Impact of medically compromising conditions on paediatric dentistry Flashcards
(172 cards)
1
Q
7 medically compromising conditions for children
A
- Cardiovascular (& Down Syndrome)
- Respiratory
- Childhood Cancer
- Chronic Renal Failure
- Diabetes mellitus
- Epilepsy
- Common Coagulation Defects
2
Q
prevelance of congenital heart diseases
A
7-8 per 1000
3
Q
cardiovascular issues in children
A
congenital heart diseases
transposition of great arteries TGA
4
Q
e.g. cyanotic HD
A
fallot of tetralogy
5
Q
e.g. ascyanotic HD
A
VSD,PDA,PS,ASD,CoA,AS
6
Q
aetiology of cardiovascular issues in young
A
- Maternal rubella
- Maternal diabetes
- Maternal drugs – alcohol, phenytoin
- Foetal chromosomal abnormality- Down syndrome
- Foetal inborn errors of metabolism and connective tissue disorder-Williams syndrome
7
Q
4 aspects of dental treatment adn CHD
A
- Importance of good oral hygiene in preventing infective endocarditis
- Follow NICE Guidelines, any
- doubt consult cardiologist
- Anticoagulant medication
- Treatment under sedation
8
Q
things to not say in regards Down’s syndrome
A
Suffers from OR is a victim of Down’s syndrome
A Down’s baby/person/child
Retarded/mentally handicapped/backward/mental disability
Disease/illness/handicapped
The risk of a baby having Down’s syndrome (in relation to pre-natal screening and probability assessments)
9
Q
how to speak in regards Down’s syndrome
A
Has Down’s syndrome
A person/baby/child with Down’s syndrome or who has Down’s syndrome
Learning disability
Condition OR genetic condition
The chance of a baby having Down’s syndrome
10
Q
myth or fact
People with Down’s syndrome don’t live very long
A
Today, people with Down’ syndrome are living into their 50s and 60s with a small number living to their 70s and beyond
11
Q
myth or fact
Only older mothers have babies with Down’s syndromes
A
Although older mothers have a higher individual chance of having a baby with Down’s syndrome, more are born to younger mothers, reflecting the higher birth rate in this group
12
Q
myth or fact
People with Down’s syndrome cannot achieve normal life goals
A
With the right support, they can. Small but increasing numbers of people with Down’s syndrome are leaving home and living with support in their communities. They are, gaining employment, meeting partners and getting the best of life
13
Q
myth or fact
People with Down’s syndrome all look the same
A
There are certain physical characteristics that can occur. Each person will have a number of the more common physical characteristics. A person with Down’s syndrome will always look more like his or her close family than someone else with the condition
14
Q
myth or fact
People with Down’s syndrome are always happy and affectionate
A
are all individuals and people with Down’s syndrome are no different to anyone else in their character traits and varying moods.
15
Q
clinical features of Down’ syndrome
A
- Congenital heart lesions in 50% - ASD,VSD AV canal
- Duodenal atresia
- Atlantoaxial instability
- Umbilical hernia +/- absence of a rib
- Immunological defects affecting skin, GIT, RespTracts
- eg. periodontal destruction seen in mouth
- ALL 20x more common
- Increased risk hypothyroidism and Alzheimers
16
Q
down’s syndrome oral manifestation
A
- Mouth – small, open lip posture
- Tongue – protrusive , fissured tongue. Circumvallate papilae may be enlarged and filiform absent
- Lips – thick, dry, fissured
- Occlusion – AOB, post x-bite, Class III
- Palate – high. Bifid uvula and CLP more common
- Teeth – eruption delayed, hypodontia, microdontia, hypoplasia, low caries incidence.
- Periodontium – immunological defect of white cell chemotaxis may cause severe early onset disease
17
Q
down’s syndrome effect on mouth
A
small
open lip posture
18
Q
down’s syndrome effect on tongue
A
protrusive
fissured tongue
circumvallate pappillae may be enlarged and filiform absent
19
Q
down’s syndrome effect on lips
A
thick
dry
fissured
20
Q
down’s syndrome effect on occlusion
A
AOB
posteriot cross bite
class III
21
Q
down’s syndrome effect on palate
A
high
bifid uvula and CLP more common
22
Q
down’s syndrome effect on teeth
A
eruption delayed
hypodontia
microdontia
hypoplasia
low caries incidence
23
Q
down’s syndrome effect on periodontium
A
immunological defect of white cell chemotaxis may cause severe early onset disease
24
Q
down’s syndrome oral and dental management (5)
A
- Preventive protocol
- OH- modify toothbrush handle or electric?
- Advice about oral hygiene reiterated in congenital heart disease
- Treat under LA if compliance allows
- Chlorhexidine gel or mouthwash specifically for periodontal disease
25
impact of down's syndrome
* Development (like all children they benefit from high expectations, social inclusion is key).
* Speech and Language – delayed speech, easy read resources
* Motor skills
* Social Development
* Memory skills
* Education-Most benefit from being in mainstream school, everyone will have some degree of learning disability.
26
prevalence of asthma
* 2-5% population
* 7-19% children in UK
* 37% of 13 year olds in Scotland
27
triad of asthma
* Excess mucus production
* Inflammation of epithelial lining of airways
* Increased bronchial smooth muscle tone
28
asthma and dental tx
* Asthma medication side effects
* Adrenal suppression
* Avoid aspirin and other NSAID’s such as Ibuprofen or Diclofenac for pain relief
* Allergy to penicillin more common
* IS (mild/mod) rather than IV sedatives (resp failure)
* GA risk
* Mild - ASA II - outpatient GA
* Moderate – ASA III – inpatient GA
* Severe - ASA IV - inpatient GA
29
oral impacts of asthma
* Acidic inhalers – not proven, spacer recommended and rinse after use
* Dryness of mouth – increased intake of acidic beverages
* Laxity of lower oesophageal sphincter – reflux of gastric acid
* Chronic cough at night – reflux of gastric acid
30
possible dental tx for asthma
palatal metal shims
composite resin
31
allergy and asthma
* Asthmatics are atopic individuals and may have other allergies.
