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Dental Management of a Complex Patient > Hematologic Diseases Dental Management > Flashcards

Hematologic Diseases Dental Management Flashcards

1
Q

Anemia

A
  • Reduction in the oxygen carrying capacity of RBCs; deficiency in red blood cells or of hemoglobin in the blood
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2
Q

Anemia
Classification
– Causes
(3)

A
  • Blood Loss
  • Inadequate production
  • Excess destruction
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3
Q

Anemia
Classification
– Morphology
(3)

A
  • Normocytic
  • Microcytic
  • Macrocytic
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4
Q

Laboratory Tests: Anemia
* CBC (Complete Blood Count)
(5)

A
  • Hb*
  • Hematocrit*
  • WBC
  • Platelet
  • RBC indices*
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5
Q
  • Hb* (Concentration of hemoglobin)
  • <— g/dL (men) or <— g/dL (women)
A

13.5
12.0

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6
Q
  • Hematocrit* (Packed cell volume)
  • <—% (men) or <—% (women)
A

41.0
36.0

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7
Q

RBC indices*
(4)

A
  • MCV (mean corpuscular volume)
  • MCH (mean cell hemoglobin)
  • RDW (red cell distribution width)
  • MCHC (mean cell hemoglobin concentration)
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8
Q

Types of Anemia (size)
(3)

A
  • Microcytic
  • Macrocytic
  • Normocytic
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9
Q
  • Microcytic
    (2)
A

– Iron Deficiency Anemia
– Thalassemias

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10
Q
  • Macrocytic
    (3)
A

– Pernicious Anemia
– Folate Deficiency
– B12 Deficiency

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11
Q
  • Normocytic
    (2)
A

– Hemolytic Anemia
– Sickle Cell Anemia

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12
Q

Iron Deficiency Anemia
(2)

A
  • Microcytic anemia
  • More common in women of
    childbearing age and children
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13
Q

Iron Deficiency Anemia
* Causes:

A

blood loss, poor iron
intake, poor iron absorption, or
increased demand for iron

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14
Q

Iron Deficiency Anemia
* Labs:

A

Serum iron, ferritin, TIBC,
transferrin

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15
Q

Macrocytic (Megaloblastic) Anemias
* Folate Deficiency
–
– Deficiency during pregnancy causes
– Labs:

A

Not stored in the body in large amounts; continual
dietary supply is needed
neural tube defects in the child
Serum folate level

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16
Q

Macrocytic (Megaloblastic) Anemias
* Cobalamin (B12) Deficiency
(3)

A

– Pernicious Anemia
– Nitrous Oxide
– Labs: Serum B12

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17
Q

– Pernicious Anemia

A
  • Deficiency of intrinsic factor which is necessary
    for B12 absorption
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18
Q

– Nitrous Oxide
(2)

A
  • Irreversible inactivation of B12
  • Neurologic symptoms
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19
Q

Anemia: Clinical Presentation
* Systemic
– Symptoms: (5)
– Signs: (3)

A

Fatigue, weakness,
palpitations, SOB, angina,
tingling of fingers and toes

pallor, splitting and
spooning of fingernails

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20
Q

Anemia: Clinical Presentation
* Oral Manifestations
(2)

A

– Atrophic glossitis with loss on
tongue papillae, redness or
cheilosis
– Mucosal pallor

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21
Q

Anemia
(3)

A

–Generally tolerate routine dental treatment well
–Avoid long N20 exposure in patients with B12
deficiency
–Identifying signs and symptoms of anemia

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22
Q

–Generally tolerate routine dental treatment well
* Severe anemia (cardiopulmonary symptoms)
(3)

A

–Defer routine dental care
–Pulse oximeter and supplemental oxygen
–Avoid strong narcotics

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23
Q

–Identifying signs and symptoms of anemia
* Important to find the cause!
(2)

A

–GI bleed, chronic inflammation pancytopenia

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24
Q

Sickle Cell Anemia
(3)

A
  • Autosomal recessive inherited
    disorder
  • RBC sickling in low oxygen or low
    blood pH environments
  • Erythrostasis, increased blood
    viscosity, reduced blood flow,
    vascular occlusion, hypoxiamore
    sickling
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25
Q

Sickle Cell Anemia
* Systemic Signs and Symptoms
(7)

A

– Result of chronic anemia and small blood vessel
occlusion
– Jaundice, pallor
– Leg ulcers
– Cardiac
– Delays in growth and Development
– Pain
– Sickle cell crisis

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26
Q

– Cardiac
(2)

A
  • Cardiac failure
  • Stroke
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27
Q

– Pain
(2)

