JICDRO is a UGC approved journal (Journal no. 63927)

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CASE REPORT
Year : 2020  |  Volume : 12  |  Issue : 2  |  Page : 173-183

Dental Surgery in an Asplenic Patient


1 Department of Periodontology, Maharashtra Institute of Dental Sciences and Research, Latur, Maharashtra, India
2 Department of Conservative Dentistry and Endodontics, Maharashtra Institute of Dental Sciences and Research, Latur, Maharashtra, India

Date of Submission08-May-2020
Date of Acceptance13-Sep-2020
Date of Web Publication14-Dec-2020

Correspondence Address:
Dr. Om Nemichand Baghele
Professor, Department of Periodontology, MIDSR Dental College and Hospital, Latur, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jicdro.jicdro_25_20

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   Abstract 


Nonsurgical endodontic treatment is a highly predictable treatment option in most cases, but surgery may be indicated for teeth with persistent periradicular pathosis unresponsive to it. The persistence of infection usually, but not always, indicates reduced immunological resistance. In such scenario, the clinician should be vigilant and find out the source of immunological incompetence before implementing treatment. Following splenectomy, individuals have an elevated risk of infection, in particular to encapsulated bacteria, Gram-negative pathogens such as Capnocytophagia carnimorsus and Bordetella holmesii, and intra-erythrocyte parasites such as malaria and babesia. After splenectomy, there are alterations in cell counts, cell quality, and immunological responses. Initially, after splenectomy, a reactive thrombocytosis and leukocytosis is observed. Splenectomized individuals are at risk to, overwhelming bacterial sepsis (overwhelming postsplenectomy infection). The complications are now infrequent because of pneumococcal vaccinations, prophylactic penicillin, and prompt medical attention at the first sign of fever. This case presents relevant management of a periradicular lesion in a 32-year-old male who has undergone splenectomy because of idiopathic thrombocytopenic purpura. The tooth was first endodontically treated that was followed by periodontal and periapical surgical treatment.

Keywords: Asplenic patient, dental management, endodontic treatment, idiopathic thrombocytic purpura, periapical surgery, periodontal surgery, persistent periapical infection, splenectomy


How to cite this article:
Baghele ON, Malbhage SU, Bhandari VD, Deshpande SR, Gaffar Khan SK, Gaddaley S. Dental Surgery in an Asplenic Patient. J Int Clin Dent Res Organ 2020;12:173-83

How to cite this URL:
Baghele ON, Malbhage SU, Bhandari VD, Deshpande SR, Gaffar Khan SK, Gaddaley S. Dental Surgery in an Asplenic Patient. J Int Clin Dent Res Organ [serial online] 2020 [cited 2021 Jun 19];12:173-83. Available from: https://www.jicdro.org/text.asp?2020/12/2/173/303400




   Introduction Top


A majority of periapical lesions develop as sequelae to pulpal disease. An array of microorganisms from the pulp tissue may lead to tractable or intractable dentoalveolar infections. They are generally diagnosed either during radiographic examination or following acute dental pain or when they become symptomatic. Most periapical lesions can be classified as radicular cyst, abscesses, or periapical granulomas. For such lesions, root canal therapy (RCT) is one of the most successful and established treatment. But still, 9.7.% of these treatments can fail because of various reasons.[1]

After the failure of the conventional root canal treatment, nonsurgical retreatment is the preferred option in most cases. Several factors, such as complex root canal system or previous procedural accidents or traumatic injuries may impede the success of nonsurgical retreatment. In these cases, periapical surgeries would be the treatment of choice to preserve the tooth. These periapical surgeries belong to the field of endodontic surgery, which also includes incision and drainage, closure of perforations, and root or tooth resections.[2] Such treatments and periapical surgeries can be performed by an endodontist, a periodontist, and/ or an oral maxillofacial surgeon, or even a General Dental Practitioner, with appropriate skill sets and expertise. Periapical surgery or an apicoectomy was well defined in 1884 by J. Farrar as “a bold act, which removes the entire cause (of disease) and which will lead to a permanent cure may not be the best in the end, but the most human.”[3] The objective of apical surgery is to surgically maintain a tooth that primarily has an endodontic lesion that cannot be resolved by conventional endodontic treatment or (re-) treatment.[2],[4] Performing root end resection and preparation, the root canal filling is placed within the created cavity to close the path of communication between infected root canal system and peri-radicular tissues.

