space management.- Dr.Anoop Harris

1. Management of medically
Compromised Patients
Dr Anoop Harris

2. A Medically compromised condition is one in which the
patient suffers from a certain systemic condition which
puts him at risk from undergoing regular dental
treatment
2

3. Heart Diseases
✔ Congenital or Acquired
Various Cardiac Conditions:
 Congenital Heart Disease
 Acyanotic congenital heart diseases
 Cyanotic congenital Heart Diseases
 Acquired Heart Disease
 Rheumatic fever
 Infective Bacterial endocarditis
 Cardiac Surgery Patients
3

4. Acyanotic Congenital Heart Disease
✔ Minimum or no cyanosis
✔ Usually 2 categories:
○ First – due to left to right shunting of blood within the heart
■ ASD
■ VSD
○ Second - That cause obstruction
■ Aortic Stenosis
■ Coarctation of the aorta
4

5. ✔ Clinical Manifestations:
○ Congestive Cardiac Failure
○ Pulmonary Congestion
○ Heart Murmur
○ Laboured Breathing
○ Cardiomegaly
5

6. Cyanotic Congenital Heart disease
✔ Cyanosis seen on minimum exertion
✔ Due to right to left shunting of blood
○ Tetralogy of Fallot
○ Transposition of great vessels
○ Pulmonary Stenosis
○ Tricuspid atresia
6

7. ✔ Clinical Manifestations:
○ Cyanosis
○ Hypoxic Spells
○ Poor Physical Development
○ Heart Murmurs
○ Clubbing of Fingers and toes
7

8. Acquired Heart Diseases
✔ Rheumatic Fever
○ Usually appears between 6 to 15 years of age
○ Characterized by the inflammation of the vessels of
the heart
○ Caused by Group A streptococcus
8

9. ✔ Infective Bacterial Endocarditis
○ Characterized by the microbial colonization of the heart valves or
endocardium
○ Two types: Acute and subacute
○ Acute – Staphylococcus, Group A Streptococcus and
Pnemococcus
○ Sub acute: - Viridans Streptoccus. Usually in patients with
existing congenital cardiac disease
9

10. Dental treatment Considerations
✔ Complete medical History
✔ Consult with Childs Cardiologist and get informed
consent
✔ Talk with Cardiologist and be aware of complications that
can arise
✔ Antibiotic Prophylaxis used be given on recommended
cases
10

11. ✔ Pulp therapy not advised on primary teeth
✔ Extraction followed by space maintainer is the treatment of choice
✔ Distal Shoe space maintainer should be avoided
✔ Permanent teeth, endodontic treatment can be undertaken
depending upon the tooth and prognosis
✔ Patient with increased anxiety, oral sedation or nitrous oxide
analgesia may be beneficial ( only after discussing with the
cardiologist)
11

12. ✔ Patient on anticoagulant therapy, cesation of anti coagulation therapy
has to be carried out
✔ Children suffering from debilitating heart disease requiring extensive
dental work should be treated in hospital under GA
12

13. 13

14. 14
Prophylaxis Recommended Prophylaxis Not recommended
Dental Extractions Restorative Dentistry
Endodontic instrumentation or surgery only
beyond apex
Intracanal endodontic treatment, post placement
etc
Subgingival Scaling or Periodontal Surgical
Procedures
Placement of rubber dams
Intraligamentry and palatal LA injection Non intraligamentary injections
Dental Implants Supragingival scaling where bleeding is not
anticipated
Orthodontic Treatments if band placement is
needed
Normal orthodontic treatments…

15. Leukemia
✔ Malignant neoplasm of hematopoietic cells that
proliferate initially in the bone marrow before
disseminating to the peripheral blood, spleen , lymph
nodes and ultimately other tissues
15

