Pedodontics III Al Azhar University Palestine Gaza Upload By: Lama El Banna lama1997bana@gmail.com Faculty of oral and dental medicine

1. ‫الرحيم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬
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2. College of Dentistry
Pedodontic III
Dental Management of Handicapped
Children -2-
Dr. Hazem El Ajrami
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3. Specific Management of CSHCN
1. Endocrine disorders
Diabetes Mellitus (DM)
 Definition:
DM is a complex multi-factorial, genetically
derived endocrine disease. It represents an
abnormality in glucose, protein and fat
metabolism due to insulin deficiency or
impaired insulin utilization.
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4. Classification:
Type I:
Insulin Dependent DM (IDDM).
Manifested in children and adolescence.
Type II:
Non Insulin Dependent DM (NIDDM).
Manifested in adult obese female.
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5. Other types of DM occurring secondary to
specific conditions as:
 Gestational diabetes (during pregnancy).
 Malnutrition related diabetes.
 Impaired glucose tolerance.
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6. General signs and symptoms:
Polyurea (Frequent urination).
Polydipsia (Increased thirst).
Polyphagia (Increased hunger).
Loss of weight.
Ketoacidosis.
Chronic skin infection.
Blurred vision.
Numbness in extremities.
Delayed wound healing.6

7.  Oral manifestations:
1. Decreased salivary flow rate and in severe
cases xerostomia (due to impaired function
of salivary glands) with the result:
A. Dry mucosa that will be easily damaged
and more susceptible to opportunistic
infection as oral candidosis.
B. Plaque accumulation and increased
incidence of dental caries and periodontal
diseases.
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8. 2. Burning tongue : may result from xerostomia
and diabetic neuropathy.
3. Increased glucose content in saliva,
consequently plaque microflora is altered
with increasing the risk of dental caries and
periodontal disease.
4. Impaired taste sensation.
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9.  Dental management of DM:
Dental management of well controlled and
uncontrolled diabetic patient:
 Before dental visit the patient should be
instructed to:
1) Take his medication either insulin or oral
hypoglycemic drugs.
2) Eat his breakfast to prevent hypoglycemia.
 Early morning appointments are preferred.
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10.  Don't keep the patient waiting.
 Short and stress free dental visit with
atraumatic dental procedures.
 Antibiotic prescription is very important
especially in patients with severe oral
infections or following dental surgeries as the
patient usually shows low body resistance,
recurrent infection, multiple abscesses and
delayed wound healing.
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11. 2. Cardiac diseases:
Cardiac diseases are classified into two
main categories:
A. Congenital heart disease.
B. Acquired heart disease.
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12. A. Congenital heart diseases:
Cyanotic or Acyanotic.
 Oral manifestations:
 Cyanotic gingiva.
 Cyanotic tongue.
 Delayed eruption of primary and permanent
dentition.
 Increased risk of dental caries and periodontal
diseases.
 Bluish white appearance of the teeth.
 Sometimes enamel hypoplasia could be found
in those patients.
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13.  Dental management of patients with congenital
heart diseases:
1) Any dental procedure that may interfere with the
integrity of oral mucosa or exposed pulp tissue
may lead to bacteremia, so antibiotic
prophylaxis is highly recommended.
2) Preoperative oral antiseptic mouth rinse such as
0.2% chlorohexidine gluconate is also
recommended.
3) Conscious sedation or general anesthesia are
preferable for those patients to minimize fear
and stress which may lead to change in blood
pressure. (Consultation with the physician is a
must).13

