1. Dental Management of
Medially Compromised
(Patients (1
Dr. Usama M. Madany
Prof. Oral Medicine, Periodontology, Diagnosis and
Oral Radiology, Faculty of Dental Medicine, Al- Azhar
.Univer. , Cairo, Egypt

2. Hemolytic Anemias
Sickle cell disease
(Sickle cell anemia (homozygous
(Sickle cell trait (heterozygous
Thalassemia
Alpha thalssemia
Beta thalssemia
(Thalsssemia major (homozygous thalassemi, Cooley’s anemia
(Thalssemia minor (heterozygous thalassemia, thlassemia trait
Glucose 6 Phosphate Dehydrogenase Deficiency (G6PDD,
Favism(

3. Sickle cell anemia is an inherited blood disorder caused by structurally
abnormal haemoglobin (Hb S ( that causes a rigid distorted red
blood cell (sickle cell(
Acute crises may occur spontaneously or precipitated by
Infection
Dehydration
Increased
viscosity and
clumping of
RBCs
Thrombosis
Ischemia
Infarction
Hypoxia
Sedatives and local anaesthetics
Cold
Hemolytic Anemia
Weakness
Splenomegaly
Heart failure

4. Dental Aspects
Oral Manifestations
Pale and yellow oral mucosa
-Maxillary overgrowth -
-Delayed eruption
-Enamel hypoplasia
Radiographic findings

6. Hair on End appearance

7. Problems
•Susceptibility to infection
•Susceptibility to develop crisis
•Bleeding tendency

8. Dental considerations and management
Never
Anesthetize or operate on patients during crisis
(except for the relief of pain and treatment of infection).
Use tourniquet
Use GA in the clinic (GA must be carried out in a
hospital with full anesthesia facilities and in close
cooperation with a hematologist)
Prescribe drugs that can cause respiratory
depression and hypoxia such as sedatives (Nitrous
oxide can be used safely as long as oxygen conc. is
<50%).

9. Expect
Cerebral or cardiac hypoxia my result in these
patients with minor procedure
Poor wound healing after minor surgery or
extraction
Pulpal symptoms are common without obvious
dental disease
Infarction of bone may result in osteomyelitis esp.
in the mandible

10. Remember
-Patient’s physician should be consulted about the
patients myocardial status.
-Preventive dental care is important.
-Dental infections should be treated vigorously, if facial
cellulitis develops patient should be admitted to the
hospital.
-Pain medications for patients with sickle cell disease
include paracetamol, paracetamol with Codeine, NSAID’s
and narcotics especially morphine. However, the use of
Meperidine (Demerol) should be avoided as much as
possible since one of its toxic metabolites
(normeperidine) has a long plasma half-life and can
cause seizures.

11. -Due
to high risk of infection in such patients,
prophylactic antibiotic regimen for prevention of
endocarditis should be followed before any dental
procedures that can cause transient bacteremia.
-After surgical procedures, antibiotics ( 500 mg penicillin
VK 4 times/day or erythromycin, 250 mg 4 times/day, for
penicillin-allergic patients) should be continued for 7-10
days postoperatively.
-Use of vasoconstrictor in local anesthesia is
controversial, however, for short routine procedures
lacking discomfort , the vasoconstrictor should not be
used. If the procedure requires long profound
anesthesia, 2% lidocaine with 1/100,000 adrenaline is the
anesthetic of choice.

12. If general anesthesia is required, it is advisable to
carry out comprehensive dental treatment,
including any extraction or restoration that may be
required, so as to avoid a second procedure.