16. Classification
✔ Based on the morphology of the predominant abnormal white cells
○ Acute Lymphocytic Leukemia
○ Acute Nonlymphocytic leukemia
■ Acute Myelocytic Leukemia
■ Acute Monocystic or myelomonocytic Leukemia
■ Erythroleukemia
■ Megakaryocytic Leukemia
○ Chronic Myelocytic Leukemia
○ Chronic Lymphocytic Leukemia
16

17. Clinical Manifestations:
○ Anemia and Thrombocytopenia with resultant pallor
○ Fever
○ Tachycardia
○ Adenopathy
○ Gingival Bleeding
○ Increased irritability
○ Persistent fever
○ Hepatospleenomegaly
✔ WBC increased but infections frequent due to non functioning blast
cells
17

18. Oral Manifestations
✔ Regional Lymphadenopathy
✔ Gingival Hypertrophy and bleeding more common in Non
Lymphocytic Leukemia where as Petechiae and ecchymoses more
common in ALL
✔ Ulceration and pallor of oral mucosa
✔ Rapid loosening of tooth due to necrosis of PDL
✔ Cranial nerve palsies, lip paresthesia, jaw pain, gangrenous
stomatis
18

19. ✔ Loss of trabeculation, destruction of crypts of developing teeth, loss
of lamina dura, widening of periodontal ligament space and
displacement of teeth and their buds
19

20. Dental Considerations
✔ Infection is the reason for fatality in 80% of cases. So primary aim is
to prevent, control and remove oral infection, inflammation and
hemorrhage
✔ Complete history and consultation with childs Physician and
complete blood examination before any treatment
✔ Elective dental procedures should be postponed if the child is not in
first remission unless there is a nidus of infection intraorally that can
be a potential cause of sysytemic infection
20

21. ✔ Avoid prescribing drugs that can alter platelet function. Eg: aspirin
✔ Topical or sysytemic antifungals may be used as candidiasis is a
common finding
✔ Pain from ulcerative lesions – topical obtundents
✔ For deep lesions that bleed spontaneously – topical bovine thrombin
✔ Pulp therapy on primary teeth is contraindicated. Endodontic teeth on
permanent teeth not recommended
21

22. ✔ If platelet less than 20,000/cubic mm – should not be undertaken
without prophylactic platelet transfusion
✔ If absolute granulocyte count is less than 1000/cubic mm elective
dental treatment should be delayed
✔ Avoid mouth brushing and substitute with moist gauze wipes
containing chlorhexidine if platelet count is low
✔ Management of xerostomia by the use of sugarless sweets, sorbitol
based gums, topical fluorides can be done..
22

23. Diabetes Mellitus
✔ Most common endocrine disease of the childhood
✔ Associated with inadequate supply of insulin to meet
physiologic needs of the body at cellular level
✔ Type I – Insulin Dependent Diabetes Mellitus
✔ Type II – Non Insulin dependent Diabetes Mellitus
23

24. Type I – Insulin dependent DM
✔ Caused by destruction of the beta cells of islets of Langerhans
✔ Also known as Juvenile Onset diabetes as it manifests in childhood
or adolescence
✔ 5% to 15%
24

25. Type II – non Insulin Dependent DM
✔ Impaired insulin function rather than deficiency
✔ Consists of 80% to 93%
25

26. General Signs and Symptoms
26
Early Features Late Features
Polyuria Nausea and Vomiting
Polydyspia Abdominal Pain
Pruritis ( skin, rectum, vagina) Renal Dysfunction
Weakness Hyperventilation
Recent weight Loss Dehydration
Constipation Hypovolemia
Acetone Breath Muscle wasting
Paresthesia of Extremeties
Shock and coma

27. Oral Manifestations
27
1. Reduced Salivary Flow
2. Burning mouth/tounge
3. Candidiasis
4. Altered taste
5. Progressive Periodontitis
6. Dental Caries
7. Oral Neuropathies
8. Parotid enlargement
9. Sialosis
10. Delayed Wound Healing
11. Increased Glucose content in Gingival Crevicular fluid

