Dental Management- Hematology Flashcards
(85 cards)
1
Q
Oral manifestations of nutritional causes (def in iron, B12 or folate)
A
Pale mucosa, loss of papilla, atrophic mucosa, burning or sore tongue, angular cheilitis, aphthae
2
Q
Iron def anemia - Plummer Vinson syndrome symptoms
A
Sore mouth, dysphagia with esophageal stenosis–> increases risk for carcinoma of oral cavity and pharynx
3
Q
Dental care for asymptomatic iron def anemia, Hb >11
A
Usually no problems with routine care
4
Q
Dental care for symptomatic iron def
A
- Short of breath
- abnormal heart rate
- O2 saturation <91,
So, defer care and oral surgery, no general anesthesia if Hb <10
5
Q
Oral manifestations of pernicious anemia (B12 def)
A
Defects in myelin synthesis (paresthesias of oral tissues, burning, tingling, numbness, tongue and lips)
6
Q
Dental care for pernicious anemia
A
Usually no need to modify care once pt is under treatment
7
Q
Oral manifestations of aplastic anemia (pancytopenia)
A
- Mucosal pallor, petechiae, ecchymoses, ulceration, gingival bleeding or swelling, necrotizing gingivostomatitis
8
Q
Thalassemias mainly affect what bones?
A
Craniofacial
9
Q
Thalassemia orofacial findings
A
Class II malocclusion, lateral displacement of orbits and development of chipmunk facies, characterized by maxillary expansion, saddle nose, frontal bossing and depressed cranial vault
10
Q
G6PD deficiency, what drugs should be avoided?
A
- Sulfonamides
- Antimalarials- dapsone, primaquine
- Chloramphenicol- risk of aplastic anemia
- Aspirin
11
Q
Oral manifestations of sickle cell anemia
A
Pale mucosa, jaundice, altered trabecular pattern jaws (marrow hyperplasia) and stepladder trabeculation between teeth, hair on end in skull film, vasoocclusive events (pukpal necrosis, osteomyelitis)
12
Q
RBC disorders- Analgesic considerations
A
Avoid strong narcotics and high doses of salicylates. Use acetaminophen with or without small doses of codeine
13
Q
RBC disorders- Antibiotic considerations
A
Ab prophy generally recommended for major surgical procedures in sickle cell
14
Q
Anesthesia considerations
A
Consider using local without epi. For surgery, use epi and limit carpules to under 3
15
Q
Non-crisis sickle cell anemia. Routine care with what added precautions?
A
- MD consult- confirm stable condition
- Short appointments
- Avoid long, complicated procedures
- Maintain good dental repair
16
Q
Aggressive preventative care for sickle cell anemia
A
- OHI
- Diet control
- Home care
- Fluoride application and fluoride gel in trays for home use
17
Q
Non-crisis sickle cell. Need to avoid infections and treat infections expeditiously
A
- High dose antibiotics
- Incision and drainage
- Heat
- Pulpectomy, extraction
- If cellulitis present, consult physician
18
Q
What is concern for local anesthetics in sickle cell anemia?
A
Hypoxia from vasoconstricotr (use without in non-surgical and with for surgical)
19
Q
What is MM?
A
Overproduction of malignant plasma cells involving bone
20
Q
What is Burkitt lymphoma?
A
Non-hodgkin B cell lymphoma involving bone and lymph nodes
21
Q
Oral manifestations of leukemia
A
Gingival enlargement (localized or generalized)
- Inflam and infiltration of atypical and immature WBCs
- Gingiva is boggy and bleeds easily, and multiple tooth sites are typically affected
22
Q
Oral manifestations of AML
A
- Generalized gingival enlargement is more common than localized (prevelant when oral hygiene is poor, patients usually have monocytic type M5, gingival bleeding and fetor oris)
- Granulocytic sarcoma or chloroma (localized mass of leukemic cells in gingiva)
23
Q
Oral manifestations of CML
A
- generalized lymphadenopathy
- Pallor
- Oral soft tissue infection may be present
24
Q
What is less likely to show oral manifestations- CML or AML?
