MANAGEMENT OF PATIENTS WITH SPECIAL NEEDS

Dr. Kimberly Anne Hilario

DDM5A Gamilong, Angelie G.

PRELIM
Extraction Techniques In INDICATIONS FOR EXTRACTION:
1. Dental Infection
Pediatric Patients 2. Over Retained primary tooth
3. Non-restorable primary teeth
4. Ankylosed primary tooth
➔ Leading obstacle in tooth extraction in
5. Supernumerary tooth
kids: FEAR
6. Impacted tooth/teeth
7. Fracture/ Trauma
➔ PREOPERATIVE HEALTH EVALUATION
8. Soft tissue trauma
● Obtain a good medical history
9. Orthodontic indications
● Obtaining appropriate medical and
-Extraction of teeth is sometimes required to
dental consultations
create space in order to carry out planned
● Preoperative radiographs
orthodontic treatment.
-The decision on which tooth/teeth are to be
➔ WHY RADIOGRAPHS ARE IMPORTANT
extracted is made by the orthodontist.
PRIOR TO EXTRACTION:
10. Natal or Neonatal tooth
● Extent of Caries
● The condition of the roots of the tooth
involved
● Proximity of Posterior Teeth to the
maxillary Sinus
 MANAGEMENT OF PATIENTS WITH SPECIAL NEEDS
Dr. Kimberly Anne Hilario
DDM5A Gamilong, Angelie G.

CONTRAINDICATIONS FOR TOOTH

EXTRACTION
Acute Systemic Infections
• Glomerulonephritis
• Congenital Heart Disease
• Rheumatic Fever

*requires regimens of chemoprophylaxis

before extraction

Blood Diseases
▪ Hemophilia
• Leukemia

*co-management with a hematologist

Uncontrolled diabetes mellitus

• Poor wound healing
• Extreme postoperative pain
• Recurrent hemorrhage

Malignant hypertension
Uncontrolled cardiac dysrhythmias
Pregnancy
Severe bleeding diathesis
● Radiation, drugs, stress could harm
the developing fetus
● Hemophilia
● Severe platelet disorders
Drugs to watch for include systemic
corticosteroids, immunosuppressive agents,
bisphosphonates, and cancer
chemotherapeutic agents

→Natal and neonatal teeth

Acute oral infection
Natal and neonatal teeth can present a challenge
▪ ANUG
when deciding on appropriate treatment. Natal teeth
• Acute Herpetic Stomatitis
have been defined as those teeth present at birth,
• Acute Dento-Alveolar Abscess
and neonatal teeth are those that erupt during the first
30 days of life.
*Eliminate the infection first.
→If the tooth is not excessively mobile or causing
feeding problems, it should be preserved and
maintained in a healthy condition if at all possible. ARMAMENTARIUM
Close monitoring is indicated to ensure that the tooth
remains stable.
→An important consideration when deciding to
extract a natal or neonatal tooth is the potential for
hemorrhage. Extraction is contraindicated in
newborns due to risk of hemorrhage." Unless the
child is at least 10 days old, consultation with the
pediatrician regarding adequate hemostasis may be
indicated prior to extraction of the tooth.
 MANAGEMENT OF PATIENTS WITH SPECIAL NEEDS
Dr. Kimberly Anne Hilario
DDM5A Gamilong, Angelie G.

1. The first step in extracting a tooth is to →During luxation, the adjacent tooth should not be
separate the soft-tissue attachment from used as a fulcrum, but only the alveolar bone.
the cervical aspect of the tooth.

2. The second step in extracting a tooth is to

use a dental elevator to luxate a tooth.

CRYER ELEVATOR
 MANAGEMENT OF PATIENTS WITH SPECIAL NEEDS
Dr. Kimberly Anne Hilario
DDM5A Gamilong, Angelie G.

→The feeling of pressure during the luxation and

extraction should be explained.
Pushing on the child's shoulder may demonstrate this
sensation.

→If a previously cooperative child begins to cry,

exhibiting pain during luxation, administration of
additional local anesthesia is indicated.

Here's what to do:

→Injections through the mesial and distal papilla from

buccal to lingual, along with injection into the gingival
sulcus, are very effective.

