1
Q
What are some reasons cleft lip/palate patients may be at higher risk for caries?
Cleft Lip/Palate
A
- Early feeding problems may lead to prolonged and more cariogenic feeding habits
- Parental indulgence
- Enamel defects
- Dental crowding, malocclusion
- Presence of other comorbidities (xerostomia)
2
Q
What is the “rule of 10s” when it comes to surgery for infants?
A
10 weeks of age
10 lbs
>10g/dL hemoglobin
>10,000 WBC
3
Q
What are some dental anomalies associated with cleft lip/palate?
A
- Missing teeth
- Supernumerary teeth
- Disorders of morphogenesis (disturbances in tooth shape and size)
4
Q
What are some syndromes that are associated with congenital heart defects?
A
- Down syndrome
- Ehlers-Danlos syndrome
- Ellis-van Crevald syndrome
- Marfan syndrome (mitral valve prolapse, aorta dilation/dissection/aneurysm
- Muscular dystrophy
- Noonan syndrome
- Orofacial-digital syndrome
- Osteogenesis imperfecta (mitral valve)
- Rett syndrome - long QT syndrome, no azithromycin
- Rubenstein-Taybi syndrome (1/3rd of patients - VSD, ASD, PDA)
- Soto syndrome - cardiac anomalies (~20% -PDA, ASD, VSD- to more severe anomalies
- Stickler syndrome - mitral valve prolapse
- Turner syndrome
- VACTERL syndrome
- Williams syndrome
- Wolf- Hirschhorn Syndrome
5
Q
What are the acynotic cardiac defects?
A
- Atrial septal defect
- Ventricular septal defect
- PDA
- Atrioventricular canal
6
Q
What are the cyanotic cardiac defects?
A
- Tetralogy of Fallot
- Tricuspid Atresia
- Transposition of the Great Vessels
- Coarctation of Aorta
7
Q
What are the right obstructive cardiac lesions?
A
Cyanotic
1.Tetralogy of Fallot
2.Tricuspid Atresia
3.Pulmonary Atresia
4.Transposition of the Great Vessels
8
Q
A mother disclosing that her child has a heart defect. What follow-up questions will you ask her?
A
- What is the cardiac diagnosis that your child has?
- Medications
- Allergies
- How often does pt see the cardiologist?
- Cardiac consult: Name and contact information of cardiologist
- Hx of surgical repair: past and future
- Activity limitations
- SBE prophylaxis
9
Q
A patient had a heart transplant 3 months ago. When can you consider any dental procedures for this child?
A
Wait at least 6 months for invasive dental procedures
Pt is immunosuppresed, bleeding problems, hypertension, renal/hepatic failure, ect
10
Q
A patient had a heart transplant 7 months ago. What are some dental considerations after this surgery?
A
- Patient is immunosuppressed and will be throughout their life - susceptibile to infections, malignancies such as Kaposi’s sarcoma, lymphomas; immunosuppressant cyclosporine = gingival overgrowtn
- On anticoagulant medication - bleeding risk
- On antihypertensives - gingival overgrowth with calcium channel blockers like nifedipine
- Xerostomia
- SBE prophylaxis if valvulopathy develops
11
Q
What are the indications for SBE prophylaxis?
A
- Prosthetic heart valve
- Previous hx of endocarditis
- Cardiac transplant pts who develop valvulopathy
- Congential heart defect, cyanotic and unrepaired
- Congentic heart defect, repaired within the last 6 months
- Congentic heart defect, repaired with residual defects
12
Q
What is the normal range for hemoglobin in a healthy child?
A
10.5-18g/dL
Low: Hemorrhage, anemia
High: Polycythemia (too many RBC)
13
Q
What is the normal range for hematocrit in a healthy child?
A
32%-52%
Low: Hemorrhage, anemia
High: Polycythemia, dehydration
14
Q
What is the normal range for WBC in a healthy child?
A
1-23 months: 6,000-14,000mm3
2-9yo: 4,000-12,000mm3
10-18yo: 4,000-10,500mm3
15
Q
What is the normal range for neutrophils in a healthy child?
A
1,500-8000mm3
<1500, consider antibiotic prophylaxis
<1000 defer elective dental care
16
Q
A
17
Q
What is the normal range for PT in a healthy child?
