Child care and high-risk pathology
EDUCATIONAL OBJECTIVES
At the end of this course, the student should be able to:
- Screen at-risk patients.
- Define the risks for each pathology.
- Determine the general and specific CATs for these young patients
1- Introduction
The management of such patients in odontostomatology, and the diagnosis of some of these pathologies by the dental surgeon requires mastery of the many skills related to them.
2- Definitions
The at-risk patient is a patient whose general health, physical, mental and/or emotional, changes from “normal” and requires certain modifications in the usual pattern of his oral cavity.
3- General conduct
The increasing number of patients at risk means that the dentist must adapt the diagnosis and treatment of oral lesions in conjunction with the patient’s medical history,
The anamnesis is prepared, systematic and thorough, but supple with tact for the complete, precise collection
The necessary collaboration of parents with the attending physician is sometimes insufficient.
Apart from emergencies, the oral examination must be systematic, going from the general to the specific:
- Exoral examination
- Endo-oral examination
- Radiological examination
- Children and blood diseases
Summary table of the different blood diseases affecting a child
3-1-1 What to do when faced with anemia
1) Carry out a complete and thorough clinical examination:
2) Contact the attending physician or hematologist to
- Inform him of the oral health check-up and the necessary care,
- Discuss interference.
3) Any surgical procedure is preceded by:
- From a hemostasis assessment
- From a formula numbering
4) The intervention must be carried out:
- Apart from hemolytic crises
- In the absence of marked neutropenia and thrombocytopenia,
- With a hemoglobin level greater than 8g/100ml,
- Under local anesthesia (avoid truncal anesthesia) and prohibiting the use of prilocaine (CITANEST*) and lidocaine (XILOCAINE*) in cases of methemoglobinemia (thalassemia, sickle cell anemia).
- With gentleness (osteoporotic bone) using the root separation technique when extracting multi-rooted bones, ensure good clot formation encouraged by alveolar tightening and sutures.
- Avoid prescribing oxidizing medications (aspirin, phenacetin), hemolyzing medications, and aplastic anaesthetics.
5) Prevention must be rigorous (Education and motivation of the child and his parents) prophylaxis by topical fluoride, regular check-ups.
3-1-2 What to do when faced with leukemia
1) Any generalized gingival involvement (gingival bleeding, ulcerative gingivitis) or mucosal involvement in a pale and tired child should lead to a blood count.
2) Recognized leukemia: close collaboration between the dentist and the hematologist is essential, because only he can determine the most appropriate period for carrying out a septic or hemorrhagic procedure.
3) During the initial phase (before treatment) and the therapeutic induction phase: any treatment, any surgical procedure, even minimal, is contraindicated.
Endogenous infections must be prevented by maintaining systematic hygiene:
- Antiseptic and antifungal mouthwashes.
- Light brushing (soft brush)
In case of mucosal involvement, alternate:
- Mouthwashes with chlorhexidine mixture (Eludril* 1/2 bottle + 500ml of 14/1000 sodium bicarbonate solution + 1 bottle of mycostatin suspension).
- Irrigation with physiological saline solution
- Application of viscous xylocaine (before meals).
- Cleanse after meals by careful swabbing with 10 volume hydrogen peroxide.
- Suspend brushing during the period of deep aplasia in favor of using a low-pressure water jet.
Management of dental infectious foci in acute leukemia.
4) During the remission phase: between 2 chemotherapy treatments, carry out as complete a condition of the mouth as possible:
- Treatment of dental caries,
- Biopulpectomy if root canal filling is feasible,
- Extraction of all infected or suspected infected teeth with eradication of infectious foci under antibiotic prophylaxis. Extractions are performed with minimal trauma and sometimes with suturing and the placement of a flexible thermoformed splint.
- Scaling and periodontal care.
- Treatment must be completed at least 4 days before the date of a new induction treatment.
- How to handle a Willebrand disease patient or a hemophiliac
– Screening can be done by the dental surgeon and includes:
- Anamnesis (history of bleeding, bruises, post-surgical bleeding).
- Biological tests (bleeding time and Cephalin Kaolin time, etc.)
- Hemophiliacs are often referred by their hematologist.
– Close collaboration between dental surgeon and hematologist is essential before any surgical procedure, however minor.
- PRECAUTIONS TO TAKE WHEN
1- Periodontal care: Deep scaling can only be performed on patients who have received antihemophilic fractions (replacement treatment).
