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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_20_библиотеки_им_акад_М_И_Перельмана
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Clinic Visits
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• The appointment should be scheduled so as to create
the minimum of disruption to the usual daily meal/
insulin plan. The patient with diabetes should bring
the following to each dental appointment: (i) blood
glucose meter; (ii) snack; (iii) glucose; and (iv) insulin
• The provider should determine: (i) if their diabetes
is well controlled (he/she is more likely to have a
hypo if control is tight); (ii) what the signs/symptoms of a hypo are for him/her (these can change
over time); and (iii) the HbA1C. A high HbA1C
places the patient at increased risk of infection and
delayed healing. However, this should not delay the
completion of necessary treatment to eliminate
infection. If the patient has ketones, surgery
should be delayed until this is addressed
• Clinicians should be aware that deterioration in
behavior during an appointment may be due to a
hypo, and the situation should be managed
appropriately with blood glucose check and
administration of glucose if needed. Provided the
usual meal plan is not disrupted and appropriate
blood glucose monitoring is available and utilized,
inhalation sedation with nitrous oxide is suitable
for children with type 1 diabetes. The clinician
should be aware that the feelings of dissociation
MEdiCAlly CoMPRoMisEd PATiEnTs
and tingling that are encountered with nitrous
oxide use may be very similar to those sensations
experienced in a hypo. Some children may find
this distressing. In‐office oral sedation and intravenous sedation should only be undertaken with
great caution, and only in close collaboration with
the diabetes care team
• General anesthesia should be undertaken in a
hospital setting. The diabetes care team should be
consulted well in advance. Day surgery is usually
possible, provided they are booked as the first case
in the morning to minimize fasting time. Blood
glucose is checked on arrival and monitored
throughout the stay
• Patients are encouraged to eat a light meal as soon
as possible after the procedure. Insulin requirements and postoperative care are tailored to the
child’s needs, in collaboration with the diabetes
care team
• Pain management is important to allow the child to
eat as normally as possible. Some modification of
the child’s diet may be required in the early days
after dental surgery, and this may entail a change in
insulin requirements. Parents should be alert to the
signs of infection and be advised to contact the
dental team should concerns arise
Self‐Study Questions
Answers are located at the end of the case
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Self‐Study Answers
background information followed by complex carbohydrate. Ensure adequate blood glucose levels
preoperatively and give a snack as needed
if infection is present, as infection can cause hyperglycemia. Provided the blood glucose is appropriate, proceed with surgery but consult promptly and
clearly with the diabetes care team to alert them to
the situation and inform parents of the importance
of maintaining blood glucose within target range
colleagues. Potentially, give glucose and continue
to monitor blood glucose level very regularly during
and after procedure
must remain under careful medical observation until
he can eat adequately and his insulin requirements
can be balanced with his dietary intake
tain whether the sugary drinks are discretionary
or are part of his glucose management. If they are
required to treat hypoglycemia, then change is challenging and may be impossible. If they are taken by
choice then change is very desirable. Close consultation with the diabetes care team may be useful
Additional Reading andResources
Hallett KB, et al. 2013. Medically compromised children. In:
Handbook of Pediatric Dentistry, 4th Edition. Cameron AC,
Widmer RP (eds). London: Mosby. pp. 329–85.
Nelson T, Killian C, Followell T, Tesini D. 2018. Patients with special
health care needs. In: The Handbook of Pediatric Dentistry,
5th Edition. Nowak AJ, Casamassimo PS (eds). Chicago:
American Academy of Pediatric Dentistry. pp. 445–87.
Wray L. 2011. The diabetic patient and dental treatment: an
update. Br Dent J 211(5):209–15.
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Asthma
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MEdiCAlly CoMPRoMisEd PATiEnTs
A
B
Figure 8.7.1 Preoperative intraoral photographs. (A) Maxillary;
(B) mandibular.
