Sunday, 4 February 2018

How to Manage Haematological Malignancies in Dentistry

This blog post is based on a talk by Avril Macpherson who spoke at the Royal College of Surgeons of Edinburgh Special Care Dentistry Study Day

What are Haematological Malignancies?

There are 4 main diagnostic groups of malignancies:
  1. Leukaemias (acute lymphoblastic, acute myeloid, chronic myeloid, chronic lymphocytic)
  2. Lymphomas (Hodgkin's, Non-Hodgkin's) 
  3. Multiple myeloma
  4. Myelodysplastic syndrome

What does normal look like?

Haematopoiesis i.e. the generation of blood from stem cells, is a dynamic process but if this is interrupted, can result in low levels of certain blood cells. The most important cell counts to consider safe for general dentistry are:

Platelets > 50 x 109 (50000/l)

Neutrophils > 0.5 (500/mm3)

Treating patients below these limits carries a significant bleeding and neutropenic sepsis risk. Neutropenic sepsis carries a 2-21% mortality rate and so the complications can be very serious!

How are these conditions treated?

  • Chemotherapy (including bisphosphonates - read about this here)
  • Radiotherapy
  • Biological therapy
  • Stem Cell/Bone Marrow transplants
  • Clinical trials

Dental Considerations

  • What is the patient's diagnosis and current treatment?
  • What are the timescales for their treatment? Are you seeing them before treatment commences or mid-chemotherapy cycles for example?
  • Are they experiencing oral pain? Mucositis (inflammation of the oral mucosa) is experienced in 75% of these patients
  • Is there existing or potential infection present e.g. long-standing peri-apical pathology?
  • What is their blood profile and could it be improved e.g. by platelet infusions?
  • What is the patient motivation like? Do they want to maintain their dentition for as long as possible?

Where can I find more information?

Certainly, managing this group of patients is not easy and management by specialists in a hospital setting is often the most appropriate; however, there is plenty of guidance available to help if you do see these patients:
  1. BSDH Clinical Guidelines: The Oral Management of Oncology Patients requiring Radiotherapy, Chemotherapy and/or Bone Marrow Transplant (under review). 
  2. SDCEP Clinical Guidelines: Oral Health Management of Patients at Risk of Medication-Related Osteonecrosis of the Jaw 2017
  3. British Society of Haematology Guidelines
  4. European Society for Medical Oncology Guidelines

Many thanks to Avril for her informative talk about a really complicated topic and the RCSEd for organising the study day. 

Do you manage these patients? What problems do you encounter? Let me know in the comments below. 

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