2- Radiological examinations and the use of surgical suction: Care must be taken when placing intraoral radiological films and when using the saliva ejector or surgical suction in order to avoid the occurrence of hematoma.
3- Anesthesia: Truncal anesthesia should be avoided due to the risk of dissecting hematoma which could lead to obstruction of the airways.
Local anesthesia is usually administered gently with a solution containing a vasoconstrictor at normal dosage.
4- Endodontic care: Endodontic care of permanent teeth is possible provided that:
- Working under a dike,
- Clean up the canal properly,
Avoid any excess paste or gutta beyond the apical foramen.
5- Prosthetic and orthodontic care: Can be carried out on well-motivated patients, but these devices must not traumatize the oral mucosa and the gum.
6- Dental extractions:
- Local anesthesia.
- Careful syndesmotomy and avulsion with as little trauma as possible.
- Placement of a hemostatic dressing in the socket
- Post-operative prescription of oral antibiotics to prevent any infection of the clot, as well as antifibrinolytics (hemocaprol 20 mg/kg/day) to slow the activity of fibrinolytic enzymes present in saliva which can dissolve the clot.
- Advice on a liquid and cold diet on the day of the procedure, then soft and barely warm in the following days.
- Ban on mouthwashes.
- Children and heart disease
3-2-1 Dental procedures in children with heart disease
- Sedative premedication may be prescribed if the child is anxious.
- Before any conservative or surgical intervention, the application of local antiseptics (3 to 5 minutes before) in the form of mouthwash or topical solution is essential.
- In terms of anesthesia, adrenaline should be contraindicated for all patients with rhythm disturbances and hypertension. Lidocaine should be used without vasconstrictors.
- For other cases, norepinephrine is recommended.
- A contact anesthetic (lidocaine gel) is applied before the injection, which should be slow and gentle.
The installation of the dam is mandatory to avoid any salivary contamination.
2. Extractions: Avulsions under mandatory antibiotic prophylaxis must be carried out quickly in the least traumatic way possible and in a reduced number of sessions.
Extractions preceding cardiovascular surgery will be completed 15 days before the procedure.
3. Scaling: Removing tartar and cleaning the gingival sulcus causes gingival bleeding, which requires systematic antibiotic prophylaxis.
4. Prosthesis and space maintainers: In permanent dentition, prosthesis is possible, however, perfect adaptation of the elements is required in order to avoid any irritation of the gingival tissues.
In temporary or mixed dentition, pedodontic caps are contraindicated.
5. Dentofacial orthopedic treatments: The installation of these devices is contraindicated when the risk is high and moderate.
If the child can benefit from it, oral hygiene monitoring must be close.
3-2-2 Modalities of antibiotic prophylaxis
Antibiotic prophylaxis is essential for procedures (extractions, scaling, endodontic care) that can cause bacteremia in at-risk heart patients.
For low or moderate risk, the route of administration is oral; for high risk, the parenteral route is preferred.
3-2-3 What to do when faced with a complication in a child with heart disease
The risks observed in these heart patients are:
- The risk of syncope
- The risk of bleeding
1. The risk of syncope :
This risk manifests itself by a brief cardio-respiratory arrest with more or less complete but reversible loss of consciousness.
It is a serious accident putting the patient’s life at risk.
To avoid the occurrence of syncope, certain rules must be respected:
- Avoid treating these subjects on an empty stomach,
- Patient comfortably installed,
- Injection of warm local or loco-regional anesthesia at 37° calmly and slowly,
- Avoid long and laborious interventions,
- Maintain psychological contact with the patient,
- Monitor the patient for 1/2 hour following the procedure.
In the event of cardio-respiratory syncope, it is necessary to :
- Stop current treatment
- Ensure ventilation with the patient placed in a strictly horizontal position,
- Check and clear the upper airway,
- Do not administer medicinal drugs.
- Favorable evolution return of consciousness in less than a minute.
- Unfavorable development, call a medical team.
2. The risk of hemorrhage
- In the event of hemorrhage, local hemostasis must be performed using:
- From a compress bitten by the patient for 20 to 30 minutes
- Absorbable materials such as gelatin-based sponges (spongel, hemofibrin, collagen, etc.)
- Children and respiratory diseases
3-3-1 Definition
Asthma is a chronic inflammatory condition of the bronchi characterized by recurrent episodes of cough, wheezing, chest tightness and dyspnea.
3-3-2 Dental care:
Anamnesis
Allows you to know the clinical history of asthma.