A. Presenting Patient
• Five‐year‐old Caucasian female
• New patient referral from community dental service
B. Chief Complaint andHistory ofPresent
Illness
• Intermittent toothache over the past two weeks
keeping child awake at night
• Allergic rhinitis
• Allergies: dust mite, pollen
• Current medications: beclomethasone twice
daily,albuterol as required, nasal corticosteroid
spray
• Admitted with an acute asthmatic episode eight
months ago
• No known food or drug allergies, vaccinations up
todate
E. Medical Consult
• No need to contact pediatrician because patient’s
asthma is generally well controlled (see Fundamental
Point 1)
F. Dental History
• Has a dental home but despite numerous previous
dental visits to manage early childhood caries, no
treatment has been accomplished
• Diet: frequent consumption of fruit juices
• Poor oral hygiene
• Brushes once daily, unsupervised
• Only occasionally uses fluoridated toothpaste
• Lives in an area with water fluoridation of 0.8 ppm
• Very anxious concerning dental treatment
G. Extraoral Exam
• Open mouth breathing
C. Social History
• Lives at home with parents and two older siblings
• Low socioeconomic status
D. Medical History
• Moderate persistent asthma: generally well controlled
with infrequent acute exacerbations (see Background
Information 1)
H. Intraoral Exam
Soft Tissues
• White plaque‐like lesions overlying hard palate
• Generalized gingivitis
Occlusal Evaluation ofPrimary Dentition
• Class I canines and molars
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Denition
• Asthma is a common chronic disorder of the
airways, characterized by variable and recurring
symptoms, airflow obstruction, bronchial hyperresponsiveness and an underlying inflammation
Prevalence
• An estimated 300 million people suffer from
asthma worldwide
• One of the most common chronic diseases among
children
Etiology
• The etiology is not fully understood. Precipitating
factors include pollens, mold spores, house dust,
viral infections, cigarette smoke, cold air, extreme
emotional arousal, exercise, and anti‐inflammatory
medication
Pathophysiology
• Airflow limitation is due to a number of changes
influenced by airway inflammation
• Bronchoconstriction following irritant exposure
• Airway hyperresponsiveness
• Airway edema and mucous hypersecretion
Signs
• Wheeze
• Tachypnea
Symptoms
• Wheeze
• Shortness of breath
Chest tightness
•
• Cough
Classication
• Based on etiology
Extrinsic: allergic
Intrinsic (specific triggers, e.g. exercise)
•
Based on severity
Severity is assessed retrospectively from the
level of treatment required to control symptoms
and exacerbations
Mild intermittent asthma:
– Symptoms twice/week or less with night time
symptoms twice/month or less
– Brief exacerbations of varying intensity
Mild persistent asthma:
– Symptoms more than twice/week but less
than once/day
– Night time symptoms more than twice/month
– Exacerbations may affect activity
Moderate persistent asthma:
– Daily symptoms with daily use of inhaled beta2
agonists
– Exacerbations affect activity and occur twice/
week or more
– Night time symptoms more than once/week
– Exacerbations could last for days
Severe persistent asthma:
– Continual symptoms with frequent exacerba-
tions and night time symptoms
– Limited physical activity
Management
• Goals:
Reduce impairment: achieve good symptom
control maintaining (near) normal lung function
and normal activity levels
Reduce risk: minimize future risk of exacerbations, need for emergency care, fixed airflow
limitation, and side‐effects of therapy
How:
•
Assessment and monitoring regularly
Patient and caregiver education, including a
written personalized asthma action plan
Control of environmental factors and comorbid
conditions
Medications
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Dental Exam
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• Heavy plaque
• Multiple teeth with carious lesions (Figure8.7.1)
• Surface wear consistent with bruxism is evident on
some teeth
I. Diagnostic Tools
• Microbiology: swab of palatal mucosa
• Intra-oral radiographs (taken under general anesthesia)
(Figure8.7.2)
J. Diagnosis andProblem List
Diagnosis
• Dental anxiety
• Severe early childhood caries
• Oral candidiasis; pseudomembranous candidiasis of
hard palate
• Tooth wear
• Pulpal pathology
Problem List
• Dental pain
• Risk of developing dental infection
• Very anxious child
• Impact of asthma medication on oral health
MEdiCAlly CoMPRoMisEd PATiEnTs
History
• Type and severity of asthma
• Frequency of asthmatic attacks
• Precipitating factors
• Last acute episode and hospital admission
• Symptoms associated with sports/exercise
• Type of medication used regularly and during
an acute episode and response to such therapy
Consult WithPediatrician inUncontrolled or
Severe Cases
• Consultation may include assessment of:
Shortness of breath
Coughing
Wheezing
Rate and depth of respiration
Use of accessory muscles of respiration
Auscultation of the lungs
Oxygen saturation
Pulmonary function test
Peak flow test
Spirometry
A
C
E
Figure 8.7.2 Preoperative radiographs. (A) Maxillary right
periapical radiograph; (B) maxillary left periapical radiograph;
(C) mandibular right periapical radiograph; (D) mandibular left
periapical radiograph; (E) maxillary occlusal radiograph.