28. Dental Management
✔ Implementation of preventive protocol,symptomatic relief of any oral
manifestations of the disease and immediate provision for primary
care
✔ Comprehensive medical history with screening tests for diabetes
✔ Consult with the diabetologist for adjusting insulin regimes
✔ Dental appoinments should be stress free, short and as atraumatic
✔ Early morning appoinments preffered, and pt should eat normal
breakfast to avoid hypoglycemia
28

29. ✔ Use of pulp capping and deciduous pulpotomy procedures
questionable
✔ Vital pulp therapy preferred to a stressful extraction
✔ Non vital tooth with evidence of infection extraction preferred over
endodontic therapy
✔ Fixed or removable orthodontic appliance should be given after
evaluating periodontal condition of the patient
✔ If surgical procedures indicated better to do under antibiotic
prophylaxis
29

30. ✔ Vasoconstrictor drugs with LA is preferred but excessive adrenaline
dosage is contraindicated to prevent an increase in blood Glucose
Levels, and for this glucocorticosteroids should be avoided.
30

31. Management of Diabetic Emergencies
✔ Hypoglycemic attack or Insulin Shock
✔ Arises due to insulin overdose, stress, and poor dietary control or
glucose levels at or below 40mg/dl
✔ Develops quickly and treatment must be given rapidly. If delay in
treatment seizures can develop which can prove fatal
31

32. Signs and Symptoms
32
1. Mood Changes and Irritability
2. Disorentation and Blurred Vision
3.Sweaty Skin
4.Loss of Consciousness
5.Lethargy,Slurred Speech
6. Strong, Bounding Pulse
7. Nausea and stomach ache
8. Hunger, Shaking, tingling around the mouth
9. Increased gastric motility
10. Hypothermia

33. Management
✔ Adiminister oral carbohydrates such as orange Juice, soft drinks,
candy
✔ In no recovery and patient unconscious
○ IV dextrose (50ml in 5% conc)
○ IM glucagon (1mg) followed by IM epinephrine(0.5mg of 1:1000
conc)
✔ Patient usually takes 5 – 10 min to recover. Observe closely until
stable
✔ When conscious give oral glucose to prevent hypoglycemia from
recurring. If no response emergency procedures to be initiated. 33

34. Diabetic Crisis or Hyperglycemia
✔ Develops from blood glucose levels rise over 11.1 mmol/L
✔ Signs:
34
1. Weak Pulse
2. Rapid and Deep Breathing ( Kussmaul’s respiration)
3. Dry Skin
4.Acetone Breath
5. Increased Frequency of micturition
6. Thirst
7.Severe Hypotension
8. Abdominal Pain and Vomiting
9. Loss of Consciousness ( daibetic coma)

35. Management
✔ Maintain open airway
✔ Administer 100% oxygen along with IV fluids to prevent vascular
collapse
✔ Perform finger stick blood glucose test
✔ Administer insulin under controlled conditions, ie monitor serum
electrolytes and glucose
✔ Patient recovery slowly than insulin shock
35

36. ✔ Child is disoriented or unconscious, and difficulty in diagnosing
between hypoglycemia and hyperglycemia management should be
for hypoglycemic emergency
✔ Small amount of glucose administered will not exacerbate
hyperglycemic state
36

37. Cystic Fibrosis
✔ Monogenetic disorder that presents as a multi system disease
involving the exocrine glands
✔ Characterized by
○ chronic obstruction,
○ airway infection,
○ Maldigestion caused by pancreatic insufficiency
○ Sexual development is delayed
○ Failure to thrive is observed
37

38. Oral Manifestations
✔ Enamel Hypoplasia, tetracycline stains
✔ Low incidence of Dental Caries – frequent intake of antibiotics,
increased pH, buffer capacity of saliva, increased levels of calcium
and phosphorus of saliva
✔ High incidence of mouth breathing,
✔ Delay in eruption and dental development
✔ Oral ulceration due to pancreatic enzymes held in oral cavity
38

