11.2
Sickle Cell Anaemia
Section I: Clinical Scenario and Dental Considerations
Clinical Scenario
A 25‐year‐old female presents for an emergency dental appointment following an accidental fall the night before which has resulted in trauma to the lower lip and maxillary anterior teeth. The patient is experiencing acute pain from her traumatised front teeth, making it impossible to eat and drink, with associated bleeding from the adjacent gingivae.
Medical History
- Sickle cell anaemia
- Blood transfusions intermittently as required; last transfusion 6 months ago
- Last acute crisis 12 months ago, triggered by cold weather and flu episode
- Autosplenectomy (spontaneous infarction of the spleen with resulting hyposplenism)
- Mild learning disability – no challenging behaviour
- Mild dental anxiety
Medications
- Folic acid supplement
- Penicillin V
Dental History
- Irregular dental attender; attends only when in pain
- Stopped going due to problems with access and mild dental anxiety
- Brushes her teeth once every other day
- Poor dietary habits (snacks on biscuits and cakes in between meals)
- Previous history of tooth fracture when the patient was young – mother does not recall exact age or date this occurred
- History of periodontal disease
Social History
- Lives at home with her parents and siblings
- Eldest of 6 children
- She is the only one in her family with a learning disability and sickle cell disease – the remaining family members have sickle cell trait
- Attends special education school
- Attends appointments with mother who is also her primary carer
Oral Examination
- Lips
- Upper lip dry and crusted
- Lower lip also dry and crusted; mild labial swelling and a traumatic lesion intraorally (Figure 11.2.1)
- Gingiva
- Generalised plaque, inflammation and oedema
- Localised bleeding and inflammation associated with both upper lateral and central incisors
- Teeth
- Grade I mobility and crown fracture of #11; tooth discoloured (Figure 11.2.2)
- Grade II mobility, buccally displaced, partially extruded #22
- Crown fracture of #21
- Localised tooth surface loss on the posterior teeth consistent with attrition and erosion
- Generalised staining
Radiological Examination
- Limited cooperation/movement impacting on the quality of the images
- Orthopantomogram, upper occlusal and long cone periapical radiographs undertaken of the anterior teeth (Figure 11.2.3)
- Increased periodontal space apically associated with #22
- Radiolucent periapical lesion associated with both the teeth # 11 and #12
- Open apex #11
Figure 11.2.1 Lower lip trauma lesion.
- Lower lip radiograph is clear from any foreign body/tooth fragments (Figure 11.2.4)
Structured Learning
- Why is it particularly urgent to treat this patient’s presenting dental complaint?
- There is a significant risk of dental pain, infection, dehydration and distress triggering a sickle cell crisis
- This risk may be compounded by the patient’s dental anxiety and her learning disability
Figure 11.2.2 Fractured crowns #11 and #21, extruded tooth # 21, localised inflammation and bleeding associated with these teeth, lip dryness and crusting.
- Following a tell–show–do approach, the patient allows you to examine her mouth more thoroughly and consents to emergency management of the dental and lip trauma. What steps would you take?
- Pain control: ensure that the patient has a supply of analgesics and starts taking this regularly at an appropriate dose; supplement with local anaesthesia in the region of the traumatised teeth to allow stabilisation
- Infection control: confirm that there are no foreign bodies in the tissue; clean the traumatised lip, gingivae and teeth; consider prescribing antibiotics
- Dental trauma treatment (Figure 11.2.5)
- Avulsion treatment: reposition #12 and stabilise the tooth for 2 weeks with a flexible splint
- Enamel‐dentine fracture treatment: tooth fragment can be bonded to the tooth; alternatively, cover any exposed dentine with an adhesive restoration
Figure 11.2.3 Upper right and left periapical and upper occlusal radiographs of the teeth involved in trauma.
Figure 11.2.4 Lower lip radiograph: no foreign body/tooth fragments.
Figure 11.2.5 Splinting of teeth #11–23 with wire and composite splint.
- For the exposed dentine, placement of calcium hydroxide base and coverage with a glass ionomer is advisable
- Enamel‐dentine‐pulp fracture treatment: pulp capping or partial pulpotomy in young patients; root canal treatment in patients with mature apical development, but pulp capping or partial pulpotomy may also be considered
- What factors do you need to consider in your risk assessment?
- Social
- Assessment of capacity in relation to the dental treatment proposed
- Appropriate communication to ensure that the information is provided in a way that is suitable for the patient
- Reliant on mother to attend appointments
- Mild dental phobia
- Medical
- Increased risk of a further sickle cell crisis
- Infection risk due to autosplenectomy
- Hypoxia risk
- Dental
- Poor oral hygiene
- Previous history of dental trauma
- Poor dental attendance
- Cariogenic diet and frequent snacks
- Social
- At the patient’s review appointment 10 days later, the pain, swelling and acute infection have resolved. After undertaking vitality testing and confirming that the #11 and #12 are non‐vital, you discuss root canal treatment. The patient becomes distressed and states that she cannot cope with this and wants to be sedated. What would you consider?
- Sickle cell anaemia is a significant risk factor for sedation
- Intravenous sedation must be used very cautiously because respiratory suppression leads to hypoxia and acidosis, which may precipitate an acute sickle crisis
- If sedation is being considered, dental care should be delivered in a hospital dental department
- Consider sedation by an anaesthetist rather than a dental sedationist
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