A
10.1-15seconds
Measures extrinsic pathway: play tennis outside
Prolonged in liver disease, impaired Vitamin K production, surgical trauma with blood loss
18
Q
What is the normal range for aPTT in a healthy child?
A
depends on lab, will give you range
Measures intrinsic pathway: play table tennis outside
Prolonged in hemophilia A, B, and C and Von Willebrand’s disease
19
Q
Cleft lip/palate patients require multidisciplinary care. Who else do you expect to be on this patient’s care team?
A
- Pediatrician
- Pediatric dentist
- Craniofacial team
- Plastic surgery
- Orthodontist
- ENT, otolaryngology
- Audiology
- Speech pathology
- Genetics
20
Q
How does caries rate in CLP vs Non-CLP patients compare?
A
Higher in CLP patients
Hasslof et al 2007 systematic review of caries in CLP
21
Q
What are some reasons that CLP may have increased caries risk?
A
- Enamel defects, enamel hypoplasia
- Early feeding problems - prolonged and more frequent feeding/eating
- Presence of other comorbidities (syndromes: Apert, DiGeorge, Goldenhar, Orofacial digital, Pierre Robin, Stickler, Treacher Collins
- Malocclusion
- Parental indulgence
22
Q
What is the surgical management for CLP?
A
- Presurgical orthopedics (PSO) or NasoAlveolar Molding (NAM) soon after birth
- 1-3 months lip repair
- 9-12 months palatal repair
- 7-9 yo alveolar grafting
- After growth cessation: orthognathic surgery, distraction osteogenesis, final lip/nose repair
23
Q
You have a male patient Noonan syndrome. What are some clinical/systemic considerations that may impact how you treat this patient?
A
- Cardiac defects: pulmonary stenosis, hypertrophic cardiopmyopathy, septal defects - need cardiologist consult
- 1/3rd have bleeding disorders: thrombocytopenia, clotting defects, easy bruising - need hemotologist consult
- 8x increased risk for cancer
- Sometimes associated with intellectual disability, ASD
24
Q
What are some intraoral findings in a patient with Noonan syndrome?
A
- High arched palate
- Malocclusion (anterior open bite, crossbites)
- Enamel defects
- Micrognathia
- Delayed eruption, impacted teeth
- Central giant cell lesions in the mandible - facial swelling that can look like cherubism
25
What are behavior management and dental consideration in a patient with Noonan syndrome?
* May need SBE prophylaxis - consult with cardiologist
* Avoid papoose due to cardiac issues
* Be aware of potential bleeding disorders
* May have GA issues: impaired anesthetic clearance and potential respiratory depression fromnarcotics
26
Outside of bone/skeletal deformities or defects, what other issues may a patient with osteogenesis imperfecta have? (OI)
* Cardiac: mitral valve weakness (poor type 1 collagen)
* Hearing problems
* Respiratory problems (underdeveloped lungs type 2)
* Vision
* Dentinogenesis imperfecta associated with Type 3 and 4
27
What dental considerations do you have when your patient has Osteogenesis Imperfecta?
* Behavior management: Papoose contraindicated due to fractures, let parent transfer pt from wheelchair to dental chair if needed
* Restorative management: Full coverage crowns indicated, avoid extractions due to bisphosphanate usage
* Ortho: can do ortho but it can take longer as bisphosphonates also decrease ortho movement but also decrease orthodontic relapse
28
What syndromes or other systemic diseases have been associated with aggressive periodontitis?
* Chédiak-Higashi
syndrome
* Diabetes
* Ehlers-Danlos
* Hypophophotasia
* Langerhans cell histiocytosis
* Leukocyte adhesion deficiency syndromes
* Papillon-Lefèvre
* Puetz-Jeghers
29
If a patient has Von Willebrand disease, do you expect them to bleed readily in the chair or at home?
VWD: defect in VWF so unable to form the primary platelet plug. This pt will bleed readily in the chair
30
If a patient has Hemophilia A, do you expect them to bleed readily in the chair or at home?
Hemophilia: normal platelets (unlike VWF) so primary plug is formed but defect in coagulation cascade and may start bleeding at home
31
A mother brings her 4 year old child with a CC that their pediatrican recommend that he sees a dentist for medical clearance since he was recently diagnosed with Leukemia.
What questions do you ask her next regarding her child's medical history?
