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

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.

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

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)

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

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

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

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.

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 * 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 * 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 * 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 * TUFTS University – Management of medically compromised patients 2007

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

Orofacial Manifestations Bony changes and expansion Malocclusions: severe maxillary protrusion If Blood transfusions have been carried out since birth  up to 50% of pts may present close to normal growth & bone development* * Medicina Oral Journal 2002

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

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

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)

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

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

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.

Thank you.