→ The last step in extracting a tooth is to remove the

tooth with forceps.

The Basic Principles In Selecting Forceps

Are As Follows:

1. The size of the beaks of the forceps should be

small enough not to engage the adjacent teeth during
luxation and removal of the tooth.
2. The beaks of the forceps should adapt to the root
surface of the tooth.
3. The beaks of the forceps should be placed under
the separated and reflected soft tissue and the tooth
firmly engaged.
Figure 7-53 Tips of force beak, tad apically under soft
4. The beaks of the forceps, when positioned and
engaging the tooth, should be parallel to the long axis
of the tooth.
5. The first force applied by the dentist when using
forceps is apically directed. The apically directed
force positions the center of rotation as close to the
root apex of the tooth as possible.
MANAGEMENT OF PATIENTS WITH SPECIAL NEEDS
Dr. Kimberly Anne Hilario
DDM5A Gamilong, Angelie G.

HELPFUL ADVICE:
(1) Explain to the child all sensations and experiences
to be encountered with tooth extraction.
(2) Undue pressure should never be placed on a
tooth when being luxated.
• Apply firm and gentle forces on the forceps.
• Delivery should not be hurried.
• Minimize root fracture while loosening the
tooth from periodontal attachments.
(3) Stabilize the mandible during manipulative action.
• Support the mandible
• Use of rubber bite block or mouth gag

(4) Use of a safety screen of gauze over the

oropharynx to guard against swallowing or aspiration
of an extracted tooth.

*turn the patient's head to the side in case the

extracted tooth will slip in the oral cavity
 MANAGEMENT OF PATIENTS WITH SPECIAL NEEDS
Dr. Kimberly Anne Hilario
DDM5A Gamilong, Angelie G.

→Once an extraction has been completed, the initial

maneuver to control postoperative bleeding is the
placement of a small piece of gauze directly over the
socket.

Odontogenic Infections Have Two Major

Origins:

(1)PERIAPICAL, as a result of pulpal necrosis and

subsequent bacterial invasion into the periapical
tissue
Odontogenic infections have two major origins:

(2) PERIODONTAL, as a result of a deep periodontal

pocket that allows inoculation of bacteria into the
underlying soft tissues.

Principles of Management of
Odontogenic Infections

MICROBIOLOGY OF ODONTOGENIC
INFECTIONS

Facts:
Almost all odontogenic infections are caused
by multiple bacteria.
The oxygen tolerance of the bacteria that Periodontal Infection
cause odontogenic infections -mouth flora is a • Possible pocket formation making oral
combination of aerobic and anaerobic hygiene a difficult task, resulting into a periodontal
bacteria, it is not surprising to find that most abscess
odontogenic infections are caused by
anaerobic and aerobic bacteria.
 MANAGEMENT OF PATIENTS WITH SPECIAL NEEDS
Dr. Kimberly Anne Hilario
DDM5A Gamilong, Angelie G.

PRINCIPLES OF THERAPY OF
ODONTOGENIC INFECTIONS

Principle 1:
Determine Severity of Infection

→When these bacteria gain access to deeper

underlying tissues, as through a necrotic dental pulp
or through a deep periodontal pocket, they cause
odontogenic infections.

→Early infections appearing initially as a cellulitis

may be characterized as predominantly aerobic
streptococcal infections.

→Chronic abscesses may be characterized as

anaerobic infections (late).
 MANAGEMENT OF PATIENTS WITH SPECIAL NEEDS
Dr. Kimberly Anne Hilario
DDM5A Gamilong, Angelie G.