1. Primary medical diagnosis
2. When it was diagnosed
3. Treatment received since the diagnosis
4. Treatment protocol for the patient/anticipated treatment (chemo, radiation fields and dosage, TBI)
5. Any complications in treatment
6. Current medications, bisphosphanate usage
7. Allergies
8. Hematological status
32
A mother brings her child and discloses that the patient has kidney disease.
What questions do you ask her next regarding her child's medical history?
1. Stage of kidney disease
2. Is the patient on hemodyalysis
3. Is a kidney transplant planned for the patient
4. Blood pressure problems, take baseline BP
5. Bone problems, is this patient on bisphosphonates
6. Bleeding problems
7. Immune status - susceptibility to infections
8. Medications that patient is taking
33
What are the most common causes of CKD?
## Footnote
CKD
Diabetes mellitus, glomerulonephritis, chronic hypertension
34
What is the most common cause of death in those with chronic kidney disease?
## Footnote
CKD
1. Cardiac failure, followed by
2. Infection
3. Malignancy
35
The treatment of choice for children with End-Stage Kidney Disease (ESRD) is a kidney transplant. What are some long-term complications of this?
## Footnote
CKD
* Diabetes mellitus
* Hypertension
* Malignancies secondary to immunosuppression
* Recurrent infection
* Mineral-bone disorders
36
What are some soft tissue oral manifestations of Chronic Kidney Disease?
## Footnote
CKD
1. Mucosa pallor (anemia)
2. Gingival enlargement (cyclosporine immunosuppressant, nifedipine calcium channel blocker)
3. Xerostomia
4. Candidiasis, angular chelitis
5. Viral infections - HSV
5. Uremia can lead to altered taste (dysguesia) and/or ammonia-like oral odor (halitosis)
6. Uremic stomatitis
7. Enamel defects
8. **Calculus**
37
What are some hard tissue oral manifestations of Chronic Kidney Disease?
## Footnote
CKD
1. Enamel defects - disruption of calcium, phosphorus, vitamin D
2. Calculus
3. Pulp canal narrowing, pulp stones
4. Delayed eruption
5. Lower caries experience - higher salivary pH
38
CKD is staged in terms of ____. What is a good baseline to determine if this pt's ____ will affect your dental management?
## Footnote
CKD
5 stages of CKD based on GFR. Stages 1-2 does not have any dental considerations
GFR <50mL/min
39
What drug considerations are there for a patient with CKD?
## Footnote
CKD
Avoid nephrotoxic drugs
Acyclovir, aminoglycosides, NSAIDs, tetracyclines, acetaminophen (at high doses but is metabolized in the liver)
Avoid CNS depressants (merpiridine narcotic-metabolite can accumulate and induce seizures, midazolam, chloral hydrate) - might get excessive sedation
When hemoglobin is <10g/dL, no GA
40
What are behavior management considerations for a patient with CKD/ESRD?
## Footnote
CKD
* Always consult with physician
* Nitrous: No modification
* Oral Sedation: Avoid CNS depressants (merpiridine narcotic-metabolite can accumulate and induce seizures, midazolam, chloral hydrate) - might get excessive sedation
* When hemoglobin is <10g/dL, no GA
41
If a patient is on dialysis, do you proceed with dental treatment the
1) day before
2) day of
3) day after dialysis
## Footnote
CKD
3) day after dialysis
42
Enamel defects can be associated with CKD. What is another dental manifestion that can happen in CKD due to compensatory measures in the face of failing kidneys?
## Footnote
CKD
Renal osteodystrophy and secondary hyperparathyroidism - leading to browns tumors
Hypocalcemia due to increased phosphate retention and decreased calcium absorption. Body sees hypocalcemia and tries to raise serum calcium = secondary hyperparathyroidism and caclcium is removed from bone stores = renal osteodystrophy
43
Walk through OHI and dental management with a patient before they receive chemotherapy/radiotherapy.
## Footnote
Cancer
1. Brushing 2x/day, both tongue and teeth, flossing if able
2. Chlorhexidine rinses for poor OH or periodontal disease
3. Management of trismus
4. All dental management should be completed BEFORE immunotherapy is started
5. Remove braces if poor OH or risk for mod/severe mucositis
44
What anticipatory guidance can you give a patient receiving chemo/radiotherapy?