Indications for apical surgery have been recently updated by the European Society of Endodontology, 2006[5] and include the following:

  1. Radiological findings of apical periodontitis and/or symptoms associated with an obstructed canal (the obstruction proved not to be removable, displacement did not seem feasible, or the risk of damage was too great)
  2. Extruded material with clinical or radiological findings of apical periodontitis and/or symptoms continuing over a prolonged period
  3. Persisting or emerging disease following the root-canal treatment when root canal re-treatment is inappropriate
  4. Perforation of the root or the floor of the pulp chamber and where it is impossible to treat from within the pulp cavity.


Contraindications for apical surgery include the following: the tooth has no function (no antagonist, no strategic importance serving as a pillar for a fixed prosthesis), the tooth cannot be restored, the tooth has inadequate periodontal support, or the tooth has a vertical root fracture. Additional general contra-indications may be an uncooperative patient or a patient with a compromised medical history for an oral surgical intervention.[6]

In endodontically treated horizontal root fractures in which the symptoms associated with the apical fragments are involved, one of the most indicated treatment is surgical removal of the fragment and apical surgery of the coronary segment.[7] Another indication for apical surgery is when wide radiotransparent periapical lesions of over 8–10 mm in diameter exist, even after endodontic therapy. These lesions may thereby be removed, and histological examination may be performed to prevent malignant lesions from going undiagnosed.[8]

Patients who have undergone splenectomy are known to have an increased risk of overwhelming infection with an overall mortality rate of 2.5%.[9],[10] Dental practitioners are urged to consult with the patient’s physician regarding the patient’s overall medical status. Risk of infection and sepsis is only one and primary concern in the asplenic patient. The dental practitioner also must examine the reason for asplenia and correlate dental therapy with the medical condition of the patient.

The spleen is a fist-sized spongy organ situated in the upper left abdomen, behind the lower ribs, that comprises approximately 25% of the body’s lymphoid tissue [Figure 1]. It consists of a white pulp, a red pulp, and a surrounding fibrous capsule. The white pulp derives its appearance from the presence of white blood cells, particularly lymphocytes that accumulate in the periarterial lymphatic sheaths and follicles. The red pulp derives its appearance from the gathering of erythrocytes in the splenic sinus capsule[11] [Figure 2].
Figure 1: anatomy of spleen

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Figure 2: cross-section view of spleen

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The spleen plays an important role in the body’s defense mechanism against microbial infections. However, trauma or diseases sometimes make removal of this important organ necessary, which predisposes patients to certain infections. This increased risk of infection and the underlying reason for the organ’s removal both may affect the provision of dental care.[11] Since the first deliberate removal of a diseased spleen by Quittenbaum[12] in 1826, splenectomy has become a well-established surgical procedure.

Spleen function: Immunological function

The spleen can initiate immune responses to blood-borne antigens, produce antibodies, and clear antibody-mediated pathogens. The spleen consists of cells involved in both innate and adaptive immunity. Red pulp macrophages filter the blood and remove bacteria, damaged erythrocytes, and erythrocyte inclusions. Marginal zone macrophages remove cellular debris in the marginal zone and tingible body macrophages (tingible body macrophage is a type of macrophage predominantly found in germinal centers, containing many phagocytized, apoptotic cells in various states of degradation, referred to as tingible/stainable bodies). They contain condensed chromatin fragments and these macrophages remove B-cell debris in the germinal center of the follicle. In addition to macrophages, there are also dendritic cells, natural killer cells, and monocytes that are involved in inducing T-cell responses to pathogens. The white pulp of the spleen is B-cell dominant (follicles) with some T-cell zones. The splenic B-cells produced specific antibodies for immunity (affinity maturation) and to enhance cytotoxic T-cell activity via specific antibodies.[13]

