Transcript student.ahc.umn.edu

CASE PRESENTATION: KATARINA WITT
Dent 6122
March 13, 2008
R Garni B Germain B Gray J Grittner A Gunderson B Haasken D Halberg C Halligan
PATIENT PRESENTATION
17 year old female
No significant Medical Hx
Chief Complaint
• “Bleeding Gums”
PATIENT HISTORY
Young healthy athletic high school
student
Physical exam six weeks prior with NSF
Dental exam and prophy three weeks
prior
“Hasn’t felt very good lately” and has
had “very little energy”
Came in because normal dentist was on
vacation
MEDICAL FINDINGS
“Physician”
Rapid onset of
symptoms
• Fatigue
• Enlarged lymph nodes
Physician differential
diagnosis:
• Flu
I believe she has
the flu!
PATIENT PRESENTATION
Head and neck exam
• Enlarged, non-tender cervical
lymph nodes
Intraoral Exam
• Hypertrophic, erythematous,
and edematous gingiva
• Spontaneous gingival bleeding
• Petechiae on soft palate
• Not much plaque
• No deep perio pockets
WHAT IS GOING ON WITH KATRINA?
Prolonged “Flu-like” symptoms
• Fatigue
• Enlarged lymph nodes
Petichiae
Bleeding gingiva
Suggest systemic disease
QUESTIONS TO ASK
Have you taken aspirin lately?
Is there a history of bleeding disorders in your family?
Have any of your family or friends been diagnosed with
mono lately?
Have you had any rashes lately?
Did you get a flu shot this year?
Have you experienced any nausea, vomitting, or
unexplained weight loss?
QUESTIONS TO ASK
Have you had any bone or joint pain recently?
Have you been thirsty a lot lately?
Have you experienced fever, chills, or clamminess lately?
Has your lack of energy start just recently?
Have you noticed a lot of bruises lately? Do you bruise
easily?
PATIENT SYMPTOMS
No aspirin.
No history of mono.
No nausea, vommitting or weight loss.
I did get a flu shot this year.
No fever.
No bone/joint pain or swelling.
I have been thirsty and cold recently.
Fatigue began suddenly.
I have been bruising easily lately.
LAB TESTS
CBC and WBC differential
Peripheral blood and bone marrow smear
Lab tests to confirm AML
•Cytochemical staining
•Immunophenotyping
•Cytogenetic analyses
•20% WBC are myeloblasts
Hemoglobin hematocrit
Platelet count
Monospot
CONSULTATION
Consultation with a physician may be necessary to:
•Obtain lab results
•Confirm said patient history
•Determine if patient had been previously diagnosed with anemia or
a bleeding disorder
•Discuss final diagnosis
Consultation with usual dentist may be necessary to:
•Discuss patient condition at previous appointments
RED BLOOD CELL DISEASES
RBC Diseases
Microcytic
Iron Deficiency
Anemia
Normocytic
Renal
Failure/Anemia
associated w/
Chronic Diseases
Aplastic Anemia
Macrocytic
Hemolytic Anemia
Pernicious Anemia
Thalassemias
Sickle Cell Anemia
Folate Deficiency
Lead Poisoning
Glucose-6-phosphate
dehydrogenase
deficiency
Hypothryroidism
WHITE BLOOD CELL DISEASES
WBC Diseases
Leukemia (Bone
Marrow Origin)
Acute Leukemias
(Rapid onset, All
ages, Immature
Cells)
Lymphoma (Lymph
Node origin)
Chronic Leukemias
(Slow Onset, Adults,
Mature Cells)
AML
CML
ALL
CLL
Hodgkin (ReedSternberg Cells,
Contiguous spread,
Better Prognosis)
Non-Hodgkin (B-Cell
has a better
prognosis than TCell)
Plasma Cell
Disorders
Myelomas
LEUKEMIA
Neoplasm of myeloid white blood
cells
Uncontrolled proliferation of bone
marrow space
Subsequent increase of myeloid
WBC in peripheral blood
Etiology
•Viruses
•Genetic factors
•Radiation
•Chemical agents
AML VS. ALL
AML
• Immature neoplastic malignancy of
myeloid cells
• Usually in younger adults
• Bleeding, anemia, poor healing, and
infection
• Fatigue, bone pain
• Enlargement of spleen, lymph
nodes, tonsils, and gingiva
• At least 20% myeloblasts in bone
marrow or peripheral blood
ALL
• Immature neoplastic
malignancy of lymphoid cells
• Common in young children (2-4
years old)
• Symptoms related to anemia,
thrombocytopenia, fever, and
neutropenia
• Higher propensity toward CNS
involvement and cranial nerve
deficiencies
DIAGNOSIS & ASA PATIENT STATUS
Level of
Control
Signs &
Symptoms
Age , Sex
& Health
Diagnosis: AML
ASA PS III
A
Antibiotics:
•Antibiotic treatment can be used to prevent post operative infections when Severe Neutropenia is present (WBC below
2000 or neutrophil count is below 500)
•2g of Penicillin one hour before dental treatment and 500mg four times a day for a week post dental treatment
•Antibiotic prophylaxis is also recommended for Patients with Hodgkin’s lymphoma who have had a splenectomy are at an
increased risk for bacterial infection is recommended for the 1st 6 months after surgery for invasive procedures
Analgesics:
•For patients with Mucositis and Ulcerations, topical anesthetics can be applied to relieve patient of pain.