B
D
High Caries Risk
• Special health needs
• Use of medication that can impair salivary flow
• Presence of dental caries
• Low socioeconomic status
• Frequent between‐meal sugar exposure (fruit juice)
Unsupervised toothbrushing only once a day
•
• Visible plaque
K. Comprehensive Treatment Plan
Preventive Plan
• Diet modification
Stop frequent juice intake
Limit between‐meal snacks
• Oral hygiene
Brush twice daily (morning and night)
• Fluoride exposure
Consistently brush with fluoridated toothpaste
Continue to consume fluoridated water
• Visit dentist every three months for recall visit and
fluoride varnish application
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Pharmacotherapy
• Therapy is initiated based on asthma severity and
adjusted as necessary based on asthma control.
Stepwise approach to asthma management
• Every patient with persistent asthma, regardless of
disease severity, should use a daily controller
medication, i.e. for children an inhaled
corticosteroid (ICS)
Quick‐Relief Medication
• To treat acute symptoms and exacerbations
• Inhaled short‐acting beta2‐agonist (SABA), e.g.
albuterol
Long‐Term Control Medication
To maintain and achieve control of persistent
•
asthma
• First choice controller: ICS, e.g. beclomethasone
• Other controller options:
Leukotriene receptor antagonist (LTRA), e.g.
montelukast
Long‐acting beta2‐agonist (LABA), e.g. formoterol
Long acting muscarinic antagonist (LAMA), e.g.
tiotropium (not for children <12 years)
Oral corticosteroids
Immunomodulators
• Long‐term use of ICS within labeled doses is safe
for children in terms of growth, bone mineral
density, and adrenal function
•
Low‐ to medium‐dose ICS are not associated with
the development of cataracts or glaucoma in children
Atopy (tendency todevelop allergic diseases)
• Many children with asthma are atopic. It is important to determine if there is a history of allergy to
any drugs (e.g. amoxicillin) or materials (e.g.