* Eg. nuts, latex, drugs.
* Latex is in the rubber bung of most cartridges of local anaesthetic including lignocaine and lignocaine with adrenaline.
* The exception is citanest and octapressin which can be given safely
32
asthma in nursery and childcare
* Asthma policy (most children not diagnosed until around 5 years)
* Avoidance of triggers (animal fur/smoke/pollen)
* Individual healthcare plans in place
33
asthma in school children
* Asthma at Primary School
* Asthma action plan (diagnosis, typical symptoms, ask for help, tummy ache, go silent??)
* Communication (how serious -3 children die every year)
* Where will reliever inhaler be kept (often blue)
* Asthma UK
* Asthma in Secondary School
* Encourage your child to take more control
* You and your child meet with school (school nurse, sports teacher)
* Asthma action plan (discuss)
* The autumn term (rise in children rushed to hospital)
* Exercise
* As normal but be prepared with asthma action plan on fridge, your phone and their phone.
* Travel
* Weather, altitude, physical activity, air travel, accommodation
34
cystic fibrosis prevalence
1 in 2500 live births
35
cystic fibrosis is
Autosomal recessive long arm chr 7
Exocrine system affected in respiratory system (thick mucous) and digestive tract (lack of pancreatic lipases)
* Diabetes, Liver cirrhosis, Reproductive problems with age
36
cystic fibrosis effects
Recurrent chest infections
* P.aeruginosa and S.aureus
Pancreas exocrine function decreased
* malabsorption especially fats
* Pancreatic supplements and Vitamins
* Need 120-150% of normal energy intake
37
6 oral manifestations of CF
* Saliva - thickened
* Caries may be reduced
* ? Higher salivary ammonia
* Higher calculus levels
* Lower plaque and gingival disease
* Enamel defects
* Delayed eruption
38
dental management of CF
* GA risk
* Diabetes and Liver disease
* Sedation contraindicated – resp failure
* Diet advice (high sugar intake)
* Sugar free liquid antibiotics
39
areas that CF impact on
* Nutrition
* Treatment
* Travel
* Physiotherapy
* School
* Higher education
* Transition
* Fertility and Pregnancy
* CF at work
* Cross Infection
* Transplant
* Combination therapies
40
incidence of childhood cancer UK
* 1:600 under 15 years of age
* 1200-1500 new cases under 15 years of age/yr
* 700 die under 14 years of age/yr
* Prognosis change 1940-1980
41
treatment modalities for childhood cancer (4)
* Chemotherapy - C/T
* Radiotherapy - R/T
* Surgery
* High dose therapy with bone marrow rescue – BMT
42
general side effects of chemotherapy (6)
* Bone marrow suppression: Hb, WCC, PLT
* Immunosuppression
* Anorexia
* Nausea and vomiting
* Gut mucosal damage
* Alopecia
43
acute complications of chemotherapy
* oral mucosa
* oral flora
* dry lips
* halitosis
* gingiva
* haemorrhage
* infection
* tooth sensitivity
* glossitis
* paraesthesia
* tooth mobility
* sialadentitis
* taste loss/ Cacogeusia
* trismus
* drysphagia
* tooth ache, head ache, bone pain
44
oral mucosal changes due to childhood cancer and treatment
ulceration and mucositis
haemorrhage
oral infection
neutropenias
45
ulceration and mucositis in childhood cancer tx
* Onset 12-15 days after R/T, 3-10 after C/T.
* Ulcers on all types of mucosa
* Mucositis often localised to oropharynx
* Stomatitis develops as burning which within 1-3 days develops into ulceration
46
treatment of mucositis and ulceration
supportive
* Sodium Bicarb – 2 hourly
* **Gelclair- 2 hourly**
* **Biotene (Oral Balance)mouthrinse – 2 hourly**
* Difflam mouthrinse or spray – 2 hourly
* **Lignocaine 2% solution/ice lolly-before meals/2hrly**
* Benzocaine 20% flavoured gel – before meals
* Orabase+/- corticosteroid –between meals
* Tetracycline oral suspension –1min spat out QD
47
biotene mouthwash/toothpaste
* Moisturises oral mucosal cells
* Antibacterial effect of proteins
* Reinforces antibacterial activity of saliva
* Contains Xylitol which inhibits bacteria
* Triple enzyme formula:
* lysozyme;
* lactoperoxidase;
* lactoferrin.
* Contains fluoride, glucose oxidase, aloe vera
48
haemorrhage in childhood cancer tx
* C/T or BMT cause:
* anaemia;
* thrombocytopenia;
* leucopenia
**Spontaneous gingival haemorrhage when**
* **platelets \< 20-30 x 109/L**
Problems reduced with good OH
49
spontaneous gingival haemorrhage when
platelets \< 20-30 x 109/L
50
management of dental haemorrhage in childhood cancer tx
* Eliminate hard foods
* Smooth sharp cusps and fillings
* Never use salicylates for pain
* Platelet count \> 80 (40-100) x 109/L for all injections, extractions, deep scaling.