Antihistamines:
•Some solutions of antihistamines, for ex: Benzydamine, have local anesthetic properties and can be used to protect
ulcerated surface of mucosa from being irritated
Antiseptics and Antimicrobials:
•Antiseptic and Antimicrobial rinses that are nonalcoholic are recommended for the prevention of oral infections, cleansing
of ulcers, and to help promote healing of intraoral ulcerations.
B
Bleeding:
•Uncontrolled leukemia patients may experience serious bleeding problems after any surgical procedure
and may have problems with healing of surgical wounds.
•Patient’s gingival may be boggy and bleed easily from poor oral hygiene or minor trauma due to
thrombocytopenia.
•Treatment of gingival bleeding include:
•Plaque control measures
•Chlorhexidine rinse
•Thrombin/microfibrillar collagen sponge
•Antifibrinolytic rinse
•Chemotherapy
•If local measures not enough to manage bleeding, platelet transfusion may be done.
•Platelet count should be 50,000/mm prior to invasive dental procedures.
C
Complications:
•Patients who are undergoing chemotherapy or radiotherapy are susceptible to many oral
complications including:
•Mucositis
•Neutropenia
•Infection
•Excessive bleeding
•Graft-versus-host disease
•Alterations in growth and development
D
Drugs
•Antibiotic prophylaxis for neutropenia and hodgkin lymphoma (discussed above)
•Vincristine (a chemotherapy drug) can cause paresthesia
•Cyclosporine is sometimes given during bone marrow transplants and a side effect of this drug is gingival
overgrowth
Dental Management
•Gather proper medical and familial history and conduct a thorough head and neck lymph node exam
•Obtain lab test results from M.D. (WBC, Hb or hematocrit level, platelet count, etc.) and get a medical consult
before any dental treatment to review the patient’s current status
•For patients with characteristic signs and symptoms, consult an M.D. before treatment and no treatment should
be rendered for patients with acute symptoms
•Undiagnosed leukemia patients may experience delayed wound healing, be prone to infections and bleed
excessively
•Once a patient has been diagnosed, the dentist should take an active role in treatment planning with the M.D.
•The primary goal of dental treatment should be to eliminate disease prior to chemotherapy commencement
and extractions should be done 10-14 days before chemotherapy is started
•Emphasize and educate the patient about the importance of excellent oral hygiene
D
Drugs
•Antibiotic prophylaxis for neutropenia and hodgkin lymphoma (discussed above)
•Vincristine (a chemotherapy drug) can cause paresthesia
•Cyclosporine is sometimes given during bone marrow transplants and a side effect of this drug is gingival
overgrowth
Dental Management
•Gather proper medical and familial history and conduct a thorough head and neck lymph node exam
•Obtain lab test results from M.D. (WBC, Hb or hematocrit level, platelet count, etc.) and get a medical consult
before any dental treatment to review the patient’s current status
•For patients with characteristic signs and symptoms, consult an M.D. before treatment and no treatment should
be rendered for patients with acute symptoms
•Undiagnosed leukemia patients may experience delayed wound healing, be prone to infections and bleed
excessively
•Once a patient has been diagnosed, the dentist should take an active role in treatment planning with the M.D.
•The primary goal of dental treatment should be to eliminate disease prior to chemotherapy commencement
and extractions should be done 10-14 days before chemotherapy is started
•Emphasize and educate the patient about the importance of excellent oral hygiene
D
Dental Management Continued: Oral complications of chemotherapy:
•1) Mucositis and Ulcers (discussed above)
•2) Neutropenia and infection:
•Inability to protect against oral bacteria resulting in acute gingivitis
•Oral mucosal ulcerations and periodontal destruction with loss of attachment
•Opportunistic infections are common (esp candidiasis)
•Recurrent herpes simplex virus is common with chemotherapy and can be Treated with:
•Oral hygiene instruction
•Frequent scaling
•Antimicrobial rinses
•Antifungal medication for candidiasis
•Antiviral medication for HSV antibody-positive patients
•3) Bleeding (discussed above)
•4) Restricted growth of jaw if chemotherapy given during childhood resulting in micrognathia, retrognathia
and/or malocclusion.
E
Emergency
• Excessive bleeding, anemia, poor healing, and infection after surgical
procedures are some emergencies that could occur in the dental chair.
• To treat such conditions you should be able to control bleeding, minimize
secondary wound healing, and keep the surgical field as sanitary as possible.
• This should reduce the chance of emergency with a patient with acute
leukemia.
PHARMACOLOGY EXAM ANSWERS
1
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2
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3
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5
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6
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7
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8
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9
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10
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40
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Good
Luck!