Hematologic Diseases Dental Management Flashcards
Anemia
- Reduction in the oxygen carrying capacity of RBCs; deficiency in red blood cells or of hemoglobin in the blood
Anemia
Classification
– Causes
(3)
- Blood Loss
- Inadequate production
- Excess destruction
Anemia
Classification
– Morphology
(3)
- Normocytic
- Microcytic
- Macrocytic
Laboratory Tests: Anemia
* CBC (Complete Blood Count)
(5)
- Hb*
- Hematocrit*
- WBC
- Platelet
- RBC indices*
- Hb* (Concentration of hemoglobin)
- <— g/dL (men) or <— g/dL (women)
13.5
12.0
- Hematocrit* (Packed cell volume)
- <—% (men) or <—% (women)
41.0
36.0
RBC indices*
(4)
- MCV (mean corpuscular volume)
- MCH (mean cell hemoglobin)
- RDW (red cell distribution width)
- MCHC (mean cell hemoglobin concentration)
Types of Anemia (size)
(3)
- Microcytic
- Macrocytic
- Normocytic
- Microcytic
(2)
– Iron Deficiency Anemia
– Thalassemias
- Macrocytic
(3)
– Pernicious Anemia
– Folate Deficiency
– B12 Deficiency
- Normocytic
(2)
– Hemolytic Anemia
– Sickle Cell Anemia
Iron Deficiency Anemia
(2)
- Microcytic anemia
- More common in women of
childbearing age and children
Iron Deficiency Anemia
* Causes:
blood loss, poor iron
intake, poor iron absorption, or
increased demand for iron
Iron Deficiency Anemia
* Labs:
Serum iron, ferritin, TIBC,
transferrin
Macrocytic (Megaloblastic) Anemias
* Folate Deficiency
–
– Deficiency during pregnancy causes
– Labs:
Not stored in the body in large amounts; continual
dietary supply is needed
neural tube defects in the child
Serum folate level
Macrocytic (Megaloblastic) Anemias
* Cobalamin (B12) Deficiency
(3)
– Pernicious Anemia
– Nitrous Oxide
– Labs: Serum B12
– Pernicious Anemia
- Deficiency of intrinsic factor which is necessary
for B12 absorption
– Nitrous Oxide
(2)
- Irreversible inactivation of B12
- Neurologic symptoms
Anemia: Clinical Presentation
* Systemic
– Symptoms: (5)
– Signs: (3)
Fatigue, weakness,
palpitations, SOB, angina,
tingling of fingers and toes
pallor, splitting and
spooning of fingernails
Anemia: Clinical Presentation
* Oral Manifestations
(2)
– Atrophic glossitis with loss on
tongue papillae, redness or
cheilosis
– Mucosal pallor
Anemia
(3)
–Generally tolerate routine dental treatment well
–Avoid long N20 exposure in patients with B12
deficiency
–Identifying signs and symptoms of anemia
–Generally tolerate routine dental treatment well
* Severe anemia (cardiopulmonary symptoms)
(3)
–Defer routine dental care
–Pulse oximeter and supplemental oxygen
–Avoid strong narcotics
–Identifying signs and symptoms of anemia
* Important to find the cause!
