Management of medically compromised child

• Obtaining a MH?


  • Follow a similar routine to that for an adult
  • Emphasis on certain conditions ie. was pregnancy and birth normal
  • allergies - more common in children
  • hospitalisations and GA experience
  • Family history and ANYTHING else
  • Take history from parent – involve child
  • Update every visit
  • Who else involved in care of child ie. lead consultant and where are they based
• Why is a MH important ?

  • ID med conditions that require Tx modification or impact on compliance
  • medication which could result in an adverse reaction or influence dental development ie xerostomia
  • Combined med and oral findings
  • Systemic disease that can affect others
  • ID if colleagues involved w pt care
  • Alert to possible med emergencies
  • Prioritise children who may require enhanced preventive care
  • Medicolegal requirement GDC 1.4 and 4.1
• Key Points common to most conditions ?

  • 4 pillars
  • Enhances DBOH (concern)
  • freq rvs 3-6/12
  • reduce barriers to dental care ie. physical and communications
  • Acclimatisation, behaviour management,
  • Conscious sedation and anaesthesia may be needed
  • Need support from parents and other involved in care can even be respite care/nurses/schools
• Asthma ?


  • diffuse obstructive lung disease, reversible episodes or airflow obstruction and bronchospasm
  • 10-15% - most common
  • 1.1 mil and 20-30 deaths
  • aetiology = complex - env and genetic influences
  • Symptoms = coughing, wheezing, breathlessness and tight chest
• Medical management of asthma ?


  • prophylactic drugs to reduce hyperactivity and inflam eg. corticosteroids beclomethasone
  • Bronchodilators eg. salbutamol
  • Classification = controlled, partially controlled or uncontrolled
  • Controlled minimal symptoms, no exercise limitation, infrequent exacerbations, minimal need for rescue medication, near normal lung function.
  • ASK what meds are, have they been hospitalised overnight and when was the last time, do they have them and what are the triggers
• Oral implications of asthma?

  • tendency to mouth breath
  • reflux
  • side effects of meds inc. xerostomia, taste alterations, discolourations, candidiasis
  • ASA grade 2
  • Erosions
  • Cant use duraphat varnish as colophony can tigger asthma
• Tx of asthmas ?

  • Fluoride varnish contra-indicated in severe asthmatics - Colophony 
  • Avoid aspirin & other NSAIDs – can induce bronchospasm 
  • Steroids (including prolonged therapy with high dose inhalers) may cause adrenal suppression - prophylactic ‘steroid’ cover?
  • Prevent oral candidiasis
  • Spacer device to deliver inhaled drugs directly to airway
  • Rinsing or tooth-brushing after using inhalers
  • Prevention: DBOH/ SDCEP – enhanced prevention
  • ID & manage asthma attack
• Diabetes overview ?


  • Endocrine/ metabolic disease resulting from defects in insulin secretion, action (or both)
  • Type 2 incidence increasing
  • Characterised by chronic hyperglycaemia
  • most common endocrine/metabolic disorder in childhood
  • 2/1000
• Type 1 - insuline dependent ?

  • 5-10% cases
  • Not assoc with obesity
  • Peak of presentation 5-7 and puberty
  • Tx = insulin therapy and monitoring blood glucose
• Type 2 ?


  • 90-95% of cases
  • Insulin resistance
  • Association with obesity
  • Middle/ older age or younger overweight individuals
  • Treatment - diet control, exercise, oral hypoglycaemic agents & / or insulin therapy (depending on severity)
• Symptoms ?


  • Polydipsia (increased thirst)
  • Polyuria (increased urination)
  • Polyphagia (increased appetite)
  • Weight loss, lethargy & weakness
  • Hyperglycaemia
  • Glucosuria
  • Ketosis
• Oral manifestations of diabetes ?

  • Xerostomia – polyuria & altered salivary gland function
  • Increased caries risk – xerostomia, increased salivary glucose, frequent snacking
  • Periodontal disease
  • Oral candidiasis – associated with xerostomia 
  • Increased risk of oral infections – impaired neutrophil chemotaxis & phagocytosis
  • Impaired wound healing
  • Taste dysfunction, burning mouth syndrome, lichen planus
• Dental management of diabetes ?

  • estb level of control
  • Morning appointments better
  • Dont keep waiting, short apts
  • Make sure pt has eaten and meds as normal
  • Fit around their schedule
  • DBOH enhanced prevention
  • Tailored OHI and diet advice so work with diabetes team and dietician
  • avoid GA
  • Know how to manage hypoglycaemic attacK (WHEN BLOOD GLUCOSE LESS THAN 3MMOL/L
• Epilepsy deifinition ?


  A brain disorder characterised by excessive neuronal discharge that can produce seizures, unusual body movements & loss or changes in consciousness. Not a disease but a term applied to recurrent seizures. Can be generalised or partial where only certain parts are affected
• Epilepsy overview ?


  • affects 1/200 under 18
  • 0.5-2% affected
  • More common in kids, can outgrow
  • Most idiopathic epilepsy or can be secondary where is acquired of congential
• Generalised epilepsy ?


  • affects entire cortex & therefore involves all of body
  • Tonic-clonic’ (Grand mal) – loss of consciousness & seizures. Normally last < 5 mins
  • Absences (Petit mal) – periods of unresponsiveness, ‘trance like’. Normally < 30secs
• Potential triggers of epilepsy ?

  • stress
  • infections
  • fever
  • sleep
  • deprivation
  • fatigue
  • low blood sugar
  • flashing lights
  • loud noises
• Medical management of epilepsy ?

  • long term anticonvulsants - sodium valporate, carbamezapine or phenytoin
  • Rescue meds - buccal midazolam
• Oral implications of epilepsy ?

