[PAEDS] Management of medical conditions

• Obtaining a Medical History

  1. Follow a 'similar' routine to that for an adult

  2. Emphasis on certain conditions

  3. Take history from parent/ carer – involve child (depending on age)

  4. Update (& record changes) every visit
• Why is a Medical History Important (1)

  • To identify any medical problems that might require modification of dental treatment or impact on patient compliance
  • To check whether the child is receiving any medication which could result in an adverse reaction or influence dental development
  • Combined medical and oral findings may help with diagnosis
• Why is a Medical History Important (2)

  • Identify systemic disease that could affect other personnel
  • Identify if medical colleagues are involved with patient care
  • Alert to possible medical emergencies
  • Prioritise children who may require enhanced preventive care
  • Medicolegal requirement
• Key points common to most special care conditions in paediatric dentistry

  • Prevention of oral & dental disease is paramount
  • 4 pillars of prevention: Oral hygiene, Diet advice, Fluorides & Fissure sealants
  • DBOH/ SDCEP – enhanced prevention
  • Frequent reviews are necessary (~ 3-6 months) to identify & manage disease early
  • Strive to reduce barriers to delivery of dental care, including physical barriers, communication difficulties & anxiety
  • Acclimatisation, behaviour management & a variety of communication techniques may be required
  • Conscious sedation & general anaesthesia may be needed to provide dental treatment
  • Support from parents (& others involved in the child's care) is paramount
• Asthma

  Diffuse obstructive lung disease - reversible episodes of airflow obstruction & bronchospasm
• Asthma Aetiology

  • Complex – genetic predisposition & environmental influences
  • Immunological, infectious, biochemical, genetic & psychological factors
  • Irritants (allergens) include house dust mite, pollen, moulds, cigarette smoke & foods
• Asthma Symptoms


  • Coughing
  • Wheezing
  • Breathlessness
  • Tightness of chest
• Asthma Medical Management - Maintenance therapy to control symptoms

  • Prophylactic drugs – reduce bronchial hyperactivity & inflammation
  • E.g. Corticosteroids, usually inhaled, (beclomethasone), mast cell stabilisers (sodium cromoglycate)
  • Symptomatic relief – bronchodilators
  • E.g. Short acting beta 2 agonists – salbutamol (Ventolin) inhaler
• Asthma Medical Management - Classification

  • Controlled, partially controlled or uncontrolled
  • Controlled = minimal symptoms, no exercise limitation, infrequent exacerbations, minimal need for rescue medication, near normal lung function
• Asthma Oral Implications

  • Tendency to mouth breathing
  • Gastro-oesophageal reflux (GORD)
  • Side effects of medication, including xerostomia, taste alterations, extrinsic discolouration of teeth, oral candidiasis
  • Dental caries - possible increased risk – multi-factorial – debatable
  • Dental erosion
• Asthma Dental Management Implications 1

  1. Establish severity of condition & adequacy of control

  2. Key questions: frequency of symptoms, when was last asthma attack?, triggers, A & E/ hospitalisation?

  3. Has patient taken 'usual' medication prior to appointment?

  4. Does patient have medication (blue reliever inhaler) with them?

  5. Potential asthma triggers in dental setting: anxiety, stress, prolonged supine positioning, aerosols

  6. Routine dental care with LA is not usually a problem

  7. Sedation to reduce anxiety – careful case selection

  8. General anaesthesia – best avoided but for severe asthmatics, usually requires inpatient hospital admission
• Asthma Dental Management Implications 2

  1. Fluoride varnish contra-indicated in severe asthmatics - Colophony

  2. Avoid aspirin & other NSAIDs – can induce bronchospasm

  3. Steroids (including prolonged therapy with high dose inhalers) may cause adrenal suppression - prophylactic 'steroid' cover?

  4. Prevent oral candidiasis:

  5. Spacer device to deliver inhaled drugs directly to airway

  6. Rinsing (with water) or tooth-brushing after using inhalers

  7. Prevention: DBOH/ SDCEP – enhanced prevention

  8. Know how to identify & manage asthma attack
• Diabetes

  • Insulin is a hormone produced in pancreas
  • Regulates blood glucose levels by removing glucose from bloodstream for utilisation/ storage by cells
• Diabetes

  • Endocrine/ metabolic disease resulting from defects in insulin secretion, action (or both)
  • Characterised by chronic hyperglycaemia
• Diabetes Classification

  • Type 1 diabetes (insulin dependent – IDDM) - 5-10% cases
  • Type 2 diabetes - 90-95% cases
• Type 1 diabetes

  • Insulin deficiency
  • Not associated with obesity
  • Peaks of presentation ~ 5-7 years & puberty
  • Treatment: insulin therapy (injections or 'insulin pump') – monitoring blood glucose essential
• Type 2 diabetes

  • 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)
• Diabetes Symptoms & features

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

  • Xerostomia – associated with polyuria & altered salivary gland function
  • Increased caries risk – xerostomia, increased salivary glucose, frequent snacking
  • Periodontal disease – diabetes is not a direct cause but 'pre-disposing' condition for developing gingivitis/ periodontitits
  • Oral candidiasis – associated with xerostomia
  • Increased risk of oral infections – impaired neutrophil chemotaxis & phagocytosis
  • Impaired wound healing
  • Taste dysfunction, burning mouth syndrome, lichen planus
• Diabetes Dental management

