DENTALMANAGEMENTOF

MEDICALLYCOMPROMISEDCHILDREN
DrDanielFord
BDSc(Hons),BSc(Hons),MDSc(Paed),FRACDS
SpecialistPaediatricDenCst

GENERALPRINCIPLES
Emergencyreliefofsymptomsonlyduringtheacute
phaseofmedicalillness
ElecCvedentaltreatmentshouldbeprovided
followingstabilisaCon/remissionofillness
ConsultaConwithchildsphysicianisessenCal
ReferraltospecialistinPaediatricDenCstrymustbe
considered

GENERALPRINCIPLES

Accuratediagnosis
Assessmentofrisk
PrevenCon
DeniCvetreatment
Review

CARDIAC
Congenital
Accountsfor80%ofallpaediatriccardiovascularcondiCons
ClassicaCon:
acyanoCcdefectswithshunts
acyanoCcdefectswithobstrucCon(stenosis)
cyanoCcdefectswithshunts

Acquired

CARDIAC
ExamplesofcongenitalcardiaccondiCons
AcyanoCcleWtorightshunt:

Ventricularseptaldefectmostcommon
Atrialseptaldefect
Patentductusarteriosus

CyanoCcobstrucCvelesions:
Pulmonarystenosis
CoarctaConoftheaorta
AorCcstenosis

CyanoCcrighttoleWshunt:
TetralogyofFallot
TransposiConofthegreatarteries
Truncusarteriosus

CARDIAC
ExamplesofacquiredcardiaccondiCons
Cardiacarrhythmias
Cardiomyopathies
Cardiacfailure
InfecCousendocardiCs
RheumaCcfevercardiCsandvalvulardamage

CARDIAC
CLINCALFEATURES:
EasilyfaCgued
Lowstresstolerance
FeedingdiculCes
Shortnessofbreath
Delayedgrowthand
development
PotenCally,
complianceissues

CARDIAC
CLINICALFEATURES:
Cyanosis
lips,cheeks,mucosa

Clubbingofngers
Dyspnoea
Heartsounds
murmur
thrill
click

Heartrate
Variesdependingon
condiCon

CARDIAC
ORALFEATURES:
Developmental
defectsofenamel
ParCcularlyinprimary
denCCon
A\ributedto:
RelaConshipbetween
thegeneCcbasisofthe
cardiaccondiConand
develomentofthe
denCCon
Metabolicfeaturesof
thecondiCon
Eectoftreatmentof
thecardiaccondiCon

CARDIAC
ORALFEATURES:
Increasedriskofdental
caries

Primaryandpermanent
denCCon
Prevalentdespitethending
thatcardiacchildrenreceive
morededicatedoralhealth
care
A\ributedto:

DDE
MedicaCons
Compliance
Diet

CyanoCcgingiviCs

DelayedtootherupCon
Instrinsictoothstains

CARDIAC
ORALFEATURES:
Increasedprevalenceofperiodontaldisease
A\ributedto:
Compliance
AssociaConwiththesyndromicpaCent;egTrisomy21
Increasedprevalenceofmalocclusionandcrowding
A\ributedtoassociaConwiththesyndromicpaCent;eg
DiGeorgesyndromeorTrisomy21
Delayeddentaldevelopment(possibly)anddelayederupCon
IntraoralsoWCssuecyanosis

CARDIAC
MEDICALIMPLICATIONS:
Oraldiseaseimpacts
adverselyonthecardiac
paCent
RiskofbacterialendocardiCs
Bacterialresistance
Bleedingtendency
anCcoagulanttherapy

Immunocompromisedif
transplantcase
OthermedicalcondiCons

CARDIAC
DENTALMANAGEMENT:
EssenCalprinciples:
EliminateoralinfecCon
Reducetheriskof
bacterialendocardiCs
Maintaingoodoral
health
LiaisewiththepaCents
cardiologist

CARDIAC
DENTALMANAGEMENT:
VigilantprevenCveregimen
Presurgical0.2%chlorhexidinemouthwash
DeterminecoagulaConstatus(INR)
ReducestresswithsedaConorGA
Reducestresswithprofoundanaesthesia
Monitorforrespiratorydistress
Regularreview

CARDIAC
DENTALMANAGEMENT:
AnCbioCcprophylaxis
ThelistofcardiaccondiConsforwhichprophylaxisisrecommendedis
muchshorterandonlyincludescondiConsassociatedwiththehighestrisk
ofadverseoutcomesfromendocardiCs.
ThelistofproceduresforwhichendocardiCsprophylaxisshouldbegivenis
moreprecise.