  • drug induced hyperplasia
  • Inc caries risk from sugary meds
  • Side effects of anticonvulsants - xerostomia, ulceration, glossitis, bone marrow suppression
  • Inc risk of trauma
• Tx implications of epilepsy ?

  • obtain history eg. aura
  • Meds prior to apt and parents have rescue meds
  • morning apts but dont assume
  • Avoid triggers like lights dark glasses
  • Enhanced DBOH prevention and OHI
  • Further options to manage hyperplasia ie. change meds
  • Ortho - careful consideration
  • Removal prosthesis - risk of inhalation, must be well retained w clasps
  • LA and sedation no contraindication
  • GA hospitalise at hospital that cares for pt
• 2 main groups of heart defects ?

  • Congenital heart defects
  • Acquired after birth
• Congenital defects overview?


  • assoc w down syndrome
  • 8/1000 births
  • wide spectrum of severity
  • Multi factorial aetiology
• Examples of cardiac issues ?

  • Ventricular septal defect – most common. Small defects asymptomatic, 30 – 50% close spontaneously (usually within 1st year of life), larger defects require surgical closure (2nd year of life)
  • Atrial septal defect
  • Patent ductus arteriosus
  • Pulmonary stenosis
  • Aortic stenosis
  • Coarctation of the aorta
  • Transposition of the great arteries
  • Tetralogy of Fallot (severe defect) 
• What do you need to ask a pt with a cardiac issue 


  How often is it reviewed
• Signs and symptoms of heart defect?

  • Wide range of clinical presentations
  • Breathlessness on exertion, tire easily & recurrent respiratory infections
  • Feeding difficulties, failure to thrive, delayed growth & development
  • Severe defects include cyanosis & finger clubbing. Some children assume a ‘squatting’ position to relieve breathlessness
• Management of heart disease ?

  • surgical correction
  • Meds include:

  diurectics

  digoxin

  ACE inhibitors

  anticoagulants
• Oral implications of heart defects ?

  •  Delayed eruption
  • Enamel defects (mostly primary dentition) – chronic hypoxia disturbs enamel formation
  • failure to thrive = cariogenic diet, work w dietician
  • Increased caries risk – multi-factorial – enamel hypoplasia, sugary medication, medication side effects (e.g. xerostomia)
  • Cyanosis oral mucous membranes
• Dental management of heart defects ?

  • infective endocarditis risk - ABx cover for XLA or scaling = lots of bleeding
  • Bleeding risk if on anticoagulants
  • Implications of assoc conditions eg. down syndrome
  • reg rads rv
  • Enhanced DBOH prevention + OHI
  • active dental disease managed before cardiac surgery
  • Short apts w breaks, maybe morning apt
  • minimise stress
• Dental management of heart conditions 2?

  • Dont lie supine if breathless
  • Caution w pacemakers w scaling
  • Pulp therapy in primary dentition contraindicated due to infection risk
  • LA caution as some interactions w adrenaline
  • Sedation needs adequate oxygenation, likely secondary care
  • GA avoid if poss
• Infective endocarditis guidelines 


  NICE 2008 Prophylaxis against infective endocarditis: antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures, updated 2016

  Updated 2016 to say: Antibiotic prophylaxis against infective endocarditis is not recommended routinely for people undergoing dental procedures

  Write to cardiologist to get advise on ABx cover!!
• Bleeding disorders are either

  inherited (genetic) - which is most relevants to kids

  Acquired - due to use of anticoagulants meds
• Classifications fo bleeding diroders ?

  • Vascular defects 
  • Platelet defects
  • Coagulation defects
• Vascular defects ?


  • Inherited bleeding disorders marked by a vascular defect
  • E.g. Marfan syndrome or Ehlers-Danlos syndrome
  • Rarely have severe bleeding after extractions
  • Can often receive dental treatment in primary care setting with appropriate measures
• Platelet defects 


  eg. thrombocytopenia where a reduction in no. of circulating pts

  idiopathic or bone marrow suppression from drugs, haematological amlginancy, haematological disease

  General manaifestations inc.

  • petechial haemorrhages into skin & mucous membranes,
  • Haematemesis, Haematuria, Melaena

  Oral manifestations:

  • Petechiae, ecchymosis
  • Gingival bleeding
  • Prolonged bleeding after tooth-brushing, minor trauma, extractions
• Coagulation defects examples


  eg. haemophilia A, B and Von willebrand disease
• Medical management of coagulation defects ?

  • suprevised by haemotology centres
  • On demand care or preventative treatment with factor replacement depending on severity of disease
  • Factor replacement therapy
  • Anti-fibrinolytic agents – Transexamic acid & EACA
  • Previously high risk of viral transmission with blood products – HIV, Hep C
  • Physiotherapy
• Dental management of Bleeding disorders in secondary care?

  • Multi-disciplinary input, close liaison with Haematology team
  • Routine care managed in primary care setting, invasive procedures secondary care
  • Secondary care for invasive procedures, plan ahead,
  • ID block and lingual infil in unavoidable need factor replacement
• dental management of bleeding disorders in primary care ?

  • Thorough Medical & Dental History 
  • Regular reviews with radiographs
  • Prevention: DBOH/ SDCEP – enhanced prevention
  • Autraumatic techniques inc care of xray placements, suction, clamps and bands etc
  • LA care
• LA and bleeding disorders ?

  • no restriction on type of LA agents, vasoconstrictors provide local haemostasis
  • B infil and intra pap usually ok
  • Avoid ID block and - risk of bleeding in pterygomandibular regions = airway obstruction
  • Avoid lingual infil - large BV plexus
  • Intra ligamental techs and b infil w articaine useful
• Neoplastic conditions definition ?

  • A group of cells which continue to proliferate indefinitely in an uncontrolled fashion