A
  • Abdominal
  • Bone (aseptic necrosis)
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28
Q

– Sickle cell crisis
(2)

A
  • Prolonged (hours-days) severe pain which pay require
    hospitalization for pain management
  • Causes: infection, higher altitude (hypoxia), dehydration,
    trauma
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29
Q

Sickle Cell Anemia
* Oral Manifestations
(6)

A

–Mucosal pallor or jaundice
–Papillary atrophy
–Delayed tooth eruption
–Aseptic bone and pulpal
necrosis
–Osteomyelitis
–Neuropathy

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30
Q

Oral Manifestations
– Radiographically
(5)

A
  • 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”
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31
Q

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:

A

non-crisis
reduce stress
infection
50% with high flow rates
Antibiotic prophylaxis
consult their primary care or hematologist (opioid contract)

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32
Q

Dental Management
* Sickle Cell Anemia

– Emphasis on oral hygiene instructions to reduce risk of infection
* If infection occurs, consider (2)

A

IM or IV antibiotics

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33
Q

Dental Management
* Sickle Cell Anemia

– Anesthetic:
(3)

A
  • Avoid prilocaine
  • Epinephrine 1:100,000-no stronger concentration
  • May consider using LA without epinephrine
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34
Q

Aplastic Anemia

A
  • Bone marrow failure resulting in
    pancytopenia
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35
Q

Aplastic Anemia
* Causes
(6)

A

– Chemotherapy and radiation
– Autoimmune diseases
– Toxic chemicals (benzene)
– Viral
– Medications (methotrexate)
– Inherited (Fanconi anemia)

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36
Q

Aplastic Anemia
* Treatment

A

– Hematopoietic cell transplant

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37
Q

Aplastic Anemia
* Oral Manifestations
(3)

A

– Anemia
– Thrombocytopenia
– Neutropenia

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38
Q

Aplastic Anemia
* Oral Manifestations
– Anemia
(2)

A
  • Atrophic glossitis with loss on
    tongue papillae, redness or
    cheilosis
  • Mucosal pallor
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39
Q

Aplastic Anemia
* Oral Manifestations
– Thrombocytopenia
(1)

A
  • Petechia, spontaneous or
    prolonged bleeding
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40
Q

Aplastic Anemia
* Oral Manifestations
– Neutropenia
(2)

A
  • Infection
    – Viral, fungal, bacterial
  • Ulceration
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41
Q

Aplastic Anemia & Bone Marrow Failure
Dental Management
(5)

A
  • Thorough medical history
  • Discussion with oncologist
  • Labs
  • Confirm patient is afebrile
  • Local hemostatic measures for patients with thrombocytopenia
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42
Q

Aplastic Anemia & Bone Marrow Failure
Discussion with oncologist
(3)

A
  • Current status and goals
  • Defer routine care
  • Dental office vs hospital
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43
Q

Aplastic Anemia & Bone Marrow Failure
Labs
* CBC
* Platelet:
* ANC-

A

may require platelet transfusion due to
thrombocytopenia
may require antibiotic prophylaxis for neutropenia
(>500)

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44
Q

Bleeding Disorders
(3)

A
  • Platelet Disorders
  • Inherited Coagulation Disorders
  • Medication related bleeding Disorders
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45
Q

Thrombocytopenia
–— platelet levels (CBC)
* Normal:
* Severe:

A

Low
150,000-400,000
<50,000

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46
Q

Thrombocytopenia
–Causes: (4)
–Signs (2)

A

decreased
production, destruction,
medications, blood loss

Prolonged bleeding, petechia

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47
Q

Thrombocytopenia
–Oral Manifestations
(3)

A
  • Petechia
  • Spontaneous gingival bleeding
  • Prolonged bleeding after
    procedures
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48
Q

Thrombocytopenia
– Dental Management
(6)

A
  • Thorough medical history
  • May defer routine dental care
  • CBC
  • Discussion with patient’s MD
  • Avoid block injections
  • Local hemostatic measures
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49
Q

Thrombocytopenia
* Thorough medical history
(2)

A

– Cause of thrombocytopenia (acute cause? chronic cause?)
– Bleeding history, transfusion history

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50
Q

Thrombocytopenia
* CBC
(3)

A

– Recent (<24 hours)
– Platelet >50,000 for most dental procedures reduces risk
– Higher for invasive surgical procedures (ex. multiple extractions)

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51
Q

Thrombocytopenia
Discussion with patient’s MD
(2)

A

– Platelet transfusions, timing
– Dental office vs hospital (<50,000 more appropriate in hospital setting)

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52
Q

– Most common inherited clotting disorder (1%
US population)