Hematological function

The spleen also sequesters blood cells including platelets. The spleen is thought to pool approximately one-third of the total platelet volume in addition to sequestration of erythrocytes and granulocytes. Tests of splenic function evaluate the capacity of the spleen to remove intra-erythrocytic inclusions such as Howell–Jolly bodies and erythrocyte pits, in addition to its ability to maintain IgM memory B-cell population.[14]

A spleenless existence was considered to be quite safe as the spleen was considered unnecessary for life until 1952 when King and Schumacher drew attention to the risk of overwhelming postsplenectomy infection (OPSI).[15] As the spleen is responsible for making antibodies and removing bacteria, aged, antibody-coated and damaged blood cells, those without a spleen have an impaired immune system.[16],[17] Because of this, splenectomized patients have a more difficult time recovering from pneumonia, meningitis, Hemophilus influenzae (Hib) flu, sepsis, nosocomial infections,  Babesiosis More Details (a tick-borne disease), malaria and other parasitic diseases and Gram-negative bacterial diseases from animal bites.[18],[19],[20] Although the liver can perform this function in the absence of the spleen, higher levels of specific antibody and an intact complement system are probably required.[17] The changes in immune function that occur after splenectomy result in increased risk of infection and predispose patients to high-grade bacteremias and overwhelming sepsis.

Absolute indications for splenectomy.[21]

  • Splenic trauma Splenic rupture-Spontaneous (tropical splenomegaly)
  • Delayed rupture (subcapsular hematoma from trauma)
  • Splenic abscess (e.g., tuberculous infection)
  • Splenic cysts
  • Neoplasm, as part of radical surgical oncological clearance of adjacent tumor, for example, locally advanced gastric carcinoma, pancreatic carcinoma, angioma, primary (rare), aneurysm of splenic artery.


Complications of splenectomy:[21] Refer to [Table 1] for complications associated with splenectomies
Table 1: Complications of splenectomy

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  • Hemorrhage
  • Thromboembolic complications
  • Subphrenic abscess
  • Chest infection.


* Overwhelming post-splenectomy infections (OPSI)

Prevention of OPSI:[22]

One of the most important aspect for an asplenic patient or a patient scheduled for splenectomy is appropriate considerations for prevention of infections from happening. The key aspects are identification of patients at risk of infection, patient information and education, immunization schedules ([Table 2] presents summary of British Society of Hematology’s guidelines on timing and type of vaccinations in elective and emergency splenectomy), anti-infection prophylaxis, and treatment of proven or suspected infection.
Table 2: Summary of British Society of Hematology guidelines on timing and type of vaccinations in elective and emergency splenectomy

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The present case report describes a combination of endodontic therapy and periapical surgery with use of Biodentine in asplenic patient, to emphasize that a vigilant approach is required to deliver dental care appropriately and successfully for the patient.


   Case Report Top


A 32-year-old male reported to Department of Periodontics at Maharashtra Institute of Dental Sciences and Research, Latur with a chief complaint of pus discharge and pain in front region of upper jaw since last 2 weeks. Medical history revealed that he was diagnosed with idiopathic thrombocytopenic purpura (ITP) 10 years ago after that he underwent splenectomy A complete haemogram [Table 3] was carried out and all the parameters found within normal limits.
Table 3: Complete hemogram

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There was no history of spontaneous bleeding and edema or any sign of ecchymosis in the recent past 6 months. Dental history revealed trauma to the upper left front teeth 18 years ago and consequent pus discharge from labial aspect later on. The concerned teeth showed discoloration and Ellis Class IV fracture. Endodontic treatment was suggested which consisted of apexification[23] for tooth # 21 due to incomplete root development seen on Intraoral Periapical Radiograph (IOPA). Accordingly endodontic treatment was performed with tooth # 21 and 22.[21],[22]

