Haematology and Oncology Flashcards
Describe what causes disorders of haematology
- May be inherited or acquired conditions
- Associated with vascular defects, platelet defects or coagulation disorders
Name 3 inherited platelet disorders
- Idiopathic Thrombocytopenic Purpura (ITP)
- Glanzmann’s Thromboasthenia
- Bernard-Soulier Syndrome
Name 4 acquired platelet disorders
- Chronic renal failure
- Drug induced (aspirin)
- Viruses (HIV)
- Bone marrow failure
Describe the dental management of a patient with inherited platelet disorders
- Liaise with haematology regarding current platelet activity
- Avoid trauma and use local measures
- Manage bleeding with tranexamic acid
- Minor surgery may be covered with desmopressin
- Avoid aspirin due to anti-platelet activity
What is a clotting disorder?
Normal vascular vasoconstriction and platelet response but defect in clotting cascade
Name 3 inherited clotting disorders, in order of most to least common
- Von Willebrand’s disease
- Haemophilia A
- Haemophilia B
Describe 4 potential systemic therapies used to manage bleeding disorders
- Desmopressin (mimics vasopressin action)
- Tranexamic acid (antifibrinolytic)
- Recombinant Factor VIII
- Human Plasma Factor VIII
Describe von Willebrand’s disease
- Affects around 1% of population
- Affects males and females equally
- Dominant inheritance pattern
- VWF is carrier protein for factor VIII which aids platelet adhesion and aggregation
- Humate-P most common vWF concentrate
Describe the clinical presentation of von Willebrand’s disease
- Bleeding from mucous membranes, GI bleeding, epistaxis, purpura of skin and mucous membranes
- Mild forms may go undetected until trauma (tooth extraction)
Describe the treatment of Von Willebrand’s disease
- Desmopressin (via nasal spray)
- Type 3 managed as severe Haemophilia A
- Can only use human factor VIII replacement
Describe the dental management of von Willebrand’s disease
- Seek advice from haematology
- Risk assess procedure with severity of disease
- Ask about previous extractions
- Prevention is key
- Atraumatic technique where possible
Describe haemophilia A
- Factor VIII deficiency
- Prevalence of 1 in 10,000 affected
- Sex-linked recessive although spontaneous mutations may occur
- Female carriers may exhibit some symptoms and required Factor VIII cover
Describe the diagnosis of haemophilia A
- Prolonged APTT
- Low factor VIII
Describe 3 possible treatments of Haemophilia A
- Desmopressin
- Factor VIII
- Tranexamic acid
NB: No one size fits all so liaise with haematology
Describe dental management of patient with haemophilia A
- Careful history taking
- Liaise with haematology to raise existing Factor VIII if necessary
- Multiple extractions or minor surgery in risky site best managed in hospital
- Prevention is key
- Infiltrations or intrapulpal injections safer than blocks
- Bleeding into larynx or pharynx after IDB can obstruct airways
Describe haemophilia B
- Hereditary bleeding disorder caused by lack of factor IX
- Inherited X-linked recessive trait, with defective gene located on the X chromosome
- Managed in same way as haemophilia A
Describe challenges in dental management of haemophilia
- Poor mobility in older patients due to haemoarthrosis
- Before 1990 many patients received contaminated blood products which led them to acquire haemophilia
- Universal precautions
- Develop auto-antibodies to Factor VIII (cover no longer works)
Describe how chemotherapy works
- Targets neoplastic cells rapidly dividing therefore cells which divide rapidly under normal circumstances also affects e.g. bone marrow cells therefore reduced platelet count
Describe leukaemia
- Acute or chronic
- Cell of origin lymphoblast or non lymphoblast
- Acute leukaemias account for 50% malignant disease in children
- Chronic leukaemias characterized by excess of mature leukocytes in blood
Describe how leukaemia occurs
- Abnormal blood cells are produced in the bone marrow
- Crowd out normal blood cells
- Abnormal white blood cells increases infection
- Impairs ability to produce red blood cells and platelets
Name 3 medical managements of leukaemia
- Chemotherapy
- Radiotherapy
- Bone marrow transplantation
Name 5 dental considerations for patients suffering from leukaemia
- Bleeding tendencies
- Susceptibility to infection
- Chemotherapy may result in mucositis
- Manifest as gingival bleeding or swelling
- Render dentally fit prior to treatment and prevention
Describe lymphoma
- Abnormal lymphocytes become lymphoma cells which multiply and collect in lymph nodes
- Painless swellings
- Tumours affect lymphatic system
- Hodgkin’s or Non-Hodgkin’s
Describe 3 ways lymphomas are treated
- Radiotherapy
- Chemotherapy
- Steroids
Describe multiple myeloma
- Disseminated plasma cell malignancy
- Mainly affects middle aged and elderly
Name 4 possible outcomes of multiple myeloma
- Plasma cells produce antibodies so susceptibility of infection
- Malignant cells release osteoclast activating actors therefore bone resorption and pain
- Bone destruction therefore hypercalcaemia
- Suppression of haemopoiesis therefore anaemia and bleeding tendency
Describe the treatment of multiple myeloma
- Chemotherapy +/- bone marrow transplantation
- Bisphosphonate medication to prevent bone fracture
Describe 4 dental implications of multiple myeloma treatments
- Anaemia, infections and bleeding
- Osteolytic lesions which may affect mandible
- Effects of chemotherapy
- Bisphosphonates and OCN
Describe the presentation of OCN
- Pain (not always)
- Soft tissue swelling
- Infection
- Tooth mobility
- Exposed bone
Describe 3 treatment options of OCN
- Local debridement
- Antibiotics
- Careful monitoring
Name 4 ways to reduce the risk of osteonecrosis
- RCT preferable to extractions
- Management of PDL
- Consider antibiotic prophylaxis where extractions unavoidable
- Prompt treatment with antibiotics
Describe the main principles of oral health care plan in oncology patients
- Stabilise oral disease to avoid complications during or following treatment
- Reduce risk of oral infections
- Enhance quality of life for patient
Describe management of oncology patients prior to therapy
- Oral examination and preventive advice
- Smooth of any sharp teeth or restorations
- Radiotherapy can result in xerostomia
- Extractions at least 10 days prior to therapy
Describe prevention of ORN
- Extractions completed at least 10 days before radiotherapy
- Minimise oral trauma (dentures etc)
- Prevention of caries and periodontal disease
- Hyperbaric oxygen therapy when extractions necessary
Describe management of oncology patients during therapy
- Avoid dental care where at all possible
- Prevention and support
- Management of side effects of radio and chemotherapy
Name 4 common side effects of radiotherapy and chemotherapy
- Mucositis
- Xerostomia
- Trismus
- Oral infections e.g candida
Describe mucositis
- Painful ulcers and raw tissues
- Presents with redness, swelling, burning pain, difficulty opening and speaking
Describe the symptomatic relief of mucositis
- Difflam (benzydamine hydrochloride)
- Lignocaine solution (severe mucositis)
- Oral cooling
- Gelclair and biotene
Describe xerostomia
- Increase in caries, periodontal disease and oral infections
- Denture intolerance and discomfort
- Use of saliva replacement therapy
Describe the management of oncology patients post therapy
- Hygienist support
- Manage xerostomia
- Manage trismus with jaw exercises
- Treat opportunistic infections
- Avoid extractions
Describe radiation caries
High prevalence of decay and root caries due to:
Xerostomia
High sugar intake (sugar tastes stronger)
Oral sensitivity prohibiting effective brushing