* Time treatment to normal platelet count
* Do not neglect
* Liaise with physician
51
oral infection types
viral
fungal
bacterial
52
oral infection caused by chemotherapy because
* Leucopenia
* Inhibition of antibody responses
* Block of the mononuclear phase of inflammation
* Abolition of delayed hypersensitivity
53
viral oral infection treatment
Acyclovir 5% cream 5xday5days
Acyclovir 400mg/10ml 5xday5days
* (under 2 yrs ½ dose)
54
bacterial oral infection treatment
Gram -ve bacilli
* systemic antibiotics
* lozenges with polymixin,
* tobramycin
55
fungal oral infection treatment
Candida–nystatin
* 100,000units 5mls QDS
* miconazole gel 25mg/ml 5ml QDS
* fluconazole 50mg/ml. 50mg caps OD
* itraconazole, ketoconazole
Aspergillus- systemic antifungal
Phagomycosis-systemic antifungal
56
granulocyte count for routince care Vs AB prophylaxis
* \> 2.0 Routine care
* \< 2.0 Ab prophylaxis
57
erythrocyte count and oral infection
* \> 5.0 Routine care
* \< 5.0 May need to alter dose of RA or anaesthetic agent
58
chronic renal failure in children
* Less common in children
* 10 per million child population
* Congenital and familial more common than acquired
* Nutrition and supplements important for normal growth, prevention renal osteodystrophy & acidosis
* Anaemia is a risk
* Growth hormone resistance may affect growth
59
why is nutrition and supplements important in childhood chronic renal failure treatment
important for normal growth, prevention renal osteodystrophy & acidosis
60
risks in childhood chronic renal failure
anaemia
growth hormone resistance may affect growth
61
impact on renal disease on parenting
coping with feeding problems - CKD children can struggle with feeding or eating
may need feeding device as they cannot eat the amounth needed for growth
62
oral findings in CKD
* Excessive plaque accumulation
* Gingivitis & bleeding
* Gingival overgrowth
* Enamel hypoplasia
* Some develop periodontitis
* Osseous changes
* Pulp obliteration
* Pallour, petechiae, ecchymosis
* Uraemic stomatitis
* Reduced caries
63
dental considerations in CKD (6)
* Bleeding tendencies and haemostasis
* Treatment: day after dialysis
* Infections can be poorly controlled
* Signs of inflammation can be masked
* Increased risk blood borne viral infections
* Osseous lesions may be seen jaws; lamina dura thinning, osteolytic lesions, giant cell lesions
64
dental aspects of chronic renal failure (5)
* Local anaesthetic ok but consider bleeding issues
* Inhalational sedation ok
* IV sedation – careful of veins, midazolam less risk thrombophlebitis
* Careful management for general anaesthetic
* Consider underlying diseases such as hypertension, diabetes & SLE.
65
antimicrobials and chronic renal failure
Benzylpenicillin potassium content
* neurotoxicity.
Give lower doses of penicillin's (except flucloxacillin & phenoxymethyl pen), metronidazole and cephaloridine to avoid toxicity CNS
* Erythromycin, cloxacillin & fucidin normal dose
Care with tetracyclines
* doxycycline & minocycline ok within usual dental constraints
Consider antimicrobial prophylaxis for surgery
Consult renal physician
66
renal transplant
RTx
Due to chronic renal failure
* From 2 years old onwards
Graft survival 85% after 2 years
Life long immuno-suppression
* Prevention of T-cell allo-immune rejection
Usually with corticosteroid plus steroid sparing drug
67
renal transplant dental considerations (7)
* Careful pre-op dental assessment
* Removed sources infection
* Maximal preventive efforts
* Defer elective treatment 6/12 after surgery
* Consider antibiotic prophylaxis within that time
Renal graft survival 5 years 70%
Patient survival 1 year post transplant 95-98%
68
dental treatment post RTx
* Anaemia & platelet dysfunction
* Gastro-intestinal – *gastritis, peptic ulcer or diverticulitis*
* Cardiovascular – *hypertension, atherosclerosis & myocardial infarction, congestive heart failure & left ventricular hypertrophy*
* Bone & joint disease associated with low calcium, high phosphorus and elevated PTH
* Sclerotic dental pulp may be due to corticosteroids
Consult paediatric nephrologist
* Ask about graft function & degree of suppression
* Modify drug dosage according to degree renal function
* Prednisolone regimen – consider steroid cover
* Frequent dental recall for preventive care
* Consider change to tacrolimus from cyclosporin (less gingival overgrowth)
69
classic triad of symptoms of diabetes mellitus
* Polyuria
* (produce abnormally large volumes of urine)
* (Frequent need for toilet)
* Polydipsia (great thirst)
* Recent weight loss
70
early clinical symptoms of diabetes mellitus
Polyuria
* (produce abnormally large volumes of urine)
* (Frequent need for toilet)
Polydipsia (great thirst)
Recent weight loss
* Pruritus
* Weakness
* Fatigue
* Polyphagia
* Constipation
* Mental confusion
* Acetone breathe
71
late clinical features of undiagnosed diabetes mellitus
* Vomiting, nausea, abdominal pain
* Renal dysfunction
* Hyperventilation – metabolic acidosis
* Dehydration
* Hypovolaemia
* Pasasthesia(extremities)
* Dysaesthesia
* Gastrointestinal neuropathy
* Muscle wasting
* Shock
* Coma
72
11 oral manifestations of diabetes mellitus
* Reduced salivary flow
* Xerostomia
* Burning mouth/tongue
* Candidal infection
* Altered taste
* Progressive periodontitis
* Dental caries
* Oral neuropathies
* Parotid enlargement
* Sialosis
* Delayed wound healing
73
signs of 'hypo' coma (12)
* Mood change, irritability
* Strong bounding pulse
* Nausea and stomach ache
* Hunger
* Shaking, tingling around mouth
* Increased gastric motility
* Hypothermia
* Disorientation
* blurred vision
* Lethargy
* slurred speech
* Sweaty skin
74
signs of 'hyper' coma (9)
* Weak pulse
* Rapid deep breathing (Kussmaul’s respiration)
* Dry skin
* Acetone breath
* Increased frequency of micturition (to want to urinate)
* Thirst
* Severe hypotension
* Abdominal pain and vomiting
* Loss of consciousness (diabetic coma)
75
glycaemic index
ranking of carbohydrate-containing foods based on the overall effect on blood glucose levels.
