tratamente stomatologice la pacienti cu afectiuni hematologice
DESCRIPTION
curs stomatologie.TRANSCRIPT
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Tratamente stomatologice la
pacientii cu afectiuni hematologice
2012
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Afectiuni hematologice
1.Sindroame anemice
2.Sindroame hemoragice
3.Sindroame mieloproliferative
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Sindroame anemiceDefinitieHb< 11,5 g%(femei);13,5 g%(barbati);
< 11g% adolescenti si varstnici
-dependenta de volumul plasmatic• VEM=77-93 fl; HEM=30-32 pg; CHEM=32-34 g%• Anemie-microcitara -hipocrome
-macrocitara -hipercrome
-normocitara -normocrome
ANEMIA este totdeauna secundara trebuie cautata cauza
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Clasificarea etiopatogenetica 1.Productie insuficienta de hematii
-prin deficit nutritional si tulburari de absorbtie-Fe,vit.B12,acid
folic,acid ascorbic
-prin reducerea precursorilor eritroiziaplazie medulara
infiltratia maduvei osoase
-prin eritropoieza ineficienta-anemiile din bolile cronice
-insuficientele endocrine
-insuficienta renala
-talasemii,SMD
2.Distrugerea crescuta a hematiilorhemoliza
-congenitale-defect structural de membrana(sferocitoza)
-deficit enzimatic care produce instabilitate membranara
-defect de sinteza a globinei /Hb cantitative sau
calitativ(siclemia,talasemia)
-dobandite-autoimuna,medicamente,transfuzie incompatibila
-distructie mecanica(valve cardiace mecanice,stenoze valvulare
stranse,CID)
-infectioase-malaria
3.Pierdere de sange acuta sau cronica
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Semne si simptome clinicePaloare-mucose,tegument,eminenta tenara,conjunctiveFanere-friabile,choilonichia,platonichia,incaruntirea
precoce,calvitia Icter hemoliticFatigabilitateDispneeTahicardia,palpitatii,sufluri cardiace Insuficienta cardiaca,angina pectoralaAgravarea afectiunilor pulmonare existenteTulburari de vedereZgomote auriculareSimptome neurologice-parestezii,tulburari ale sensibilitatii
vibratorii,paraplegiiTulburari psihice In sarcina-defecte de inchidere a tubului neural,despicaturi labio-
velo-palatine
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Semne si simptome cliniceManifestari abdominale-splenomegalie,sdr. de
malabsorbtie,hemoragii digestive,cancere digestive,ascita,hepatomegalie
Manifestari urinare-insuficienta renala,hematurieAdenopatii infiltrativeCrizele ocluzive (siclemie)
Severitatea simptomelor depinde de:-severitatea anemiei,ritmul de instalare,varsta pacientului,statusul cardiovascular,capacitatea de transport a O2
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Manifestari intraorale si extraoraleUlceratii bucaleCheilite angulareGlosite atrofice,aspecte eritroplaziceGlosodiniiDisfagieArsuri oraleCandidoze agravate sau precipitate de anemieAfte bucaleModificari osoase ale viscerocraniului si neurocraniului,spatieri
dentare,diasteme,os alveolar rarefiat,dureri si tumefactii parotidiene,xerostomie,pneumatizarea sinusurilor intarziata(talasemii)
Dureri osoase maxilare sau mandibulare,osteomielita mandibulara,anestezie labiala,simptome pulpare,calcificari pulpare,hipercementoza,maxilare largi cu overjet,overbite,hipomineralizarea smaltului(siclemie)
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Particularitatile tratamentului stomatologic in sindroamele anemiceTratrea cauzei sindromului anemic!Anestezia locala-preferata si satisfacatoare in cotrolul
durerii
-nu se foloseste Prilocaina in siclemie(creste
methemogobinemia)Anestezia generala-contraindicata cand Hb<10 g%
-aport suplimentar de O2Evitarea administrarii Aspirinei si Benzodiazepinelor in siclemiePacientii politransfuzati-posibil infectati cu VHB,VHC,HIVPacientii splenectomizati imunodepresieantibioprofilaxieTratamente ortodontice -talasemie
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Sindroame hemoragiceHemostaza primara-purpurele vasculare -trombocitopeniile -trombopatiile -boala von WillebrandHemostaza secundara-deficite congenitale in
factori de coagulare(hemofilii) -CIDHemostaza tertiara-fibrinoliza activata de
saliva
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Purpurele vasculareAfectare a peretelui vascular-
