Dental abnormalities in children with chronic renal failure

Resident: Roberts
Date: 1/8/10
Article title: Dental abnormalities in children with chronic renal failure
Journal: Pediatric Dentistry
Volume#4 number 4
Pages 281 – 285
Discussion/Results:
17 children with Chronic renal failure were examined radiographically and clinically. Enamel hypoplasia was the most common abnormality (11 out of the 17); results inidicated that geographic location on the teeth corresponded to the age of onset of advanced renal failure. Completely developed teeth were unaffected by formation or mineralization if CRF set in after development. Mild and moderate renal failure did not present any serious effects on the maturation of the enamel. Discoloration and hypocalcification although present were in much fewer percentages.

Author hypothesized that careful supplementation of vit D and dietary phosphorus reduction may diminish hyperparathyroidism which may decrease the severity of enamel hypoplasia

A review of liver transplantation for the dentist and guidelines for dental management

Resident: Roberts
Article: A review of liver transplantation for the dentist and guidelines for dental management
Author: Glassman, Paul. Et al
Journal: Special Care in Dentistry
Volume # 13 No. 2 pages 74 – 80
Year: 1993
The American Council of Transplantation states that a “successful transplant is one in which there is normal organ function one year after the transplant procedure.”
Chronic Liver Disease and Fulminant Hepatic Failure are the primary indications for a liver transplant. Imunosuppressive therapy is vital to postoperative success. However, a fine balance must be achieved in order to retain a healthy immune system and a successful graft. Infection is the most frequent cause of mortality and morbidity in liver transplant patients. Within the first 6 months most infections are related to the cytomegalovirus and after 6 months most infections are bacterial. Prior to transplant, dentist should be cautious about liver complications when regarding treatment. Definitive treatment should be performed prior to transplantation and the dentist should be aware of conditions such as PT, PTT. In the presence of ascites use prophylactic antibiotics for invasive procedures to avoid risk of infection. After transplantation, the dentist should consider steroid supplementation prior to stressful dental procedures such as extractions. Drugs such as acetaminophen, narcotics, lidocaine and other LA’s, barbiturates, and antibiotics should be used only after consultation with the patients physician and should be used conservatively. The main focus of the dentist at this point should be preventative and care should be taken so that infections do not occur and spread systemically.

Conclusion: Always know your med hx. BAZAam!

Dental Trauma After Cardiac Syncope in a Patient with Long QT Syndrome 1/8/10

Department of Pediatric Dentistry
Resident’s Name: Murphy Program: Lutheran Medical Center - Providence

Article title: Dental Trauma After Cardiac Syncope in a Patient with Long QT Syndrome
Author(s): Karp, Jeffrey DMD. Gabriela Ganoza, DDS.
Journal: Pediatric Dentistry
Year, Volume (number), Page #’s: 2006. 28:6. 547-551
Major topic: How to approach a child with LQTS for dental TX
Minor topic(s): Use of a multidisciplinary approach
Main Purpose: Highlight the potentially malignant course of symptomatic LQTS and emphasize the importance of warning signs and multidisp. Medical management of children with LQTS
Overview of method of research: Review of syndrome, case report

Findings: Syncope occurs in roughly 1 out of every 800 pediatric patients seeking medical attention. Syncope is defined as a loss of consciousness related to decreased cerebral perfusion and can be mediated by several mechanisms. Neurocardiogenic, AKA vasovagal syncope, is the most common and occurs during periods of emotional stress. The prodromal symptoms are1. Lightheadedness2. Dizziness3. Nausea4. Pallor5. diaphoresis6. Visual changesVasovagal syncope is normally benign. The other type of syncope is cardiac syncope, which is a result of cardiac abnormalities in which obstruction to blood flow, myocardial dysfunction, and arrhythmias occur. These conditions can be due to genetic mutations, following a familial distribution. Long QT syndrome is a cardiac electrophysiological abnormality where the QT interval indicative of ventricular depolarization is prolonged on an ECG. LQTS can occur through either autosomal dominant of de novo mutation. It occurs in 1 out of every 5,000-10,000 individuals in the US(wide range???). The prolonged ventricular repolarization can lead to complex reentry circuits within the heart, loss of cardiac rhythm, and V-Tac, known as torsades de pointes(TdP). Tdp can be self-limiting; it can persist, or can cause V-Fib. All of these disarythmias compromise oxygen supply to the brain and other organs, leading to syncope, seizures, and death…, which stinks. Symptoms of LQTS include1. Unexplained syncope2. syncope during exercise in kids3. familial history of unexplained syncope4. seizures5. Sudden death in people <406. Congenital deafness7. QT interval longer than 440ms in males, 450 in females.There are four main treatment options for people diagnosed with LQTS.1. Beta blocker2. pacemakers3. implantable defibs. ICD4. left cardiac sympathetic denervation(LCSD)Success of treatment depends largely on the underlying genetic mutation. The article reviews a case of a 7 year old girl with a medical history of Pierre Robin Syndrome(PRS), ADHD, LQTS, and an implanted cardioverter defibrillator. The child was on 81mg of aspirin, 25mg of atenolol, and 10mg of atomoxetine. The child suffered avulsion of 8 and 9, and lateral luxation of 7. Apart form the initial exam, further dental TX was denied by the ED trauma team because the child developed a TdP rhythm. The child was later admitted. After multiple failed attempts due to cardiac complications, the dental team was finally allowed to render TX on the 5th day of the child’s hospital stay with the use of IV sedation. #7 had +2 mobility, and was deemed to be an aspiration and infection risk, and thus was planned for extraction. Due to the child’s medical status and complication associated with her conditions(glossoptosis, micrognathia), TX in the OR was decided on. The child received consults from her cardiologist, an anesthesiologist, and their PCP before TX under GA. Once in the OR, #7 was extracted and an impression was taken. There were no complications, and the child was discharged later that day.