The patient was asymptomatic for 4 months, after endodontic treatment, until he reported to the department of Endodontics with complains of pus discharge with tooth # 21. There was sinus tract opening in relation to the tooth # 21 and tooth # 21.22 after RCT. On performing sinus tracing, it revealed that sinus originated particularly with tooth # 21 (on the labial aspect). Intra-oral gingival examination showed reddish pink color of gingiva with melanin pigmentation and pocketing, Gingival margins were scalloped (the periodontal findings are presented in [Table 4]).
Table 4: Periodontal examination w.r.t upper 13-23

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Radiographic Examination:

Cone beam computed tomography (CBCT) of concerned teeth revealed a well defined periapical radiolucency akin to periapical dento-alveolar abscess or infection. The maximum dimensions were found to be 22 mm mesiodistally, 12 mm apicocoronally and, 10 mm buccopalatally [Figure 3].
Figure 3: cone-beam computer tomography (post-endodontics)

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IOPA also showed well defined periapical radiolucency in relation to tooth numbers 21 and 22, and an open apex with tooth # 21 [Figure 4].
Figure 4: intraoral periapical radiograph (preoperative IOPA before endodontic therapy)

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Diagnosis

The differential diagnosis included periapical abscess, granuloma or radicular cyst secondary to necrosed pulp because of accidental trauma.

The periodontal diagnosis according to 2017 Classification of Periodontal and Peri-implant Diseases and Conditions was put forth as “Generalized gingivitis-dental plaque induced on intact periodontium-mediated by systemic factor (splenectomised condition) with endo-perio lesion without root damage in a non-periodontitis patient-Grade 1.”

Treatment plan

Endodontic management: Based on diagnosis

The combined endodontic-periodontic lesions are best treated by first performing the necessary endodontic care followed by periodontal therapy, if required. Still, the periodontal hygiene procedures are started first. Pulp vitality tests were performed. Thermal tests and electrical pulp tester elicited a negative response when compared to control teeth. The clinical and radiological evaluation confirmed the maxillary left lateral incisor associated with periapical pathology. Under rubber dam isolation, necrotic pulp was removed from root canals. Cleaning and shaping was achieved using stainless steel K Files [Figure 5] (Mani, Japan) by crown down technique to minimize the apical extrusion.
Figure 5: rubber dam isolation, necrotic pulp was removed from root canals. Cleaning and shaping was achieved using stainless steel K files

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The irrigants used were 5.25% sodium hypochlorite and 17% EDTA (ethylene diaminetetraacetic acid) and saline was used in between two irrigants. The canals were finally flushed with chlorhexidine and then repeated water based ca (OH)2 paste [Figure 6] was given for approximately period of 1 year. The tooth was asymptomatic and the periapical radiolucency showed sign of reduction with tooth # 21.
Figure 6: water based ca (OH) 2 paste dressing (repeat applications were done for a period of 1 year)

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Apexification done with 21 using Bio-dentine apical plug followed by final obturation using thermoplastisized Gutta Percha [Figure 7]. Postobturation restoration done using composite resin. The patient was re-examined after 2 months for review then there was a sinus tract opening w. r. t 21 after tracing it with gutta percha point [Figure 8] it was confirmed that sinus opening was associated with 21 and periapical radiolucency remained unchanged. Patient was planned for surgical intervention. The history at patient presentation may differ for Dept. of Periodontics and Dept. of Endodontics, but despite this the patient was under treatment and follow up at the Dept. of Endodontics for more than 1-year, after that it was considered for periapical surgery.
Figure 7: apexification done with 21 using Bio-dentine apical plug followed by final obturation using thermoplastisized gutta percha

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Figure 8: sinus tract opening w. r. t 21 after tracing it with gutta percha point

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Periapical management

The surgical procedure was initiated using infraorbital and nasopalatine nerve blocks and field blocks as necessary, by infusing lignocaine with 1:80000 adrenaline as local anaesthetic [Figure 9] and [Figure 10]. A Trapezoidal flap design was planned. Buccal full thickness mucoperiosteal flaps were raised extending from the maxillary right central incisor tooth to the maxillary left first premolar tooth, with a buccal vertical relieving incision at the maxillary left premolar tooth and at maxillary right central incisor [Figure 11] and [Figure 12].
Figure 9: maxillary and mandibular facial view