congenital,imunologic, infectiosTeleagiectazii,petesii,echimozeHemoragiile postextractionale sunt rareori
graveCriochirurgia,electrocoagulare,fotocoagulare
a cu laserSutura si tamponament supralveolar cu
hemostatice localeTamponament compresiv cu gutiere de
mentinere
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Aspecte clinice-purpura,teleangiectazie
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Trombocitopeniile,trombopatiilePetesii,echimoze,sangerari post-interventii chirurgicale Interventii chirurgicale mari(OMF)>75000/mmm3Chirurgie dentoalveolara >50000/mm3Transfuzie de masa trombocitara-1 unitatecrestere cu doar 10000
trombocite/mm3;1/2 inainte de interventia chirurgicala si ½ dupa tratamentul chirurgical
Concentratul de masa trombocitara iv/aplicatii localeDesmopresin(vasopresina)Acidul tranexamicSplenectomiarisc infectiosCorticoterapiaefectele secundareNu se administreaza Aspirina sau alte AINSEfectul antiagregant plachetar al Aspirinei nu este dependenta de dozaEfect redus al COX2 inhibitorilor aspra plachetelor(Rofecoxib,Celecoxib)
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Hemofilia A (deficienta factorului VIII)
Deficit cantitativ sau calitativ al factorului VIII
Transmitere X-linkataSangerare prelungita dupa
traumatisme,hemoragii interne ,cerebrale,hemartroze,retrobulbare,planseu retro si laterofaringiene,hematurie
Gravitatea sangerarii depinde de nivelul plasmatic al factorului VIII- < 1% forme grave; 1-5 % forme medii; > 5-25% forme usoare
Modificate TC,TH,nivelul plasmatic al factorului VIII
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Hemofilia AMedalion de tip “medic-alert”Evitarea traumatismelorContraindicate injectiile i.m,antiagregantele plachetare,AINSTratament substitutiv-Ce?,Cum?,Cat? -colaborare cu hematologul-factor VIII -20-30%-interventii chirurgicale mici -50-80%-interventii chirurgicale mari -100%-hemoragii SNCTratamente adjuvante-corticoterapie-desmopresin-intranazal/i.v-0,3-0,5 μg/kg-acidul tranexamic-local/i.v-30 mg/kg-sutura-agenti topici hemostatici-colagen,fibrina,gelatina,trombina -gutiera-antibioterapia-dieta
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Hemofilia B(deficit de factor IX)Transmitere X-linkataTratament-Ce?,Cum? Cat?Timp de injumatatire mai mareConcentratia factorului IX creste mai lent prin
tratamentul de substitutieTratamentul cu desmopresina este ineficientHemofilia C(deficit de factor XI)Boala von Willebrand-transmitere AD,menoragii-TS crescut-aderarea deficitara la ristocetina
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Particularitatile tratamentului stomatologic la pacientii cu hemofilieTratamentele conservative in hemofilii-preventia primara si
secundara,diga,matricile,aspiratorul de saliva,tampoane de vataTratamentele endodontice in hemofilii-anestezia intrapulpara cu
vasoconstrictor,sangerari pulpareChirurgia parodontala in hemofilii-anestezie locala,substitutia
factorului de coagulare deficitar(50-75%);detartraj –anestezie topica,antifibrinolitice
Tratamentul ortodontic in hemofilii-nu este contraindicat,sistemele aplicate sa nu traumatizeze mucoasa
Extractia si chirurgia dento-alveolara in hemofilii-planificata cu atentie,substitutia factorului de coagulare deficitar(50-75%),gruparea interventiilor chirurgicale intr-o sedinta,traumatism minim,,protejarea planseului,anestezie locala,ace atraumatice,sutura cu fir neresorbabil,hemostatice intraalveolar,tamponament compresiv,+/_gutiera,antibioterapie,dispensarizare
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Tratamentul anticoagulant,antiagregant plachetarDerivatii cumarinici-
Trombostop,Warfarina,SintromINR Heparina,heparine cu greutate moleculara
micaAspirina,Clopidogrel,Ticlopidine,DipiridamolDializa renala
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Sindroame mieloproliferative
Leucemia acuta-tratament doar de urgenta(fractura,hemoragia,obstructia cailor respiratorii superioare,durerea) si paleativLeucemia cronica-risc infectios,hemoragic,sindrom anemicMielomul multiplu-osteoliza circumscrisa fara reactie osteogenetica periferica,fracturi patologice,resorbtii radiculare,avulsii dentare,macroglosie,hiperplazie gingivala
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Echimoze,adenopatie cervicala