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:
- Leukaemias (acute lymphoblastic, acute myeloid, chronic myeloid, chronic lymphocytic)
- Lymphomas (Hodgkin's, Non-Hodgkin's)
- Multiple myeloma
- 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:
- BSDH Clinical Guidelines: The Oral Management of Oncology Patients requiring Radiotherapy, Chemotherapy and/or Bone Marrow Transplant (under review).
- SDCEP Clinical Guidelines: Oral Health Management of Patients at Risk of Medication-Related Osteonecrosis of the Jaw 2017
- British Society of Haematology Guidelines
- 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.
0 comments