A

Von Willebrand Disease

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53
Q

Von Willebrand Disease
(2)

A

– Missing or defective VWF (clotting protein)
* Required for platelet adhesion
– Type 1 (20-50% normal levels), Type 2
(qualitative), Type 3 (quantitative, severe
symptoms)

54
Q

Von Willebrand Disease
– SS: (5)
– Tx: (1)

A

epistaxis, petechia, ecchymosis,
excessive/prolonged bleeding from invasive
procedures, hemarthrosis

DDAVP (desmopressin)

55
Q

Bleeding Disorders: Platelet Disorders
* Von Willebrand Disease
–Dental Management
(4)

A
  • Thorough medical
    history/bleeding history and
    physical exam
  • Discussion with patient’s MD
  • Avoid block injections
  • Local hemostatic measures
56
Q
  • Von Willebrand Disease
    Discussion with patient’s MD
    (3)
A

– Confirm history and severity of
disease
– DDAVP, aminocaproic acid
– Dental office vs hospital

57
Q

Hemophilia
(2)

A

–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%

58
Q

Hemophilia
–SS: (3)
–Tx: (2)

A

prolonged or spontaneous
bleeding, ecchymosis, hemarthrosis

factor infusions, DDAVP (A)

59
Q

Bleeding Disorders: Inherited Coagulation
* Hemophilia
–Dental Management
(4)

A
  • Thorough medical history/bleeding
    history and physical exam
  • Discussion with patient’s hematologist
  • Avoid block injections
  • Local hemostatic measures
60
Q

Hemophilia
* Discussion with patient’s hematologist
(3)

A

– Confirm history and severity of disease
– Dental office vs hospital
– Factor infusions, aminocaproic acid

61
Q

Plavix (clopidogrel)
(3)

A

–Antiplatelet agent
–Reduce risk of MI and stroke
–Increased risk of bleeding and
bruising

62
Q

Plavix (clopidogrel)
–Dental Management
(2)

A
  • Medication list to evaluate bleeding
    risk
    – Other anticoagulants
  • Local measures
    – Low risk of bleeding far outweighs
    interrupting Plavix treatment
63
Q

Coumadin (warfarin)
–
– For patients with (4)
– Common side effect:

A

Vitamin K antagonist
Afib, heart
failure, prosthetic heart valves,
stroke/MI history…
bleeding

64
Q

Coumadin (warfarin)
– Monitoring
* PT/INR goals:
* Higher in patients with
– Antidote
(1)

A

2.0-3.0
prosthetic heart valves (3.0-3.5)

  • Vitamin K
65
Q

Coumadin (warfarin)
–Dental Management
* Dental procedures are generally considered — risk of
bleeding
(2)

A

low

– Thromboembolic risk vs procedural bleeding risk
– Discussion with patients MD for procedures with higher risk of
bleeding

66
Q

Coumadin (warfarin)
–Dental Management
Review INR (within 24 hours)
– INR: — dental treatment

A

2.0-3.0

67
Q

Coumadin (warfarin)
–Dental Management
* Local hemostatic measures
* Medications
(2)

A

– Many medication interactions due to narrow therapeutic range
– Avoid cytochrome P-450 inhibitors (ex. fluconazole) and inducers

68
Q

Bleeding Disorders: Medication Related
* Direct Oral Anticoagulants (DOAC) and Direct Thrombin Inhibitors
(6)

A

–Direct inhibitor of factor Xa and thrombin
–Class of newer anticoagulants
* Alternative to warfarin
–Highly effective
–No lab monitoring
–Reversal agent
–More expensive

69
Q

DOAC and Direct
Thrombin Inhibitors
–Dental Management
(3)

A
  • No lab monitoring
  • Bleeding risk for dental
    procedures seems to be low
  • Local hemostatic measures
70
Q

Hematologic Malignancies
(3)

A
  • Leukemia
  • Lymphoma
  • Myeloma
71
Q

Leukemia
Cancer of WBCs
* Affects (2)
* Proliferation of WBCs which can
be

A

bone marrow and
circulating blood

non-functional (blasts) or
overtime overcrowd/suppress
normal marrow production

72
Q

Leukemia
Classification
* Lineage:
* Timing:

A

Myeloid vs Lymphoid

Acute vs Chronic

73
Q

Leukemia
(4)

A
  • Acute Myeloid (AML)
  • Chronic Myeloid (CML)
  • Acute Lymphocytic (ALL)
  • Chronic Lymphocytic (CLL)
74
Q

Leukemia
Causes Include:
(4)