14. B. Acquired heart disease:
I. Rheumatic fever.
II. Infective bacterial endocarditis.
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15. I. Rheumatic fever:
 It is a very serious inflammatory disease that
occurs as a delayed sequela to pharyngitis or
tonsillitis by group A Beta hemolytic
streptococci. The heart valves, joints, skin
and central nervous systems are the mostly
affected by that type of infection.
 Cardiac involvement is the most significant
pathologic sequela of rheumatic fever, which
could be fatal in some cases or may lead to
chronic rheumatic heart disease as a result of
scarring and deformity of the heart valves.
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16. II. Infective Bacterial Endocarditis:
It is a microbial infection of heart valves
or endocardium as a result of bacteremia. It
may be acute or subacute.
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17.  Dental management of patients with
acquired heart disease:
Prophylactic antibiotic regimen is
highly recommended for those patients.
According to the American Heart
Association:
1. Amoxicillin (Unasyn or Augmentin) → for
children 50 mg/kg given orally one hour
before dental treatment. e.g.: a child weight
20 kg x 50 mg =1000 mg (i.e. one gm).
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18. 2. In patients who is unable to take oral
medication: Ampicillin 50 mg/kg IM
injection 30 minutes before treatment.
3. In patients allergic to penicillin: Clindamycin
e.g.: Dalacin-C. Or Erythromycin orally one
hour before treatment.
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19. Dental procedures requiring prophylactic
antibiotic:
Any dental procedure could induce bleeding
as:
Extraction of a tooth.
Scaling and root planning.
Endodontic treatment and instrumentation
beyond the apex.
Placement of orthodontic band.
Intraligamentary local anesthesia.
Dental implants.
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20. Dental procedures not requiring prophylactic
antibiotic:
Filling and restoration.
Local anesthesia injection.
Placement of rubber dam.
Oral impression.
Removal of sutures.
Shedding of primary teeth.
Placement of orthodontic brackets.
Taking radiographs.
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21.  General consideration for cardiac patients:
1) Prevention is always preferable than
treatment.
2) In primary teeth extraction is preferred than
pulp therapy.
3) In permanent teeth with poor prognosis
should be removed.
4) If major cardiac surgery is planned, dental
treatment should be completed 3 - 4 weeks
before surgery to allow for healing and return
of normal flora.
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22. 3. Bleeding disorders:
• Hemophilia:
Patients with bleeding disorder present a
great challenge to the dentist due to the
presence of hemostatic problems.
Hemophilia A is the most obvious bleeding
disorder and results from deficiency in factor
VIII (known as antihemophilic factor).
Deficient factor VIII is an x-linked recessive
trait and transmitted from the mother
(carrier) to her sons.
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23.  Oral manifestations:
1) Spontaneous bleeding from oral mucosa,
gingiva, lips, palate and tongue.
2) Poor oral hygiene due to irregular tooth
brushing (fear of patient from excessive
bleeding from his gingiva).
3) High dental caries incidence as the patient
cannot eat hard or fibrous food and usually
eats soft carbohydrates.
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24.  Dental management for hemophilic patient:
1. Analgesics as aspirin and anti-inflammatory
drugs should not be used as it may alter
platelets function and increase the risk of
bleeding.
2. Local anesthesia: Nerve block is
contraindicated as it may lead to hematoma
in the lateral laryngeal wall that may block
the airway and may be fatal. Therefore,
infiltration anesthesia is recommended for
those patients and should contain
vasoconstrictor.24

25. 3. Periodontal therapy:
 Gingivitis can predispose to spontaneous
gingival bleeding so instructions for
brushing cannot be over looked.
 Supragingival calculus can be removed
atraumatically with ultrasonic scaler or
hand instrument.
 Subgingival scaling and root planning could
be performed but with replacement therapy
with the factor deficiency.
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26. 4. Restorative treatment:
 Rubber dam should be used to isolate the
operating field and to protect the cheeks,
lips and tongue.
 Precautions should be taken during
preparation of the teeth for crowns.
 For taking an impression the periphery of
the tray should be lined with wax to prevent
injury of soft tissue.
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27. 5. Pulp therapy:
 Pulpotomy and pulpectomy are preferred
than extraction and indirect pulp procedure
is preferred than Pulpotomy.
 If vital pulp is exposed an intrapulpal
injection should be given to control pain.
Bleeding from the pulp chamber doesn't
present a significant problem and could be
controlled by pressure with a cotton
pellets.
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28. 6. Oral surgery:
 For patient undergoing dental surgeries or
even extractions, consultation with the
hematologist for preoperative evaluation
and postoperative management.
 Before oral surgery the patient should
receive blood transfusion.
 Simple extraction of permanent or primary
teeth can be done by 40 % factor
replacement one hour before dental
procedure.
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29.  Direct topical application of hemostatic agents
such as bovine thrombin or surgicel may be
used after extraction.
 The use of suture should be avoided unless it
enhances healing.
 The patient should take liquid diet for 72 hours
and soft diet for 10 days this to prevent chewing
of any hard food to avoid disturbance of the soft
tissue or the formed blood clot.
 Normal exfoliation of primary teeth does not
require factor replacement and bleeding could
be controlled by direct finger pressure and
gauze with topical application of local
hemostatic agent.29