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Figure 10: left lateral view

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Figure 11: sulcular, vertical incisions placed

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Figure 12: full-thickness flap raised

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After full thickness flap reflection buccally, degranulation done in periapical region of 21, 22, then flushed with povidone iodine and with the normal saline (0.9%), followed by a small osteotomy produced to locate the root-end that was resected by about 3 mm [Figure 13] and [Figure 14] The resection plane was slant or perpendicular (for avoiding the apical microleakage) to the long axis of the tooth. After this root end filling material was placed into the cavity preparation (Biodentine) [Figure 15] Before suturing a radiographic verification made. Flap approximation and suturing was done (continuous sling sutures) [Figure 16]. Appropriate postoperative instructions were given and medication prescribed. Post-operative radiograph taken [Figure 17], after 8 days follow up given [Figure 18]. Patient reported for follow up after 1 month [Figure 19] and [Figure 20].
Figure 13: locating the periapical access

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Figure 14: debridement done

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Figure 15: ostectomy followed by apicoectomy done w, r, t, 21,22

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Figure 16: continuous sling sutures placed

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Figure 17: postoperative radiograph

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Figure 18: after suture removal (8 days after)

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Figure 19: radiograph after 1 month post-surgery follow-up

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Figure 20: Follow-up after 1 month

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   Discussion Top


After the failure of the conventional root canal treatment (RCT), nonsurgical retreatment is the preferred option in most cases. Several factors, such as a complex root canal system or previous procedural accidents, may impede the success of nonsurgical retreatment. In these cases, periradicular surgery and apicoectomy would be the treatment of choice to preserve the tooth[24] Periapical surgery is the last hope to save an endo-dontically treated tooth with a periapical lesion. The treatment outcome of apical surgery should be assessed clinically and radiographically. Only the combination of clinical and radiographic healing criteria is accepted today to determine the outcome of apical surgery[25] Clinical healing is based on the absence of signs and symptoms such as pain, sinus tract, swelling, apico-marginal communication, and tenderness to palpation or percussion. Standard radiographic healing responses include complete healing, incomplete healing (“scar tissue formation”), uncertain healing (partial resolution of postsurgical radiolucency), and unsatisfactory healing (no change or an increase in postsurgical radiolucency). This classification is based on landmark studies that have compared radiographic findings with histopathologic results of periapical tissues of teeth that had to be extracted after apical surgery.[26] Several studies have also compared the healing outcome of re-surgery and first-time surgery cases.[27] For re-surgery cases, the healing outcome was 7%–27% lower than for first-time surgery cases. A recent 5-year longitudinal study found a low success rate of 59% for re-surgeries compared to a high success rate of 86% for first-time surgeries.[28] Another important issue to consider in the healing outcome of apical surgery is the difficulties and challenges of combined endo-perio lesions, in particular the absence of the buccal bone plate with a completely exposed buccal root surface.

Only a few clinical studies have compared the healing outcomes in apical surgery of teeth with intact and with missing buccal bone. Wesson and Gale(2003) determined the 5-year success rates associated with molar apical surgery in consideration of the width of the buccal ‘‘bone cuff’’ prior to wound closure.[29] Teeth with a width of 3 mm or greater of cuff had a healing rate of 76%, whereas teeth with no buccal bone cuff had a significantly lower healing rate of 46% (P < 0.0001). Numerous materials have been recommended for root end obturation, and many studies have attempted to identify an ideal material; however, an ideal material has not been found.[30]

Dental considerations in asplenic patient

Patients who have undergone splenectomy are known to have an increased risk of overwhelming infection, with an overall mortality rate of 2.5%[10] In the early 1980s, Terezhalmy and Hall supported the use of antimicrobial prophylaxis before performing dental procedures in these patients.[31] Chaikof and McCabe reported that fatal sepsis can occur up to 30 years after splenectomy, Ellison and Fabri found that 20% of fatal sepsis cases occurred in the first 6 months and 60% occurred within 2 years.[32] It is known that dental procedures that induce mucosal bleeding may cause transient bacteremias, but generally these occurrences do not overwhelm an intact immune system. Streptococcus pneumonia, Hib,  Escherichia More Details coli, N. meningitides and Pseudomonas aeruginosa are not endogenous to the oral cavity and have not been shown to cause bacteremias from dental procedures.[33]