Dependentuponthelesion(includingallcongenitalcondiCons,
prostheCcvalves,previousbacterialendocardiCs)andthedental
procedure
Protocol:www.tg.com.au
CochranereviewbyOliveretal.(2004)noevidencetosupport
anCbioCcprophylaxisduringorodentalprocedurestoreducetheriskof
bacterialendocardiCsinatriskpaCents.Notwithstanding,generally
consideredthattheconsequencesaretooseveretodeviatefrom
currentguidelines

CARDIAC
DENTALMANAGEMENT:
Pulptherapy
ExtracConofpulpallyinvolvedprimaryteeth
VitalandnonvitalpulptherapyoftheprimarydenCConis
contraindicatedinchildrenatriskofbacterialendocardiCs.Thisis
duetothefactthatcleansing,shapingandobturaConis
problemaCcinprimaryteeth,resulCnginthepotenCalfor
recurrentand/orsubclinicalbacterialinfecConoftheprimaryroot
canalsystem.
EndodonCctreatmentofthepermanentdenCConisnot
contraindicatedincardiacpaCents,eventhoseatriskofbacterial
endocardiCs;providedcanalcleansing,shapingandobturaConis
eecCve,andtechniqueisemployedtoavoidtransportaConof
debristhroughtheapex.

HAEMATOLOGY
CoagulaConmechanismdisorders
Plateletdisorders
Vasculardisorders

HAEMATOLOGY
CoagulaConmechanismdisorders
Inherited
HaemophiliaA
HaemophiliaB(Christmasdisease)
vonWillebrandsdisease

Acquired
Liverdisease
VitaminKdeciency
Renalfailure
Bonemarrowsuppresson
AnCcoagulaContherapy

HAEMATOLOGY
Plateletdisorders
Manifestaseither:

QuanCtaCve:reducedplateletnumbers(thrombocytopenia)
QualiCaCve:alteredplateletfuncCon.

QuanCtaCve:
Inherited:manyforms;allarerare
Acquired

ReducedproducCon;eginfecCons(HIV),medicaCons,marrowinltraCon
(leukaemia)
PlateletsequestraCon;egduetohyperspleniasecondarytoliverdiseaseor
malignancy
IncreaseddestrucCon;egimmunethrombocytopenicpurpura,druginduced

QualitaCve:
Inherited:includeformsofvonWillebranddisease
Acquired:mostlydruginduced;mostlyaspirinorNSAIDviainhibiConof
COXwhichblocksproducConofthormboxaneA2,whichresultsin
reducedplateletaggregaCon

Mucocutaneousbleedingisthehallmarkofplateletdisorders.

HAEMATOLOGY
Vasculardisorders
EssenCallytheseare
disordersof
connecCveCssue.
Examplesinclude
VitaminCdeciency
(scurvy)andEhlers
Danlossyndrome.

HAEMATOLOGY
ORALFEATURES:
Prolongedbleeding
Bruisingskin/mucosa
petechiae
purpura

Deepjointbleeding
haemarthrosis

Otherassociatedmedical
condiCons;egliverdiseaseor
malignancy

HAEMATOLOGY
ORALFEATURES:
Excessiveor
prolongedbleeding
followingtrauma,
surgeryorextracCon
Oralpetechiae,
purpura,haematoma
Spontaneousgingival
bleeding

HAEMATOLOGY
MEDICALIMPLICATIONS:
Prolongedorexcessive
bleedingtrauma,oral
surgery
IncreasedriskofinfecCon
Delayedwoundhealing
AnCcoagulantconsideraCons
OthermedicalcondiCons;eg
liverdiseaseormalignancy