Psychological approach
- Reassure parents and child
- Minimize the anxiety of the young patient
- In severe forms of asthma, it is important to contact the treating physician to determine possible sedative premedication, for example: Atarax* 1mg/kg/day
- Ask the patient to bring their medication (ventolin*, Bricanyl*) and possibly their inhalation chamber.
Oral care
All oral care can be performed on children with asthma.
Anesthesia
- Ester-type local anesthetics should be avoided.
- Use an amide-type anesthetic containing a vasoconstrictor.
Drug prescriptions
Avoid :
- Acetylsalicylic acid
- Nonsteroidal anti-inflammatory drugs
- lactams.
3-3-3 The asthma attack in the dental chair
Minor Form : It manifests itself by:
- Paroxysmal dyspnea with wheezing.
- An increased respiratory rate.
- A dry cough.
The course of action:
- Calm the child
- Have him take 2-stimulants (BRICANYL®VENTOLINE®) preferably with an inhalation chamber.
- After this intake, if no improvement is observed, the progression is towards a major form.
Major form : The child shows signs of worsening of the crisis with:
- Increased dyspnea,
- Tachycardia,
- Cyanosis,
- Drop in respiratory rate.
3-3-4 The conduct to be adopted
Depends on the therapeutic means as well as the medical assistance that the practitioner can quickly access.
- Leave the patient in the position where he or she is most comfortable for breathing.
- Call a medical team while waiting for them to arrive
- Oxygenation
- Broncho dilation
- Corticosteroid therapy
3.5 Children and endocrinopathies
3-5-1 Definition of diabetes
Diabetes mellitus is characterized by high blood glucose levels and an unbalanced metabolism linked to a defect in the production or secretion of insulin.
There are three types of diabetes:
• Type 1 or insulin-dependent. Of genetic origin, it manifests in childhood and is linked to the autoimmune destruction of pancreatic cells that produce insulin.
• Type 2 manifests later. It is more likely to be caused by obesity and lack of exercise, does not require insulin administration, but can be controlled by diet and exercise.
• Type 3 is gestational diabetes.
Diagnostic elements are high blood sugar (> 11.1 mmol/l) and glycated hemoglobin measurement.
3-5-2 Conduct to be adopted
-For balanced and controlled patients, there is no need to take special precautions; they can be treated normally.
– It is advisable to perform the treatment in the morning after breakfast and to avoid, as much as possible, stress, which could trigger a hyperglycemic crisis.
-To reduce stress, it is possible to administer benzodiazepines, hydroxyzine or nitrous oxide.
-Due to the risk of infection, it is important to suture the extraction sites and explain oral hygiene precautions to the patient.
-In the case of unbalanced patients, treatments must be carried out under antibiotic prophylaxis. Furthermore, the prescription of corticosteroids and salicylic acid is not recommended.
3.6 Children and kidney disease
3-6-1 definition
Chronic renal failure (CRF) in children and adults is defined by a progressive and irreversible alteration of exocrine and endocrine renal functions related to the destruction of a certain number of nephrons, which is the lesion process.
Treatment of CKD:
1 Conservative treatment:
It is the first means of appropriate treatment, which includes an integrated set of dietary and medicinal therapeutic measures aimed at ensuring the patient’s autonomy in renal function for as long as possible.
2 Replacement treatments
The survival of kidney failure patients in the final stage of their disease is only possible thanks to replacement techniques such as:
– periodic hemodialysis,
– peritoneal dialysis,
– kidney transplantation.
These techniques are complementary and can be alternated over time in the same patient. However, in the majority of cases, hemodialysis will be the first treatment used.
3-6-2 Conduct to be adopted
-Contact the attending physician
– Motivation for oral hygiene: This involves:
* Teaching brushing techniques
* Use of a soft or medium bristle toothbrush
* Use of a mouthwash with an antiseptic product.
-Precautions against stress:
Care should preferably be carried out in the morning
Drug sedation based on benzodiazepine or barbiturate has no contraindications in patients with renal failure, as does per-operative sedation by inhalation of nitrous oxide.
-Precautions in the context of anesthesia: The use of vasoconstrictors is not contraindicated if the rules of use are respected
– Precautions regarding the treatment taken by the patient: In patients undergoing conservative treatment, there are no special precautions to take. Some authors advise prescribing anti-infectious prophylaxis.
– Precautions regarding hemostasis and coagulation disorders: Before performing procedures likely to cause bleeding, a platelet count and blood count as well as a hemostasis assessment must be carried out.