## Footnote
Cancer
1. Brush 2x/ day with fluoride toothpaste, foam toothbrush only in cases, airdry brushes between use
2. Avoid any soft tissue trauma during pancytopenia - waterpiks, electric toothbrushes, no flossing if not experienced
3. No dental care when immunosuppressed
4. For oral mucositis: bland rinses, cryotherapy or palifermin (stimulates epithelial cells to accelerate healing)
5. Dental sensitivity/pain from vincristine or HSCT (during phase III/2-3 months post transplant)
6. Xerostomia management
45
What are some oral/dental considerations when you see the following immunosuppressive medications on a pt's health history?
1. Cyclosporine
2. Tacrolimus
3. Prednisone
4. Serolimus
## Footnote
Cancer
1. Cyclosporine: gingival hyperplasia
2. Tacrolimus: pyogenic-granumola-like lesions intraorally, can induce post-transplant lymphoproliferative disease
3. Prednisone: increased risk for candidiasis or viral (HSV) infections
4. Serolimus: apthous ulcers
Immunosuppression = greater risk of infections and/or malignancies down the line
46
What are some long term effects/concerns of immunosuppresive therapy?
## Footnote
Cancer
1. Tooth agenesis
2. Microdontia
3. Disturbances in size/shape
4. Enamel hypoplasia
5. Root closure (blunting, short roots)
6. Reduced mandibular length
7. Reduced alveolar height
8. Reduced vertical growth of the face
9. Salivary gland dysfunction
10. Secondary malignancies
47
When you do complete elective dental treatment after:
Solid organ transplant
Hematopoieic stem cell transplant
## Footnote
Cancer
Solid organ: 3 months and when the pt is well enougth
HSCT: 100 days
48
A patient's medical history shows that they have epilepsy. What questions would you like to ask the patient?
## Footnote
Epilepsy
1. Frequency of seizures
2. Last seizure episode
3. Type of seizures that the patient experiences and for how long
4. Prodromal symptoms
5. Triggers
6. Medications that the patient takes
7. Compliance with the medication
8. Hx of dental trauma
9. Does pt have vagal nerve stimulator (>12yo, no electrocautery)
49
What kind of seizures are there?
## Footnote
Epilepsy
1. Absence – impaired consciousness, staring, and eye blinking
2. Atonic – abrupt loss of muscle tone, loss of consciousness, and sudden collapse
3. Myoclonic – brief but sudden jerking of arms and/or legs and impaired consciousness
4. Tonic - muscle rigidity
5. Tonic-clonic – loss of consciousness, repetitive jerking, sustained stiffening, post-seizure amnesia, and possibly cyanosis
50
How do you manage a seizure in the event of a medical emergency?
## Footnote
Epilepsy
1. Call out time seizure initiated
2. Recline pt and position to prevent injury, can place them on their side
3. Ensure open airway and adequate ventilation
4. Monitor vitals
5. If status elipticus, Diazempam 0.2mg/kg, 10mg Max (5mg/mL) OR Midazolam 0.2mg/kg
6. Call 911 if seizure continues for >3mins
51
What is the general goal of dental management in a patient diagnosed with epilepsy?
## Footnote
Epilepsy
Avoidance of a seizure (avoid overhead lighting, stress)
52
A patient's medical history discloses that they have asthma. What questions would you like to ask them?
## Footnote
Asthma
1. How well controlled is their asthma
2. When was their last acute episode of asthma, when was their last hospitalization for asthma
3. How often are their daytime symptoms, if any (want <2x/week)
4. How often are nighttime symptoms
5. What are triggers/precipitating factors
6. Medications
7. How often is reliever medication used
7. Any activity limitations
53
What are some oral and dental considerations for a patient with asthma?
## Footnote
Asthma
1. Inhaled corticosteroid use: can cause intrinsic staining, at greater risk for candidiasis
2. Possible craniofacial changes from mouthbreathing
3. Increased caries risk (double the caries risk in both dentition): Xerostomia, reduction of pH with inhalers, sucrose-risk medications, parental indulgence, sweet "chaser" to follow bitter taste after inhaler
4. Enamel erosion from possible comoribidity with GERD, enamel defects
5. No nitrous or sedatives (ie meperidine) in severely asthmatic children
6. Use rubber dam
OCE
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