76
management of sugars in type 1
* testing
* insulin
* injections
* pumps
* hypos
* hypers and DKA
For people with [Type 1 diabetes](https://www.diabetes.org.uk/Type-1-diabetes/) on a basal bolus insulin regime or insulin pump
* possible to match the amount of insulin given at meal times to the amount of carbohydrate eaten.
* important to estimate total carbohydrate - will involve reading labels and weighing food portions until you become familiar with the carbohydrate content of common foods.
* Insulin ratios can then be adjusted with help from your diabetes healthcare professional. This is what we call carb counting.
77
manangement of sugars type 2
being aware of the total amount of carbohydrate you eat, including both starchy and sugary carbohydrates, can help you achieve good blood glucose control
78
individual management of diabetes
* Support from other people
* Parents, siblings, extended family who looks out for signs of hypo/hyper
* Taking control: set goals (HbA1c)
* carb count and insulin adjustment
* Healthy eating
* Recording test result
* Being vigilant for infection (examine your feet)
* Know the sick day rule
* Effect stress/infection/temp
* Wear identification in case of emergency
* Getting active and staying active
* Affect of alcohol on sugar levels
79
easy prevention of hypo
**keep something sugary nearby, such as glucose tablets, in case you feel hypo**
* Physical activity will nearly always have an effect on your blood glucose. Because you are being active, your body uses up more glucose as fuel.*
* If you have taken your usual dose of insulin and then do some activity, you will have less glucose than normal, and this can lead to a hypo.*
* How to stop them*
* *reduce your dose of insulin and increase the amount of food you eat beforehand. Talk to your nurse or doctor about this.*
* *Check your blood glucose before, and after activity, and maybe during the activity as well.*
* Delayed hypos*
* *Hypos can happen up to 36 hours after a lot of physical activity. That's a long time – it's because when you've stopped being active, muscles will still continue to use extra glucose to replace their stores.*
80
epilepsy prevelance
4 in 1000 children
81
types of epilepsy
* Primary
* no cause found
* Secondary
* first year - congenital, birth trauma
* later – meningitis, encephalitis, RTA
* generalised
* focal
EEG, MRI diagnosis
82
EEG
electroencephalogram
test that detects electrical activity in your brain using small, metal discs (electrodes) attached to your scalp
83
epileptic children - likelihood to have other health issues
Two thirds of children in mainstream education
* Often behavioural problems
One third of children have multiple disabilities including CP and educational delay
* May have recognised syndromes which include teeth and palate
84
impact of epilepsy
Emotional problems may increase during the teenage years if epilepsy is not well controlled.
* Common emotional problems include
* Anxiety
* depression
* low self-esteem
* a lack of confidence.
Children show emotional distress in different ways from adults. Mood swings, irritability and frequent temper outbursts can be signs of anxiety or stress, especially in young or developmentally delayed children.
85
oral manifestations of epilepsy (3 types\_
* Injuries caused by fit:
* Soft tissue laceration of tongue or buccal mucosa
* Facial fractures
* Trauma to teeth
* TMJ dislocation
* Injuries caused by drug therapy:
* Gingival hyperplasia
* Recurrent aphthous like ulceration
* Anomalous development – small teeth, delayed eruption
* Cervical lymphadenopathy
86
epilepsy oral and dental management (4 aims)
* prevent pain
* prevent infection
* treat any trauma due to fits
* try to retain natural teeth
87
seizure management in dental surgery
* Recovery position
* Diazepam up to 10mg
* Oxygen
* Call ambulance
88
coagutalion defects categories
congenital
acquired
89
common congenital coagulation defects
* Haemophilia A
* Haemophilia B
* Von Willebrands Disease
* Single clotting factors eg. XI and XII
90
common acquired coagulation defects
* Vit K deficiency(liver disease)
* Clotting antibodies
* Stored blood transfusions
* Anticoagulant drugs eg. warfarin
* DIC-Diffuse Intravascular Clotting eg.meningococcal septicaemia
91
what is leukaemia
cancer of the white blood cells.
Normally white blood cells are made in the bone marrow and develop, repair and reproduce themselves in an orderly and controlled way. In leukaemia, however, the process gets out of control and although the **cells continue to divide in the bone marrow, they do not mature**. **These immature dividing cells fill up the bone marrow and stop it from making healthy blood cells**. As the leukaemia cells are immature, they cannot work properly – leading to an increased risk of infection.
There are 4 types of leukaemia, named according to the type of white blood cell affected and whether it is acute or chronic.
* Acute Lymphoblastic Leukaemia (ALL)
* Acute Myeloid Leukaemia (AML)
* Chronic Myeloid Leukaemia (CML)
* Chronic Lymphocytic Leukaemia (CLL)
92
how is ALL treated
**Chemotherapy** is the main treatment for ALL.
* aim of treatment is to destroy the leukaemia cells and enable the bone marrow to work normally again.
stages
* Induction:
* Consolidation and CNS treatment:
* Maintenance treatment:
**Bone marrow transplantation**
Bone marrow treatment is needed by a minority of patients and is used for children with ALL that is likely to come back following standard chemotherapy.
