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PBL: Special Health care Need
Patients
BY:
Mennat Allah Alkaram
Under supervision of:
Professor Nagwa Khattab
Management of CSHCN: Answer Key
Specific
management
for
each
condition:
Home
Dental
Care Diet
Analysis
General
considerations:
Regular
Professional
supervision
Preventive
restoration
Fluoride
application
Cardiac Pt
Dawn’s
syndrom
Leukemic
pt
Bleeding
disorders
Sensory
impairment
Cerebral
Pulsy
Autism
Epilepsy
Case 1
Case 1
 2-year-, 3-month-old female
 Congenital Heart Defects
 Warfarin po 3 mg daily
 Baseline INR range: 3.0
 Proximal and smooth surface
cavitations on maxillary incisors
 Fissure cavitations on molars
 Smooth surface demineralization on
molars
 Currently bottle feeding with
sweetened liquids at night
 Generalized Severe Plaque
Accumulation
Diagnosis and Problem List:
• Active early childhood caries
• Untreated carious lesions (pulp involvements)
• Poor infant feeding practice
• High risk of infective endocarditis
• High risk of uncontrolled hemorrhage from invasive dental
procedure
• Behavior assessment: uncooperative
Comprehensive treatment plan:
• Caries Prevention Plan:
1. Cease bottle feeding
2. Limit sugar intake between meals
3. Brush after oral medicine intake
• Remove Any Potentially/Pulpally Involved
Teeth to Reduce Future Risk of Chronic
Bacteremia (IE)
• Comprehensive Treatment of Carious Lesions
Under General Anesthesia Due to the Complex
Medical History, Dental Needs, and Behavior
Management Issues
• IE Prevention With IV Antibiotic Prophylaxis
Perioperative
• Stop Anticoagulant Drug (after consultation)
Case 2
Case 2: Senario A:
 4-year-, 2-month-old Hispanic male
 Child states, “My tooth hurts when I eat
candy”
 Severe Hemophilia A
 Two emergency room visits in the past
year for injury-associated bleeding (knee
and elbow)
 Medications: IV Advate® (recombinant
factor VIII) three times a week
 Multiple carious lesion with pulp
involvements
 Marginal gingivitis around molars
 Moderate Plaque Accumulation
Diagnosis and Problem List:
• High risk of bleeding with invasive dental procedures and
nerve blocks
• Untreated caries lesions
• High caries risk
Comprehensive treatment plan:
• Appointments should be planned to minimize the need
for factor infusions
• Avoid iatrogenic trauma to the oral mucosa by careful
use of saliva ejectors, rubber dam, Vaseline lubrication of
soft tissues, and gentle placement of radiograph fil,
particularly in the sublingual area
• Buccal, intrapapillary, and periodontal ligament
infiltrations can be administered without factor
replacement.
• Due to the risk of dissecting hematoma formation and
potential airway compromise Factor replacement should
be raised to 30% to 40% before posterior superior
alveolar or inferior alveolar nerve blocks
• Pulp treatment usually presents a low risk of bleeding and
is generally preferable to extractions
Case 2: Senario B
 Patient Need Extraction ?!!!
 Factor replacement
 Use Local Hemostatic Measures:
Fibrin glue , sutures, ……..
Case 2: Senario c
 Patient Need Extraction & have
done joint replacement ?!!!
 Factor replacement
 Use Local Hemostatic Measures :
Fibrin glue , sutures, ……..
 Administration of AB
Case 3
Case 3
 3-year-, 4-month-old Caucasian male.
 Cell lymphoblastic leukemia
 Chemotherapy and supportive
therapy
 Cariogenic diet with high caloric
supplementation to increase body
weight.
 Multiple carious lesions on visual
exam
 Gingival bleeding, and oral ulceration
Diagnosis and Problem List
• Active early childhood caries
• Carious lesions with pulp involvements
• High caries risk
• High risk of bleeding
• Immunocompromised patient
• High risk of oral sepsis and subsequent medical
complications
Comprehensive treatment plan:
• Establish a caries prevention plan as well as a dental
home
• 0.2% CHX mouthwash, Soft brush, Topical anesthesia
• Remove any sources of tissue irritation (to avoid
mucositis)
• Remove any potentially/pulpally involved teeth (due
to impaired immune function) => After checking
platelet count.
• Administer IV antibiotic prophylaxis at time of dental
treatment to reduce risk of bacteremia
• Restore multi-surface caries lesions with stainless steel
crowns due to their longevity and ability to prevent
further caries progression
Case 4
Case 4 senario A
6-year-, 6-month-old male.
Diagnosed with Trisomy 21.
