulopathy
2. Acquired Coagulopathy
3. Platelet disorder
4. Vascular disorder

Question 11

Inherited Coagulopathy

Answer 11

Haemophilia A (factor VIII deficiency)
Haemophilia B (factor IX deficiency)
Disorder of platelet function - von willebrand

Question 12

Acquired Coagulopathy

Answer 12

Liver disease
Vitamin k deficiency
anticoagulant therapy eg warfarin/heparin

Question 13

Platelet disorders

Answer 13

Primary - idiopathic thrombocytopenia purpura (ITP)
Secondary - systemic disease - leukaemia, drug induced

Question 14

Vascular disorders

Answer 14

Hereditary Haemorrhagic Telangiectasia (HHT)

Question 15

Extractions and IDB

Answer 15

Tx should be carried out in hospital
Extractions or IDB will require haematology cover (factor concentrates/DDAVP/Antifibrinolytics such as tranexamic acid)
If IDB block required - danger of haematoma/airway compromise
Extractions - consider local measures such as surgicel and sutures

Question 16

Respiratory disorders

Answer 16

Asthma
Cystic Fibrosis

Question 17

Asthma

Answer 17

Diffused obstructive lung disease
Leading cause of chronic illness in children
about 1/2 will be symptom free as adults
10% children at some time will have signs

Question 18

Dental implications of asthma

Answer 18

Link between asthma and erosion
Inc likelihood of oral candidiasis

Question 19

Dental implications of asthma

Answer 19

Oral candidiasis
Erosion link weak

Question 20

Dental management implications of asthma

Answer 20

medications
LA and IHS may be used
Avoid GA if possible

Question 21

Cystic Fibrosis

Answer 21

Hereditary disease affecting endocrine glands causing progressive multisystem failure

1 in 25 carry gene, autosomal recessive

Multisystem disorder: Lungs/GIT/Pancreas/Liver/GUT

Question 22

Dental implications of CF

Answer 22

Hypoplasia
Hypomineralisation
Increased caries risk with diet high in carbohydrates (buffering effect of saliva increased, high intake of antibiotics)
Previous tetracycline staining
Erosion - inc risk due to GORD

Question 23

Dental management implications in CF

Answer 23

High risk GA
Preventive advice and early tx for high risk pt
Consider IHS but liaise with physician
8% may have cirrhosis of liver so potential clotting defect
May have Vit K deficiency - coagulation defects

Question 24

Endocrine Disorders

Answer 24

Diabetes

Question 25

Diabetes

Answer 25

Most common endocrine disorder
Deficiency of insulin and abnormal metabolism of carbohydrate/protein/fat
Type 1 IDDM - 95% of childhood diabetes

Question 26

Dental implications of Diabetes

Answer 26

Poorly controlled
- increased glucose in saliva
- decreased saliva (higher caries risk)
- altered response to healing
- increased susceptibility to infection esp Candida
- inc perio problems

Question 27

Dental treatment of Diabetes

Answer 27

Well controlled dental tx
normal breakfast
normal insulin

Question 28

Neurological disorders

Answer 28

Epilepsy

Question 29

Epilepsy

Answer 29

Recurrent seizures
Causation - idiopathic (genetic predisposition)/secondary (neoplasm/cerebral malformation)

Question 30

Dental implications of epilepsy

Answer 30

Drug side effects
Phenytoin - gingival overgrowth
Carbamazepine - oral ulceration, xerostomia
Sodium valproate (decreased platelets and possible clotting problems)

Drug interactions
Phenytoin - metronidazole/miconazole/NSAID
Carbamazepine and Sodium Valproate - erythromycin

Question 31

Dental management of epilepsy

Answer 31

Prevention
Good OH to minimise gingival hypertrophy
Trauma may occur following seizures
Restorative - fixed prosthesis

Question 32

Emergency management of epilepsy

Answer 32

Remove sharp objects
Protect from injury
Prolonged seizure (>3 mins) – ambulance

Question 33

Oncology

Answer 33

1,200 cases of childhood cancer per year
90% paeds pts suffer oral complications

Question 34

Dental implications of oncology

Answer 34

Chemotherapy
Bone marrow transplantation
Radiotherapy to head and neck
Aim to minimise mucositis/infection/haemorrhage

Question 35

Effects of chemotherapy on developing dentition

Answer 35

Enamel defects (discolouration/hypoplasia)
Agenesis
Microdontia

Question 36

Effects of chemo and radiotherapy

Answer 36

Enamel defects (discolouration/hypoplasia)
Agenesis
Microdontia
Arrested root development
Increased caries esp if xerostomia
Facial growth
TMJ

Question 37

CLP

Answer 37

1 in 700 live births
fusion disorder affecting mid face skeleton
approx 40 cases born per year NI
30% associated with other syndromes
70% are non-syndromic - but still have a significantly inc risk of CHD
Different presentations:
- Lip only
- Palate only
- Complete unilateral
- Complete bilateral
- Submucous cleft

Question 38

Dental implications of clp

Answer 38

inc caries risk
ortho issues (crowding/class II tendency/cross-bites)
fistula formation

Question 39

Dental implications of clp: alveolus

Answer 39

inc caries risk
ortho - crowding/class III tendency
fistula
hypoplasia in teeth adjacent to cleft site
hypodontia/supernumerary teeth in region of cleft
lip tethering - difficult access and plaque retention