colophony/rosin in some fluoride varnishes) used in
dentistry–if allergic to a drug or material then it
must not be used in that patient
Oral Mucosal Changes
• Gingivitis (associated with mouth breathing)
Oral candidiasis (associated with use of ICS)
•
• Dryness of mouth (associated with use of ICS)
Dental Caries
• Possible increased risk of dental caries and/or
erosion in patients with asthma
• Lactose is the carrier for many devices; it gives taste
so patient knows that a dose was dispensed
• Inhalers do not taste good; at risk of consumption
of flavored and sweetened beverages
Asthma Medication
• Beta2‐agonist medications are associated with:
Decrease in salivary flow
Decrease in plaque pH
Muscle relaxation with subsequent gastroesophageal reflux and associated acidreflux
Management ofOral Candidiasis
• Prevention
Consider use of aerosol holding chamber
Rinse with water following exposure to ICS
• Treatment
Rinse with chlorhexidine mouthwash daily while
candidiasis is present
Consider topical antifungal drug therapy in more
persistent cases
Comprehensive Dental Treatment Under
General Anesthesia
• Medical (see Background Information 2)
Preventive asthma medication as normal
Many anesthetic gases are bronchodilators
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• Dental (see Background Information 3)
Removal of extremely carious, mobile (e.g. maxillary central incisors), and nonvital teeth
Restoration of remaining carious teeth: stainless
steel crown restoration of two or more surface
carious lesions, vital pulpotomy and stainless steel
crown if pulp is involved
Restoration of single surface carious lesions in
molar teeth with high‐viscosity glass ionomer
cement
Consider space maintenance
• Behavioral management considerations
Comprehensive dental treatment under general
anesthesia to facilitate all necessary procedures at one
time due to anxiety and extent of treatment needs
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MEdiCAlly CoMPRoMisEd PATiEnTs
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• Follow‐up care
Postoperative and home care instructions: asthma
medication as normal, resume toothbrushing
Recall plan: two weeks postoperatively, establish
regular recall schedule
L. Prognosis andDiscussion
• Prognosis for limiting caries progression is guarded
• Prognosis for changing current dietary habits is
guarded
• Prognosis for prevention of asthmatic attack is good
because of regular use of asthma medication and
bronchodilator effect of many anesthetic agents
• Prognosis for prevention of further candidiasis is
guarded because of regular use of ICS and difficulty in
rinsing mouth
• Optimal asthma control is desired prior to dental
treatment
• If wheezing, severe, or poorly controlled asthma:
reappoint, arrange a medical consult and consider a
hospital setting for dental treatment
• Asthma medication should be taken as normal on
day of dental treatment. Bronchodilator should be
brought by patient or by parent/caregiver to dental
appointments
• Behavior guidance to alleviate anxiety and reduce
risk of an acute episode
• For patients taking long‐term oral corticosteroids,
routine dental treatment under local analgesia does
not require any change in medication regime.
However, steroid supplementation for patients on
long‐term oral corticosteroids should be considered
for difficult dental extractions under local anesthesia
and always for treatment under general anesthesia
• Use rubber dam whenever possible
• Certain materials used in the dental office can
trigger attacks: sealants, enamel dust, cotton rolls,
sulfites, dentrifices, methyl methacrylate
M. Common Complications andAlternative
Treatment Plans
• Noncompliance with dietary advice
• Continued caries progression
• Acute asthmatic episode (see Fundamental Point 2)
• Alternative treatment plans may include:
Anxiolysis using nitrous oxide/oxygen analgesia/
anxiolysis
Caries arrest with silver diamine fluoride
Alternative restorative materials, e.g. amalgam
orcomposite for small single or two‐surface
restorations
Alternative pulpal management (e.g. pulpectomy) in
nonvital teeth
• Avoid long appointments
• For pain management, nonsteroidal anti‐
inflammatory drugs (NSAIDS) should be used
with caution in all children with asthma: 4% of
asthmatics are allergic to aspirin and other
NSAIDS. Avoid use of opiates. It is recommended that acetaminophen be used as an
analgesic
Anxiolysis andSedation
• Nitrous oxide/oxygen anxiolysis may be used
together with local anesthesia to provide comfortable dental treatment in the dental office for an