Some clinicians feel that prophylactic measures with antimicrobial medications are less effective than prompt recognition and treatment of infection with aggressive antibiotic therapy when asplenic patients become febrile.[34] There is evidence of prophylactic antimicrobial therapy failing to prevent infection in asplenic patients,’ and numerous animal studies have cast doubt on its efficacy[35],[36] Because compliance with long term, routine antibiotic prophylaxis is unreliable and its efficacy remains unproven in prospective randomized trials, it is prudent to avoid indiscriminatory use of antibiotic prophylaxis before dental procedures. Patient was on medication (i.e. Tab. Pentid 400 mg once a day, contained penicillin G potassium) for last 10 years which was prescribed by his physician, there were no history of any complication after taking this antibiotic dose, no history of any surgical procedure patient underwent during this prophylaxis, also no history of any infection (e.g. Overwhelming Post Splenectomy Infection). The patient informed that he is taking the medications religiously without any break or missed doses. Before performing periodontal surgery the patient was asked to take a dose of his routine antibiotics, after the surgical procedure he was suggested to take analgesics only if needed. No additional antibiotics were prescribed.

When treating other immunocompromised patients, dentists can take certain measures during the perioperative period to minimize the chance of infection. Patient education and scrupulous oral hygiene, use of antimicrobial mouth rinses before and after dental procedures, aggressive elimination of potential intraoral sources of infection and frequent oral health maintenance all serve to minimize infectious complications in these patients[37] Dental practitioners are urged to consult with the patient’s physician regarding the patient’s overall medical status. Risk of infection and sepsis is only one concern in the asplenic patient. The dental practitioner also must examine the reason for asplenia and correlate dental therapy with the medical condition of the patient.

Thrombocytopenia, a condition which is characterized by a reduced number of platelets in the peripheral blood, is associated with a number of diseases and conditions, including leukemia, lymphoma, certain anemias, systemic lupus erythematosus, HIV infection and hypersplenism. This condition also can be autoimmune-related, drug-related or idiopathic. It is believed that in some of these diseases and conditions, platelets are attacked by antibodies and subsequently destroyed in the spleen. Initial therapy to increase the number of platelets focuses on reduction of antibody production by high dose, long-term corticosteroid therapy. When this treatment modality fails, splenectomy is usually indicated[38] Therefore, asplenic patients may often suffer from underlying conditions that may alter routine dental procedures. Patients with ITP who have undergone splenectomy also have been shown to be at increased risk of developing chronic active hepatitis.[39] The body’s immunological armor is damaged with removal of the spleen, providing a gateway for infections with poorly opsonized bacteria. Sepsis in the splenectomised individual is often severe and associated with high morbidity and mortality. Ongoing prevention with vaccination, antibiotic prophylaxis, and patient education is imperative in reducing the risk of infection. Treatment of the patient with chronic and chronic-acute viral hepatitis involves evaluation of liver function to rule out bleeding tendencies and altered drug metabolism. So the dentists should be familiar with all the important considerations in treating asplenic patients who may have multiple medical conditions and a constant risk of overwhelming infections.


   Conclusion Top


With advancing medical and technological prowess, many people are living their lives without an important organ or a group of organs. Similarly many people have transplanted or added organs, and the number of such survivors will increase in the future. Such patients will definitely require dental treatment also. A dentist should not only be knowledgeable about these eventualities but also be able to manage them as and when necessary.

The burden is on the general dentist to understand the immunological condition of patients who are asplenic or have splenic dysfunction and to recognize associated underlying conditions that may require modification of dental care. The identification and prompt management in the high probability of infection provide the splenectomised individual the best chance of early recovery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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    Abstract
   Introduction
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