Medical Issues in Paeds Patients Flashcards
Why is it important to know if a dental patient has a bleeding disorder?
Aids treatment planning
Know if any procedures are contraindicate
Indicates the location of treatment- i.e. hospital setting or general practice
They have an increased bleeding risk- know to take step to combat this.
Why is tooth decay of a concern in haemophilic patients?
Tooth decay will require some form of invasive treatment that involves either LA, dental dam or involving the gingival margin.
What would be the priority in haemophiliac patients?
Enhanced prevention.
Fissure sealants
Fluoride varnish 4 times a year- 22,600 ppm.
Mouthwash- 225ppm.
Fluoride toothpaste suitable for their age.
OHI at each recall visit
Diet advice at each recall visit.
If a patient presents with advanced caries and has a lot of medical issues- how do you think their co-operation would be for treatment?
Caries presenting at a late stage would suggest avoidance of treatment.
Medical kids will be exhausted with medical treatment- may be fearful of the healthcare setting.
Previous GA patients are also more anxious- he has had extractions in the past.
You are also a stranger- this will make kids more anxious.
If a patient presented as an emergency and was a haemophilic, what would you do?
Pain- antibiotics and pain relief (contact haemophilia centre for advice on analgesia).
- Phenoxymethylpenicillin- 6-11 years old is 250mg 4 times a day for 5 days.
Trauma- Management in a Haemophillia centre- contact them for advice and post-op advice.
- use local haemostatic measures.
Explain the management options for extractions in patients with different levels of severity of Type A haemophilia?
If patient is severe (less than 2% factor percentage) or Moderate (2-5% factor percentage)- all treatment other than prosthodontics must be carried out in a haemophilia centre.
If patient is mild (6-40%)- Close liaison with haemophilia centre- if they require prophylactic cover for a procedure, then this will be given by the haemophillia centre.
- usually most treatment will be carried out in general practice.
Before proceeding with an extraction, what should you do for a haemophillia patient?
Check that the patient has had their factor replacement therapy and that they know what to do to take more after the extraction.
If multiple teeth are required to be extracted- stage the treatment and only take out 1 or 2 teeth at a time.
Observe all patients for at least a few hours afterwards.
Suture the gingival margins
Surgicel into socket
Bone wax
Give LA with adrenaline into socket
Soft vacuum formed splint to protect the socket if needed.
What is the minimum coagulation factor level required for any invasive procedure?
50%
What standard dental tools/techniques would you need to take extra care with to avoid causing a bleed?
Aspirator/saliva ejectors
X-ray packet
Impressions
Clamp
Sharp probe
How should LA be administered for a haemophilia patient?
Rinse with Chlorhexidine mouthwash for 2 minutes prior to LA
- risks of this would be anaphylaxis.
Slow technique with a fine boar needle.
Safe techniques- buccal infiltration, intrapapillary, intraligamental (don’t need cover for these).
Do need cover for IDB- do not do a lingual infiltration because there is a risk of haematoma in the FOM.
Lidocaine and articaine for buccal infiltrations in the mandible instead of IDB- always make sure you use LA with adrenaline.
What local measures might be needed for an extraction in a haemophillia patient?
LA with adrenaline- either inject into socket or soak the gauze in LA
Direct pressure on gauze
Surgicel
Bone wax
Diathermy
Tranexamic acid soaked gauze
Fibrin glue
Describe the pre, peri- and post-op steps for the extraction in a haemophilia patient?
Pre-op steps
- Check that the patient has had their factor replacement if required and that they know what to do after the extraction.
- Remove all plaque and calculus deposits- reduces inflammation.
Peri-op steps-
- Patient rinses with chlorhexidine (0.2%) for 2 minutes before administering LA.
- Administer LA slowly using a fine-boar needle- Lidocaine or Articaine.
- Use traumatic extraction technique- no sharp bits of bone left, don’t break roots.
- Suture socket and use local haemostatic agents.
- Soft splint to protect socket if required.
Post-op steps-
- Keep the patient for at least 20 minutes.
- Remind them to take any medication from their haematologist when required.
- Make sure the patient has an emergency contact number.
- Soft diet, don’t eat until numbing goes away.
- Avoid touching the socket.
- Chill out for the rest of the day.
- No mouth rinsing for 24 hours- warm salty mouthiness after that.
- Phone haemophillia centre if they start bleeding again for advice.
Why might bleeding increase if the patient is nervous?
