SEMINAR ON

DENTAL MANAGEMENT OF PATIENT WITH LEUKEMIA

 CONTENTS

1.Introduction of Leukemia

2.Definition

3.Classification

4.Manifestations of Leukemia

5.Dental Management of Patient with Leukemia

6.Conclusion

7.References
DENTAL MANAGEMENT OF PATIENT WITH LEUKEMIA

Introduction of Leukemia

 It is also called as Leukosis.

 It is a progressive and Fatal Condition causing death
from hemorrhage and infection.
 Considered as primary disorder of bone Marrow.
 It effects 5 in 100,000 children.
Definition

Leukemias are hematopoietic malignancies in which there

is proliferation of abnormal leukocytes in the bone

marrow and dissemination of these cells into the

peripheral blood The abnormal leukocytes (blast cells)

replace normal cells in bone marrow and accumulate in

other tissue and organs of body.

 CLASSIFICATION
(According clinical courses)

Acute Chronic
(Primitive Blast cells) (Mature Leukocytes)
85% cases Disease of adult life

Acute Acute Chronic Chronic

Lymphoblastic Myeloblastic Lymphocytic Myelocytic
Leukemia Leukemia Leukemia Leukemia
Why manifestations of acute leukemia ?

Leukemic cells -----------> tissue, organs and bone marrow

infiltrate

Anaemia Thrombo Granulocyt

cytopenia openia

Systemic Manifestations

1. High no. of WBC (Circulating)

Stasis in small vascular channels

Tissue anoxia in areas of necrosis and ulceration

 2. Person with thrombocytopenia
 Bleeds spontaneously.
 Petechiae
 Ecchymoses
 Frank bleeding in gingival sulcus

3. Direct invasion of tissues by infiltration of leukemic cells

 Gingival hypertrophy.
 Strangulation of pulp tissue
 Spontaneous abcess formation
 Teeth mobility
 Generalized Osteoporosis
 Loss of trabecular
bone
 Skeletal lesions are
visible in
Radiograph up to 63% of
children with Acute
leukemia.
Oral Manifestations

In 29% children that too high with ALL

COMMON RARE
1. Lymphadenopathy 1. Cranial nerve palsy
2. Petechiae 2. Chin, lip paraesthesia
3. Ecchymoses 3. Odontalgia
4. Gingival bleeding 4. Jaw pain
5. Pallor 5. Loose teeth
6. Ulcerations 6. Extruded teeth
7. Gangrenous stomatitis
DENTAL MANAGEMENT OF PATIENT WITH LEUKEMIA

Any Rx following information is collected

1. Primary medical diagnosis
2. Anticipated clinical course and prognosis
3. Present general state of health
4. Present and future therapeutic modalities
5. Present hematological status
Key points -

 Pulp therapy is contra indicated in Leukemia.

 For a child whose Ist remission has not been obtained
or who is in relapse all elective procedures should be
deferred.
 A patient who has been in complete remission for at
least 2 yrs and no longer requires chemotherapy
treated normally.
Phases of Management

1. Induction of remission
2. Prophylactic Rx
3. Consolidation phase
4. Relapse
5. Supportive therapy
6. Psychological support

On this regimen 70% of children now

survive and can be regarded as cured.
Induction of Remission
 To remove abnormal cells from the blood and bone
marrow.
 Vincristine (1.4 mg/m2 every week of 1 month)
 L-Asparaginaase (600 units/m2 bi weekly per month)
 Prednisolone (40mg/m2 orally daily for one month)

Prophylactic Rx
 Use of soft nylon tooth brush.
 Local irritants as orthodontic
appliance are removed.
 Warm saline rinses
 0.1% chlorhexidine mouth wash
 For erosive For granulocyt- For deep lesions For candidiasis –
ulcerative lesions openic patient who –
develop ulcerative
lesions
methoteraxate topical obtundants. Bovine Nystatin oral

anthracycline, thrombin, suspension 100,000

doxorubicin. avitene, U/ml swish 5 ml for

placement of 5min then swallow

oral adhesive repeat for 6 hr.

for protection continue till lesion

disappears.