39. Dental Management
✔ Complete Medical History and consultation with Childs Physician
✔ Keep in upright position to enable for clearance of secretions
✔ Cosmetic treatments can be done using veneering or jacket crowns
✔ Sedation not indicated as carries risk of respiratory depression and
compromised airway
✔ General Anesthesia should only be considered if local anesthesia not
successful or only in extremely difficult children
39

40. Asthma
✔ Disease of airways that is characterized by an increased
responsiveness of the tracheobronchial tree to multiple stimuli
✔ Manifested by wide spread narrowing of the air passages and
clinically by paroxysm of dyspnea, cough, and wheezing
✔ Attacks are short lived and patient usually seems to recover from
them completely clinically
40

41. Dental Problems and Management
✔ Complete medical history should be taken. Frequency of attacks,
irritating stimuli, severity of attacks, medications taken
✔ Seat the patient in an upright position for dental procedures
✔ Treat the child after a dose of medication is given
✔ If the child is using an inhaler it should be brought along for the
dental appoinment
✔ If child is receiving corticosteroid therapy , are at risk from stress.
Double or triple the steroid dosage and adjust the time of appoinment
to ensure that patient is seen shortly after medication is administered 41

42. ✔ Use of Aspirin, NSAID and penicillin is contraindicated
✔ Local Anesthesia can be used
✔ If indicated sedation and General Anesthesia can be given
Emergency mangement:
Administer 100% oxygen with the patient in sitting position, leaning
forward and subcutaneous administration of 0.3 ml of 1:1000
epinephrine
42

43. Hematological Disorders
✔ Red cell Disorders
✔ White cell Disorders
✔ Disorders of hemostasis, including platelets and
coagulation factors
43

44. Anemia
✔ Is defined as the reduction in the volume of red blood cells, in the
packed cell volume or in the concentration of hemoglobin in the
peripheral venous blood
○ Iron deficiency Anemia
○ Vitamin B12 deficiency Anemia
○ Folate deficiency Anemia
○ Pernicious Anemia
○ Hemolytic Anemia
○ Aplastic Anemia
○ Sickle Cell Anemia 44

45. Aplastic Anemia
✔ Bone marrow dysfunction or failure in production of erythrocytes
✔ Oral Findings
○ Gingival Hemorrhage
○ Mucosal pallor
○ Petechial spots
○ Oral Ulceration and infection
○ Neutropenia – lack of resistance to infection
45

46. Dental Management
✔ Physician’s consent
✔ Bleeding tendency
✔ Increased susceptibility to infection
✔ Block Anesthesia and pulp Therapy are contraindicated
✔ Topical anesthetic agents for oral ulcerations
✔ Adv: soft brushes
46

47. Sickle Cell Anemia
✔ Inherited autosomal recessive disorder
✔ Abnormal Hemoglobin known as Hemoglobin ‘S’
✔ Hypoxia induces distortion of the erythrocytes into a sickle shape
✔ Lack of oxygen causes hemolysis and vaso-occlusive crisis,resulting
in pain and tissue damage caused by infarction
47

48. General features:
✔ Anemia due to Hemolysis
✔ Aplastic Crisis
✔ Impaired growth
✔ Skeletal deformities
48

49. Dental Features
✔ Jaw pain caused by infarction or oesteomyelitis
✔ Labial Anesthesia due to cranial neuropathies
✔ Mental nerve palsy due to vaso- occlusive crisis
✔ Suspected to infection from capsulated organisms
✔ Hypomineralisation of dentin, abrupt alteration of dentinogenesis,
calcified bodies in pulp chamber
✔ Hypercementosis
✔ Osteoporosis of the jaw due to bone marrow hyperplasia
49

