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Dental Management of the Medically Complex Patient > Hematologic Disease > Flashcards

Hematologic Disease Flashcards

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1
Q

What is 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

How do you classify anemia?

A

Causes
* Blood Loss
* Inadequate production
* Excess destruction

Morphology
* Normocytic
* Microcytic
* Macrocytic

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3
Q

What is included in a CBC (complete blood count)?

A
  • Hb
  • Hematocrit
  • WBC
  • Platelet
  • RBC indices
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4
Q

What parts of a complete blood count are important for anemia?

A
  • Hb
  • Hematocrit
  • RBC indices
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5
Q

What is the Hb and Hematocrit levels in a person with anemia?

A
  • HB = <13.5 g/dL(men) or <12.0 g/dL(women)
  • Hematocrit = <41.0% (men) or <36.0% (women)
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6
Q

What are the four types of BC indices?

A
  • MCV (mean corpuscular volume)
  • MCH (mean cell hemoglobin)
  • RDW (red cell distribution width)
  • MCHC (mean cell hemoglobin concentration)
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7
Q

What are the types of microcytic anemia?

A

– Iron Deficiency Anemia
– Thalassemia

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8
Q

What are the types of macrocytic anemia?

A

– Pernicious Anemia
– Folate Deficiency
– B12 Deficiency

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9
Q

What are the types of normocytic anemia?

A

– Hemolytic Anemia
– Sickle Cell Anemia

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10
Q

What are the features of iron deficiency anemia?

A
  • Microcytic anemia
  • More common in women of childbearing age and children
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11
Q

What are the causes of iron deficiency anemia?

A
  • blood loss
  • poor iron intake
  • poor iron absorption
  • increased demand for iron
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12
Q

What labs are run to diagnose iron deficiency anemia?

A

Serum iron, ferritin, TIBC, transferrin

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13
Q

What are the features of folate deficiency anemia?

A

– Not stored in the body in large amounts; continual dietary supply is needed
– Deficiency during pregnancy causes neural tube defects in the child
– Labs: Serum folate level

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14
Q

What are the features of cobalamin (B12) deficiency anemia?

A
  • Pernicious Anemia
    — Deficiency of intrinsic factor which is necessary for B12 absorption
  • Nitrous Oxide
    — Irreversible inactivation of B12
    — Neurologic symptoms
  • Labs: Serum B12
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15
Q

What is the systemic clinical presentation of anemia?

A
  • Symptoms:
    — Fatigue
    — weakness
    — palpitations
    — SOB
    — angina
    — tingling of fingers and toes
  • Signs:
    — pallor
    — splitting and spooning of fingernails
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16
Q

What is the oral manifestations of anemia?

A
  • Atrophic glossitis with loss on tongue papillae, redness or cheilosis
  • Mucosal pallor
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17
Q

What is the dental management for patients with anemia?

A
  • Generally tolerate routine dental treatment well
  • Avoid long N20 exposure in patients with B12 deficiency
  • Identifying signs and symptoms of anemia
    — Important to find the cause!
    — GI bleed, chronic inflammation pancytopenia
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18
Q

What is the dental management for patients with severe anemia (cardiopulmonary symptoms)?

A
  • Defer routine dental care
  • Pulse oximeter and supplemental oxygen
  • Avoid strong narcotics
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19
Q

What are the features of sickle cell anemia?

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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20
Q

What are the systemic signs and symptoms of sickle cell anemia?

A
  • Result of chronic anemia and small blood vessel occlusion
  • Jaundice, pallor
  • Leg ulcers
  • Cardiac
    — Cardiac failure and Stroke
  • Delays in growth and Development
  • Pain
    — Abdominal
    — Bone (aseptic necrosis)
  • Sickle cell crisis
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21
Q

What is a sickle cell crisis?

A
  • Prolonged (hours-days) severe pain which pay require hospitalization for pain management
  • Causes: infection, higher altitude (hypoxia), dehydration, trauma
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22
Q

What are the oral manifestations of sickle cell anemia?

A
  • Mucosal pallor or jaundice
  • Papillary atrophy
  • Delayed tooth eruption
  • Aseptic bone and pulpal necrosis
  • Osteomyelitis
  • Neuropathy
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23
Q

What are the oral radiographic signs of sickle cell anemia?

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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24
Q

What is the dental management for sickle cell anemia?