93
induction stage of chemotherapy treatment
involves intensive treatment, aimed at destroying as many leukaemia cells as possible, restore the balance of cells in your blood and relieve your symptoms
isusually started within days of being diagnosed (4 to 6 weeks)
* Hospital or specialist centre
* Need regular blood transfusions because blood will not contain enough healthy blood cells
* Vulnerable to infection
* Chemotherapy - kill the leukaemia cells in bone marrow (methotrexate) - tablets, injections (IV) and/or into CSF
* Steroid injections or tablets can help improve effectiveness
A bone marrow sample is taken at the end of induction treatment to confirm whether or not the child still has leukaemia.
94
consolidation and CNS treatment phase of chemotherapy treatment
Aimed at maintaining the remission (kill any remaining leukaemia cells) and preventing the spread of leukaemia cells into the brain and spinal cord.
* Regular chemotherapy injections - outpatient basis (only stay overnight if bad symptoms)
* Several months
* CNS treatment involves performing a lumbar puncture and injecting a drug, usually methotrexate, into the spinal fluid (intrathecal treatment).
After this consolidation treatment there is a recovery period which is called interim maintenance.
* This is when more drugs will be given to try to keep the leukaemia in remission. The exact details will depend on which arm of treatment the child follows dependant on the child’s response to treatment so far. Further doses of chemotherapy treatment, called ‘delayed intensification’, are given to kill off any remaining leukaemia cells.
95
maintenance treatment of chemotherapy
Lasts for 2 years from the start of interim maintenance for girls and 3 years from the start of interim maintenance for boys.
It involves the child taking daily and weekly tablets, some children also have monthly injections of chemotherapy and oral pulses of steroids and three-monthly intrathecal treatment.
* stop the leukaemia coming back
Children will be able to take part in their normal daily activities as soon as they feel able to. Most children return to school before beginning maintenance treatment.
96
bone marrow transplantation for chemotherapy pts when
needed by a minority of patients and is used for children with ALL that is likely to come back following standard chemotherapy.
97
4 short term effects of chemotherapy
* **Cytotoxic**: due to direct effect on cells – mucositis and decreased salivary gland function
* **Haemorrhagic**: Due to bone marrow suppression – defective heamostasis resulting in petichiae, gingival bleeding
* **Infectious**: Due to Bone marrow suppression – viral, bacterial and fungal infections
* **Neurological** (with vincristine): trismus and jaw pain
98
4 long term effects of chemotherapy
* Tooth agenesis
* Microdontia
* Crown hypoplasia
* Disturbed root formation
\*\*\*Effect will be on teeth mineralising during chemotherapy\*\*\*
99
possible medical factors for an ALL pt needing dental tx
Counts; immunosuppresion; potential bleeding risk
100
possible patient/social factors for ALL pt who needs dental care
Co-operative ability;
Not practical to attend GDP due to long periods of hospital admittance and/or multiple hospital appointments
101
dental factors for ALL pt who has caries into dentine
Complete caries removal under LA required ?Co-operative ability?
Unsuitable for IS due to diagnosis; Treatment under GA may be possible as a joint procedure;
**All teeth of poor prognosis must be treated – treatment planning more radical**
dental caries into dentine - due to his recent ALL diagnosis, not suitable for treatment at this time in GDP
* dental treatment should be undertaken in a Children’s Hospital setting by the Paediatric Dental Team following liaison with the oncology team.
In the future, during maintenance treatment, could have dental reviews and non-interventive treatment in GDP such as fluoride varnish and fissure sealants.
Until the end of treatment all interventive treatment should be undertaken within the Hospital setting following liaison with the oncology team.
102
is hall technique PMC suitable for ALL pt
No.
* Caries left in situ in Hall PMC.
* Due to consequences of infection in a child with ALL treatment planning must be more radical.
Hall technique PMC are unsuitable and extraction of teeth likely. Any teeth in which existing Hall technique PMCs have been placed should be extracted.
103
what can be used to aid oral cleaning if ALL pt uncomfotable due to mucositis
Alcohol free 0.2% Chlorhexidine mouthwash- This can be diluted and wiped round the teeth and gingivae with gauze if the patient is struggling to brush their teeth.
104
mouth care advice for pt who has developed mucositis
* Reinforcement of enhanced oral hygiene advice.
* A soft, small headed toothbrush can be considered.
* Ice-chips- to soothe and relieve symptoms
* Low Level Light Therapy.
* A low power laser emitting less than 500 mW on the red or near infra-red spectrum. The light stimulates cells thereby reducing inflammation, increasing cell metabolism and inducing endorphins.
* Protective barriers eg. *Gelclair*:
* Poly-Vinyl-Pyrrolidone and Hyaluronic Acid-based gel that forms a protective film on the oral mucosa
* Other mouthrinses eg.
* *Caphasol* mouthwash
* supersaturated calcium-phosphate rinse.
* lubricates the mucosa and has mineralising potential.
* 2% lidocaine mouthwash:
* Can be used before eating.
* Difflam (benzydamine hydrochloride mouthwash 15%)
105
radiotherapy
high doses of controlled radiation are used to kill cancerous cells.
It's usually used to treat acute lymphoblastic leukaemia when:
* acute lymphoblastic leukaemia has spread to the nervous system or brain
* the body needs to be prepared for a bone marrow transplant
106
when is immunotherapy used in cancer treatment
do not respond or cancer comes back
107
6 general side effects of Chemotherapy
* Bone marrow suppression: Hb, WCC, PLT
* Immunosuppression
* Anorexia
* Nausea and vomiting
* Gut mucosal damage
* Alopecia
108
ulcerations and mucositis due to C/T
* Onset 12-15 days after R/T, 3-10 after C/T.
