Download MANAGEMENT OF MEDICALLY COMPROMISED PATIENTS

MANAGEMENT OF MEDICALLY
COMPROMISED PATIENTS
SAKINAH MOHD SALEH
MOHD AZIZUL MOHD ATAN
ABDULLAH ZAHID AZHARI
NUR AMALINA ZULKEPRE
NURMARZURA ABDUL LATIF
AHMAD ZULKHAIRI RESALI
NURUL ASMAT ABDUL RAHMAN
1090041
1090042
1090043
1090044
1090045
1090046
1090048
GROUP 3: ONCOLOGY
Discuss the aetiologies, clinical presentations,
problems related to dental management and
general management of patients with
this medical problem.
Introduction
 Cancer is a complex illness that requires clinical care by a
physician or other health care professional.
 Among 50 types of childhood cancers, the most common forms
include leukemias, lymphomas, central nervous system tumours,
primary sarcoma of bone and soft tissues.
 Chemotherapy, radiotherapy and surgery has resulted in 70%
cure rate
What is cancer?
 Cancer is an abnormal growth of cells. Cancer cells rapidly
reproduce despite restriction of space, nutrients shared by other
cells or signals sent from the body to stop reproduction. Cancer
cells are often shaped differently than healthy cells, they do not
function properly and they can spread to many areas of the body.
AETIOLOGY
ONCOLOGY
 The factors involved may be genetic, environmental or
constitutional characteristics of the individual.
 Lifestyle factors :
-smoking, high-fat diet and working with toxic chemicals
 Genetics:
- genetic mutation, exposure to chemicals near a family's
residence, a combination of these factors or simply coincidence.
- genetic disorders)
 Exposure:
-viruses such as the Epstein-Barr virus (EBV) and human
immunodeficiency virus (HIV).
- environmental such as pesticides, fertilizers, and power
CLINICAL PRESENTATION
ONCOLOGY
Clinical presentations: Incidence
2nd leading cause of death
Clinical presentations
 Incidence of childhood cancer
Cancer
Incidence
leukemia
30.2
Central nervous system
21.7
lymphoma
10.9
neuroblastoma
8.2
Soft tissue sarcoma
7.0
Renal tumor
6.3
Bone tumor
4.7
others
11.0
Recent trends in childhood cancer incidence and mortality in the United States.
J Nati Cancer Inst 1999;91:1051-8
Clinical presentations
Cancer diagnosis in children is
often delayed
because the presenting symptoms
tend to be
nonspecific and
resemble
those of benign
conditions.
Common disease of childhood cancer
LEUKEMIA
2. NON-HODGKIN’S LYMPHOMA
3. NEUROBLASTOMA
1.
Leukemia
 Definition:
‘a heterogenous group of haematological malignancies caused
by proliferation of primitive white blood cells’
 Types:
-Acute lymphoblastic leukemia
-Acute myeloid leukemia
-Chronic myeloid leukemia
i- Acute lymphoblastic leukemia
 Accounts for 80-85% of childhood leukemias
 Defined by the presence of 30% lymphoblasts in the bone




marrow.
Therapy is tailored to the risk of relapse and includes
combination inductio chemotherapy, central nervous system
and maintenance chemotherapy.
Approximately 2 years for total therapy.
Generally 70% of patients are cured
Prognosis depends on age, initial white cell count, cytogenic
abnormalities.
ii- Acute myeloid leukemia
iii- Chronic myeloid leukemia
 15-20% of acute childhood
 Rare in childhood, accounts for
leukemias.
 Bone marrow infiltrated with
primitive myeloid cells,
classified by morphological
apppearance.
 Induction therapy may be
followed by bone marrow
transplantation (autogenous or
allogenic)
 Cure rate is less than acute
lymphoblastic leukemia –
approximately 50%
<5% of cases.
 2 types: -identical to adult and is
characterized by presence of
Philadelphia chromosome (Ph)
-juvenile forms
 Bone marrow biopsy reveals
granulocytic proliferation
without an excess of blasts.
 Preferred therapy: allogenic
bone marrow transplant within
1 year of diagnosis
Leukemia
Clinical features
 Fatigue and weight loss
 Anaemia
 Purpura
 Infection and febrile
episodes.
 Hepatosplenomegaly and
lymphadenopathy
 Bone pain
Investigations
 Full blood count
-anaemia
-neutropenia
-thrombhocytopenia
 Leucocytosis plus circulating
blasts.
 Bone marrow biopsy
required
 Lumbar puncture to exclude
central nervous system.
Problems related to dental
management
 Mainly as a result of cancer therapy; radiotherapy or
chemotherapy
 Oral problems pain, mucositis, oral ulceration, bleeding,
taste dysfunction, increase risk of infection (2°), dental caries,
xerostomia, osteonecrosis, trismus, neurotoxicity.
 Late complicationsalterations of shape (microdontia,
macrodontia, taurodontia), number (anodontia) and root
formation (root shortening and blunting of the roots, root
stunting) of the teeth.
 Head and neck radiotherapy abnormalities in the growth and
maturation of the craniofacial skeleton structures.
Dental Management of Pediatric Patients
Receiving Chemotherapy, Radiation
Management
Before
Initial
evaluation
PMH
PDH
Oral/dental
assessment
During
Preventive
strategy
Oral hygiene
Diet
Fluoride
Trismus
prevention
Education
Dental
procedure
After
General ManagementBefore the cancer therapy
Dental procedure
 Should be completed before start cancer tx- ideally
 Prioritizing procedure
 when all dental needs cannot be treated before cancer therapy is initiated.
 Prioritize: infections, extractions (7-10 d), periodontal care (eg,scaling,
prophylaxis), and removal sources of tissue irritation .