A
  • Routine care during non-crisis states
  • Keep appointments short to reduce stress
  • Emphasis on oral hygiene instructions to reduce risk of infection
    — If infection occurs, consider IM or IV antibiotics
  • Monitor oxygen saturation, when using nitrous oxide, provide oxygen at greater than 50% with high flow rates
  • Antibiotic prophylaxis for major surgical procedures
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25
What anesthetic should be used for sickle cell anemia patients?
* Avoid prilocaine * Epinephrine 1:100,000-no stronger concentration * May consider using LA without epinephrine
26
What should you do for pain management after dental procedures for those with sickle cell anemia?
consult their primary care or hematologist (opioid contract)
27
What is aplastic anemia?
Bone marrow failure resulting in pancytopenia
28
What are the causes of aplastic anemia?
- Chemotherapy and radiation - Autoimmune diseases - Toxic chemicals (benzene) - Viral - Medications (methotrexate) - Inherited (Fanconi anemia)
29
What is the main treatment for aplastic anemia?
Hematopoietic cell transplant
30
What are the oral manifestations of aplastic anemia?
- Anemia --- Atrophic glossitis with loss on tongue papillae, redness or cheilosis --- Mucosal pallor - Thrombocytopenia --- Petechia, spontaneous or prolonged bleeding - Neutropenia --- Infection – Viral, fungal, bacterial --- Ulceration
31
What is the dental management for aplastic anemia and bone marrow failure?
* Thorough medical history * Discussion with oncologist --- Current status and goals --- Defer routine care --- Dental office vs hospital * Labs --- CBC --- Platelet: may require platelet transfusion due to thrombocytopenia --- ANC-may require antibiotic prophylaxis for neutropenia (>500) * Confirm patient is afebrile * Local hemostatic measures for patients with thrombocytopenia
32
What are the types of platelet disorders?
* Thrombocytopenia * Von Willebrand Disease
33
What are the features of thrombocytopenia?
- Low platelet levels (CBC) --- Normal: 150,000-400,000 ---Severe: <50,000 - Prolonged bleeding, petechia
34
What are the causes of thrombocytopenia?
- decreased production - destruction - medications - blood loss - many, many ways to get this
35
What are the oral manifestations of thrombocytopenia?
* Petechia * Spontaneous gingival bleeding * Prolonged bleeding after procedures
36
What is the dental management for thrombocytopenia?
* Thorough medical history --- Cause of thrombocytopenia (acute cause? chronic cause?) --- Bleeding history, transfusion history * May defer routine dental care * CBC --- Recent (<24 hours) --- Platelet >50,000 for most dental procedures reduces risk --- Higher for invasive surgical procedures (ex. multiple extractions) * Discussion with patient’s MD --- Platelet transfusions, timing --- Dental office vs hospital (<50,000 more appropriate in hospital setting) * Avoid block injections * Local hemostatic measures
37
What are the features of von willebrand disease?
- Missing or defective VWF (clotting protein) --- Required for platelet adhesion - Most common inherited clotting disorder (1% US population)
38
What are the types of von willebrand disease?
- Type 1 (20-50% normal levels) - Type 2 (qualitative) - Type 3 (quantitative, severe symptoms)
39
What are the signs and symptoms of von willebrand disease?
- epistaxis - petechia - ecchymosis - excessive/prolonged bleeding from invasive procedures - hemarthrosis
40
What is the treatment for von willebrand disease?
DDAVP (desmopressin)
41
What is the dental managment for von willebrand disease?
* Thorough medical history/bleeding history and physical exam * Discussion with patient’s MD --- Confirm history and severity of disease --- DDAVP, aminocaproic acid --- Dental office vs hospital * Avoid block injections * Local hemostatic measures
42
What are the features of hemophilia?
- 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%
43
What are the signs/symptoms of hemophilia?
- prolonged or spontaneous bleeding - ecchymosis - hemarthrosis
44
What is the treatment for hemophilia?
factor infusions, DDAVP (A)
45
What is the dental management for hemophilia?
- Dental Management --- Thorough medical history/bleeding history and physical exam - Discussion with patient’s hematologist --- Confirm history and severity of disease --- Dental office vs hospital --- Factor infusions, aminocaproic acid * Avoid block injections * Local hemostatic measures
46
What are the medication related bleeding disorders?
- Plavis (clopidogrel) - Coumadin (warfarin) - Direct Oral Anticoagulants (DOAC) and Direct Thrombin Inhibitors
47
What are the features of plavix (clopidogrel) bleeding disorder?
- Antiplatelet agent - Reduce risk of MI and stroke - Increased risk of bleeding and bruising
48
What is the management for plavix (clopidogrel) bleeding disorder?