* Ulcers on all types of mucosa
* Sore, uncomfortable, knock on eating
* Mucositis often localised to oropharynx
* Stomatitis develops as burning which within 1-3 days develops into ulceration
109
treatment options for ulceration and mucositis
* Sodium Bicarb – 2 hourly
* **Gelclair**- 2 hourly
* **Biotene** (Oral Balance)mouthrinse – 2 hourly
* Difflam mouthrinse or spray – 2 hourly
* Lignocaine 2% solution/ice lolly-before meals/2hrly
* Benzocaine 20% flavoured gel – before meals
* Orabase+/- corticosteroid –between meals
* Tetracycline oral suspension –1min spat out QD
110
biotene mouthwash/toothpaste
* Moisturises oral mucosal cells
* Antibacterial effect of proteins
* Reinforces antibacterial activity of saliva
* Contains Xylitol which inhibits bacteria
* Triple enzyme formula:
* lysozyme;
* lactoperoxidase;
* lactoferrin
* contains F, glucose oxidase, aloe vera
111
C/T or BMT affect on blood (3)
* anaemia;
* thrombocytopenia;
* leucopenia
112
spontaneous gingival haemorrhage when
* platelets \< 20-30 x 109/L (due to bone marrow suppression
Problems reduced with good OH
113
management of haemorrhage due to C/T
* Eliminate hard foods
* Smooth sharp cusps and fillings
* Never use salicylates for pain
* Platelet count \> 80 (40-100) x 109/L for all injections, extractions, deep scaling.
* Time treatment to normal platelet count
* Do not neglect
* Liaise with physician
114
how can chemotherapy increase oral infection chance
* Leucopenia
* Inhibition of antibody responses
* Block of the mononuclear phase of inflammation
* Abolition of delayed hypersensitivity
115
3 types of oral infection
viral
fungal
bacterial
116
treatment of viral oral infections
* Acyclovir 5% cream 5xday5days
* Acyclovir 400mg/10ml 5xday5days
* (under 2 yrs ½ dose)
117
treatment of bacterial oral infection
* G-ve bacilli
* systemic antibiotics
* lozenges with polymixin,
* tobramycin
118
treatment of fungal oral infections
* Candida–nystatin
* 100,000units 5mls QDS
* miconazole gel 25mg/ml 5ml QDS
* fluconazole 50mg/ml. 50mg caps OD
* itraconazole, ketoconazole
* Aspergillus- systemic antifungal
* Phagomycosis-systemic antifungal
119
granulocyte count for needing AB prophylaxis
* 2.0 Routine care
* \< 2.0 Ab prophylaxis
120
neutropenias
* when you have too few neutrophils, a type of white blood cells.
* While all white blood cells help your body fight infections, neutrophils are important for fighting certain infections, especially those caused by bacteria.
* Cyclic - disappearance/drops in 21 day intervals
121
3 oral impacts of neutropenias
* Ulceration with scarring
* Gingivitis
* Periodontitis
122
neurological nerve issues due to chemotherapy
trismus
jaw pain
123
chemotherapy affect on appetite
reduced
124
enhanced prevention accorinding to SDCEP
* Fluoride
* 2800ppmF toothpaste prescription,
* F varnish 4x year
* F mouthwash at different time to brushing
* OHI
* Diet diary and advice
* Bitewings – every 6-12 months
* Start as soon as contacts closed
* May change to 12 months depending on OH compliance
* Fissure seal all permanent posterior dentitions
125
describe this OPT for ALL pt
nasogastric feeding tube seen on OPT
Caries lower left and right 6s
* Remove caries - composite
* Extraction - best as source of infection
* Bit early as no bifurcation of 7s - but child is unwell so need to protect life
* Take out all 4 -- overeruption uppers if no lowers
Can deal with orthodontic and malocclusion later in life
126
4 effects of cancer Tx on developing dentition
* Can delay eruption of permanent teeth
* Effect teeth mineralising during chemo - microdontia, roots not formed properly
* Hypoplasia of crowns
* Hypodontia teeth not formed
127
layers of heart
* Pericardium – outer layer
* Myocardium – thick muscle middle layer
* Endocardium – thin inner layer
128
chambers of heart
4
* 2 atrium
* Upper chamber
* Receiving
* 2 ventricles
* Lower chamber
* Pump blood
129
what divides the right and left heart
muscular wall - septum
to prevent deox and ox mixing
130
role of valves in heart
Act like gates that open and close – making sure that blood travels in one direction
Beat - valves open to allow blood flow
Close to prevent backwards flow
131
4 valves of heart
* Atrium and ventricle
* Tricuspid (right)
* Bicuspid (left)
* Ventricle and arteries
* Pulmonary (right)
* Aortic (left)
132
blood flow through healthy heart
Right atrium - deox from body
* Tricuspid
* Right vent
* Pulmonary valve and artery
Lungs - gain O2
Comes back to left atrium pulmonary veins
* Bicuspid valve
* Left vent
Aortic valve and aorta
133
congenital cardiac defect
* Structural defect of the hear or adjacent great vessels
* Develops in the womb before a baby is born
* picked up often at 20 week scan
134
most common congenital heart defects (3)
* Septal defects
* Narrowing of main artery - coartarion of aorta
* Pulmonary valve stenosis - narrowing of
Most no known cause
135
6 symptoms of congenital heart defects
* Blue tinge
* Poor feeding
* Breathing problems
* Extreme tiredness
* Excessive sweating
* Chest pain
136
2 classes of congenital heart defect
cyanotic
acyanotic
137
cyanotic heart disease
characteristics
* deoxygenated blood is shunted from R to L heart bypassing the lungs
* deoxygenated into systemic circulation
* Can appear blue, especially on exertion and/or finger clubbing
* Lower exercise tolerance as less O2 in system
* Higher risk of IE
138
acyanotic heart diseases (6)
* Ventricular septal defects
* Atrial septal defects
* Patent ductus arteriosus
* Pulmonary stenoisis
* Aortic stenosis
* Coartication of aorta
139