 Pulp therapy
 Choose extraction – avoid infection later
 Endodontic tx
 At least 1 week b4 therapy (if symptomatic), extract if not possible
 Ortho
 Perio
Management
Before
Initial
evaluation
PMH
PDH
Oral/dental
assessment
During
After
Preventive
strategy
Oral hygiene
Diet
Fluoride
Trismus
prevention
Education
Dental care
Dental
procedure
General ManagementBefore the cancer therapy
 Objective
 To Identify, stabilise & eliminate existing & potential source infection &
irritants in oral cavity
 to communicate with the oncology team -patient’s oral health status,
plan, and timing of treatment.
 To educate the patient and parents about the importance of optimal oral
care to minimise
 oral problems/discomfort before, during, and after treatment
 the possible acute and long-term effects of the therapy
General ManagementBefore the cancer therapy
1-Initial evaluation
a) PMH
 Disease/condition(type, stage, prognosis),
 treatment protocol (conditioning regimen, surgery, chemotherapy,
radiation, transplant),
 medications (including bisphosphonates),
 allergies, surgeries, secondary medical diagnoses, hematological
status [complete blood count (CBC)], coagulation status,
immunosuppression status, presence of an indwelling venous access
line, and contact of oncology team/primary care physician(s).
b) PDH
c) Oral/dental assessment
General ManagementBefore the cancer therapy
Initial evaluation
a) PMH
b) PDH
• Fluoride exposure,habits, trauma, symptomatic teeth,
previous care, preventive practices, oral hygiene, and diet
assessment.
c) Oral/dental assessment
•
•
•
head, neck, and intraoral examination,
OH assessment and training,
radiographic evaluation based on history and clinical findings.
General ManagementBefore the cancer therapy
2-Preventive strategy
Oral hygiene
•
Brushing- 2 to 3x/day
•
Floss- only allowed if aptient properly trained
•
Poor OH- alcohol free chlorhexidine
b) Diet
a)
•
c)
Advice parent- non cariogenic diet
Fluoride•
Toothpaste,gel,varnish,supplement,
General ManagementBefore the cancer therapy
2-Preventive strategy
d)
Trismus prevention
 who receive radiation therapy to the masticatory muscles
 daily oral stretching exercises/physical therapy should start
before radiation is initiated and continue throughout treatment.
e) Education
 importance of optimal care – minimise problem/ discomfort
General ManagementBefore the cancer therapy
3-Dental Care (haematological consideration)
 absolute neutrophil count –(antibiotic prophylaxis)
 >2,000/mm3: no need for antibiotic prophylaxis
 1000 to 2000/mm3: Use clinical judgment1based on the patient’s
health status and planned procedures. Some authors1,5 suggest that
antibiotic coverage (dosed per AHA recommendations)
 <1,000/mm3: defer elective dental care.
General ManagementBefore the cancer therapy
3-Dental Care (haematological consideration)
 platelet count-(
 >75,000/mm: no additional support needed.
 40,000 to 75,000/mm3:
 platelet transfusions may be considered pre- and 24 hours post-operatively.
 Local-ized procedures to manage prolonged bleeding may include sutures,
hemostatic agents, pressure packs, and/or gelatin foams is needed.
 <40,000/mm3: defer care.
 other coagulation test
General ManagementBefore the cancer therapy
4-Dental procedure
 Should be completed before start cancer tx- ideally
 Prioritizing procedure
 when all dental needs cannot be treated before cancer therapy is initiated.
 Prioritize: infections, extractions, periodontal care (eg,scaling,
prophylaxis), and removal sources of tissue irritation .
General ManagementBefore the cancer therapy
Dental procedure
 Pulp therapy
 No studies for safety of performing pulp therapy in primary teeth
before starting chemotherapy and/or radiotherapy.
 Choose extraction – avoid infection later
 Endodontic tx
 Symptomatic non-vital permanent teeth should receive RCT at least
one week before initiation of cancer therapy
 if not possible- extract
General ManagementBefore the cancer therapy
Dental procedure
 Orthodontic appliances and space maintainer
 Poorly fitting – abrade mucosa risk of microbial invasion to
deeper tissue.
 Should be removed in poor OH patient
 Simple,non-irritating appliance can e used if OH good
 Periodontal consideration
General ManagementBefore the cancer therapy
Dental procedure
 Extraction
 removed ideally two weeks (or at least seven to 10 days) before
cancer therapy )
 Nonrestorable teeth, root tips, teeth with periodontalpockets
greater than six millimeters, symptomatic impacted teeth, and
teeth exhibiting acute infections,significant bone loss,
involvement of the furcation, or mobility.
Management
Before
During
A. Preventive
strategies
After
B. Dental
care
C. Mx of oral
conditions related
to cancer therapies
A. Preventive strategies
 Oral hygiene
 Diet
 Fluoride
 Lip care
 Education
 need for regular follow-ups (potential dental developmental
problems after radiotherapy)
B. Dental care
 Periodic evaluation
 should be seen at least every 6 months (or in shorter intervals)
 moderate or severe mucositis and/or chronic oral GVHD
should be followed closely for malignant transformation
 Orthodontic treatment
 Light force
 Oral surgery
 Only minor procedure
Oral surgery
 Non-elective oral surgical and invasive periodontal
procedures
 Consultation with an oral surgeon/periodontist & physician is
recommended
 to decrease the risk of osteonecrosis and osteoradionecrosis
 Elective invasive procedures should be avoided
C. Management of oral conditions
related to cancer therapies
 Xerostomia
 Trismus
References
Guideline on Dental Management of Pediatric Patients
Receiving Chemotherapy, Hematopoietic Cell Transplantation,
and/or Radiation
2. Handbook of Pediatric Dentistry, A Cameron, R Widmer
1.
Thank you