dental management of b- thalassemic patients dr. rana darwish dds, mph the 3 rd national palestinian...

Dental Management of B- Thalassemic Patients

Dr. Rana Darwish

DDS, MPH

The 3rd National Palestinian Conference on Thalassemia &

other Hemoglobinpathies

Bethlehem 21st – 22nd Oct 2009

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.

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Clinical Classification of B- Thalassemia

• Severe B – Thalassemia Thalassemia Major (Transfusion dependant) Thalassemia Intermedia (no regular

transfusions required)

• B – Thalassemia Trait

(Thalassemia Minor)

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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)

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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

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* TUFTS University – Management of medically compromised patients 2007 & British Dental Association

Cirrhosis Dental Management*

• Minimize bleeding

• Monitor PT / INR & Liver function tests

• No Aspirin or NSAID

• Acetaminophin (with or without Codeine)

• Antibiotics: Amoxicillin is safe

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* TUFTS University – Management of medically compromised patients 2007 & British Dental Association

• Diabetes: one of major manifestations

• Varies if controlled or poorly controlled

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Endocrine Glands Impairment*

* TUFTS University – Management of medically compromised patients 2007 & American Dental Association 2003

Diabetes Oral Manifestations*

• Associated with: Increased incidence of infections Delayed wound healing Xerostomia (medications taken by patients) Burning mouth syndrome Periodontal disease

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* TUFTS University – Management of medically compromised patients 2007 & American Dental Association 2003

• Periodontal Disease: Attachment loss Alveolar bone loss Uncontrolled 3 folds

when compared to non-

diabetic controlled pts

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Diabetes Oral Manifestations*

* TUFTS University – Management of medically compromised patients & American Dental Association

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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.

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Diabetes & Smoking

• Smoking increases the risk of periodontal disease several folds in diabetics

• Synergistic effect

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

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* TUFTS University – Management of medically compromised patients & American Dental Association

Heart Impairment*

• Congestive heart failure & arrhythmias

• Increases with the number of received blood transfusions

• Antiarrhythmic medications side effects: xerostomia & gingival enlargement

• Dyspnea

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* TUFTS University – Management of medically compromised patients 2007 & Medicina Oral Journal 2002

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

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* TUFTS University – Management of medically compromised patients 2007 & Medicina Oral Journal 2002

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

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* TUFTS University – Management of medically compromised patients 2007

• Hypersplenism with leukopenia & thrombocytopenia provide antibiotic coverage & platelet concentrates before dental procedure can be carried out.

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Other Medical Conditions*

* TUFTS University – Management of medically compromised patients

Orofacial Manifestations

• Bony changes and expansion

• Malocclusions: severe maxillary protrusion

* Medicina Oral Journal 2002 17

If Blood transfusions have been carried out since birth up to 50% of pts may present close to normal

growth & bone development*

• Dental Caries

• Periodontitis & Gingivitis

• Both are more prevalent in pts with splenectomy

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Orofacial Manifestations

Medicina Oral Journal 2002

Consequences of Dental Caries

• Pain & distress

• Pulpal infection

• Dental abcess

• Facial cellulitis

• Early loss of teeth

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Dental Management ChecklistAppropriate full medical historyDental historyPatient on medication or notType of ThalassemiaName of treating physician / specialistClinical Examination (extraoral / intraoral)

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Dental Management

• Good oral hygiene practice

• Plaque control

• Diet modification• Topical Fluoride application varnish/toothpaste

• Fissure sealant application

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Management of Xerostomia *

• Treat salivary gland dysfunction

• High dose fluoride• Chlorhexidine mouthwash or

gel• Saliva stimulation

(Pilocarpine)• Saliva substitution

* Prevention of oral disease. 4th edition. 2003

Dental Management

• Teeth restorations

• Root canal treatment (pulpal involvement)

• Professional scaling

• Surgical involvement & remodeling in Thalassemia intermedia

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

References• Ganda K. Management of medically compromisd dental patient. TUFTS University.

Tufts Denatl school. 2007.• Cutando A. et al. Thalassemias and their dental implications. Medicina Oral Journal.

2002; 7: 36 – 45.• Murray J.J. Prevention of Oral Disease. 4th edition, 2003, Oxford Press.• Lalla & D’ambrosio. Dental management considerations for the patient with diabetes

mellitus. American Dental Association Journal. 2001; 132; 1425 – 1432.• Vernillo A. Dental considerations for the treatment of patients with diabetes mellitus.

American Dental Association Journal. 2003; 134; 24S – 33S.

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Thank you.

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