A
CML
25
Oral manifestations of CLL
- Generalized lymphadenopathy
- Pallor
- Oral soft tissue infection may become evident as the patient develops hypogammaglobulinemia
26
Oral manifestations of Hodgkin lymphoma
- Painless mass or a group of firm, nontender, enlarged lymph nodes, rubbery consistency
(often affect mediastinal nodes or neck nodes)
27
Oral manifestations of non-hodgkin lymphoma
Cervical lymphadenopathy and extranodal or intraoral tumors
28
Lymphoma in the oral cavity usually appears as
extranodal disease
29
Sjogren syndrome patients are at an increased risk for
lymphoma
30
Intraoral lymphoma most commonly involves
Waldeyer's ring (soft palate and oropharynx)
31
Endemic burkitt lymphoma
- Predilection for tumors of the jaw (common pts under 5)
- Also in kidneys, ovaries and adrenal glands
- 90% EBV +
32
Non-endemic burkitt lymphoma
- Abdominal mass involving lymph nodes of intestine and peritoneum
- Jaw lesions less common
- 15-20% EBV+
33
Endemic Burkitt Lymphoma oral manifestation
- Rapidly expanding tumors (post mand or max)
- Rapid growth pushes adjacent teeth
- Pain and paresthesia accompany the condition
- Radiographic appearance: tumor produces osteolytic lesion, porly demarcated margins, erosion of cortical plate, soft tissue involvement)
34
Multiple myeloma oral manifestations
- May have jaw lesions, soft tissue lesions and soft tissue deposits of amyloid
- Bone and soft tissue lesions often painful
- Radiographs show punched out or mottled areas
35
MM: Describe the extramedullary plasma cell tumors that can occur in the oral pharynx
- Amyloid like protein is found sometimes in oral soft tissues
- Areas may be swollen and painful
- Biopsy and special amyloid stains can be used for diagnosis
36
Up to 80% of newly diagnosed MM patients present with
Osteopenia, osteolysis and pathologic fractures
37
Multiple myeloma oral manifestations often treated with what drugs?
Ones that inhibit osteoclast activity- such as bisphosphonates, RANKL inhibitors
38
What is Medication-related osteonecrosis of the jaw? (MRONJ)
potentially serious complication of antiresorptive agents commonly used in the management of MM
39
MRONK is characterized by areas of
exposed and necrotic bone (more likely in mandible)
40
Leukemic patients whose disease has not been diagnosed may experience
serious bleeding problems after any surgical procedure, have problems with healing of surgical wounds, have postsurgical infections
41
An enlarges supraclavicular node is highly suggestive of
malignancy
42
PANs can show
osteolytic lesions associated with WBC disorders
43
Treatment planning for pts undergoing chemo involves
- Pretreatment assessment and prep of pt
- oral health care during medical therapy
- Posttreatment management, including long term considerations and possible remission
44
What should pretreatment assessment include for pts undergoing chemo?
- Extraoral and intraoral exams
- PAN
- Review blood lab findings
- Overall goal of minimizing or eliminating oral disease before start of chemo or radiation therapy
45
Prior to chemo, pt has poor dental status
Consider full mouth EXTs
46
Prior to chemo, pt has good dental status
maintain dentition
47
Prior to chemo, extraction considerations
- Done a min of 2 weeks between time of EXT and initiation of chemo or radiotherapy
- Attain primary closure
- If invasive procedures are planned and platelets below 50,000, discuss platelet transfusion prior to treatment
48
Can neutropenic patients undergo invasive dental procedures?
Not without special prep and precautions
49
If pt is neutropenic, physician may select to use
recombinant human granulocyte colony stimulating factor to promote growth and differentiation of neutrophils before surgical procedures
50
Neutropenic patients, antibiotic considerations
Prophy ABx often recommended, (consider amox+ clavulanic acid)
51
Patients who undergo chemo or radiotherapy are susceptible to many oral complications which include
- Mucositis
- Neutropenia
- Infection
- Excessive bleeding
- Graft versus host disease if given bone marrow transplant
- Alterations in growth and development
52
Describe mucositis
- Affected mucosa becomes red, raw and tender
- Breakdown of epi barrier produces oral ulcerations
- Usually begins 7-10 days after initiation of chemo
- resolves after cessation of chemo
53
What and who is more likely affected by mucositis?
- Younger pts
- Nonkeratinized sites
- ventral tongue, labial and buccal mucosae, floor of mouth
54
What are treatments for mucositis?
- Maintain good hygiene
- Use bland mouth rinse to clean surface of ulcer
- Topical anesthetics and systemic analgesics
- Magic mouthwash
- Thin layer Orabase
- repeat protocal multiple times a day
- Remove sharps in restos
- Chlorhexidine without ETOH
- Novel cytoprotective agents
55
Pts with chronic neutropenia may develop
severe destruction of the periodontium with loss of attachment
56
Patients with neutropenia are unable to provide a
protective response against oral microbes
57
Why are oral infections less of a problem with chronic leukemia than with acute leukemia?