(2)
–GI bleed, chronic inflammation pancytopenia
Sickle Cell Anemia
(3)
- Autosomal recessive inherited
disorder - RBC sickling in low oxygen or low
blood pH environments - Erythrostasis, increased blood
viscosity, reduced blood flow,
vascular occlusion, hypoxiamore
sickling
Sickle Cell Anemia
* Systemic Signs and Symptoms
(7)
– Result of chronic anemia and small blood vessel
occlusion
– Jaundice, pallor
– Leg ulcers
– Cardiac
– Delays in growth and Development
– Pain
– Sickle cell crisis
– Cardiac
(2)
- Cardiac failure
- Stroke
– Pain
(2)
- Abdominal
- Bone (aseptic necrosis)
– Sickle cell crisis
(2)
- Prolonged (hours-days) severe pain which pay require
hospitalization for pain management - Causes: infection, higher altitude (hypoxia), dehydration,
trauma
Sickle Cell Anemia
* Oral Manifestations
(6)
–Mucosal pallor or jaundice
–Papillary atrophy
–Delayed tooth eruption
–Aseptic bone and pulpal
necrosis
–Osteomyelitis
–Neuropathy
Oral Manifestations
– Radiographically
(5)
- Increased widening and
decreased number of
trabeculations - Generalized osteoporosis
(thinning of the inferior border of
the mandible) - Trabeculations and lamina dura
appear more prominent - “Stepladder” trabeculae
- “Hair on end”
Dental Management
* Sickle Cell Anemia
– Routine care during — states
– Keep appointments short to —
– Emphasis on oral hygiene instructions to reduce risk of —
– Monitor oxygen saturation, when using nitrous oxide, provide oxygen at greater than —
– — for major surgical procedures
– Pain management:
non-crisis
reduce stress
infection
50% with high flow rates
Antibiotic prophylaxis
consult their primary care or hematologist (opioid contract)
Dental Management
* Sickle Cell Anemia
– Emphasis on oral hygiene instructions to reduce risk of infection
* If infection occurs, consider (2)
IM or IV antibiotics
Dental Management
* Sickle Cell Anemia
– Anesthetic:
(3)
- Avoid prilocaine
- Epinephrine 1:100,000-no stronger concentration
- May consider using LA without epinephrine
Aplastic Anemia
- Bone marrow failure resulting in
pancytopenia
Aplastic Anemia
* Causes
(6)
– Chemotherapy and radiation
– Autoimmune diseases
– Toxic chemicals (benzene)
– Viral
– Medications (methotrexate)
– Inherited (Fanconi anemia)
Aplastic Anemia
* Treatment
– Hematopoietic cell transplant
Aplastic Anemia
* Oral Manifestations
(3)
– Anemia
– Thrombocytopenia
– Neutropenia
Aplastic Anemia
* Oral Manifestations
– Anemia
(2)
- Atrophic glossitis with loss on
tongue papillae, redness or
cheilosis - Mucosal pallor
Aplastic Anemia
* Oral Manifestations
– Thrombocytopenia
(1)
- Petechia, spontaneous or
prolonged bleeding
Aplastic Anemia
* Oral Manifestations
– Neutropenia
(2)
- Infection
– Viral, fungal, bacterial - Ulceration
Aplastic Anemia & Bone Marrow Failure
Dental Management
(5)
- Thorough medical history
- Discussion with oncologist
- Labs
- Confirm patient is afebrile
- Local hemostatic measures for patients with thrombocytopenia
Aplastic Anemia & Bone Marrow Failure
Discussion with oncologist
(3)
- Current status and goals
- Defer routine care
- Dental office vs hospital
Aplastic Anemia & Bone Marrow Failure
Labs
* CBC
* Platelet:
* ANC-
may require platelet transfusion due to
thrombocytopenia
may require antibiotic prophylaxis for neutropenia
(>500)
Bleeding Disorders
(3)
- Platelet Disorders
- Inherited Coagulation Disorders
- Medication related bleeding Disorders
Thrombocytopenia
–— platelet levels (CBC)
* Normal:
* Severe:
Low
150,000-400,000
<50,000
Thrombocytopenia
–Causes: (4)
–Signs (2)
decreased
production, destruction,
medications, blood loss
Prolonged bleeding, petechia
Thrombocytopenia
–Oral Manifestations
(3)
- Petechia
- Spontaneous gingival bleeding
- Prolonged bleeding after
procedures
Thrombocytopenia
– Dental Management
(6)
- Thorough medical history
- May defer routine dental care
- CBC
- Discussion with patient’s MD
- Avoid block injections
- Local hemostatic measures
Thrombocytopenia
* Thorough medical history
(2)
– Cause of thrombocytopenia (acute cause? chronic cause?)
