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Dental Management of B- Thalassemic Patients Dr. Rana Darwish DDS, MPH The 3 rd National Palestinian Conference on Thalassemia & other Hemoglobinpathies.

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Presentation on theme: "Dental Management of B- Thalassemic Patients Dr. Rana Darwish DDS, MPH The 3 rd National Palestinian Conference on Thalassemia & other Hemoglobinpathies."— Presentation transcript:

1 Dental Management of B- Thalassemic Patients Dr. Rana Darwish DDS, MPH The 3 rd National Palestinian Conference on Thalassemia & other Hemoglobinpathies Bethlehem 21 st – 22 nd Oct 2009

2 Responsibilities of a dentist Full awareness of managing medically compromised patients Full awareness of different treatment modalities Dealing with the dental patient as a whole Cooperating with & consulting patients’ physicians. 2

3 Clinical Classification of B- Thalassemia Severe B – Thalassemia Thalassemia Major (Transfusion dependant) Thalassemia Intermedia (no regular transfusions required) B – Thalassemia Trait (Thalassemia Minor) 3

4 Clinical & Medical Manifestations of concern to dentists Depends on the severity of Thalassemia Iron accumulation & overload (continuous blood transfusions) affecting: Liver Heart Endocrine Glands Unsafe blood transfusions (hepatitis) 4

5 Liver Impairment * Fibrosis with infrequent progression to Cirrhosis Cirrhosis result in decrease in clotting factors (necessary for haemostasis) Cirrhosis may lead to increased bleeding time. Dentist determination of clinically significant bleeding following invasive dental procedure 5 * TUFTS University – Management of medically compromised patients 2007 & British Dental Association

6 Cirrhosis Dental Management * Minimize bleeding Monitor PT / INR & Liver function tests No Aspirin or NSAID Acetaminophin (with or without Codeine) Antibiotics: Amoxicillin is safe 6 * TUFTS University – Management of medically compromised patients 2007 & British Dental Association

7 Diabetes: one of major manifestations Varies if controlled or poorly controlled 7 Endocrine Glands Impairment* * TUFTS University – Management of medically compromised patients 2007 & American Dental Association 2003

8 Diabetes Oral Manifestations* Associated with: Increased incidence of infections Delayed wound healing Xerostomia (medications taken by patients) Burning mouth syndrome Periodontal disease 8 * TUFTS University – Management of medically compromised patients 2007 & American Dental Association 2003

9 Periodontal Disease: Attachment loss Alveolar bone loss Uncontrolled 3 folds when compared to non- diabetic controlled pts 9 Diabetes Oral Manifestations* * TUFTS University – Management of medically compromised patients & American Dental Association

10 10 Diabetes Oral Manifestations Hyperglycemia  Increase glucose level in gingival crevicular fluid  alter periodontal wound healing event by changing interaction between cells & extracellular matrix with periodontium.

11 11 Diabetes & Smoking Smoking increases the risk of periodontal disease several folds in diabetics Synergistic effect

12 Diabetes Dental Management* Treat patient with care & consult physician Monitor blood glucose (FBS, HbA1c) Maintain hygiene recall every 3-4 months In uncontrolled patients: Control Diabetes first Delay dental Tx in absence of emergency Use non absorbable suture material 12 * TUFTS University – Management of medically compromised patients & American Dental Association

13 Heart Impairment* Congestive heart failure & arrhythmias Increases with the number of received blood transfusions Antiarrhythmic medications side effects: xerostomia & gingival enlargement Dyspnea 13 * TUFTS University – Management of medically compromised patients 2007 & Medicina Oral Journal 2002

14 Heart Diseases Management* Consult patient’s cardiologist Appointments of short duration Dental chair in reclining or erect position (not supine) Careful use of local anesthetics with vasoconstrictor 14 * TUFTS University – Management of medically compromised patients 2007 & Medicina Oral Journal 2002

15 Other Medical Conditions* Salivary glands: iron deposits  painful inflammation (normal /diminished salivary flow) Splenectomy: - prevent any source of bacterial spread - Antibiotic coverage (variations ?) / resistance - platelet count  Thrombosis risk  antiplatelet medication  monitor bleeding time 15 * TUFTS University – Management of medically compromised patients 2007

16 Hypersplenism with leukopenia & thrombocytopenia  provide antibiotic coverage & platelet concentrates before dental procedure can be carried out. 16 Other Medical Conditions* * TUFTS University – Management of medically compromised patients

17 Orofacial Manifestations Bony changes and expansion Malocclusions: severe maxillary protrusion * Medicina Oral Journal If Blood transfusions have been carried out since birth  up to 50% of pts may present close to normal growth & bone development*

18 Dental Caries Periodontitis & Gingivitis Both are more prevalent in pts with splenectomy 18 Orofacial Manifestations Medicina Oral Journal 2002

19 Consequences of Dental Caries Pain & distress Pulpal infection Dental abcess Facial cellulitis Early loss of teeth 19

20 Dental Management Checklist Appropriate full medical history Dental history Patient on medication or not Type of Thalassemia Name of treating physician / specialist Clinical Examination (extraoral / intraoral) 20

21 Dental Management Good oral hygiene practice Plaque control Diet modification Topical Fluoride application varnish/toothpaste Fissure sealant application 21

22 Management of Xerostomia * Treat salivary gland dysfunction High dose fluoride Chlorhexidine mouthwash or gel Saliva stimulation (Pilocarpine) Saliva substitution * Prevention of oral disease. 4 th edition. 2003

23 Dental Management Teeth restorations Root canal treatment (pulpal involvement) Professional scaling Surgical involvement & remodeling in Thalassemia intermedia 23

24 24 We can Work Together to Improve the Quality of Life for Such Patients…

25 References Ganda K. Management of medically compromisd dental patient. TUFTS University. Tufts Denatl school Cutando A. et al. Thalassemias and their dental implications. Medicina Oral Journal. 2002; 7: 36 – 45. Murray J.J. Prevention of Oral Disease. 4 th edition, 2003, Oxford Press. Lalla & D’ambrosio. Dental management considerations for the patient with diabetes mellitus. American Dental Association Journal. 2001; 132; 1425 – Vernillo A. Dental considerations for the treatment of patients with diabetes mellitus. American Dental Association Journal. 2003; 134; 24S – 33S. 25

26 Thank you. 26


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