HAEMATOLOGY
DENTALMANAGEMENT:
PrevenCveregimentoavoiddentaldisease
Liaisewithhaematologist
AvoidextracCon/oralsurgeryinthegeneraldentalseing
Coordinatedentaltreatmentwithmedicaltreatment;egtreataWerplatelet
transfusionorfactorreplacement
Monitorvalues;egplateletsmustbe>50,000,preferably>80,ooo
AvoidprescripConofdrugsthatwouldexacerbate;egNSAID

HAEMATOLOGY
DENTALMANAGEMENT:
Gentlesurgicaltechnique
Appropriatelocalmeasurestocontrolhaemorrhagesutures,packing
Localanaesthesia
Usevasoconstrictor
MaxillaryinltraConisgenerallyOKwithouthaematologicprophylaxis
PDLinjecConisgenerallyOKwithouthaematologicprophylaxis
Nerveblock(egIANblock)requireshaematologicprophylaxis

ONCOLOGY
Theeectsofneoplasmsmaybeaconsequenceof:
masslesions,includingtheeectsofaspaceoccupying
lesionandoflocalCssuedestrucCon,withorwithout
haemorrhage
metastaCclesions
metabolicdisturbances
abnormalfuncConalacCvity.

ONCOLOGY
Neoplasmsinchildren;inorderoffrequency:
Leukaemia
PrimaryCNStumours
Lymphomas
Wilmstumour
Neuroblastoma
Rhabdomyosarcoma
Ewingsarcoma
HisCocytosis
Others

ONCOLOGY
CLINICALFEATURES:
FaCgueandweightloss
ChronicinfecCon
Anaemia
Skinpurpura
Febrileepisodes
Hepatosplenomegaly
Bonepain
Swelling
Generallyunwell

ONCOLOGY

BE
SUSPICIOUS
!!!

ONCOLOGY
ORALFEATURES:
Oralpain
Gingivalswelling
Otherswelling
Spontaneousbleeding
Toothmobility
Malocclusion
NeoplasCcinltrateof
gingivae

ONCOLOGY
ORALFEATURES:
Salivarychangesqualityand
quanCty
MucosiCs
OpportunisCcinfecCon
candidiasis
herpessimplex

GingiviCs
Periodontaldisease
EnameldemineralisaCon
Dentalcaries

ONCOLOGY
MEDICALIMPLICATIONS:
PotenCaloralfocusofinfecCon
IncreasedriskofopportunisCcinfecCon
Delayedwoundhealing
TransmissionofinfecCousviralagents
Prolongedbleedingfrombonemarrowsuppression
(disease/chemotherapy)

ONCOLOGY
DENTALMANAGEMENT:
IniCalpretreatmentexaminaConismandatory
EliminateallsitesofpotenCaloralinfecCon
Avoiddentaltreatmentduringacutestage
emergencyonly
Monitorplateletlevelspriortosurgery>80,000/ml
forhaemostasis
ProphylacCcanCbioCcs,anCfungalandanCviral
agentsasindicated

ONCOLOGY
DENTALMANAGEMENT
SoWTissues
Aimistoprevent/
minimiseinfecConand
mucosiCsandpain
0.2%chlorhexidine
mouthwash
Sodiumbicarbonate
mouthwash
TopicalanCfungalagent
TopicalanCbacterials
TopicalLA(ointment/rinse)

ONCOLOGY
DENTALMANAGEMENT
HardTissues:
Twicedailytoothbrushing
4001000ppmMPFpaste

Lowcariesrisk
0.05%neutralNaF
mouthwash

Highcariesrisk
0.05%neutralNaFgelin
customtrays

ONCOLOGY
OralcomplicaConsofchemotherapy
MucosiCsduetocytotoxicity
ofthedrugs
InfecConriskdueto
neutorpeniaand
thrombocytopenia,secondary
tobonemarrowsuppression
Bacterial(egStaph)
Fungal(egCandidiasis)
Viral(egherpes)

Haemostasisproblems
Salivarychangeswith
increasedcariesrisk

ONCOLOGY
OralcomplicaConsofradiotherapy
Salivaryglandatrophy
MucosalkeraCnisaCon
Enamelcaries/
demineralisaCon
Arrestedrootdevelopment
MicrodonCa
Osteoradionecrosis