  1. Well controlled diabetics can receive dental treatment in primary care:

  2. Establish level of control

  3. Morning appointments preferable

  4. Don't keep patient waiting, keep appointments as short as possible

  5. Make sure patient has eaten & taken usual medication prior to appointment

  6. Prevention: DBOH/ SDCEP – enhanced prevention

  7. Tailored OHI

  8. Advice about sugary snacks – work with diabetes team & dietician

  9. Manage infections appropriately – antibiotics may be necessary

  10. Avoid GA – if necessary, requires in-patient hospital admission

  11. Emergencies – identify & know how to manage - Hypoglycaemia – blood glucose < ~3mmol/ L
• Epilepsy

  A brain disorder characterised by excessive neuronal discharge that can produce seizures, unusual body movements & loss or changes in consciousness
• Epilepsy Features

  • Generalised – 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
  • Partial – affects only part of brain & therefore involves restricted areas of body
  • Potential triggers – stress, infections, fever, sleep deprivation, fatigue, low blood sugar, flashing lights, loud noises
• Epilepsy Medical Management

  • Usually long-term anticonvulsant therapy
  • E.g. sodium valproate, carbamazepine & phenytoin
  • Rescue medications – mostly midazolam – previously 'rectal, now more often 'buccal
• Epilepsy Oral Implications

  • Drug induced gingival hyperplasia (phenytoin – causes gingival enlargement in ~ half of patients)
  • Increased caries risk – sugared liquid medication
  • Other oral side effects of some anti-convulsant drugs – xerostomia, oral ulceration, glossitis, bone marrow suppression & thrombocytopenia
  • Increased risk of dental trauma associated with falls & seizures
• Epilepsy Dental Management 1

  1. Well controlled epileptics can receive dental treatment in primary care:

  2. Obtain history on epilepsy management & control

  3. Ensure patient has taken usual medication prior to appointment

  4. Check if parents have rescue medication with them - know when & how to use it

  5. Mornings appointments might be preferable, don't keep patient waiting, short appointments

  6. Avoid/ minimise known (or potential) triggers - flickering lights, loud noises & stress
• Epilepsy Dental Management 2

  1. Prevention: DBOH/ SDCEP – enhanced prevention

  2. Intensive OHI to minimise drug induced gingival overgrowth

  3. Advice on sugar free medication

  4. Consider further options to manage gingival hyperplasia

  5. Orthodontic treatment – careful consideration

  6. Removable prostheses – risk of # & inhalation if patient has a seizure - if required, must be well retained (with clasps)

  7. LA & Conscious sedation – no contra-indications if well controlled – sedation may help reduce seizures induced by stress

  8. GA for dental treatment – normally hospitalise, especially if poorly controlled

  9. Know how to identify & manage seizures
• Congenital Cardiac Defects Types

  • Ventricular septal defect
  • Atrial septal defect
  • Patent ductus arteriosus
  • Pulmonary stenosis
  • Aortic stenosis
  • Coarctation of the aorta
  • Transposition of the great arteries
  • Tetralogy of Fallot (severe defect)
• Congenital Cardiac Defects Signs & Symptoms

  • Breathlessness on exertion, tire easily & recurrent respiratory infections
  • Feeding difficulties, failure to thrive, delayed growth & development
  • Severe defects - cyanosis & finger clubbing. Some children assume a 'squatting' position to relieve breathlessness
• Congenital Cardiac Defects General Management

  • Surgical correction
  • Medication – diuretics, Digoxin, ACE inhibitors, anticoagulants
• Congenital Cardiac Defects Oral Implications

  • Delayed eruption
  • Enamel defects (mostly primary dentition) – chronic hypoxia disturbs enamel formation
  • Increased caries risk – multi-factorial – enamel hypoplasia, sugary medication, medication side effects (e.g. xerostomia). Children might be on a high calorie/ sugar intake diet to meet high energy demands & ensure fit for surgery
  • Cyanosis oral mucous membranes
• Congenital Cardiac Defects Dental Management 1


  1. Depending on type of defect & associated impairment,

  2. At risk of infective endocarditis

  3. Bleeding risk – anticoagulant medications

  4. Implications of associated conditions e.g. learning disability (Down syndrome)

  5. Regular reviews with radiographs (as per Guidelines)

  6. Prevention: DBOH/ SDCEP – enhanced prevention

  7. Emphasising the importance of good OH & maintaining a good standard of oral health

  8. Active dental disease managed before cardiac surgery undertaken
• Congenital Cardiac Defects Dental Management 2

  1. Short appointments with regular breaks – mornings may be preferred

  2. Caution lying child supine if breathless, minimise stress

  3. Caution with use of electronic devices in children with pacemakers e.g. electric pulp testers, ultrasonic scalers

  4. Pulp therapy in primary dentition contra-indicated – potential risk of infection

  5. LA – caution with some potential drug inter-actions with adrenalin

  6. Sedation – must ensure adequate oxygenation - if necessary, best managed in secondary care

  7. GA for dental treatment – avoid if possible
• Platelet defects

  • Thrombocytopenia – reduction in number of circulating platelets
• Normal platelet levels

  150-400 x 10^9 / L
• Causes of thrombocytopenia

  • Idiopathic – ITP (idiopathic thrombocytopenic purpura)
  • Bone marrow suppression – related to drugs (including chemotherapy), haematological disease (e.g. aplastic anaemia), haematological malignancy (e.g. leukaemia)
• General manifestations of thrombocytopenia

  • Petechial haemorrhages into skin & mucous membranes
  • Haematemesis
  • Haematuria
  • Melaena
• Oral manifestations of thrombocytopenia

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

  • Haemophilia A
  • Haemophilia B
  • von Willebrand disease
• Haemophilia A

  Deficiency factor VIII, Inherited – X linked recessive (about ~ 30% - no FH), Affects 1 in 5000-10000 males
• Classification of haemophilia A by factor VIII level

  • < 1% - severe – spontaneous joint/ muscle bleeds
  • 2 – 5% - moderate – bleed following minor trauma
  • 6 – 25% mild – bleed after surgery