30. 4. Neuromuscular disorders
A. Epilepsy
B. Cerebral palsy
A. Epilepsy:
 Definition:
Epilepsy is an abnormal electrical activity
in the cerebral neurons that results in certain
changes in the normal balance between the
excitatory and inhibitory influences on the
activity of the nerve cell.
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31. Etiology:
Idiopathic: Genetic or acquired.
Post traumatic - post infectious.
Post toxic (lead or arsenic poisoning).
Or secondary to brain injury.
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32. Clinical manifestations:
Grand Mal Seizures:
Preceded by momentary aura (smell, taste
and vision).
Twitching of muscles.
Followed by generalized convulsion with
tonic and clonic phases of muscular spasm.
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33. • Tonic phase: Lasts for 30 seconds and
characterized by:
 Dilated pupil.
 Head thrown back.
 Abdomen and limbs contracted.
 Contraction of the jaw's muscle.
 Tongue may be severely bitten.
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34. • Clonic phase: Spasm in which rigidity and
relaxation is alternate in rapid succession.
After this phase, the body returns back to
normal within 15 minutes to 8 hours.
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35. Petit Mal Seizures:
Characterized by no aura.
The attack lasts for few seconds.
The patient lose his consciousness for few
seconds with or without spasm.
This patient represents a little difficulty for the
dentist to manage him.
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36. Drug therapy of epileptic patient:
Dilantin (Phenytoin): is the widely used
drug to suppress the seizures.
Recent studies have shown that gingival
hyperplasia is the most common side effect
of dilantin and occurs in about 32- 84 % of
patients using the drug. The reason behind
this is still not clear.
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37. Dental management of the epileptic patient:
Management of the gingival hyperplasia.
Management of epileptic patients in the
dental clinic.
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38.  Management of the gingival hyperplasia:
1) Preventive and oral hygiene measures,
instructions and gingival curettage.
2) Gingivectomy to return the gingiva to its
normal anatomy.
3) After surgery: follow up by the dentist to
prevent gingival hyperplasia again.
Chlorohexidine may be beneficial in
prevention of recurrence of the condition.
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39.  Dentist should avoid the precipitating
factors that may lead to convulsions as:
I. Operating light (should not be focused on
the patient's eyes).
II. Loud noise and high music.
III. Insufficient sleeping hours before dental
appointments.
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40.  Management of patient having seizure in the dental
office:
1. All appliances such as matrix bands, rubber dam
clamp ... etc should be removed quickly.
2. Put the patient in a supine position with his head
tilted to the side that saliva or any vomits can exit
and possibility of aspiration is reduced.
3. Dentist should try to maintain patent airway by
suctioning of any secretions to prevent aspiration.
4. Patient's extremities should be gently restrained to
uncontrolled movements.
5. Wooden tongue blades or rubber mouth props
should be tied to string for easy removal and to
prevent injury of the tongue.40

41. B. Cerebral palsy: (Muscular impairment with
mental retardation).
 Definition:
Cerebral palsy in not a single disease entity
but rather a collection of disabling conditions
caused by permanent damage to the brain in
the prenatal and perinatal period.
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42.  Etiology:
 Decreased oxygenation to the brain.
 Traumatic injury during labor and its
complications.
 Infection such as meningitis.
 Congenital defects in the brain.
 Accident or trauma to the brain.
 Premature births.
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43. General manifestations:
Mental retardation in 60 % of the cases.
Seizures disorders and hyperirritability.
Sometimes sensory disorders are present as
hearing or visual impairments.
Speech disorders as the patient cannot
articulate because of lack of control of
speech muscles.
Abnormal limb position and limited control
of the neck muscles.
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44.  Oral signs and symptoms:
1. Periodontal diseases due to:
A. Eating soft diet as the patient cannot chew
food as a result of poor muscular
coordination.
B. Neglecting of the oral hygiene and tooth
brushing due to lack of manual dexterity.
C. Patients taking anticonvulsants (dilantin)
show a degree of gingival hyperplasia.
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45. 2. Dental caries due to:
A. Poor oral hygiene.
B. Impaired chewing and swallowing will lead
to poor eating habits as soft diet.
C. Patients show higher incidence of enamel
hypoplasia.
3. Malocclusion:
A. Protrusion of maxillary anterior teeth.
B. Excessive overbite and overjet.
C. Open bite.
D. Unilateral crossbite.45

46. • The most important causative factor of
malocclusion may be:
A. Disharmony between intraoral and perioral
muscles.
B. Uncoordinated and uncontrolled movement
of the jaws, lips and tongue.
4. Bruxism:
 Severe attrition of primary and permanent
teeth.
 Loss of the vertical dimension.
 TMJ disorders.
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47. 5. Trauma of maxillary anterior teeth due to:
 Repeated fall accidents.
 Protrusion of maxillary teeth.
6. Tongue thrust and mouth breathing.
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48.  Dental management:
1. It is preferable to treat the patient while he
is sitting in his wheel chair.
2. It is advisable not to treat the patient in a
supine position as the patient shows
difficulty in swallowing.
3. Impaired cough reflex of those patients
make the use of rubber dam is so important
to prevent aspiration of any foreign body.
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49. 4. Use mouth prop to protect the tongue from
involuntary movement of the jaws.
5. Avoid abrupt movement of the instrument
intra-orally.
6. Stabilization of the head is important to
avoid.
7. General anesthesia is preferred for those
patients.
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50. Thank You
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