Dental Management of Patient with Leukemia

Hematologic diseases

Leukemia

Case Presentation

Outline Case scenario

Case analysis

Background

Types of leukemia

Etiology of leukemia

Signs and symptoms of leukemia

Medical diagnostic tests

Management of leukemia

Oral manifestation

Dental Management

Treatment plan modification

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Case 2A 52 year old came to your clinic for severe bleeding gums. Extraoral examination revealed multiple bruises on the arms and legs (when further asked she reports bruising much more easily lately). Intraoral examination showed enlarged gingiva that bleeds easily. History revealed that she has had flulike symptoms for the past 4 weeks, unexplained weight loss, fatigue, shortness of breath and bone/joint pain.

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Case Analysis 52 years oldAge

femaleGender

severe bleeding gumsChief

complaint

Flulike symptoms for the past 4 weeks, unexplained weight loss, fatigue, shortness of breath, bone/joint pain.

Medical history

Not providedDental history

Extraoral examination multiple bruises on the arms and legs

Intraoral examination enlarged gingiva that bleeds easily

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leukemia is cancer of the WBCs that affects the bone marrow and circulating

blood. It involves exponential proliferation of a clonal myeloid or lymphoid cell.

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Etiology of leukemia The cause of leukemia is unknown

Increased risk is associated with large doses of ionizing radiation, certain chemicals( benzene), and infection with specific viruses [EPV] and human lymphotropic virus [HTLV]-1

Cigarette smoking and exposure to electromagnetic fields also have been proposed to be causative.

Genetic factors may cause cytogenetic abnormalities that affect transcriptional cascades of myeloid precursor cells.

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Types of Leukemia & Pathophysiology

Acute leukemia

Result from accumulation of immature , functionless WBCs in the marrow and blood

Acute myeloid leukemia (AML)

Acute lymphocytic leukemia (ALL)

Chronic leukemia

Have slower onset which allows production of larger numbers of more mature, functional cells

Chronic myeloid leukemia (CML)

Chronic lymphocytic leukemia (CLL)

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Signs and symptoms

•Night sweats

•Fatigue and weakness

•Weight loss

•Bone pain and tenderness

•painless, swollen lymph nodes (especially in the neck and armpits)

•Enlargement of the liver or spleen

•Petechiae

•Bleeding and bruising easily

•Fever or chills

•Frequent infections

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Potential Medical Problems

• Anemia which is a condition in which a person has low number of red cells which can cause fatigue and shortness of breath

• Neutropenia is condition when there is low number of white cells

• Thrombocytopenia

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Medical Diagnostic Tests

Complete blood count (CBC)

Abnormal level of white blood cells

and platelet

Blood chemistry tests

blood urea nitrogen (BUN)

creatinine phosphateaspartate

aminotransferase (AST)

uric acid alanine aminotransferase

(ALT)

lactate dehydrogenase

(LDH)

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Medical Diagnostic Test Bone marrow test

- Bone marrow aspiration :

Remove a liquid marrow sample

- Bone marrow biopsy

Lumbar puncture:

Removes a small amount of cerebrospinal fluid (CSF) from the space around the spine

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Oral manifestations

Gingival Enlargement

Direct infiltration with leukemic cells of local tissues, through immunodeficiency, thrombocytopenia

Gingival ulceration

Result from impaired immune defense in combating normal microbial flora

Oral infection

Manifestations of thrombocytopenia are more common when the platelet count is below 50,000 cells/mm3and may manifest as bruising, petechiae in the hard and soft palate, and also spontaneous gingival bleeding, especially if the platelet count is below 20,000 cells/mm3

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Oral Complications

Primary complications (Mainly occurring due to the disease itself )

leukemic gingival enlargement.

Secondary complications (Associated with direct effect of the radiation or chemotherapy)

These include tendency to bleeding, susceptibility to infections, and ulcers

Tertiary complications (Due to complex interplay of therapy itself, its side effect, and a systemic condition arising out of the therapy)

Ulcerations, mucositis, taste alteration, candidiasis, gingival bleeding, xerostomia, dysphasia, opportunistic infections and trismus.

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Management of Leukemia

Chemotherapy

The main treatment for many kinds of leukemia

It has 3 phases:

1- Induction

2- Consolidation

3- Maintenance

Radiation therapy

To prevent leukemia from spreading to, or treat leukemia that has spread to, the central nervous system (CNS)

Bone marrow transplant

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Dental management of patient with Leukemia

Before starting the dental treatment:

Refer the patient for medical evaluation and treatment

Hematological information is needed before any invasive procedures (such as extractions)as leukemia patients have higher bleeding tendencies and they are liable to infections.

Preventive oral care is important in leukemia patients such as:

• Frequent topical fluoride applications

• Fissure sealants

• Dietary advice to the patient

• Give proper tooth brushing instructions to both patient and parents

• Antibiotic cover is needed before any surgery to prevent any postoperative infection

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Dental management of patient with Leukemia

Deliverska, Elitsa G., and Assya Krasteva. "Oral signs of leukemia and dental management–literature data and case report." J of IMAB 19.4 (2013): 388-391. 17

Treatment Plan ModificationPatient Prior to Chemotherapy

Dental treatment should be scheduled in consultation with the oncologist

The dental examination should perform before initiation of chemotherapy

Dental treatment at this stage is based on priorities and should be directed to the acute needs

Eliminate existing of infection and manage potential sources of infection and sites of trauma

Elective treatment should be postponed to a time when the patient is appropriate for clinical and laboratory conditions

Educate the patient about the

importance of maintaining oral health in reducing

problems before, during, and

after cancer treatment

Warn about the possible effects of chemotherapy in

the oral cavity, such as mucositis

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Treatment Plan ModificationPatient During Chemotherapy

The most appropriate time to schedule dental treatment during chemotherapy is after patients' blood counts have recovered, usually just prior to their next course of chemotherapy

General consideration :

Alcohol-based mouthwashes and full-strength peroxide solutions or gels should not be used due to their drying and irritating effects.

The prophylactic use of chlorhexidine rinse is helpful in suppressing bacterial colonization

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How to manage the bleeding

Use of hemostatic

agent

Epinephrine helps to

reduce the flow of blood

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Treatment Plan ModificationPatients after Chemotherapy

Patients are considered cured of leukemia and not having oral manifestations due

to illness or chemotherapy

The patient is considered low risk and can be met with normal dental treatment regimens

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References •Little, James W et al. Little And Falace's Dental Management Of The Medically CompomisedPatient. 8th ed.

•Sol Silverman. Essentials Of Oral Medicine. 1st ed. 2001.

•Zimmermann, Caroline et al. "Dental Treatment In Patients With Leukemia". Journal of Oncology2015 (2015): 1-14. Web.

•"Oral & Dental Care". Bccancer.bc.ca. N.p., 2017. Web. 11 May 2017.

•Deliverska, Elitsa G., and Assya Krasteva. "Oral signs of leukemia and dental management–literature data and case report." J of IMAB 19.4 (2013): 388-391.

•"Diagnosis Of Leukemia - Canadian Cancer Society". www.cancer.ca. N.p., 2017. Web. 11 May 2017.

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Quick Test1- Which of following is considered primary complication of leukemia:

A. Gingival enlargement

B. Ulceration

C. Mucositis

2- Which is not correct regarding dental management of patient with Leukemia:

A. Refer the patient before starting the treatment for medical evaluation

B. Preventive oral care is important in leukemia patients

C. Treat the acute needs then refer the patient

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3- All of following are symptoms of leukemia except

A. Bruising

B. Weight loss

C. Bone pain

D. Excessive salivation

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