– Bleeding history, transfusion history
Thrombocytopenia
* CBC
(3)
– Recent (<24 hours)
– Platelet >50,000 for most dental procedures reduces risk
– Higher for invasive surgical procedures (ex. multiple extractions)
Thrombocytopenia
Discussion with patient’s MD
(2)
– Platelet transfusions, timing
– Dental office vs hospital (<50,000 more appropriate in hospital setting)
– Most common inherited clotting disorder (1%
US population)
Von Willebrand Disease
Von Willebrand Disease
(2)
– Missing or defective VWF (clotting protein)
* Required for platelet adhesion
– Type 1 (20-50% normal levels), Type 2
(qualitative), Type 3 (quantitative, severe
symptoms)
Von Willebrand Disease
– SS: (5)
– Tx: (1)
epistaxis, petechia, ecchymosis,
excessive/prolonged bleeding from invasive
procedures, hemarthrosis
DDAVP (desmopressin)
Bleeding Disorders: Platelet Disorders
* Von Willebrand Disease
–Dental Management
(4)
- Thorough medical
history/bleeding history and
physical exam - Discussion with patient’s MD
- Avoid block injections
- Local hemostatic measures
- Von Willebrand Disease
Discussion with patient’s MD
(3)
– Confirm history and severity of
disease
– DDAVP, aminocaproic acid
– Dental office vs hospital
Hemophilia
(2)
–Hemophilia A (Factor 8 deficiency)
and B (Factor 9 deficiency)
* X-linked recessive
–Severity
* Mild 6%-30% (A)or 49% (B), moderate
1%-5%, severe <1%
Hemophilia
–SS: (3)
–Tx: (2)
prolonged or spontaneous
bleeding, ecchymosis, hemarthrosis
factor infusions, DDAVP (A)
Bleeding Disorders: Inherited Coagulation
* Hemophilia
–Dental Management
(4)
- Thorough medical history/bleeding
history and physical exam - Discussion with patient’s hematologist
- Avoid block injections
- Local hemostatic measures
Hemophilia
* Discussion with patient’s hematologist
(3)
– Confirm history and severity of disease
– Dental office vs hospital
– Factor infusions, aminocaproic acid
Plavix (clopidogrel)
(3)
–Antiplatelet agent
–Reduce risk of MI and stroke
–Increased risk of bleeding and
bruising
Plavix (clopidogrel)
–Dental Management
(2)
- Medication list to evaluate bleeding
risk
– Other anticoagulants - Local measures
– Low risk of bleeding far outweighs
interrupting Plavix treatment
Coumadin (warfarin)
–
– For patients with (4)
– Common side effect:
Vitamin K antagonist
Afib, heart
failure, prosthetic heart valves,
stroke/MI history…
bleeding
Coumadin (warfarin)
– Monitoring
* PT/INR goals:
* Higher in patients with
– Antidote
(1)
2.0-3.0
prosthetic heart valves (3.0-3.5)
- Vitamin K
Coumadin (warfarin)
–Dental Management
* Dental procedures are generally considered — risk of
bleeding
(2)
low
– Thromboembolic risk vs procedural bleeding risk
– Discussion with patients MD for procedures with higher risk of
bleeding
Coumadin (warfarin)
–Dental Management
Review INR (within 24 hours)
– INR: — dental treatment
2.0-3.0
Coumadin (warfarin)
–Dental Management
* Local hemostatic measures
* Medications
(2)
– Many medication interactions due to narrow therapeutic range
– Avoid cytochrome P-450 inhibitors (ex. fluconazole) and inducers
Bleeding Disorders: Medication Related
* Direct Oral Anticoagulants (DOAC) and Direct Thrombin Inhibitors
(6)
–Direct inhibitor of factor Xa and thrombin
–Class of newer anticoagulants
* Alternative to warfarin
–Highly effective
–No lab monitoring
–Reversal agent
–More expensive
DOAC and Direct
Thrombin Inhibitors
–Dental Management
(3)
- No lab monitoring
- Bleeding risk for dental
procedures seems to be low - Local hemostatic measures
Hematologic Malignancies
(3)
- Leukemia
- Lymphoma
- Myeloma
Leukemia
Cancer of WBCs
* Affects (2)
* Proliferation of WBCs which can
be
bone marrow and
circulating blood
non-functional (blasts) or
overtime overcrowd/suppress
normal marrow production
Leukemia
Classification
* Lineage:
* Timing:
Myeloid vs Lymphoid
Acute vs Chronic
Leukemia
(4)
- Acute Myeloid (AML)
- Chronic Myeloid (CML)
- Acute Lymphocytic (ALL)
- Chronic Lymphocytic (CLL)
Leukemia
Causes Include:
(4)
- Radiation
- Chemotherapy
- Genetic
- Down syndrome
Leukemia
Diagnosis
(3)
- CBC
- Blood smear
- Molecular studies
Leukemia
Treatment