A
  • Radiation
  • Chemotherapy
  • Genetic
  • Down syndrome
75
Q

Leukemia
Diagnosis
(3)

A
  • CBC
  • Blood smear
  • Molecular studies
76
Q

Leukemia
Treatment
(4)

A
  • Chemotherapy
  • Radiation
  • Targeted therapy
  • Hematopoietic stem cell
    transplant
77
Q

Leukemia
Signs and Symptoms
(2)

A
  • Fatigue, malaise, petechiae,
    ecchymoses, fever
  • Related to functional or
    treatment related neutropenia
    and thrombocytopenia
78
Q

Leukemia
Oral Manifestations
(5)

A
  • Leukemia infiltrate
  • Spontaneous gingival bleeding
  • Oral ulceration (neutropenic
    ulcer, mucositis)
  • Infection - Viral, fungal, bacterial
  • Lymphadenopathy (chronic)
79
Q

Leukemia
Dental Management
* Urgent referral to PCP or emergency room for

A

leukemic infiltrate-CBC, smear, flow cytometry

80
Q

Leukemia
If Dx known:
* Thorough medical history
* Discussion with oncologist
(3)

A
  • Current status and goals (comprehensive vs. palliative)
  • Dental office vs hospital
  • Timing of dental care-not on active chemotherapy for routine care
81
Q

Leukemia
Labs
* CBC
(2)

A
  • Platelet: may require platelet transfusion due to
    thrombocytopenia
  • ANC-may require antibiotic prophylaxis for neutropenia (>500)
82
Q

Leukemia
* Confirm patient is —
* Local hemostatic measures for patients with —

A

afebrile
thrombocytopenia

83
Q

Lymphoma

A

Cancer of lymphoid organs and tissues

84
Q

Hodgkin Lymphoma
(3)

A
  • Reed-Sternberg cell
  • Young adults
  • LAD
  • Non-tender, firm
  • > 50% affect mediastinal or neck
    nodes
85
Q

Non Hodgkin Lymphoma (NHL)
* Median Age:
* B-symptoms
(3)
* Over 20 types
(2)

A

67
- Fever, night sweats (drenching),
weight loss (unintentional >10%)

  • Diffuse Large B-cell (DLBCL)
  • Follicular
86
Q

Lymphoma
Causes Include
(4)

A
  • Autoimmune diseases
  • Hepatitis C
  • EBV
  • Sjogren syndrome
87
Q

Lymphoma
Diagnosis
(2)

A
  • Bone marrow or lymph node biopsy
  • MRI for staging
88
Q

Lymphoma
Treatment
(5)

A
  • Chemotherapy
  • Radiation
  • Immunotherapy
  • Stem cell transplant
  • Watching
89
Q

Lymphoma
Oral Manifestations
(3)

A
  • LAD (Waldeyers ring, neck)
  • Extranodal involvement
  • Infection (Viral, fungal, bacterial)
90
Q

Extranodal involvement
(3)

A
  • Oral Ulceration
  • Localized infiltrate
  • Osteolytic radiographic lesions
91
Q

Lymphoma
* Treatment related

A
  • Head and Neck Radiation
    (lymphomas in head and neck
    region only)
  • Hyposalivation
  • Trismus
  • Osteonecrosis
92
Q

Lymphoma
* Dental Management
(6)

A

– 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

93
Q

Discussion with oncologist
(3)

A
  • Current status and goals (comprehensive vs. palliative)
  • Dental office vs hospital
  • Timing of dental care-not on active chemotherapy for routine care
94
Q

– Labs
* CBC
(2)

A

– Platelet: may require platelet transfusion due to thrombocytopenia
– ANC-may require antibiotic prophylaxis for neutropenia (>500)

95
Q

Multiple Myeloma

A
  • Cancer of plasma cells
    – Prevents normal production of antibodies
96
Q

Multiple Myeloma
Signs and Symptoms
(5)

A

– Hypercalcemia
– Renal damage
– Anemia
– Bone pain
– Infection

97
Q

Multiple Myeloma
Treatment
(3)

A

– Chemotherapy (RVD)
– Bisphosphonates
– Hematopoietic Stem Cell Transplant

98
Q

Multiple Myeloma
Oral Manifestations
(3)

A

– Plasmacytoma
– Lytic bone lesions
– Infection (Viral, fungal, bacterial)

99
Q

Multiple Myeloma
– Treatment Related
(2)
* Radiographic
(5)

A
  • Neuropathy
  • MRONJ (IV Zometa)

– Thick lamina dura
– Persistent extraction site
– Sclerosis
– Sequestra
– Fracture