cyanotic heart diseases (5)
* Tetralogy of fallot
* Transposition of great arteries
* Complete atrioventricular septal defect
* Tricuspid atresia
* Pulmonary atresia
140
dental considerations of congenital heart diseases (4)
* Risk of bleeding
* Risk of infective endocarditis – *adhere to heart valves/defects*
* Risk of general anaesthetic
* Often need to be performed in specialist care
* Active dental disease may delay surgery
* Need to be deemed dentally fit
141
congenital heart defect
risk of bleeding because (3)
* Blood thinning medication
* Sluggish microcirculation
* Polycythaemia in cyanotic CCD
142
congential heart defects and infective endocarditis considerations
Importance of optimal oral health
* Prevent dental infection/avoid need for treatment
* Bacteraemia risk
* Poor OH – bleeding gingiva = brush or eat is bacteraemia
Consideration of antibiotic prophylaxis
143
infective endocarditis
* Rare but serious illness (30% mortality, 1 in 3)
* An inflammation of the inner layer of the heart (endocardium)
* Most commonly caused by bacteria entering the bloodstream and travelling to the heart
Initial symptoms
* High temperature
* Chills
* Headache
* Joint and muscle pain
educate pts to seek prompt care
144
change in IE guidelines
Children with congenital cardiac defects are at increased risk of IE
* Many dental procedures result in bacteraemia
In the past all patients at increased risk of IE were given AB prophylaxis prior to invasive dental procedures
* NICE 2008 - no longer recommended
* NICE 2016 - not routinely recommended
* challenge - **SDCEP follow**
Chlorohexidine pre op rinse - not recommended
145
2 quesions to ask when considering AB prophylaxis for IE
1. Is the patient in a special consideration category for risk of IE?
2. Will the dental procedure result in bacteraemia?
146
if pt at risk of IE (but not special consideration group)
convey OH messages but don’t need AB cover
147
if pt in special consideration group for IE
liaise with cardiologist to see if AB needed
148
cyanotic Vs acyanotic
“blue” or “red” babies
Cyanotic
* where deoxygenated blood bypasses the lungs and enters the systemic circulation, or a mixture of oxygenated and deoxygenated blood circulates
Acyanotic
* blood is shunted from the left side of the heart to the right, through a structural defect in the septum. These pts can often retain a near-normal oxygen saturation in their systemic circulation
149
considerations when developing dental tx plan for congenital heart defect pt
* Is he on any medication that may impact on dental treatment?
* e.g. diuretics, digoxin, vasodilators, anticoagulants, aspirin (haemostasis concern)
* has he any further surgical cardiac procedures approaching?
* Is he at risk of infective endocarditis?
* What is anxiety level like in the dental setting? (management, GA, referral considerations)
150
who to consult if unsure how best to dentally tx a congenital heart defect ot
their consultant cardiologist
Ask advice from local paediatric specialist (hospital, cardiac network) re Tx plan, modality if concern over AB
151
what does IE effect
infection of endocardium usually on the valves (microbial colonisation of thrombi on endocardial surface abnormalities)
* inner layer
* Any part - more common on damaged valves
152
special consideration pt subgroup for IE
* Pt with any prosthetic valve, inc transcatheter valve or those whom any prosthetic material was used in a cardiac valve repair
* Pt with previous episode of IE
* Pt with congenital heart disease (CHD)
* Any type cyanotic CHD
* Any type CHD repaired with prosthetic material – surgical or percutaneous
* Up to 6 months after the procedure or lifelong if residual shunt or regurgitation remains
## Footnote
*acyanotic can become cyanotic - check*
153
SDCEP AB guidelines for IE
AB Prophylaxis before at risk procedures
* Amoxycillin 3g oral 1hr before procedure – even if used recently
UNLESS ALLERGIC
* Clindamycin 1.5g
Higher ADA risk – ONLY use if penicillin allergic
154
symptoms of IE
acute and subacute
Acute – take place in a few days, pt becoming rapidly unwell
Subacute – more gradual, over weeks/months
Clinical symptoms include:
* Temp \>38oC
* Shortness of breath on exertion
* Fatigue
* Muscle and joint pains
* Unexplained weight loss
* Flu-like symptoms
* Pale skin
* Heart murmur
155
ULD – subgingival caries extending into pulp, asymp, no clinical sign of infection
congenital heart defect pt
what Tx
**EXTRACT**
**deal with occlusion/ortho consequences later**
not
* Restore ULD – caries removal and restore X
* into pulp so need pulp therapy - not option for cardiology paeds pt
* Keep under observation
* Maybe If fit and well, 3 months - risk nfection unnoticed - not here as heart defect
* Hall crown
* Not manage subgingival caries
* Contraindicated with cardiac defects - infection present
156
tetraology of Fallot
Critical
Cyanotic – special risk – liaise with cardiologist for invasive treatment
made up of the following 4 defects of the heart and its blood vessels:
1. A hole in the wall between the two lower chambers―or ventricles―of the heart. This condition also is called a [ventricular septal defect](https://www.cdc.gov/ncbddd/heartdefects/ventricularseptaldefect.html).
2. A narrowing of the pulmonary valve and main pulmonary artery. This condition also is called pulmonary stenosis.
3. The aortic valve, which opens to the aorta, is enlarged and seems to open from both ventricles, rather than from the left ventricle only, as in a normal heart. In this defect, the aortic valve sits directly on top of the ventricular septal defect.