(4)
- Chemotherapy
- Radiation
- Targeted therapy
- Hematopoietic stem cell
transplant
Leukemia
Signs and Symptoms
(2)
- Fatigue, malaise, petechiae,
ecchymoses, fever - Related to functional or
treatment related neutropenia
and thrombocytopenia
Leukemia
Oral Manifestations
(5)
- Leukemia infiltrate
- Spontaneous gingival bleeding
- Oral ulceration (neutropenic
ulcer, mucositis) - Infection - Viral, fungal, bacterial
- Lymphadenopathy (chronic)
Leukemia
Dental Management
* Urgent referral to PCP or emergency room for
leukemic infiltrate-CBC, smear, flow cytometry
Leukemia
If Dx known:
* Thorough medical history
* Discussion with oncologist
(3)
- Current status and goals (comprehensive vs. palliative)
- Dental office vs hospital
- Timing of dental care-not on active chemotherapy for routine care
Leukemia
Labs
* CBC
(2)
- Platelet: may require platelet transfusion due to
thrombocytopenia - ANC-may require antibiotic prophylaxis for neutropenia (>500)
Leukemia
* Confirm patient is —
* Local hemostatic measures for patients with —
afebrile
thrombocytopenia
Lymphoma
Cancer of lymphoid organs and tissues
Hodgkin Lymphoma
(3)
- Reed-Sternberg cell
- Young adults
- LAD
- Non-tender, firm
- > 50% affect mediastinal or neck
nodes
Non Hodgkin Lymphoma (NHL)
* Median Age:
* B-symptoms
(3)
* Over 20 types
(2)
67
- Fever, night sweats (drenching),
weight loss (unintentional >10%)
- Diffuse Large B-cell (DLBCL)
- Follicular
Lymphoma
Causes Include
(4)
- Autoimmune diseases
- Hepatitis C
- EBV
- Sjogren syndrome
Lymphoma
Diagnosis
(2)
- Bone marrow or lymph node biopsy
- MRI for staging
Lymphoma
Treatment
(5)
- Chemotherapy
- Radiation
- Immunotherapy
- Stem cell transplant
- Watching
Lymphoma
Oral Manifestations
(3)
- LAD (Waldeyers ring, neck)
- Extranodal involvement
- Infection (Viral, fungal, bacterial)
Extranodal involvement
(3)
- Oral Ulceration
- Localized infiltrate
- Osteolytic radiographic lesions
Lymphoma
* Treatment related
- Head and Neck Radiation
(lymphomas in head and neck
region only) - Hyposalivation
- Trismus
- Osteonecrosis
Lymphoma
* Dental Management
(6)
– Similar to leukemia but risk for neutropenia and thrombocytopenia is lower and
generally treatment related (chemotherapy, radiation)
– Thorough medical history
– Discussion with oncologist
– Labs
– Confirm patient is afebrile
– Local hemostatic measures for patients with thrombocytopenia
Discussion with oncologist
(3)
- Current status and goals (comprehensive vs. palliative)
- Dental office vs hospital
- Timing of dental care-not on active chemotherapy for routine care
– Labs
* CBC
(2)
– Platelet: may require platelet transfusion due to thrombocytopenia
– ANC-may require antibiotic prophylaxis for neutropenia (>500)
Multiple Myeloma
- Cancer of plasma cells
– Prevents normal production of antibodies
Multiple Myeloma
Signs and Symptoms
(5)
– Hypercalcemia
– Renal damage
– Anemia
– Bone pain
– Infection
Multiple Myeloma
Treatment
(3)
– Chemotherapy (RVD)
– Bisphosphonates
– Hematopoietic Stem Cell Transplant
Multiple Myeloma
Oral Manifestations
(3)
– Plasmacytoma
– Lytic bone lesions
– Infection (Viral, fungal, bacterial)
Multiple Myeloma
– Treatment Related
(2)
* Radiographic
(5)
- Neuropathy
- MRONJ (IV Zometa)
– Thick lamina dura
– Persistent extraction site
– Sclerosis
– Sequestra
– Fracture
Multiple Myeloma
* Dental Management
– Disease related management
(3)
- Soft tissue swelling, radiographic findings
- Infection management
- Pre-bisphosphonate exam
Multiple Myeloma
Medication related
* MRONJ
(5)
– Bisphosphonate history (number of doses, active)
– Chlorhexidine rinses
– Oral Hygiene
– Antibiotic regimen
– Sequestration
Multiple Myeloma
Surgical Procedures
(4)
– Informed consent
– As atraumatic as possible
– Thorough post surgical instructions including chlorhexidine rinses and antibiotic prophylaxis
– Re-eval after surgical procedures to ensure healing
Hematopoetic Stem Cell Transplant
(2)
- Infusion of stem cells to re-establish hematopoietic
function in patients whose bone marrow or immune
system is damaged or defective - Treatment for solid or hematologic malignancies or other