 Mother states, “My son has been to
other dentists, but they were not able to
take care of him”.
 congenital defect of tricuspid valve.
 He is not currently on any medications
 Mild to moderate intellectual disability.
 Mouth breathing & Xerostomia.
 Rapid destructive periodontal disease.
Diagnosis and Problem List
• Lack of a dental home
• Congenital heart defects
• Hypodonia
• Increased risk for periodontal disease due to poor oral hygiene .
• Increased risk for ectopic eruption or impaction of teeth, especially
in maxillary arch (due to maxillary hypoplasia).
• Relative macroglossia.
Comprehensive Treatment Plan
• Establish a dental home & Encourage improved oral hygiene.
• Monitor eruption of permanent dentition.
• many of Dawn syndrome patient are treatable for routine
dental care with little or no modifications in care necessary.
• Mother can assist, holding her child in the dental chair.
• Tell-show-do.
• dental visit should be as atraumatic as possible.
Case 4 senario B
 Pulpaly involved primary molar?!!!
 Extraction, to avoid SEC
 AB Prophylaxis
Case 5
Case 5
 8-year-, 2-month-old Caucasian male.
 Cerebral palsy, mixed type (spastic and
dyskinetic)
 Status post bronchopulmonary dysplasia
 use inhaled medication for
control of asthma
 History of hospitalization for aspiration
pneumonia at age 2
 Generalized marginal gingivitis
 Clinical exam suggests caries-free dentition
 9-mm overjet, anterior open bite
Diagnosis and Problem List
• Cerebral palsy.
• Cognitive impairment (mild)
• Gingival inflammation due to poor oral hygiene
• Hypotonia of the tongue and perioral musculature & Immature swallow pattern
can result in anterior open bites and constricted palates
• Large overjet increases risk of traumatic dental injury
• Use inhaled medication for control of asthma:
– Gingivitis
– Candidiasis
• Delayed cough reflex.
• Involuntary body movement & possibility of sudden jaw closure.
Comprehensive Treatment Plan
• Review of oral hygiene and diet (with parent and child)
• Orthodontic consultation.
• Patient should take a dose of bronchodilator befor the dental
appointment
• Asprin & NSADS should be avoided ( use acetaminophine)
• increase risk of foreign body aspiration: use rubber dam.
• Use restraining devices & mouth probes.
• Treat patient on his wheel chair.
• Elevate back of dental chair (difficulty in swallowing & impaired
cough reflex).
Management of Children with special health care needs

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Management of Children with special health care needs

  • 1. PBL: Special Health care Need Patients BY: Mennat Allah Alkaram Under supervision of: Professor Nagwa Khattab
  • 2. Management of CSHCN: Answer Key Specific management for each condition: Home Dental Care Diet Analysis General considerations: Regular Professional supervision Preventive restoration Fluoride application Cardiac Pt Dawn’s syndrom Leukemic pt Bleeding disorders Sensory impairment Cerebral Pulsy Autism Epilepsy
  • 4. Case 1  2-year-, 3-month-old female  Congenital Heart Defects  Warfarin po 3 mg daily  Baseline INR range: 3.0  Proximal and smooth surface cavitations on maxillary incisors  Fissure cavitations on molars  Smooth surface demineralization on molars  Currently bottle feeding with sweetened liquids at night  Generalized Severe Plaque Accumulation
  • 5. Diagnosis and Problem List: • Active early childhood caries • Untreated carious lesions (pulp involvements) • Poor infant feeding practice • High risk of infective endocarditis • High risk of uncontrolled hemorrhage from invasive dental procedure • Behavior assessment: uncooperative
  • 6. Comprehensive treatment plan: • Caries Prevention Plan: 1. Cease bottle feeding 2. Limit sugar intake between meals 3. Brush after oral medicine intake • Remove Any Potentially/Pulpally Involved Teeth to Reduce Future Risk of Chronic Bacteremia (IE) • Comprehensive Treatment of Carious Lesions Under General Anesthesia Due to the Complex Medical History, Dental Needs, and Behavior Management Issues • IE Prevention With IV Antibiotic Prophylaxis Perioperative • Stop Anticoagulant Drug (after consultation)
  • 8. Case 2: Senario A:  4-year-, 2-month-old Hispanic male  Child states, “My tooth hurts when I eat candy”  Severe Hemophilia A  Two emergency room visits in the past year for injury-associated bleeding (knee and elbow)  Medications: IV Advate® (recombinant factor VIII) three times a week  Multiple carious lesion with pulp involvements  Marginal gingivitis around molars  Moderate Plaque Accumulation
  • 9. Diagnosis and Problem List: • High risk of bleeding with invasive dental procedures and nerve blocks • Untreated caries lesions • High caries risk
