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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.
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Clinical Classification of
B- Thalassemia
• Severe B – Thalassemia
 Thalassemia Major (Transfusion dependant)
 Thalassemia Intermedia (no regular
transfusions required)
• B – Thalassemia Trait
(Thalassemia Minor)
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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)
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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
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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
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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
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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
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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
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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.
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Diabetes & Smoking
• Smoking increases the risk of periodontal
disease several folds in diabetics
• Synergistic effect
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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
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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
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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
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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
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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
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Orofacial Manifestations
• Dental Caries
• Periodontitis & Gingivitis
• Both are more prevalent in pts with
splenectomy
Medicina Oral Journal 2002
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Consequences of Dental Caries
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•
•
•
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Pain & distress
Pulpal infection
Dental abcess
Facial cellulitis
Early loss of teeth
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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)
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Dental Management
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•
•
•
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Good oral hygiene practice
Plaque control
Diet modification
Topical Fluoride application
Fissure sealant application
varnish/toothpaste
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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
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•
•
•
Teeth restorations
Root canal treatment (pulpal involvement)
Professional scaling
Surgical involvement & remodeling in
Thalassemia intermedia
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We can Work
Together to Improve
the Quality of Life
for Such Patients…
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References
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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.
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