Flight or fight respose- blood pressure increases.
Make sure you explain everything in detail of what is going to happen.
Let the patient know how it is going to full and what to expect.
Check the patient is completely numb beforehand.
Give control- start and stop signals.
If someone has a cleft, what further aspects of the medical history would you want to know?
What type of cleft is it?
What surgeries have you had in the past? Any future surgeries planned?
Are you currently under the care of any other dental speciality?
Medications and allergies.
Full medical history to illustrate any other medical findings.
What dental findings are commonly found in patients with cleft lip and palate?
Upper arch crowding
Narrow and elevated hard palate
Supernumeraries
Caries
Ectopic teeth/impacted teeth
Delayed oral clearance
Hypoplastic enamel
Reduced salivary flow
Hypodontia (most common)
Microdontia or macrodontia
Pulp stones
Class III growth tendency
What is the patient journey for timings of surgeries in cleft lip and palate?
Lip closure- 3 months
Palate closure- 6-12 months
8-10 years0 alveolar bone graft
12-15 years- definitive orthodontics
18-20- elective surgery
Why is hypodontia common in cleft lip and palate patients?
When the cleft goes through the palate, it destroys the dental lamina- so there is no template from which the teeth can develop from in that area.
Which professionals may be involved in the MDT care of a cleft lip and palate patient?
ENT
Max-Facs
Speech therapists
Orthodontics
Paediatric specialist
GDP
Restorative consultant
Psychology
Cardiovascular
Genetics
Audiologist
What is the role of the GDP in the care of a cleft lip and palate patient?
Acclimatise the patient from an early age.
Prevention
Treatment in practice
What support is available for children and their families who have a cleft lip and palate?
CLAPA website- phone number on here to speak to a volunteer.
Facebook groups
Twitter and instagram pages
Organised support group meetings
Support nurse associated with the family.
What is Autism spectrum disorder?
Lifelong neurodevelopment disorder.
Characteristics vary dramaticallt- spectrum.
What are the main challenges in autism spectrum disorder?
Difficulty with communication and language
Difficulties in firing relationships with other people
A limited pattern of behaviour and resistance to small changes in familiar surroundings.
How might you overcome the challenges of autism spectrum disorder?
Have the appointment at a good time for the patient/carer.
Arrange to not have the patient waiting- just bring them straight into the surgery.
Don’t have any instruments laid out, no noise, etc.
Find out how they communicate- verbal, makaton, pictures.
Find out if they have a special interest and speak to them about that.
Keep the routine the same, do not disturb this- keep the routine of each appointment the same.
Why might the dental environment be a challenge for patients with autism spectrum disorder?
Strange environment, not in the usual routine.
New people they haven’t met before
May find it difficult to communicate frustrations
Invading personal space
Sensory overload- tastes, textures, smells, sounds
Tactile sensation may be difficult
Usually have very specific diets, may be difficult to change
OH may be difficult to do- tastes, smells, textures.
What healthcare teams are involved in autism spectrum disorder?
Paediatrician
Dietician
Educational psychologist
GMP
Speech and language therapist
GDP
Play therapist
Health visitor
What are some of the potential dental features of autism spectrum disorder?
NCTSL
Caries- depending on risk factors (diet, fluoride exposure, plaque control)
Trauma/self injurious behaviour
Xerostomia
What considerations/modifications may be required to prepare a child with ASD for a dental appointment?
Drop in visit prior to appointment- see reception, loo at the dental surgery, introduce yourself.
Arrange the appointment for first thing in the morning or immediately after lunch- get them to wait in the car and phone them to come in.
- determine a time of day that is best for the child.
Social story- prepare them, go through the routine of what will happen during the appointment.
Phone the parent prior to the appointment- get all the history from the parent prior to the appointment. Ask how the child communicates, any triggers, what are they sensitive to.
Make sure safety hazards are out the way.
Quiet environment, relaxed.
Tell the parent to get the child to bring things along with them- comforters, blanket, bring own toothbrush and sunglasses to wear.
What considerations should be made during the visit for someone with ASD?
Turn the radio off- calm and quiet environment.
Don’t have any instruments out on the bracket table or on the counters.
Dim bright lights, snozelan effect.
Acclimatisation- gradual introduction to tell show do
Examine in non dental chair- on the floor, parent tickling the child.
Be aware that things are taken literally- be careful with language.
Give the child and parent some plastic dental instruments away with them to practice.
Keep appointments structured and predictable.