Box 16-2 Criteria for Referral to an

Oral-Maxillofacial Surgeon
➔ Difficulty breathing
➔ Difficulty swallowing
➔ Dehydration]
➔ Moderate to severe trismus (interincisal
opening less than 20 mm)
➔ Swelling extending beyond the alveolar
process Elevated temperature (greater than
101°F)
➔ Severe malaise and toxic appearance
➔ Compromised host defenses
➔ Need for general anesthesia
➔ Failed prior treatment

Principle 3:
Determine Whether Patient Should Be Treated by
General Dentist or Oral and Maxillofacial Surgeon

Principle 2:
Evaluate State of Patient's Host Defense
Mechanisms

Box 16-1 Compromised Host Defenses Principle 4:

Uncontrolled Metabolic Diseases
➔ Poorly controlled diabetes
➔ Alcoholism
➔ Malnutrition
➔ End-stage renal disease
Immune System-Suppressing Diseases
➔ Human immunodeficiency
virus/acquired immunodeficiency
syndrome
➔ Lymphomas and leukemias
➔ Other malignancies
➔ Congenital and acquired immunologic
diseases
Immunosuppressive Therapies
➔ Cancer chemotherapy
➔ Corticosteroids
➔ Organ transplantation
Treat Infection Surgically
→Treatment of the necrotic pulp by standard
endodontic therapy or extraction of the tooth should
resolve the infection. Antibiotics alone may arrest, but
do not cure, the infection because the infection is
likely to recur when antibiotic therapy has ended
without treatment of the underlying dental cause.
Thus, the primary treatment of pulpal infections is
endodontic therapy or tooth extraction, as opposed to
antibiotics.
Indications for Culture and Antibiotic Sensitivity
Testing
➔ Infection spreading beyond the alveolar
process
➔ Rapidly progressive infection
➔ Previous, multiple antibiotic therapy
➔ Nonresponsive infection (after more than 48
hours)
➔ Recurrent infection
➔ Compromised host defenses.
 MANAGEMENT OF PATIENTS WITH SPECIAL NEEDS
Dr. Kimberly Anne Hilario
DDM5A Gamilong, Angelie G.

presence of infection is to be encouraged; a prior

period of antibiotic therapy is not necessary.
Moreover, when surgery cannot be done immediately,
a course of antibiotics does not reliably prevent
worsening of the infection.

Principle 5:
Support Patient Medically

-Even patients without medically compromising

diseases may have reduced or altered physiologic
reserves to draw on as they combat an odontogenic
infection.

-Children are particularly susceptible to dehydration

and high fevers.

Principle 6:
Choose and Prescribe Appropriate Antibiotic

Determine the need for antibiotic administration:

(1)The first factor is the seriousness of the infection
when the patient comes to the dentist.
If the infection has caused swelling, has
progressed rapidly, or is diffuse cellulitis, evidence
supports the use of antibiotics in addition to surgical
therapy.
→Use the narrowest-spectrum antibiotic.
If the antibiotic is a narrow-spectrum antibiotic, it kills
bacteria of a narrow range.
When an antibiotic is administered to a patient, most
of the susceptible bacteria are killed.

(2) The second consideration is whether adequate

surgical treatment can be achieved.
Extraction of the offending tooth may result in rapid
resolution of the infection.

(3) The third consideration is the state of the patient's

host defenses.
A young, healthy patient may be able to mobilize host
defenses and may not need antibiotic therapy for
resolution of a minor infection.