ONCOLOGY
BONEMARROWTRANSPLANT
[fromRCHMelbournepaCenteducaConliterature]

BoneMarrowistheorganresponsiblefortheproducConofbloodcells.Stem
cellsfromthemarroweitherdividetoproducemorestemcellsordierenCate
toproduceRBCandWBC,orplatelets.RBCcarryoxygen,WBCarethebody's
maindefenceagainstinfecCon,plateletsplayanessenCalroleinhaemostasis.
WithouteecCvebonemarrowstemcells,thepaCentwilldieofanaemia,
infecCon,orbleeding
Abonemarrowtransplant(BMT)replacesdefecCvebonemarrowstemcells
withhealthycells.Stemcellsmayfaileitherbecauseofanunderlyingdiseaseor
duetotheeectsofchemotherapyorradiotherapy.BMTisusedasameansto
curediseasesinwhichthemarrowisdefecCve,butalsoallowhigherdosesof
chemotherapyandradiotherapytobeused,thanwouldotherwisebepossible.

ONCOLOGY
BONEMARROWTRANSPLANT
[fromRCHMelbournepaCenteducaConliterature]

PriortotheBMTthereisaneedforcondiConing:highdosesof
chemotherapyandpossiblytotalbodyirradiaCon(TBI).Thisdestroys
thechild'slymphocytes,(thecellswhichmayrecognisethenewbone
marrowasforeign)sothattheydonota\ackandrejectthedonor
marrow,andkillsanysurvivingleukaemiacellswhichcouldotherwise
causearelapse.

ONCOLOGY
BONEMARROWTRANSPLANT
[fromRCHMelbournepaCenteducaConliterature]

Oncethebonemarrowhasbeentransplanted,thereisaperiodof
twotofourweeksbeforethemarrowcellsdividesucientlyandthe
bloodcountstartstoimprove.DuringthisCmethebloodcountis
verylowandmostpaCentsdevelopafever,requiringIVanCbioCcs.
ThepaCentisinisolaCon.TheinfecCngagentisgenerallycommensal
microorganismsfromthepaCentsmouth,GIT,skinandnose;
enteringthecirculaConthroughbreaksintheskinorthroughmouth
orGITulcers.CarefulmouthcareisessenCal.OdontogenicinfecCon
(egabscesssecondarytocaries)wouldkillatthisstage.

ONCOLOGY
BONEMARROWTRANSPLANT
[fromRCHMelbournepaCenteducaConliterature]

Oncethebonemarrowhastaken(engraWment)andthebloodcount
improves,thelymphocytesofthedonormayrecognisethatthecellsof
therecipientaredierentfromthoseofthedonor,andtrytorejectthe
recipientCssues.Areastargetedfora\ackaretheskin,oralandgut
mucosa,andliver.ThisreacConiscalledgraWversushostdisease.

ONCOLOGY
OralcomplicaConsofbonemarrowtransplant

MucosiCs
Mucosalsloughing
StomaCCs
Xerostomia
LossoftastesensaCon
Increasesalivaacidity
KeraCnisaCon

ONCOLOGY
GraWvsHostdisease

Oralmucosalerythema
DesquemaCvegingiviCs
AngularcheiliCs
Losslingualpapillae
Xerostomia

RENALDISEASE
RENALDISEASE
Acuteandchronicrenalfailure
Uretericreuxnephropathy
ObstrucCveuropathy
UrinarytractinfecCons
Systemiclupuserythematosus
Dialysisandrenaltransplant

RENALDISEASE
CLINICALFEATURES:
Pale(secondary
anaemia)
GrowthretardaCon
Progressive
hypertension
FluidretenCon
MetaboliteretenCon

RENALDISEASE
ORALFEATURES:
Chronologicalenamelhypoplasia
IntrinsicdiscolouraCon
Lowcariesrate
Gingivalhyperplasia

RENALDISEASE
MEDICALIMPLICATIONS:
Bleedingtendency(thrombocytopeniaand
anCcoagulaCon)
Poorwoundhealing
SecondaryinfecCon
Hypertension
Osteodystrophy(hypocalcaemia)