50. Treatment Considerations
✔ Informed consent and consultation with the Physician
✔ Conservative approach. Minimal stress and increase in stress
decreases the childs ability to oxygenate tissues adequately
✔ Risk of use of Local Anesthetic with Vasoconstrictor
✔ Prevention of infection by use of post operative antibiotics and
prophylatic antibiotics before surgical procedures
✔ Inhalation sedation is safe provided 100% oxygen is administered for
at least 4 – 5 minutes. At the end of procedure to avoid diffusion
hypoxia airway should be maintained with N2O2 – O2
50

51. ✔ General Anesthesia unavoidable maintenance of Hb S at 30% is
mandatory
✔ Desferrioxamine mesylate by subcutaneous infusion and
hydroxyurea may be used to raise HbF levels and reduce the
frequency and severity of vaso – occlusive crisis
51

52. Hemophilia
✔ Hereditary blood disease characterized by a deficiency of plasma
proteins needed for normal clotting
✔ Types:
○ Hemophilia A – Factor VIII deficiency
○ Hemophilia B – Factor IX deficiency
○ Hemophila C – Factor XI deficiency
○ Von Willebrand’s Disease – Defective Von Willebrand Factor
52

53. Oral Manifestations:
✔ Hemorrhage from many sites intra orally
✔ Gingival hemorrhage may be prolonged and massive
✔ Occurrence of caries and periodontal diseases is high because of
poor oral hygiene
✔ Presence of mandibular pseudotumor with radiographic changes of
tooth displacement, enlargement of bony structures, delicate
trabeculae and areas of radiolucency.
53

54. Classification
54
Degree of Severity % of factor Characteristics
Mild 5 – 35%  Significant Hemorrhage only after major injury
Moderate 1 – 5%  Occasional spontaneous joint bleeding
 Minor injury can initiate Hemorrhage
 Develops target joints with repeated episodes of bleeding
Severe Less than 1%  Frequent spontaneous bleeding episodes occurring 2 – 4
times/month
 Bleeding without a specific history of trauma
 Bleeding into joints and muscles
 Hemarthrosis
 Musculoskeletal problems
 Pseudotumors in jaws and bones
 Deep hematomas and hematuria

55. Dental Considerations
✔ Informed consent and consultation with Childs physician
✔ Routine Blood Examination with clotting time
✔ Intramuscular injections should be avoided
✔ Factor replacement required before surgical procedures
✔ Electrosurgery is preferred because of continuous bleeding
✔ For patients who need deep scaling, initially plan for supragingival
scaling followed by deep scaling after 7-14 days after proper healing
55

56. ✔ Small carious lesions and procedures which do not anticipate
bleeding can be done without factor replacement
✔ Adv: use of wedges and matrix for class 2 lesions
✔ Use retraction cord for crown preparation procedures
✔ Antibiotic prophylaxis should be carried out before minor surgical
procedures
✔ Use of topic hemostatic agents like Bovine thrombin, absorbable
oxidized cellulose are indicated for minor surgical procedures
56

57. ✔ Fixed appliances preferred over removable appliance but arch fires
should be secured with elastic bands
✔ Preformed bands preferred over band adaptation
57

58. Protocol for Dental management of Hemophilia A
58
Factor VIII levels Mild (> 5 U/dl) Moderate (5 – 2 U/dl) Severe (< 2U/dl)
Local Anesthetic Infiltration - - -
LA – Inferior alveolar - Factor VIII at 10 U/kg pre
treatment
Factor VIII at 10 U/kg pre
treatment
Supragingingival Scaling - - Pretreatment dose of 1g oral
Tranexamic acid capsules
Subgingival Scaling or
restoration with Matrix band
Pretreatment dose of 1g oral
Tranexamic acid capsules
followed by 1 gm qid for 24
hrs post treatment
Pretreatment dose of 1g oral
Tranexamic acid capsules
followed by 1 gm qid for 3 days
post treatment
Factor VIII at 7U/kg and a
Pretreatment dose of 1g oral
Tranexamic acid followed by
1 gm qid for 3 days post
treatment
Minor soft tissue
abscess/swelling
Factor VIII at 10 U/kg
pretreatment
Factor VIII at 10 U/kg
pretreatment
Factor VIII at 10 U/kg
pretreatment