 In more resistant cases of candidiasis fluconazole oral/IV

 Older children – 16 mg/kg Ist day then 3 mg/kg/day.
 Dentist should avoid aspirin in patient who are thrombocytopenic
Topical obtundants for oral pain
Combination Administration Indications
A. 1 Part kaopectate and  Swish 5-10 ml for  General stomatitis
1 part Benadryl elixir 1 min. then and mild
B. Benacort – Tetrastat expectorate discomfort.
mary’s magic potion
 Hydrocortisone poser
60mg
 Swish 5-10 ml for  General stomatitis
 Tetracycline 1.5g
 Nystatin susp. 1 lac 1 min. then and mild
u/ml 60ml expectorate discomfort.
 Benadryl elixir q.s.
240 ml
C. Orabase with  Apply locally to  Discrete painful
benzocaine or viscous lesions with lesions
lidocaine 0.2% or cotton swab
dyclonine Hcl 0.5%
Consolidation phase
 Irradiation and intrathecal therapy. Cytarabine and
methoteraxate, to eradicate the disease from central
nervous system.
 Radiation reduces the risk of relapse in central Nervous
system.

Maintenance Phase
 Use of prednisolone (Oral)
 Vincristine (IV)
 Mercaptopurine (Oral)
 Methotrexate (Oral)
 Till 2- 3 yr.
Important diagnostic findings

Platelet count

Count (cells/mm3) Significance

 Normal
1.5 Lac – 4 Lac
 Pt can tolerate most routine
50,000 – 1 Lac
procedure
 Moderate risk of bleeding, defer
20,000 – 50,000
elective procedure
< 20,000  At significant risk of bleeding

If pt’s platelet count is < 20,000 cells /mm3 the patient should
probably be given Prophylactic platelet transfusions.
WBC Count
ANC Significance
 > 1500  Normal
 500 – 1000  Pt at some risk for infection defer elective
procedure that would induce significant
transient bacteremia.
 200 – 500  Pt. must be admitted to hospital if febrile and
given broad spectrum antibiotics at moderate
risk for sepsis defer all elective dental
procedure.
 < 200  At significant risk for sepsis

ANC – Absolute Neutrophil count

ANC – (% of polymorphonuclear leukocytes + % of bands) × total white count ÷ 100
* If ANC is less than 1000/mm3 elective dental treatment should be deferred. Broad
spectrum antibiotics given.
Relapse
 Allogenic bone marrow transplantation done.
Pretransplant preparation.
1. Before 4 week all clinical and Radiographic examination
done.
2. Instruct patient about daily mouth care.
• Use of soft nylon tooth brush, floss,
• Topical fluoride gel and peridex rinse.
• Potential foci of infection like - pulpally, periodontally
involved teeth, exfoliating primary teeth, carious teeth
with defective restoration are extracted.
Oral complication of Bone marrow transplantation and
their Rx

Complication Rx
1. Oral ulceration & 1. Topical obtundant solution
Mucositis 2. Topical anaesthesia
3. Analgesics

2. Oral Bleeding 1. Platelet transfusion

2. I.V. Amino caproic acid (Amicar)
3. Topical application of avitene, bovine
corium collagen hydrochloride powdered
thrombin, pressure.
Supportive therapy
 Transfusion of red cells and platelets required in
Aneamia, thrombocytopenia respectively.
 Combination of higher antibiotics like aminoglycosides
with cephalosporin.
 Allopurinol before starting antileukemic agents to
prevent hyperuricemia.

Psychological Support
 An optimistic attitude of staff is of vital importance
Reassure the patient by answering his all questions and
doubts.
Conclusion

 Dentist must diagnose the underlying disease and prior

to any dental procedure all necessary clinical/lab

investigation must be done. So, as to avoid complication

and for better treatment planning.

References

 Mc Donald Avery, Dean - Dentistry for the child and

Adolescence - 8th Edition

 Medical Emergencies in dental practice – By Scully

 Pediatric Dentistry – Grovan Koch.

 Pediatric dentistry – By Richard R. Welburry

 Master dentistry – Volume -2 – By Peter Heasman