Key points/Summary: The basic purpose of the case report is to raise awareness on the early signs and symptoms of LQTS and how it should be dealt with in the dental setting. A comprehensive medical history is paramount. A multidisciplinary approach is best. Consults are needed with the child’s cardiologist, neurologist, and PCP. With LQTS, use of choral hydrate and epinephrine are contraindicated because they prolong QT. Treatment under GA is the best option for care due to the necessity of monitoring the child’s cardiac condition by a cardiologist, even for routine dental treatment. In terms of treatment, a definitive restoration should be placed when possible, minimizing the risk of recurrent decay, failed pulpal therapies, and subsequent emergent care. With regards to trauma, the more appropriate treatment is extraction rather than endo. And some form of complex restorative care (in SOME instances). Replacement of lost teeth is assessed on a case by case basis, taking into account the child’s risk factors, health status, etc.
Assessment of Article: Good article. Concise, to the point on how to best treat kids with LQTS. The main points to take away are that a multidisciplinary approach is the only way to properly and safely treat these kids, and that they should be seen in the OR. Werd. Holla back youngin'.

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Tetralogy of Fallot: Characteristics, dental implications and case study

Department of Pediatric Dentistry

Lutheran Medical Center

Date: 01/08/2010

Article title: Tetralogy of Fallot: Characteristics, dental implications and case study

Author(s): Roy A. Rockman, DDS

Journal: Journal of Dentistry for Children

Volume (number): page 147

Month, Year: March-April 1989

Major topic: Tetralogy of Fallot

Minor topics:

Type of Article: Informative and Case Study

Main Purpose: Familiarize the reader with this case entity and how it relates to dental treatment

Overview of method of research: Review of current treatment modalities and case review

Findings: Tetralogy of Fallot can cause Cyanosis, especially when children are under stress, which can lead to loss of consciousness, temporary paralysis, or even death. Bacterial endocarditis and brain abscesses secondary to dental treatment are also concerns.

Follow prophylactic guidelines and for acute hypoxic spells treat with O2 administration, place child in knee-to-chest position, administer morphine sulfate and/or propranolol. General anesthesia may be required as a therapeutic modality.

Key points/Summary :

Frequency and etiology

• 10% of all congenital heart disease, most common cardiac malformation resulting in cyanosis after one year of age.

Clinical features

• Children are prone to hypoxic or blue spells. Marked by anxiety and a sudden increase in cyanosis.
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• Child can become unconscious, experience paralysis, have convulsions or even die.
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• Infants like to lie on one side in a fetal position, oder kids don’t like to stand for long periods and often squat after exertion.
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• Clubbing of fingers and toes is common
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• Polycythemia may result from low arterial O₂ concentrations. Hemorrhage can result.
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• Cerebral abscess is common: 20% incidence in children over 2.

Medical Management

• Corrective surgery is performed. Often it is palliative until age 5 when the pulmonary arteries are large enough for definitive corrective surgery.
• Pediatric illness that could cause dehydration or thrombic complications are treated aggressively.

Case Report: 3.5 year old boy presents to dental clinic in Kansas with severe tetralogy of Fallot. His only medication is Digoxin. His medical condition was considered stable at that time. Hx. of Blalock-Taussig shunt was performed as palliative surgical intervention.

Dentally, the child needed full mouth rehabilitation, had poor OH and cyanotic gingiva. After parent and pediatrician consultations General Anesthesia was chosen for modality of treatment. 2 years later, the child was treated in the OR.

Primary concerns were reduction of extreme agitation, avoidance of hypoxia and maintenance of normal blood volume.

IV antibiotic prophylaxis was used.

The dentist believes that pulpotomy and pulpectomy are contraindicated for patients with cardiac complications, so many primary teeth were removed and space maintenance was done.

Assessment of article:

The article shows its age by the extreme concern over bacterial endocarditis. Also it talks about a case of cerebral abscess in a child, who had a pulpotomy performed 3 years prior and it suggests that the pulpotomy was the source of the bacteria causing the cerebral abscess. It was so speculative, it seemed like a stretch to me.

Otherwise informative and useful to know for these patients.