59. Protocol for dental management of Hemophilic B
patients
59
Hemophilia B
( Factor IX Levels)
Mild (> 5 U/dl) Moderate (5 – 2 U/dl) Severe (< 2U/dl)
Local Anesthetic Infiltration - - -
LA – Inferior alveolar - Prothrombinex – HT 20 U/kg Prothrombinex – HT 20 U/kg
Supragingingival Scaling - - Pretreatment dose of 1g oral
Tranexamic acid capsules
Subgingival Scaling or
restoration with Matrix band
Pretreatment dose of 1g oral
Tranexamic acid capsules
followed by 1 gm qid for 24
hrs post treatment
Prothrombinex – HT 14 U/kg
and a Pretreatment dose of
1g oral Tranexamic acid
capsules followed by 1 gm
qid for 3 days post treatment
Prothrombinex – HT 14 U/kg
and a Pretreatment dose of
1g oral Tranexamic acid
followed by 1 gm qid for 3
days post treatment
Minor soft tissue
abscess/swelling
Prothrombinex – HT 20 U/kg Prothrombinex – HT 20 U/kg Prothrombinex – HT 20 U/kg

60. Protocol for Dental management of Von Willerbrand’s
Disease Patients
60
Von Willerbrand’s Disease
( Factor VIII levels)
Mild (> 30 U/dl) Moderate (10 – 30 U/dl) Severe (<10 U/dl)
Local Anesthetic Infiltration - - -
LA – Inferior alveolar - - Factor VIII at 10 U/kg
pretreatment ( Humate P)
Supragingingival Scaling - - Pretreatment dose of 1g oral
Tranexamic acid capsules
Subgingival Scaling or
restoration with Matrix band
Pretreatment dose of 1g oral
Tranexamic acid capsules
followed by 1 gm qid for 24
hrs post treatment
Pretreatment dose of 1g oral
Tranexamic acid capsules
followed by 1 gm qid for 24
hrs post treatment
Factor VIII at 7U/kg and a
Pretreatment dose of 1g oral
Tranexamic acid followed by
1 gm qid for 3 days post
treatment
Minor soft tissue
abscess/swelling
Desmopressin Pretreatment Prothrombinex – HT 20 U/kg Factor VIII at 10 U/kg pre
treatment

61. Platelet Disorders
✔ Platelet dysfunction
✔ Inadequate number of platelets
✔ Normal range: 150,000 and 400,000/cu/mm of blood
✔ <100,000 moderate cases
✔ <50000 severe thrombopenia
✔ <30,000 spontaneous bleeding occurs
61

62. Idiopathic Thrmbocytopenic Purpura
✔ Autoimmune disease where there is abnormal reduction in circulating
blood platelets
✔ Clinical Features
○ Sudden onset of purpura
○ Bruising
○ Conjunctival and retinal hemorrhages
○ Epistaxis
○ Risk of intra cranial hemorrhage
○ Hemorrhages, bullae and vesicles of mucous membrane –
20000/cu/mm
○ No Clinical bleeding or surgical hemorrhage expected if count greater
than 50,000/cu mm 62

63. Oral Manifestations
✔ Ecchymoses and Frank hemorrhages
✔ Profuse gingival Hemorrhages
✔ Petechiae occur in mucosa and mainly in platelets
63

64. Dental Management
✔ Elective dental treatment should be deferred until platelet count is
above 50,000/mm3
✔ Steroid therapy at a dose of 1 to 2mg/kg to bring up the platelet level
✔ Use local measures of hemostatsis
✔ Avoid extractions and minor surgical procedures during acute phase
✔ Use IV immunoglobulin 1 kg/day twice before dental extraction
✔ Avoid NSAIDs and aspirin 7 days preoperatively before any surgical
procedures
64