anxious child with asthma
• Sedation with an oral medication in a child with
asthma should only be considered following
consultation with the patient’s pediatrician
Intravenous Sedation andGeneral Anesthesia
• Preanesthetic review is necessary by a physician
for children with moderate, severe, or uncontrolled
asthma. Nonurgent dental treatment should be
postponed until asthma is controlled
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Recognition ofanAsthma Attack
• Audible expiratory wheezing with restlessness and
apprehension
• Hacking, nonproductive cough
• Dyspnea
• Nasal flaring and intercostal retraction
• Cyanosis: look around the lips and the nailbeds
• Coarse rhonchi
• Tachycardia
• In an acute asthma attack, the loss of the
wheezing sound is a serious warning sign–the
airways are totally collapsed and a respiratory
arrest is likely
Treatment ofanAsthma Attack
Help patient into a position of comfort, usually
•
sitting
• Airway support as needed
•
Supplemental oxygen and ventilation support as
needed with a bag‐valve‐mask
• Call for emergency assistance if deemed a true
emergency
• Only persons with advanced airway training should
attempt an intubation
• Administer the appropriate medication if adequately trained:
Beta2 agonists:
– Albuterol inhalers
– Nebulized breathing treatments
– Subcutaneous injections of epinephrine or
terbutaline
Anticholinergics:
– Inhaled atrovent
Administer corticosteroids:
– Oral prednisone
(American Academy of Pediatric Dentistry [AAPD]
2018–2019)
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Self‐Study Questions
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MEdiCAlly CoMPRoMisEd PATiEnTs
Answers are located at the end of the case
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Self‐Study Answers
control, precipitating factors, frequency of acute
asthmatic episodes, last acute episode and whether
admitted to the hospital, and type of medication
used regularly and during an acute episode
tions, cigarette smoke, cold air, extreme emotional
arousal, exercise, and certain anti‐inflammatory
medications
Bibliography and Additional Reading
andResources
American Academy of Pediatric Dentistry. 2018–2019.
Management of medical emergencies. In: Clinical Practice
Guidelines and Best Practices (Reference Manual). Pediatr
Dent 40:513–14. https://www.aapd.org/research/oral‐health‐
policies‐‐recommendations/management‐of‐medical‐
emergencies
Boynton JR. 2018. Allergic and immune disorders. In: The
Handbook of Pediatric Dentistry, 5th Edition. Nowak AJ,
Casamassimo PS (eds). Chicago: American Academy of
Pediatric Dentistry. pp. 314–37.
Cornell A, Shaker M, Woodmansee DP. 2008. Update on the
pathogenesis and management of childhood asthma. Curr
Opin Pediatr 20:597–604.
Ersin NK, Gülen F, Eronat N etal. 2006. Oral and dental mani-
festations of young asthmatics related to medication, severity and duration of condition. Pediatr Int 48:549–54.
Garcia RI, Gregorich SE, Ramos‐Gomez F etal. 2017. Absence
of fluoride varnish–related adverse events in caries prevention trials in young children, United States. Prev Chronic
Dis 4:160372. doi: https://doi.org/10.5888/pcd14.160372
(Accessed 20 June 2019).
control of environmental factors and other asthma
triggers, and pharmacotherapy
Global Initiative for Asthma. Global Strategy for Asthma Prevention.
2017. www.ginasthma.org (Accessed 20 June 2019).
Kil N, Zhu JF, VanWagnen C, Abdulhamid I. 2003. The effects of
midazolam on pediatric patients with asthma. Pediatr Dent
25:137–42.
National Heart, Lung and Blood Institute. Guidelines for the
Diagnosis and Management of Asthma. Full report. 2007. http://
www.nhlbi.nih.gov/guidelines/asthma/ Accessed 20 June 2019).
Redding GJ, Stoloff SW. 2004. Changes in recommended treatments
for mild and moderate asthma. J Fam Pract 53:692–700.
Ryberg M, Möller C, Ericson T. 1991. Saliva composition and
caries development in asthmatic patients treated with beta
2‐adrenoceptor agonists: a 4‐year follow‐up study. Scand
JDent Res 99:212–8.
SIGN 153. British guideline on the management of asthma.
A national clinical guideline. 2016. http://www.sign.ac.uk/
sign‐153‐british‐guideline‐on‐the‐management‐of‐asthma.
html (Accessed 20 June 2019).
Steinbacher DM, Glick M. 2001. The dental patient with
asthma – an update and oral health considerations. JADA
132:1229–39.
Tootla R, Toumba KJ, Duggal MS. 2004. An evaluation of the
acidogenic potential of asthma inhalers. Arch Oral Biol
49:275–83.
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