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Dental Management of BThalassemic Patients The 3rd National Palestinian Conference on Thalassemia & other Hemoglobinpathies Bethlehem 21st – 22nd Oct 2009 Dr. Rana Darwish DDS, MPH Responsibilities of a dentist • Full awareness of managing medically compromised patients • Full awareness of different treatment modalities • Dealing with the dental patient as a whole • Cooperating with & consulting patients’ physicians. 2 Clinical Classification of B- Thalassemia • Severe B – Thalassemia Thalassemia Major (Transfusion dependant) Thalassemia Intermedia (no regular transfusions required) • B – Thalassemia Trait (Thalassemia Minor) 3 Clinical & Medical Manifestations of concern to dentists • Depends on the severity of Thalassemia • Iron accumulation & overload (continuous blood transfusions) affecting: Liver Heart Endocrine Glands • Unsafe blood transfusions (hepatitis) 4 Liver Impairment * • Fibrosis with infrequent progression to Cirrhosis • Cirrhosis result in decrease in clotting factors (necessary for haemostasis) • Cirrhosis may lead to increased bleeding time. • Dentist determination of clinically significant bleeding following invasive dental procedure * TUFTS University – Management of medically compromised patients 2007 & British Dental Association 5 Cirrhosis Dental Management* • • • • • Minimize bleeding Monitor PT / INR & Liver function tests No Aspirin or NSAID Acetaminophin (with or without Codeine) Antibiotics: Amoxicillin is safe * TUFTS University – Management of medically compromised patients 2007 & British Dental Association 6 Endocrine Glands Impairment* • Diabetes: one of major manifestations • Varies if controlled or poorly controlled * TUFTS University – Management of medically compromised patients 2007 & American Dental Association 2003 7 Diabetes Oral Manifestations* • Associated with: Increased incidence of infections Delayed wound healing Xerostomia (medications taken by patients) Burning mouth syndrome Periodontal disease * TUFTS University – Management of medically compromised patients 2007 & American Dental Association 2003 8 Diabetes Oral Manifestations* • Periodontal Disease: Attachment loss Alveolar bone loss Uncontrolled 3 folds when compared to nondiabetic controlled pts * TUFTS University – Management of medically compromised patients & American Dental Association 9 Diabetes Oral Manifestations Hyperglycemia Increase glucose level in gingival crevicular fluid alter periodontal wound healing event by changing interaction between cells & extracellular matrix with periodontium. 10 Diabetes & Smoking • Smoking increases the risk of periodontal disease several folds in diabetics • Synergistic effect 11 Diabetes Dental Management* • • • • Treat patient with care & consult physician Monitor blood glucose (FBS, HbA1c) Maintain hygiene recall every 3-4 months In uncontrolled patients: Control Diabetes first Delay dental Tx in absence of emergency Use non absorbable suture material * TUFTS University – Management of medically compromised patients & American Dental Association 12 Heart Impairment* • Congestive heart failure & arrhythmias • Increases with the number of received blood transfusions • Antiarrhythmic medications side effects: xerostomia & gingival enlargement • Dyspnea * TUFTS University – Management of medically compromised patients 2007 & Medicina Oral Journal 2002 13 Heart Diseases Management* • Consult patient’s cardiologist • Appointments of short duration • Dental chair in reclining or erect position (not supine) • Careful use of local anesthetics with vasoconstrictor * TUFTS University – Management of medically compromised patients 2007 & Medicina Oral Journal 2002 14 Other Medical Conditions* • Salivary glands: iron deposits painful inflammation (normal /diminished salivary flow) • Splenectomy: - prevent any source of bacterial spread - Antibiotic coverage (variations ?) / resistance - platelet count Thrombosis risk antiplatelet medication monitor bleeding time * TUFTS University – Management of medically compromised patients 2007 15 Other Medical Conditions* • Hypersplenism with leukopenia & thrombocytopenia provide antibiotic coverage & platelet concentrates before dental procedure can be carried out. * TUFTS University – Management of medically compromised patients 16 Orofacial Manifestations • Bony changes and expansion • Malocclusions: severe maxillary protrusion If Blood transfusions have been carried out since birth up to 50% of pts may present close to normal growth & bone development* * Medicina Oral Journal 2002 17 Orofacial Manifestations • Dental Caries • Periodontitis & Gingivitis • Both are more prevalent in pts with splenectomy Medicina Oral Journal 2002 18 Consequences of Dental Caries • • • • • Pain & distress Pulpal infection Dental abcess Facial cellulitis Early loss of teeth 19 Dental Management Checklist Appropriate full medical history Dental history Patient on medication or not Type of Thalassemia Name of treating physician / specialist Clinical Examination (extraoral / intraoral) 20 Dental Management • • • • • Good oral hygiene practice Plaque control Diet modification Topical Fluoride application Fissure sealant application varnish/toothpaste 21 Management of Xerostomia * • Treat salivary gland dysfunction • High dose fluoride • Chlorhexidine mouthwash or gel • Saliva stimulation (Pilocarpine) • Saliva substitution * Prevention of oral disease. 4th edition. 2003 Dental Management • • • • Teeth restorations Root canal treatment (pulpal involvement) Professional scaling Surgical involvement & remodeling in Thalassemia intermedia 23 We can Work Together to Improve the Quality of Life for Such Patients… 24 References • • • • • Ganda K. Management of medically compromisd dental patient. TUFTS University. Tufts Denatl school. 2007. Cutando A. et al. Thalassemias and their dental implications. Medicina Oral Journal. 2002; 7: 36 – 45. Murray J.J. Prevention of Oral Disease. 4th edition, 2003, Oxford Press. Lalla & D’ambrosio. Dental management considerations for the patient with diabetes mellitus. American Dental Association Journal. 2001; 132; 1425 – 1432. Vernillo A. Dental considerations for the treatment of patients with diabetes mellitus. American Dental Association Journal. 2003; 134; 24S – 33S. 25 26