Cells are more mature and functional in chronic leukemia.
58
What sings of infection are often masked in patients with leukemia because of neutropenia?
Swelling and erythema and severe infections can have minimal signs
59
Why are opportunistic infections common in leukemic patients?
- Malignant leukocytes are immature
- Chemo induces an immunocompormised state
- Use of broad spectrum antibiotics produces selective antimicrobial killing
60
How do you treat pseudomembranous candidiasis due to Candida albicans?
treat with usual antifungals
61
Unusual oral fungal infections (torulopsis, aspergillosis and mucormycosis) or fungal septicemia may originate from the oral cavity require
potent systemic anntifungal agents such as voriconazole
62
Recurrent HSV infection may be common in patients receiving
chemo
63
Chemo patients who are HSV antibody positive may be given
prophylaxis with acyclovir, valacyclovir or famciclovir
64
Immunocompromised leukemic patients are also susceptible to
varicella zoster and CMV
65
How do you control bleeding in leukemic patients?
Use local measures- gelatin sponge with thrombin or microfibrillar collagen. Oral antifibrinolytic rinse. If those fail, may need platelet transfusion
66
Describe gingival bleeding you may see in leukemic patients
Spontaneous and severe gingival bleeding from enlarged and boggy gingiva that is aggravated by poor oral hygiene
67
What is graft versus host disease?
Common sequela of patients who undergo allogeneic hematopoietic cell transplantations (stem cless from another host). donor T cells react against Histocompatibility antigens of host
68
How is the acute stage of graft versus host defense marked?
Rash, mucosal ulcerations, elevated liver enzymes and diarrhea
69
Describe the chronic stage of graft versus host disease
mimics Sjogren syndrome and scleroderma by thickening and lichenoid changes of skin and mucosa, arthritis, xerostomia, xerophthalmia, mucositis and dysphagia
70
What are some damages to the developing teeth during chemo?
- Shortened or blunted roots
- Dilacerations
- Calcifications and abnormalities
- Pulp enlargement
- Microdontia
- Hypodontia
71
Bleeding disorders exam
- Jaundice, pallor
- Spider angiomas
- Ecchymoses
- Petechiae
- Oral ulcers
- Hyperplastic gingival tisues
- Hemarthrosis
72
What to do pre-op if pt is on warfarin
- Med consult
- Confirm diagnosis
- Level of INR intended, pt compliance
- Schedule procedure withiin 2 days of intended INR confirmation
73
What determines a low intensity- INR 2-3
- Venous thrombosis
- Pulmonary embolism
- Prevention of systemic embolism (tissue heart valves, acute MI, afib, valvular heart disease)
74
What determines high internist- INR 2.5-3.5
- Mechanical prosthetic heart valve
- Prevention recurrent MI
75
What level of INR, do you not need to alter dosing of warfarin?
between 2-3
76
Pt is on warfarin, what local measures do you use to control bleeding?
- Sutures
- Gelfoam with or without thrombin
- Oxidized regenerated cellulose (No thrombin)
- Microfibrillar collagen (no thrombin)
77
Post-op if pt is on warfarin, what should be avoided?
aspirin and NSAIDs
78
Post-op pt is on warfarin, what drugs can be used?
Acetaminophen, with or without codeine
79
ADP inhibitor (anti platelet)
Clopidogrel
80
Hemophilia oral manifestations
- Spontaneous bleeding
- Prolonged bleeding after extractions
- Hematomas
- Oral lesions associated with HIV infection
81
Pre-op if pt has hemophilia A
- Hematology consult
- Determine where to treat
- Hematologist prescribes and administers management recommendations
- Treat acute oral infection
- Good oral hygiene
- Construct palatal splints
82
With proper preperation, what procedures can you usually provide in office to pts with hemophilia?
- Simple restorations
- Endodontics
- Conservative periodontal procedures- prophy & supragingival calculus removal
83
How soon after procedure, should you see and examine a pt with hemophilia?
24-48 hours
84
Dental pre-op prep for pt with vWF
- Treat acute oral infection
- Good oral hygiene
- Construct splints for multiple extractions (Type 2 and 3 variants, protect clot)
85
Pts with vWF should avoid what drugs post-operatively?
ASA and NSAIDs