hematologic disorders
Indications for Stem Cell Transplant
* Malignancy
– Hematologic
(3)
- Leukemia
- Lymphoma
- Multiple Myeloma
Indications for Stem Cell Transplant
* Malignancy
– Solid
(5)
- Neuroblastoma
- Desmoplastic small round
cell tumor - Ewings sarcoma
- Choriocarcinoma
- Ovarian
Indications for Stem Cell Transplant
* Hematologic Disorder
(3)
– Phagocyte Disorder
(myelodysplasia)
– Anemia
– Myeloproliferative
Indications for Stem Cell Transplant
Anemia
(4)
- Aplastic
- Fanconi
- Sickle Cell
- Thalassemia
Indications for Stem Cell Transplant
Myeloproliferative
(1)
- Polycythemia vera
Indications for Stem Cell Transplant
Other
(2)
- Amyloidoses
- Autoimmune disorders
skipped
Pre-Transplant Evaluation
- History and physical
- Blood workup
– CBC, blood type, HCG, HLA - Restaging studies
– Bone marrow aspirate, cytogenics, LP, CT/MRI, PET scan - Infectious disease testing
– CMV, Hep A/B, EBV, HIV, HSV, VZV, toxoplasmosis - PPD, chest x-ray, EKG
- Dental screening
- Fertility
– Sperm banking, oocyte or embryo freezing
Pre-Transplant Evaluation:
Dental Screening Goals
* Remove
* Dentition to be stable for at least
* Patient education about
* If planned correctly, pre-transplant evaluation + patient
compliance=
active foci of infection and limit potential foci of infection
12 months
home care
dental maintenance
Dentition to be stable for at least 12 months
(2)
– Urgent care only for 12 months post transplant
– Risk of salivary GVHD and hyposalivation
caries
Dental Screening Pre-HSCT
(2)
- Comprehensive hard and soft tissue exam
- Full mouth series of radiographs
Dental Screening Pre-HSCT
Treatment
(5)
– Scaling and prophylaxis
– Removal of caries
– Extraction of all hopeless teeth
& 3rd molars with hx periocoronitis
* Including teeth with questionable or poor prognosis
– Caries risk assessment and need for adjuncts (fluoride)
– Dental management based on primary disease
– Removal of caries
(3)
- Restorations
- Endodontic therapy
- Extractions
Graft Types
* Autologous:
– Pros:
– Cons:
– Indications include:
– Receive own bone marrow or PBSC, “stem cell rescue”
no HLA matching, no GVHD, immune suppression
contamination of cells, no graft vs tumor, higher risk of relapse
lymphoma, multiple myeloma
Graft Types
* Allogeneic:
– Pros:
– Cons:
– Indications include:
– Donor: relative, unrelated
– Pros: graft free from tumor, graft versus tumor, lower risk of relapse
– Cons: matching, GVHD, higher risk of complication
– Indications include: leukemia, MDS, aplastic anemia, high grade lymphoma
Graft Types
* Syngenic
(1)
– Receive bone marrow or PBSC from identical twin
Phases of Transplant
(4)
- Collection
- Preparative Regimen (Conditioning)
- Stem cell infusion
- Engraftment
Oral Manifestations HSCT
(6)
- Mucositis
- Bleeding
- Infection
- Medication side effect/toxicities
- Graft versus host disease
- Increased risk of oral cancer
- Mucositis
– Acute; resolves after engraftment
- Bleeding
– Petechiae, ecchymosis, hematoma
- Infection
(3)
– Viral (ex. HSV)
– Fungal (ex. candidiasis)
– Bacterial
- Medication side effect/toxicities
(2)
– Gingival hyperplasia (cyclosporine)
– Oral ulceration (sirolimus)
- Graft versus host disease
(2)
– Mucosal (lichenoid changes)
– Salivary-hyposalivation, caries
Hematopoietic Cell Transplant
* Dental Management After Transplant
– Thorough medical history
- Original diagnosis, date of transplant, immune suppression, GVHD
Hematopoietic Cell Transplant
– Thorough clinical exam
- Hyposalivation, caries, infection, GVHD, oral cancer
Hematopoietic Cell Transplant
– Discussion with oncologist
(2)
- Current status and goals (comprehensive vs. palliative)
- Dental office vs hospital
Hematopoietic Cell Transplant
– Labs
* CBC-
* ANC-
may require platelet transfusion due to thrombocytopenia
may require antibiotic prophylaxis for neutropenia
Hematopoietic Cell Transplant
– Medications
(3)
- Immune suppression (dose and length of tx)
- Bactrim-myelosuppression
- Avoid medications that are cytochrome P450 inhibitors for patients on immunosuppressants with low therapeutic index (ex. tacrolimus and fluconazole)
