3/2/11 Dental Management of a Child with Congenital Sideroblastic Anemia: A Case Report

Department of Pediatric Dentistry
Resident’s Name:Murphy Program: Lutheran Medical Center - Providence
Article title:Dental Management of a Child with Congenital Sideroblastic Anemia: A Case Report
Author(s): Rochelle Lindemeyer, DMD, Erick Goldberg, DMD, Andres Pinto, DMD MPH
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2007. v29 NO4. 315-319
Major topic: Dental management of SA
Minor topic(s): Treatment of SA
Main Purpose: To review a case report of a child with SA
Overview of method of research: Case Report

Findings:
Sideblastic Anemias(SA) are made up of a group of acquired disorders that have the following traits in common.
1. Anemia
2. Presence of ring sideroblast in bone marrow
3. Impaired heme biosynthesis

The primary pathophysiology of sideroblastic anemia is failure to completely form heme molecules, whose biosynthesis takes place partly in the mitochondrion. This leads to deposits of iron in the mitochondria that form a ring around the nucleus of the developing red blood cell. The X-linked pattern of transmission is the most common form and generally occurs in males. Clinically the patient will present with symptoms including fatigue, dizziness, and decreased tolerance to activities. High iron levels may interfere with growth and development, and can cause cardiac arrythmias and congestive heart failure.

Treatment of children that have SA involves routine blood transfusions. This is done to
1. Maintain hemoglobin levels
2. Manage symptoms
3. Allow for normal growth/development.

Potential risks of this treatment is the development of autoimmunity to repeated transfusions, especially if started at a young age. These patients are often on deferoxamine, which is the current drug used to treat excess iron.

Case Report
Dentists at Children’s Hospital of Philadelphia were consulted regarding a 3 yo girl suffering from SA and intermittent neutropenia. The child was receiving transfusions every 4 weeks, and all of her lab values were normal. A dental exam revealed a full primary dentition w/ maxillary incisors that were unrestorable. The hematologist was consulted, and GA was decided to be the best treatment for the child. Pre-op clindamycin was given due to the child history of neutripenia (even though her labs were WNL). She was intubated. Her mouth was swabbed with .12% chlorhexidine to reduce bacterial load, and the teeth were EXT’d. Recovery was uneventful. The child failed to attend any recall appointments, and did not return for three years.

3 years later, at age 7, the child returned to the dental clinic for an emergency appointment. She was now getting transfusions every 3 weeks, and was taking deferoxamine and folic acid. IOE showed mixed dentition, class I occlusion, extremely poor OH, and multiple decayed teeth. Again, the hematologist was consulted, and GA was determined to be the best tx for her. This time, her lab values were not normal, so the hem. Recommended that she receive a transfusion no more than one week before the surgery, which she did. During the surgery she was
1. nasally intubated, given 1g ampicillin, and the mouth was swabbed with .12% chlorhexidine.
2. FMX was taken and read
3. scaling, prophy,
4. All primary teeth either got GI or ssc’s, 6 ym were sealed
5. Pt. Was discharged that day with no complications

Once again, the family failed to return for any follow up appointments.
Key points/Summary:
1. Management of a child with a blood dyscrasias presents a unique challenge
2. Multidisciplinary care is essential
3. In this case report, due to the child’s neutropenia, the use of rinses and antibiotics before surgery was deemed necessary.

Assessment of Article:
Excellent case report highlighting the possible steps and complications when dealing with a child with a blood dyscrasia.

Dental Management of patients receiving anticoagulation or antiplatelet treatment

Resident: Roberts

Date: 3/2/2011

Article title: Dental Management of patients receiving anticoagulation or antiplatelet treatment

Authors: Pototski, M and Amenabar, Jose

Journal: Journal of Oral Science

Volume: 49

Number: 4 pages: 253-258

Year: 2007

Platelets are the major player in arterial thrombosis and therefore are attractive targets in the prevention and treatment of cardiovascular deseases such as myocardial infarction, cerebral ischemia, and peripheral arterial insufficiency. Acetylsalicylic acid(aspirin) and Warfarin are the standard drugs for the prevention of vascular diseases.

Bleeding times historically have been measured by Prothrombin time (PT) and partial thromboplastin time (PTT). However, in 1983 the World Health Organization introduced the International Normalized Ratio (INR patients PT/ mean normal PT) to standardize values globally.

A patient with a normal coagulation profile would have an INR of 1.0. It is recommended that a patient undergoing invaisive treament should have a PT within 1.5 to 2.0 times the normal INR which corresponds to a value of 1.5 to 2.0.

It has been suggested that complication from invasive procedures with patients on anti-platelet/anti-coagulation therpay arrise from the complication of four criteria: 1. bleeding time continues beyond 12 hours, 2. the bleeding causes the patient to call or return to the clinic for continued care, 3. development of a large hematoma or ecchymosis occurs within the soft tissues, 4. the patient requires a blood transufusion.

Patients undergoing anti-platelet therapy may have bleeding times twice that of what they normally would. However, this may still be acceptable for most dental procedures. A study investigating stopping or continuing low dose ASA prior to dental extractions was done by Ardekian. Thirty nine patients taking 100mg daily were studied. 19 cont’d as normal before the extractions and 20 stopped taking ASA 7 days prior to treatment. The mean bleeding time was longer in patients who continued ASA compared to those who stopped. However, none of the patients had a bleeding time outside of normal limits.

Wahl studied the impact of patients who stop or continue anti-coagulation therapy prior to a variety of dental procedures. 542 documented cases involving 493 patients were reviewed. He reported that four patients experienced fatal thromboembolic events(2 cerebral thromboses, 1 myocardial infarction, 1 embolus - type not specified). One patient experienced two non-fatal throbomembolic complications and the majority of patients had not adverse effects. The incidence of adverse effects was 1%. In another study, he reviewed 2400 dental procedures that were undergone by 950 patients who continued their regime prior to treatment. Only 12 patients (less than1.3%) experienced bleeding uncontrolled by local measures and none were reported to have serious side effects or harm from the incidence. Of the 12 patients seven had higher than recommended INR values.

Conclusion: Bleeding complications while inconvenient, do not carry the same risks as thromboembolic complications. Patients are more at risk of permanent disability or death if they stop antiplatelet or anticoagulation therpay prior to treatment. There is no single report of uncontrollable bleeding when dental procedures have been carried out without stopping treatment before hand. In contrast serious fatalities have been noted by those that have stopped by to recieving treatment. Research has concluded that minor dental surgical procedures can be done safely with an INR within the range of 2.0 - 4.0 and anything above should be dealt with prior to treatment. Ideas for management include: scaling one quad at a time, using local anesthetic with epinephrine as a hemostatic agent when doing extractions, avoid regional nerve blocks when infiltrations are possible. After extractions pack the socket with absorbable dressing and suture the site with resorbable sutures, and allow the patient to apply pressure to gauze over the extractions site.

Assessment: Great article. Because this research was published fairly recently, more research is needed. However, this may be a mindset adopted within the dental community once more research has been published.