1. 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

2. 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.

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

4. 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)

5. 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

6. 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 & British Dental Association

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

8. 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

9. 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

10. 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.

11. Diabetes & Smoking
Smoking increases the risk of periodontal disease several folds in diabetics
Synergistic effect

12. 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

13. 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 & Medicina Oral Journal 2002

14. 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 & Medicina Oral Journal 2002

15. 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

16. 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

17. 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

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

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

20. 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)

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

22. 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

23. Dental Management Teeth restorations
Root canal treatment (pulpal involvement)
Professional scaling
Surgical involvement & remodeling in Thalassemia intermedia

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

25. References
Ganda K. Management of medically compromisd dental patient. TUFTS University. Tufts Denatl school
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.

26. Thank you.