The muscular wall of the lower right chamber of the heart (right ventricle) is thicker than normal. This also is called ventricular hypertrophy
157
heart defect when blood flow right to left
deox into systemic circulation
CYANOTIC
158
heart defect when blood flows left to right
ACYANOTIC
pressure on right side = hypertrophy
increase blood flow to lungs = damage
159
children with CCD and dental disease
priority group for prevention
* Increased risk of IE
* Risk of bacteraemia from dental infections or treatment
* Dental decay may delay cardiac surgery
Management of dental disease for those with CCD should be radical ensuring sources of possible infection are managed definitively.
* Some treatment (inc hall crowns and pulp treatment) in the primary dentition are contraindicated
Treatment can be complicated by pt medication, risk of GA (often requiring tx in specialist units), and need to consider antibiotic prophylaxis
risk of IE and the need for optimal OH should be explained to all pts with CCD
* Should include advice on signs/symptoms of IE and need to seek prompt advice if concerned
160
how to reassure mother of ASD child before dental visit
Obtain a profile of the likes and dislikes from the parent or school
* Any Useful phrases from parents
* Rewards
* what they use (e.g. speak about what they like currently), firm touch better (soft touch can be associated with pain)
* toilet trained?
* Internal awareness, adaptability
* If not and at special needs school – greater challenge
Communication technique
* his preference - be prepared for it
Send out social story explaining dental journey using PECS
* preparatory information
* Send out a plastic mirror
* So they can familiarise themselves with it
Be ready and on time
* They have limited and restricted behaviours – don’t want to keep them out of their comfort zone for longer than necessary
* Ask what time she thinks be best for her son - i.e. better first thing, straight after lunch
Avoid sensory overload
* Declutter
* Turn radio off, block of/minimise sound from neighbouring surgery
* Avoid using tastes they don’t like - banana (not use duraphat), oro nurse (no flavour, non foaming) 1450ppmF - run on particular tooth if high risk
* Dim light/turn off completely (build up acclimatisation initially), Darker glasses
* Adjust chair before they get in
161
useful paperwork to have before ASD pt comes in
New pt questionnaire - series of Qs to help visit run smoothly, *paed dental clinic*
Give a key contact - that parent can call to discuss autism needs
* Need to train all staff on what autism is and how to deal with - autistic style in distress rather than badly behaved
162
3 characteristics of ASD
lifelong neurodevelopmental disorder - perceive the world slightly differently
* Social interaction
* Social communication
* Can be non verbal
* Can use - makaton, PECS Picture Exchange Communication System, widget
* Need to be direct and clear
* Limited and restricted patterns in behavior *reflects limited imagination*
* Don’t like change – like prediction
* Challenging for parents
163
how may you need to change your appointment routine for ASD
Sometimes need to act quickly for check up - reverse appointments to do history after to utilise window of opportunity
164
variations in ASD
* Spectrum disorder
* Symptoms and characteristics varies widely
* Many related conditions - ask if they have any
165
issues for communication and ASD (3 key)
**Difficult to communicate and understand language** - mild (take literally) severe (non verbal)
* Take a seat
* Hoover
* Eyes peeled
* Raining cats and dogs
**Take in less sensory information**
* overwhelmed - may look at floor to concentrate on what you are saying
**Like predictability**
* find new situations or people hard
* be very clear and address them, slow
166
dental team modifications for ASD
* Allow sufficient appointment time - give extra to be prepared
* Ensure ready on time for them - minimise time they are out of comfort zone
* Keep calm and not rush/get frustrated
* Spend time acclimatising the pt so that they feel comfortable and at ease in new situation
* Be aware may need more appointments that initially thought
167
how to modify pain history for ASD
Point to pain possibly
**Tell the parent in a way to show you understand their difficulties -** help build their trust, adjust Qs
How long? Has school noticed?
* Painkillers
* may not take if they don't like change
* hard to tell if tooth pain responds
* How is the sleep pattern
* Sleep disturbance common - on melatonin - not good indicator
* Has it changed recently - got worse
* Does your child have a more restricted diet?
* Can have quite strict eating patterns - only eat certain things
* May not need to take a food diary to take away - as may be able to tell straight away
* Habits can take a long time to break - not an easy option need to work with them
* One at a time
Self injurious behaviour
* Does this effect the mouth - bang head, pick gum (can be indicator of dental pain if changed recently as could be trying to get rid of it)
168
how to help parent with oral hygiene of ASD child
try to find a way to get to have twice daily regular brushing routine
* Ask if any issues with
* toothpaste (SLS free maybe option if sensory overload)
* Brush - modifications needed, technique change (2 brushes), finger props
* have system - do reverse at night so not neglecting one area
169
system for brushing for ASD
Areas of higher risk pain when brushing other teeth
* posterior, lower lingual; frenum between central incisors
demonstrate to parent
* Take care
* Sit behind the child
* Finger over the frenum gently when retract lip
* Can often be sore due to grossly decayed teeth
* Don’t brush with cold water if have sensitive teeth (water free)
do reverse at night so not neglecting one area
170
enhanced protection modification for ASD under 10
* 1500ppm if not 1450ppmF oranurse that he will use regularly
* F varnish 3-4 months (banana, or colocophony free melon taste)
* See every 3-4 months
* Can be shared care - 2 times GDP, 2 time paed hosp
* attempt radiographs every 6 months
171
how to place FS on ASD pt
taste salt
* GI on finger and vaseline
* Rub over toothpaste they like,
* if they don’t like any - put finger in longer with GI then vaseline in longer and quick rinse so more hopeful set
172
how to manage arrested caries in ASD pt
* Ask parent to rub extra toothpaste on it at night
* SDF (need bitewing)
* Preformed metal crown
* Hard to acclimatise too
* 24hrs - prep parent, ask what they would rather biologically treated or prevention
* Could be left if successfully arrested
* Take one home to get used to
