Dental treatment implications As part of a team approach to the management of a patient with craniofacial abnormalities, dental providers should engage the patient at the earliest possible time. Initial care may involve orthodontic care along with craniofacial surgery for the patient with cleft lip, cleft palate, or Robin sequence, for example. Oral and maxillofacial surgeons, as well as otolaryngologists, might be involved in performing mandibular distraction osteogenesis followed by orthodontics. As the child develops and matures, prosthodontists may be involved if the case requires implant dentistry. Patients with craniofacial abnormalities may present with severe crowding and excessive soft tissues around the teeth. However, many children with Robin sequence outgrow the condition and may need only conventional orthodontics when they get older.
Because of behavioral issues or access complications, dentistry to correct these issues may be indicated under general anesthesia. In this case, consideration of a team approach would be highly desirable, in which both periodontal and restorative procedures could be delivered at the same time while the patient is in the operating room receiving craniofacial surgery. This approach could minimize the need for multiple trips to the operating room to provide overall care. The dental team should provide a comprehensive maintenance regimen that stresses prevention, including use of a caries risk assessment tool to identify and balance protective versus risk factors, as should be done for all children in pediatric dental offices.
ORGAN TRANSPLANTS
rate of 88%. Because of enhanced diagnostic and surgical techniques, along with advances in drug therapy, patients receiving organ transplants are growing in number and living longer. Organ transplant recipients experience compromised health and immune suppression. This places them at higher risk for oral and systemic infections.
According to the American Academy of Pediatric Dentistry, 18.5% of U.S. children under the age of 18 have a special healthcare need (AAPD, 2022a). Certain systemic disorders place patients at a significant risk of developing oral diseases, increasing the risk of developing a dental infection that could worsen their systemic disease or significantly complicate their overall dental health (AAPD, 2022e). Since 1988, roughly 51,000 pediatric patients have received kidney, liver, or heart transplants, with a 5-year survival Medical considerations/current medical therapies Since the 1980s, the refinement of immunosuppressant agents has improved the outcome of organ transplantation in the pediatric population. Since this group of patients must be maintained in a state of continuous immune suppression to prevent rejection of the newly acquired organ, the treating clinician needs to be vigilant about the Table 3: Commonly Used Immunosuppressant Medications Generic Name Trade Name
short-term and long-term oral effects of these medications. (See Table 3.) Of particular importance is the prevention of acute or chronic oral infections when the patient is in an immunosuppressed state. In this case, the patient’s immune system might not be able to handle bacterial insult from the oral cavity, resulting in septicemia.
Systemic Effects
Oral Effects
Cyclosporine
Gengran Neoral
• Changes in liver function • Changes in kidney function • Hypertension
• Gingival hyperplasia (children are more susceptible)
• Bleeding problems • Poor wound healing
Tacrolimus
Prograf Hecoria
• Less gingival overgrowth • More problems with oral ulcerations • Numbness or tingling periorally
Azathioprine
Azasan Imuran
• Bone marrow suppression • Decreased WBC counts • Excessive bleeding • Decreased WBC counts • Opportunistic infections • GI problems • Hypertension • Hyperglycemia • Increased risk for infection • Poor wound healing • Depression • Adrenal suppression • Hypertension • Joint pain • Low WBC count • Hypercholesterolemia
• Opportunistic infections • Stomatitis
Mycophenolate
Cellcept Myfortic
Corticosteroids (prednisone)
• May mask early signs of oral infection
Deltasone Orasone
Sirolimus
Rapamune
• Oral ulcerations
Note . Adapted from A. H. Jeske. (2018). Mosby’s dental drug reference (12th ed.). Elsevier.
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