* Medication list to evaluate bleeding risk --- Other anticoagulants * Local measures --- Low risk of bleeding far outweighs interrupting Plavix treatment
49
What are the features of coumadin (warfarin) bleeding disorder?
- Vitamin K antagonist - For patients with Afib, heart failure, prosthetic heart valves, stroke/MI history… - Common side effect: bleeding
50
What are the things you monitor for coumadin (warfarin) bleeding disorder?
* PT/INR goals: 2.0-3.0 * Higher in patients with prosthetic heart valves (3.0-3.5)
51
What is the antidote for coumadin (warfarin) bleeding disorder?
Vitamin K
52
What is the dental management for coumadin (warfarin)?
* Dental procedures are generally considered low risk of bleeding --- Thromboembolic risk vs procedural bleeding risk --- Discussion with patients MD for procedures with higher risk of bleeding * Review INR (within 24 hours) --- INR: 2.0-3.0 dental treatment * Local hemostatic measures * Medications --- Many medication interactions due to narrow therapeutic range --- Avoid cytochrome P-450 inhibitors (ex. fluconazole) and inducers
53
What are the features of direct oral anticoagulants (DOAC) and direct thrombin inhibitors?
- Direct inhibitor of factor Xa and thrombin - Class of newer anticoagulants --- Alternative to warfarin - Highly effective - No lab monitoring - Reversal agent - More expensive
54
What are the dental managements for direct oral anticoagulants (DOAC) and direct thrombin inhibitors?
* No lab monitoring * Bleeding risk for dental procedures seems to be low * Local hemostatic measures
55
What are things you can use to control bleeding locally?
- gauze - gelfoam - cellulose (surgical, oxycel) - thrombin - tranexamic acid - amicar
56
What are the types of hematologic malignancies?
* Leukemia * Lymphoma * Myeloma
57
What is leukemia?
* Affects bone marrow and circulating blood * Proliferation of WBCs which can be non-functional (blasts) or overtime overcrowd/suppress normal marrow production
58
What are the classifications of leukemia?
* Lineage: Myeloid vs Lymphoid * Timing: Acute vs Chronic
59
What are the types of leukemia?
* Acute Myeloid (AML) * Chronic Myeloid (CML) * Acute Lymphocytic (ALL) * Chronic Lymphocytic (CLL)
60
What are the causes of leukemia?
* Radiation * Chemotherapy * Genetic * Down syndrome
61
How is leukemia diagnosed?
* CBC * Blood smear * Molecular studies
62
What is the treatment for leukemia?
* Chemotherapy * Radiation * Targeted therapy * Hematopoietic stem cell transplant
63
What are the signs and symptoms of leukemia?
- Fatigue - malaise - petechiae - ecchymoses - fever - Related to functional or treatment related neutropenia and thrombocytopenia
64
What are the oral manifestations of leukemia?
* Leukemia infiltrate * Spontaneous gingival bleeding * Oral ulceration (neutropeniculcer, mucositis) * Infection --- Viral, fungal, bacterial * Lymphadenopathy (chronic)
65
What is the dental managament of leukemia?
* Urgent referral to PCP or emergency room for leukemic infiltrate-CBC, smear, flow cytometry * If Dx known: --- Thorough medical history --- Discussion with oncologist --- Timing of dental care-not on active chemotherapy for routine care * Labs --- CBC --- Platelet: may require platelet transfusion due to thrombocytopenia --- ANC-may require antibiotic prophylaxis for neutropenia (>500) * Confirm patient is afebrile * Local hemostatic measures for patients with thrombocytopenia
66
What are the features of lymphoma?
Cancer of lymphoid organs and tissues
67
What are the features of hodgkin lymphoma?
* Reed-Sternberg cell * Young adults * LAD --- Non-tender, firm --- >50% affect mediastinal or neck nodes
68
What are the features of non hodgkin lymphoma (NHL)?
* Median Age: 67 * B-symptoms --- Fever, night sweats (drenching), weight loss (unintentional >10%) * Over 20 types --- Diffuse Large B-cell (DLBCL) --- Follicular
69
What are the causes of lymphoma?
* Autoimmune diseases * Hepatitis C * EBV * Sjogren syndrome
70
How do you diagnose lymphoma?
* Bone marrow or lymph node biopsy * MRI for staging
71
What is the treatment for lymphoma?
* Chemotherapy * Radiation * Immunotherapy * Stem cell transplant * Watching
72
What are the oral manifestations of lymphoma?
* LAD (Waldeyers ring, neck) * Extranodal involvement --- Oral Ulceration ---Localized infiltrate --- Osteolytic radiographic lesions * Infection --- Viral, fungal, bacterial * Treatment related --- Head and Neck Radiation (lymphomas in head and neck region only) --- Hyposalivation --- Trismus --- Osteonecrosis
73
What is the dental management for lymphoma?
- Similar to leukemia but risk for neutropenia and thrombocytopenia is lower and generally treatment related (chemotherapy, radiation) - Thorough medical history - Discussion with oncologist --- Current status and goals (comprehensive vs. palliative) --- Dental office vs hospital --- Timing of dental care-not on active chemotherapy for routine care - Labs --- CBC --- Platelet: may require platelet transfusion due to thrombocytopenia --- ANC-may require antibiotic prophylaxis for neutropenia (>500) - Confirm patient is afebrile - Local hemostatic measures for patients with thrombocytopeni