→ Several studies have shown that removal of a

tooth in the presence of infection hastens the
resolution and minimizes the com- plications of the
infection, such as time out of work, hospitalization,
and the need for extraoral I&D. Therefore, prompt
removal of the offending tooth (or teeth) in the
 MANAGEMENT OF PATIENTS WITH SPECIAL NEEDS
Dr. Kimberly Anne Hilario
DDM5A
→In summary, antibiotics that have narrow-spectrum
activity against causative organisms are just as
effective as antibiotics that have broad- spectrum
activity, but without upsetting normal host microflora
populations and increasing the chances of bacterial
resistance. With appropriate surgery, an appropriate
choice can be made from among the commonly used
antibiotics on the basis of safety, cost, and the
medical history of the patient.
Use the antibiotic with the lowest incidence of
toxicity and side effects.
➢ Allergy is the major side effect of penicillin.
➢ Clindamycin may cause severe diarrhea,
called pseudomembranous colitis or
antibiotic-associated colitis.
→ The elimination of much of the anaero- bic gut flora
allows the overgrowth of another antibiotic-resistant
bacterium, Clostridium difficile. This bacterium
produces toxins that injure the gut wall, which results
in colitis. Patients who take clinda- mycin, amoxicillin,
or cephalosporins should be warned of the possibility
of profuse watery diarrhea and should be told to
contact their prescribing dentist if it occurs.
→Among the new members of the macrolide
(erythromycin) family, azithromycin has the best
combination of effectiveness, low toxicity, and
infrequent drug interactions. Erythromycin is no
longer considered effective against the oral
pathogens, and it shares with clarithro- mycin the
propensity to cause drug interactions involving the
liver microsomal enzyme system.
→Oral cephalosporins such as cephalexin and
cefadroxil have lost much of their effectiveness in
treating odontogenic infections. These antibiotics are
no longer commonly used for treating odontogenic
infections, even though they are associated with only
mild toxicity problems. As with penicillin, the
cephalosporins may cause allergic reactions.
Cephalosporins should be given cautiously to patients
with penicillin allergies because these patients may
also be allergic to cephalosporins. Patients who have
experienced an anaphylactic type of reaction to
penicillin should not be given a cephalosporin
because of increased chance for that life-threatening
event to recur.
Gamilong, Angelie G.
No longer considered useful for treating
odontogenic infections:
Erythromycin
Cephalosporins
Tetracyclines
→Use the antibiotic with the lowest incidence of
toxicity and side effects.
•Moxifloxacin is contraindicated in children
under 18 years and pregnant females because of
interference with the growth of cartilage.
→Use the antibiotic with the lowest incidence of
toxicity and side effects.
•Metronidazole produce a disulfiram effect
patient taking metronidazole who also consumes
ethanol may experience sudden, violent abdominal
cramping and vomiting.
Principle 7:
Administer Antibiotic Properly
→Once the decision is made to prescribe an
antibiotic to the patient, the drug should be
administered in the proper dose and at the proper
dose interval.
→Clearly, some patients stop taking their antibiotics
after acute symptoms have subsided and rarely take
their drugs as prescribed after 4 or 5 days. Therefore,
the antibiotic that would have the highest compliance
would be the drug that could be given once a day for
not more than 4 or 5 days. Studies have shown that
for odontogenic infections a 3- or 4-day course of a
penicillin, combined with appropriate surgery, has
been as effective as a 7-day course of the antibiotic.
OLD SCHOOL:Finish the 7-day antibiotic course.
then, do surgery. Evaluate patient status.
Extend the antibiotics, prn.
CURRENT TRENDS:Prescribe antibiotics, evaluate
patient status on the 3rd day, do surgery on the 4th or
5th day,continue until the 7th day.
Evaluate.
 MANAGEMENT OF PATIENTS WITH SPECIAL NEEDS
Dr. Kimberly Anne Hilario
DDM5A Gamilong, Angelie G.

Principle 8:
Evaluate Patient Frequently

→ At the clinical follow-up examination, additional

prescription of antibiotics may be necessary in the
case of infections that do not resolve rapidly. The
clinician must make it clear to the patient that the
entire prescription must be taken. If for some reason
the patient is advised to stop taking the antibiotic
early, all remaining pills or capsules should be
discarded. Patients should be strongly discour- aged
from keeping small amounts of unused antibiotics to
self-treat a sore throat next winter. Casual
self-administration of antibiotics is not only useless,
but also may be hazardous to the health of the
individual as well as that of the community.

Box 16-9 Reasons for Treatment Failure

➔ Inadequate surgery
➔ Depressed host defenses
➔ Foreign body
➔ Antibiotic-related problems:
• Patient noncompliance
• Drug not reaching site
• Drug dose too low .
• Wrong identification of bacteria
• Wrong antibiotic
 MANAGEMENT OF PATIENTS WITH SPECIAL NEEDS
Dr. Kimberly Anne Hilario
DDM5A Gamilong, Angelie G.

Computing Prescription In
Pediatric Dentistry
MANAGEMENT OF PATIENTS WITH SPECIAL NEEDS
Dr. Kimberly Anne Hilario
DDM5A Gamilong, Angelie G.

-don't prescribe on first line; reserve for a more

complicated infection
MANAGEMENT OF PATIENTS WITH SPECIAL NEEDS
Dr. Kimberly Anne Hilario
DDM5A Gamilong, Angelie G.

200mg/5m not 250 mg