RENALDISEASE
DENTALMANAGEMENT:
ConsultaConwithspecialist
HaemostaCcprophylaxispriortosurgery
AnCbioCcprophylaxispriortosurgery
Intolerancetonephrotoxicdrugse.g.paracetamol,
penicillinandtetracycline
ExtracConofpulpallyinvolvedteeth
AggressivemanagementofinfecCon
EecCveprevenConandregularreview

GASTROENTEROLOGY
Oesophagealdisorders(reux)
Liverdisease
hepaCCsA/B/C
biliaryatresia
1anCtrypsindeciency

Livertransplant
Inammatoryboweldisease(Crohns)
Coeliacdisease

GASTROENTEROLOGY
Reux
CLINCALFEATURES:
OWenasymptomaCc
IndigesCon/heartburn
Badtasteinmouthin
morning
24hourpHmanometry
showsmulCpleacidic
events

GASTROENTEROLOGY
Reux

ORALFEATURES:
Enamelerosion
RestoraConsoWen
high
Halitosis
Frothysaliva

GASTROENTEROLOGY
Liverdisease
CLINICALFEATURES:
Hepatomegaly
Biliarycirrhosis
Portalhypertension
CoagulaConproblems
VitaminKdependantfactors

AbnormalLFT

GASTROENTEROLOGY
Liverdisease
CLINICALFEATURES:
Developmentaldefectsof
enamel
stains
hypoplasia

DelayedtootherupCon
Gingivalhyperplasia
Periodontaldisease

GASTROENTEROLOGY
MEDICALIMPLICATIONS:
PoornutriCon
Failuretothrive
Coagulopathy(VitaminKdependentfactors)
Associatedviralagents
OpportunisCcinfecCon

GASTROENTEROLOGY
DENTALMANAGEMENT:
ConsultaConwithgastroenterologist(mightbereferral
togastroenterologist)
Steroidprophylaxisasindicated
AnCbioCcprophylaxisasindicated
DeniCvetreatment
VigilantprevenCveregimen,includinguoride
supplementaCon

ENDOCRINOLOGY
Diabetes
Pituitarydisorders
Thyroiddisorders
Parathyroiddisorders
calciumandphosphatemetabolism

ENDOCRINOLOGY
CLINICALFEATURES:
GrowthalteraCons
AlteredphysicalacCvity
Neuromuscular
excitability
Cardiovascular
dysfuncCon
GastrointesCnal
disturbances
Polyuria

ENDOCRINOLOGY
ORALFEATURES:
Alteredorofacial
development
Altereddentaldevelopment
Developmentaldefectsof
enamel
Develomentaldefectsof
denCne
Spontaneousabscesses
Periodontaldisease
Xerostomia

ENDOCRINOLOGY
MEDICALIMPLICATIONS:
Alteredgeneralgrowth/
development
Hyperglycaemia
Hypertension
Skeletalanomalies
Poorwoundhealing
Inabilitytotoleratestress

ENDOCRINOLOGY
DENTALMANAGEMENT:
Consultwithendocrinoligist
Emergencycareonlyduringacutephase
Steroidprophylaxisasrequired
DeniCverestoraCvecare
DeniCveperiodontalcare
VigilantprevenCveregimen
TimingandduraConofappointments

TRISOMY21
CLINICALFEATURES:
MentalretardaCon
Cardiac
GastrointesCnal
Immunity

TRISOMY21
OROFACIALFEATURES:
Delayeddentaldevelopment
IrregularerupCon
Developmentaldefectsofenamel
HypodonCa
MicrodonCa
RelaCvemacroglossia
Increasedriskperiodontaldisease
Brachycephalic
Flatnasalbridge
Midfacialhypoplasia

ECTODERMALDYSPLASIA
Clinicalfeatures
CLINICALFEATURES
Finesparsehair
Dryskin
Frontalbossing
Protuberantlips
Periorbital
pigmentaCon
DysplasCcnails

ECTODERMALDYSPLASIA
ORALFEATURES
OligodonCa
Conicalteeth
Developmentaldefectsof
enamel
Maxillaryhypoplasia
Reducedalveolar
growth/development
ReducedocclusalverCcal
dimension