74
What is multiple myeloma?
Prevents normal production of antibodies
75
What are the signs and symptoms of multiple myeloma?
- Hypercalcemia - Renal damage - Anemia - Bone pain - Infection
76
What is the treatment for multiple myeloma?
- Chemotherapy (RVD) - Bisphosphonates - Hematopoietic Stem Cell Transplant
77
What are the oral manifestations of multiple myeloma?
- Plasmacytoma - Lytic bone lesions - Infection --- Viral, fungal, bacterial - Treatment Related --- Neuropathy --- MRONJ (IV Zometa) --- Radiographic (Thick lamina dura, Persistent extraction site, Sclerosis, Sequestra, Fracture)
78
What is the management for multiple myeloma disease related?
Disease related management * Soft tissue swelling, radiographic findings * Infection management * Pre-bisphosphonate exam
79
What is the management for multiple myeloma medication related?
MRONJ - Bisphosphonate history (number of doses, active) - Chlorhexidine rinses - Oral Hygiene - Antibiotic regimen - Sequestration Surgical Procedures - Informed consent - As atraumatic as possible - Thorough post surgical instructions including chlorhexidine rinses and antibiotic prophylaxis - Re-eval after surgical procedures to ensure healing
80
What is hematopoetic stem cell transplant?
* 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
81
What diseases are indications for stem cell transplant?
Malignancy - Hematologic --- **Leukemia** --- **Lymphoma** --- **Multiple Myeloma** - Solid --- Neuroblastoma --- Desmoplastic small round cell tumor --- Ewings sarcoma --- Choriocarcinoma --- Ovarian Hematologic Disorder - Phagocyte Disorder (myelodysplasia) - **Anemia** --- **Aplastic** --- **Fanconi** --- **Sickle Cell** --- Thalassemia - Myeloproliferative --- Polycythemia vera Other - Amyloidoses - Autoimmune disorders
82
What is involved in the pre- stem cell 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
83
What are the goals for a dental screening before stem cell transplant?
- Remove active foci of infection and limit potential foci of infection - Dentition to be stable for at least 12 months --- Urgent care only for 12 months post transplant --- Risk of salivary GVHD and hyposalivation -> caries - Patient education about home care - If planned correctly, pre-transplant evaluation + patient compliance=dental maintenance
84
What is the dental screening for Pre-HSCT (Hematopoetic Stem Cell Transplant)?
* Comprehensive hard and soft tissue exam * Full mouth series of radiographs * Treatment --- Scaling and prophylaxis --- Removal of caries (Restorations, Endodontic therapy, Extractions) --- Extraction of all hopeless teeth & 3rd molars with hx periocoronitis --- Caries risk assessment and need for adjuncts (fluoride) --- Dental management based on primary disease
85
What are the types of grafts?
* Autologous * Allogeneic * Syngenic
86
What is an autologous graft?
- Receive own bone marrow or PBSC, “stem cell rescue” - Pros: no HLA matching, no GVHD, immune suppression - Cons: contamination of cells, no graft vs tumor, higher risk of relapse - Indications include: lymphoma, multiple myeloma
87
What is an allogeneic graft?
- 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
88
What is an syngenic graft?
Receive bone marrow or PBSC from identical twin
89
What are the phases of treatment for a stem cell transplant?
* Collection * Preparative Regimen (Conditioning) * Stem cell infusion * Engraftment * Post-transplant immune suppression/GVHD
90
What are the sources for the stem cell transplant?
- Bone marrow - Peripheral Blood - Cord Blood
91
What are the oral manifestations of HSCT?
* Mucositis – Acute; resolves after engraftment * Bleeding– Petechiae, ecchymosis, hematoma * Infection – Viral (ex. HSV)– Fungal (ex. candidiasis)– Bacterial * Medication side effect/toxicities --- Gingival hyperplasia (cyclosporine) --- Oral ulceration (sirolimus) * Graft versus host disease --- Mucosal (lichenoid changes) --- Salivary- hyposalivation, caries * Increased risk of oral cancer
92
What is the dental management after a hematopoietic steam cell transplant?
- Thorough medical history --- Original diagnosis, date of transplant, immune suppression, GVHD - Thorough clinical exam --- Hyposalivation, caries, infection, GVHD, oral cancer - Discussion with oncologist --- Current status and goals (comprehensive vs. palliative) --- Dental office vs hospital - Labs --- CBC-may require platelet transfusion due to thrombocytopenia --- ANC-may require antibiotic prophylaxis for neutropenia - Medications --- 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 the Medically Complex Patient (26 decks)

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