  • 10. Comprehensive treatment plan: • Appointments should be planned to minimize the need for factor infusions • Avoid iatrogenic trauma to the oral mucosa by careful use of saliva ejectors, rubber dam, Vaseline lubrication of soft tissues, and gentle placement of radiograph fil, particularly in the sublingual area • Buccal, intrapapillary, and periodontal ligament infiltrations can be administered without factor replacement. • Due to the risk of dissecting hematoma formation and potential airway compromise Factor replacement should be raised to 30% to 40% before posterior superior alveolar or inferior alveolar nerve blocks • Pulp treatment usually presents a low risk of bleeding and is generally preferable to extractions
  • 11. Case 2: Senario B  Patient Need Extraction ?!!!  Factor replacement  Use Local Hemostatic Measures: Fibrin glue , sutures, …….. Case 2: Senario c  Patient Need Extraction & have done joint replacement ?!!!  Factor replacement  Use Local Hemostatic Measures : Fibrin glue , sutures, ……..  Administration of AB
  • 13. Case 3  3-year-, 4-month-old Caucasian male.  Cell lymphoblastic leukemia  Chemotherapy and supportive therapy  Cariogenic diet with high caloric supplementation to increase body weight.  Multiple carious lesions on visual exam  Gingival bleeding, and oral ulceration
  • 14. Diagnosis and Problem List • Active early childhood caries • Carious lesions with pulp involvements • High caries risk • High risk of bleeding • Immunocompromised patient • High risk of oral sepsis and subsequent medical complications
  • 15. Comprehensive treatment plan: • Establish a caries prevention plan as well as a dental home • 0.2% CHX mouthwash, Soft brush, Topical anesthesia • Remove any sources of tissue irritation (to avoid mucositis) • Remove any potentially/pulpally involved teeth (due to impaired immune function) => After checking platelet count. • Administer IV antibiotic prophylaxis at time of dental treatment to reduce risk of bacteremia • Restore multi-surface caries lesions with stainless steel crowns due to their longevity and ability to prevent further caries progression
  • 17. Case 4 senario A 6-year-, 6-month-old male. Diagnosed with Trisomy 21.  Mother states, “My son has been to other dentists, but they were not able to take care of him”.  congenital defect of tricuspid valve.  He is not currently on any medications  Mild to moderate intellectual disability.  Mouth breathing & Xerostomia.  Rapid destructive periodontal disease.
  • 18. Diagnosis and Problem List • Lack of a dental home • Congenital heart defects • Hypodonia • Increased risk for periodontal disease due to poor oral hygiene . • Increased risk for ectopic eruption or impaction of teeth, especially in maxillary arch (due to maxillary hypoplasia). • Relative macroglossia.
  • 19. Comprehensive Treatment Plan • Establish a dental home & Encourage improved oral hygiene. • Monitor eruption of permanent dentition. • many of Dawn syndrome patient are treatable for routine dental care with little or no modifications in care necessary. • Mother can assist, holding her child in the dental chair. • Tell-show-do. • dental visit should be as atraumatic as possible.
  • 20. Case 4 senario B  Pulpaly involved primary molar?!!!  Extraction, to avoid SEC  AB Prophylaxis
  • 22. Case 5  8-year-, 2-month-old Caucasian male.  Cerebral palsy, mixed type (spastic and dyskinetic)  Status post bronchopulmonary dysplasia  use inhaled medication for control of asthma  History of hospitalization for aspiration pneumonia at age 2  Generalized marginal gingivitis  Clinical exam suggests caries-free dentition  9-mm overjet, anterior open bite
  • 23. Diagnosis and Problem List • Cerebral palsy. • Cognitive impairment (mild) • Gingival inflammation due to poor oral hygiene • Hypotonia of the tongue and perioral musculature & Immature swallow pattern can result in anterior open bites and constricted palates • Large overjet increases risk of traumatic dental injury • Use inhaled medication for control of asthma: – Gingivitis – Candidiasis • Delayed cough reflex. • Involuntary body movement & possibility of sudden jaw closure.
  • 24. Comprehensive Treatment Plan • Review of oral hygiene and diet (with parent and child) • Orthodontic consultation. • Patient should take a dose of bronchodilator befor the dental appointment • Asprin & NSADS should be avoided ( use acetaminophine) • increase risk of foreign body aspiration: use rubber dam. • Use restraining devices & mouth probes. • Treat patient on his wheel chair. • Elevate back of dental chair (difficulty in swallowing & impaired cough reflex).