In all cases, bleeding control will be achieved through the use of local hemostasis techniques:
*Two-digital compression for 10 minutes.
*Topical application of local, absorbable hemostatic agents.
*The creation of sutures.
*Compression by applying a gutter.
-Precautions regarding the risk of infection:
* universal hygiene and asepsis measures must be respected to minimize the risk of cross-transmission of bacterial and/or viral infectious diseases.
* The compulsory wearing of gloves which must be systematically changed after any break-in.
*Wearing disposable goggles, masks, clots and gowns, as well as using a dam.
* Minimize the use of aerosol-producing instruments such as air syringes, turbines or inserts.
Antibiotic prophylaxis: This consists of the systemic administration of a single dose of antibiotic within one hour of the invasive procedure. It is important to reserve such a prescription for situations for which it is recommended.
3.8 Child and cancer
The goal of oral care is to avoid or minimize the side effects of radiotherapy and chemotherapy
1- Before anti-cancer treatment
-Eliminate infectious foci:
-Extractions are performed at least 15 days before the start of anticancer treatment.
-Coronary fillings are made using amalgam in the posterior sectors and composites in the canine incisor groups.
-If orthodontic treatment is in progress, the multi-attachment appliance is removed to avoid the risk of mucosal injuries if the patient presents a phase of bone marrow aplasia during treatment.
-making soft silicone splints for topical fluoridation from 8 years of age.
-Dietary management is essential if we want to mitigate the side effects of the treatment.
Treatment of other disorders:
- Vomiting: antiemetics.
Candida albicans: antifungals.
Virals: antivirals.
Xerostomia: Jaborandi tincture.
Dysphagia: gastric tube.
Skin reactions: Biafine, aqueous eosin.
2- After anti-cancer treatment
Manage oral pathologies, dental growth anomalies as well as soft tissue retractions.
1-Caries: Post-radiation caries are somewhat similar to those of baby bottle syndrome. They are caused by the decrease in salivary flow and the drop in oral pH. The only effective weapon is the topical application of fluoride, but this therapy is difficult, if not impossible, to perform in very young children without risking them ingesting toxic doses of fluoride.
2-Dry mouth: You should drink water and refresh the oral cavity with a mouthwash without chlorhexidine.
3- Disorders of odontogenesis: Cytotoxic drugs are not very selective. When chemotherapy is administered during the maturation and growth phase of teeth, it can cause microdontia, malformations or the arrest of the development of germs. The eruption and occlusion of these teeth will need to be managed.
4- Eating disorders: Often patients have lost the notion of chewing.
It is necessary to support the advice of the pediatrician who recommends resuming a normal diet.
5 Orthodontics : Space maintainers or progressive pedodontic prostheses allow you to wait for the eruption of permanent teeth.
Multi-attachment treatments should be avoided and piloted extractions and early treatments that utilize the eruption sequence, growth, and muscle function should be favored.
- Conclusion
In addition to helping with a diagnosis, they will allow the practitioner to adopt an appropriate therapeutic attitude and give his patient appropriate advice. Subsequently, the latter must follow the pathology in parallel with other practitioners and ensure its balance and the effectiveness of its treatment. Finally, a dental surgeon, like other health professionals, must be able to take charge of a medical emergency situation linked to these pathologies and which may arise in their office.
- Bibliographies
1-Naima OTMANI, Mohammed-Nacer NACHEF, Fouzia MSEFER ALAOUI, Management of dental treatment in children with acute leukaemia., 2004.
2- V. ARMENGOL, C. DUPAS, I. HYON, A. GAUDIN, Endodontics and patients at risk, 2014.
3-Chloé Villain. Oral care in pediatric dentistry: retrospective analysis of children treated in an oral medicine department . Life Sciences [q-bio]. 2021. ffdumas-03560846f
4-Albane MAINGUY, Oral and dental care of patients at high risk of infective endocarditis, November 2021
Child care and high-risk pathology
Untreated cavities can cause painful abscesses.
Untreated cavities can cause painful abscesses.
Dental veneers camouflage imperfections such as stains or spaces.
Misaligned teeth can cause digestive problems.
Dental implants restore chewing function and smile aesthetics.
Fluoride mouthwashes strengthen enamel and prevent cavities.
Decayed baby teeth can affect the health of permanent teeth.
A soft-bristled toothbrush protects enamel and sensitive gums.