13. Trait
of hemoglobin is HbS 60%Patient is asymptomatic and lives normal life Sickle cell crisis can be precipitated by reduce oxygen tension
Few problems in managementGeneral anesthesia better be performed in hospital *
with full oxygen supply
Acute infections should be treated immediately*
Prophylactic antibiotic cover before surgery*

14. Thalassemia
Group of congenital disorders characterized by
deficient synthesis of either α or β chains of
.hemoglobin in Hb
Alpha thalssemia
Imbalance in globin chain
chains in RBCs
+ hemolysis
Beta thalassemia
precipitation of these
ineffective erythropoiesis

15. Beta thalassemia
Homozygous thalassemia (Cooly’s anemia) no or few normal-1
beta chains
Heterozygus thalassemia-2
Cooley’s anemia
Oral manifestations
Pale or/and oral mucosa
Painful swelling of salivary glands
Painful tongue
Large head and mongoloid
characters
Teeth discoloration
Enlargement of premaxilla
Hyperplasia of bone marrow
Spacing of upper ant. teeth
Delayed sinuses’
pneumatization

16. a
b

17. Dental implications
Expect poor wound healing- 1
Antibiotic is required to control infection without delay- 2
.Avoid GA in dental clinic- 3
.Avoid excessive bleeding during surgery- 3

18. Glucose 6 Phosphate Dehydrogenase
)Deficiency (G6PDD
Erythrocyte metabolic defect characterized by hemolysis due to
.denaturing of hemoglobin in presence of oxidant compounds
Life span of RBCs is 2/3 the normal and this is compensated by liver
and bone marrow
Diabetes
Infection
Oxidants compounds
Hemolysis
General anesthesia
Dental management
Avoid oxidant drugs eg asprin, phenacetin, sulphonamides,- 1
chloramphenicol, and vit .K
Infection should be treated without delay-2

19. Renal Disorders
• Chronic
renal failure/hemodialysis.
• Renal transplantation.

20. Renal Disorders
Problems
• Increased susceptibility to infection + immunosuppression
•Bleeding tendency.
•Decreased ability to excrete drugs.
•Existence of A-V shunt.
•Cross infection.

21. Dental Aspects and management
Chronic renal failure
It is generally preferable to treat patients before rather than after
dialysis or transplantation
1-Consult patient’s physician
2-Monitor blood pressure
3-Check lab values, PTT, PT, platelet count, bleeding time, blood
urea nitrogen (do not treat if less than 60 mg/100ml) and serum
creatinine (do not treat if less than1.5 mg/100ml).
4. If medical parameters permits
Eliminate all foci of infection
Keep only the easily maintainable teeth
Try to keep good oral hygiene

22. Normal Lab
Values
Normal
Comfort Zone
PT
PTT
12-14sec
1.5x normal
25-35sec
1.5xnormal
Platelets
150,000-450,000
Min 50,000
Hemoglobin
Males: 13.5-17.5 g/dL
10g/dL
Hematocrit
Females: 12-16 g/dL
Males: 39-49%
BT
min 3-9
30%
Females: 35-45%
1.5x normal

23. Avoid prescribing- 5
Tetracyclines, streptomycin, Vancomycin, Gentamycin. Acyclovir
acetaminophen, phenacetine, NSAIDs, asprin, antihistamines,
phenobarbitones
Decrease dose of
Cephalosporins, penicillins,, ampicillin, metronidazole, acyclovir,
paracetamol, benzodiazpine
Normal dose
Cloxacillin, erythromycin, minocycline, codiene, diazepam,
lidocaine

24. Hemodialysis
High incidence of serum hepatitis
High incidence of anemia
Significant incidence of secondary hyperparthyroidism
Uremic stomatitis may exist
Undergo heparinization during hemodialysis
Have arteriovenous shunt or fistula
a

25. Dental management
Screen for HBsAg and HBsAb-1
Antibiotic prophylaxis to prevent endartritis of-2
arteriovenous fistula
Prevent hypoxia-3
Provide treatment on the day after hemodyalisis-4
5-Be careful to protect the fistula or shunt when patient
on dental chair
6-Refer the patient to physician if uremic stomatitis is
noted to develop

26. Renal transplant patient
Infection in such patients is life –threatening
Before transplantation easily only maintained teeth should be
determined by dental team approach
Teeth with furcation involvement, periodontal abscesses, or
extensive surgical requirements should be extracted
Management
Emergency tx only for 1st 6 months- 1
HBsAg screening- 2
3-Prophylactic antibiotics according to AHA recommendations
4- Erythromycin is contraindicated in patients on cyclosporins
5Immunosuppressed
pt
requires
supplemental
corticosteroids