EPIDERMOLYSISBULLOSA

ORALFEATURES:
Oralbullae/scarring
Microstomia
Ankyloglossia
Tongueatrophy
Severeperiodontaldisease
Developmentaldefectsof
enamel

RESPIRATORY
Asthma
CysCcbrosis(CF)

RESPIRATORY
ORALFEATURES:
Developmental
defectsofenamel
Dentalerosion

RESPIRATORY
MEDICALIMPLICATIONS:
RestrictedlungfuncCon
Dyspnoea
Riskofacuterespiratory
distress
Chronichypoxaemia

RESPIRATORY
DENTALMANAGEMENT:
Avoidlongappointments
Rubberdamtoavoidtriggers
Steroidprophylaxisasindicated
VigilantprevenCveregimen
UseofRAorGAmustbediscussedwithphysician
DeniCvetreatment
Emergencyprotocol

ALLERGY
HypersensiCvity
Anaphylaxis
AllergicrhiniCs
UrCcariaandangiooedema
AtopicdermaCCs(eczema)

ALLERGYAnaphylaxis
Prodrome
coughing
chokingsensaCon

Cutaneous
urCcaria
angiooedema

Cardiovascular
tachycardia
hypotension

Respiratory
bronchospasm

ALLERGY
ORALFEATURES:
Metallictaste
Pallor/cyanosis
Paraesthesia
Angiooedemalips
ContactstomaCCs
Leukoplakia
PerioraldermaCCs
Facialblushing

ALLERGY
MEDICALIMPLICATIONS:
PotenCalallergens
GA,LA,insects
preservaCves

ProphylacCctherapy
IVadrenaline5g/Kg

AllergyskintesCng
Ongoingassessment

ALLERGY
DENTALMANAGEMENT:
Avoidknownallergens
ConsideralternaCveLA(anChistamine)
Bepreparedtodealwithanaphylaxis
Referraltoallergistifindicated

NEONATES
Highriskpregnancies
Birthtraumaandinjury
Birthprematurity
NeonatalmedicalcondiCons
ProlongedvenClaCon

NEONATES
CLINICALFEATURES:
Respiratorydistress
venClaCon

Metabolicdisorders
Facialdysmorphism

NEONATES
ORALFEATURES:
Palatalgroove
Vshapedpalate
Maxillaryhypoplasia
Enamelanomalies
hypoplasia
hypocalcicaCon
(opaciCes)

Dentalcaries

NEONATES
MEDICALIMPLICATIONS:
CongenitalmalformaCons
Respiratorydistress
syndrome

NEONATES
DENTALMANAGEMENT:
Developmentaldentalanomalies
enamelhypoplasia

Comprehensiveantenatal,neonataland
postnatalhistory
Parentalcounselling
Neonatalteeth/soWCssuelesions
SupporCvedentalappliances

 Burn

IMMUNODEFICIENCY
NeutrophilDisorders
qualitaCve

chemotacCc/phagocyCc

quanCtaCve
neutropenia<1.8x106cells/ml

Primaryimmunodeciency
Bcelldefects(selecCveIgAdeciency)
Tcelldefects(thymicaplasia)
combined(Wisko\Aldrichsyndrome)
acquired(HIV/AIDS)

IMMUNODEFICIENCY
CLINCIALFEATURES:
Pale/anaemic
Failuretothrive
GrowthretardaCon
Febrileepisodes
ChronicinfecCon
pneumoniCs

Encephalopathy

IMMUNODEFICIENCY
ORALFEATURES:
Candidiasis
AbscessformaCon
GingivostomaCCs
Recurrentaphthous
ulceraCon
RecurrentherpeCcinfecCons
PrematuretoothexfoliaCon

IMMUNODEFICIENCY
MEDICALIMPLICATIONS:
Sepsis
OpportunisCcinfecCons
Prolongedbleeding
(thrombocytopenia)
Delayedwoundhealing
TransmissionofinfecCon

IMMUNODEFICIENCY
DENTALMANAGEMENT:
Oralmouthwash0.2%chlorhexidineqid
Determineplateletstatuspriortosurgery
ProphylacCcanCbioCcs,anCfungalandanCviral
agentsmandatory
ExtracConofpulpallyinvolvedteeth
EecCveprevenConandregularreview