100
Q

Multiple Myeloma
* Dental Management
– Disease related management
(3)

A
  • Soft tissue swelling, radiographic findings
  • Infection management
  • Pre-bisphosphonate exam
101
Q

Multiple Myeloma
Medication related
* MRONJ
(5)

A

– Bisphosphonate history (number of doses, active)
– Chlorhexidine rinses
– Oral Hygiene
– Antibiotic regimen
– Sequestration

102
Q

Multiple Myeloma
Surgical Procedures
(4)

A

– Informed consent
– As atraumatic as possible
– Thorough post surgical instructions including chlorhexidine rinses and antibiotic prophylaxis
– Re-eval after surgical procedures to ensure healing

103
Q

Hematopoetic Stem Cell Transplant
(2)

A
  • 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
104
Q

Indications for Stem Cell Transplant
* Malignancy
– Hematologic
(3)

A
  • Leukemia
  • Lymphoma
  • Multiple Myeloma
105
Q

Indications for Stem Cell Transplant
* Malignancy
– Solid
(5)

A
  • Neuroblastoma
  • Desmoplastic small round
    cell tumor
  • Ewings sarcoma
  • Choriocarcinoma
  • Ovarian
106
Q

Indications for Stem Cell Transplant
* Hematologic Disorder
(3)

A

– Phagocyte Disorder
(myelodysplasia)
– Anemia
– Myeloproliferative

107
Q

Indications for Stem Cell Transplant
Anemia
(4)

A
  • Aplastic
  • Fanconi
  • Sickle Cell
  • Thalassemia
108
Q

Indications for Stem Cell Transplant
Myeloproliferative
(1)

A
  • Polycythemia vera
109
Q

Indications for Stem Cell Transplant
Other
(2)

A
  • Amyloidoses
  • Autoimmune disorders
110
Q

skipped
Pre-Transplant Evaluation

A
  • 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
111
Q

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=

A

active foci of infection and limit potential foci of infection
12 months
home care
dental maintenance

112
Q

Dentition to be stable for at least 12 months
(2)

A

– Urgent care only for 12 months post transplant
– Risk of salivary GVHD and hyposalivation
caries

113
Q

Dental Screening Pre-HSCT
(2)

A
  • Comprehensive hard and soft tissue exam
  • Full mouth series of radiographs
114
Q

Dental Screening Pre-HSCT
Treatment
(5)

A

– 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

115
Q

– Removal of caries
(3)

A
  • Restorations
  • Endodontic therapy
  • Extractions
116
Q

Graft Types
* Autologous:
– Pros:
– Cons:
– Indications include:

A

– 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

117
Q

Graft Types
* Allogeneic:
– Pros:
– Cons:
– Indications include:

A

– 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

118
Q

Graft Types
* Syngenic
(1)

A

– Receive bone marrow or PBSC from identical twin

119
Q

Phases of Transplant
(4)

A
  • Collection
  • Preparative Regimen (Conditioning)
  • Stem cell infusion
  • Engraftment
120
Q

Oral Manifestations HSCT
(6)

A
  • Mucositis
  • Bleeding
  • Infection
  • Medication side effect/toxicities
  • Graft versus host disease
  • Increased risk of oral cancer
121
Q
  • Mucositis
A

– Acute; resolves after engraftment

122
Q
  • Bleeding
A

– Petechiae, ecchymosis, hematoma

123
Q
  • Infection
    (3)
A

– Viral (ex. HSV)
– Fungal (ex. candidiasis)
– Bacterial

124
Q
  • Medication side effect/toxicities
    (2)
A

– Gingival hyperplasia (cyclosporine)
– Oral ulceration (sirolimus)

125
Q
  • Graft versus host disease
    (2)
A

– Mucosal (lichenoid changes)
– Salivary-hyposalivation, caries

126
Q

Hematopoietic Cell Transplant
* Dental Management After Transplant
– Thorough medical history

A
  • Original diagnosis, date of transplant, immune suppression, GVHD
127
Q

Hematopoietic Cell Transplant
– Thorough clinical exam

A
  • Hyposalivation, caries, infection, GVHD, oral cancer
128
Q

Hematopoietic Cell Transplant
– Discussion with oncologist
(2)

A
  • Current status and goals (comprehensive vs. palliative)
  • Dental office vs hospital
129
Q

Hematopoietic Cell Transplant
– Labs
* CBC-
* ANC-

A

may require platelet transfusion due to thrombocytopenia
may require antibiotic prophylaxis for neutropenia

130
Q

Hematopoietic Cell Transplant
– Medications
(3)

A
  • 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)

Dental Management of a Complex Patient (13 decks)

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