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The Dental Management of Patients with Hematologic Disease

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Anemia

Anemia comprises a large number of conditions involving impaired hemostatic mechanisms and lymphoreticular abnormalities. Anemic disorders may be primary or secondary to other conditions such as gastrointestional or other types of internal bleeding, infection, or gut absorption abnormalities. The result is impaired oxygenation of tissues.

An awareness of the signs and symptoms of hematologic disease is an important aspect of dental management of this constellation of conditions. Review of published studies indicates that the hematologic conditions most likely associated with orofacial signs and symptoms include iron deficiency anemia, Plummer-Vinson syndrome, megaloblastic anemia, sickle cell anemia, and thalassaemia and aplastic anemia. (Adeyemo TA, Adeyemo WL, Adediran A, Akinbami AA, Akanmu AS. Orofacial manifestations of hematological disorders: Anemia and hemostatic disorders. Indian J Dent Res 2011;22:454-61)

As described by Adeyemoto and colleagues, the oral manifestations of these hematologic diseases may include atrophic glossitis or tongue baldness, dysphagia, angular stomatitis, gingival bleeding, as well as post-extraction bleeding. Also reported in the literature is osteoclerosis, osteomyelitis, and paraesthesia/anesthesia within the trigeminal system (e.g. mental nerve). Candida infection may also occur in patients with anemia. Patients with sickle cell anemia may experience severe facial pain associated with blood vessel occlusion and facial swelling. Those patients with aplastic anemia are susceptible to oral ulceration as well as fungal and viral infection.

There are several management considerations in the dental treatment of patients with hematologic disease. In patients with anemia that is or was associated with stomach ulceration as a source of the GI bleed, aspirin or non-steroidal medication should be avoided. Drugs combined with phenacetin should not be prescribed for patients with anemia caused by glucose-6-phosphate dehydrogenase deficiency. This form of anemia has also been associated with an increased incidence of sensitivity to sulfonamides, aspirin, and chloramphenicol.

Patients with sickle-cell anemia should only receive dental treatment when they are not in crisis. Management of caries is extremely important as non-treated caries leading to periapical infection can precipitate a crisis. Infection has to be managed aggressively with local and systemic measures including appropriate dental treatment, antibiotics, and surgical procedures if necessary (i.e. incision and drainage, extraction). A cellulitis warrants medical consultation and possible hospitalization. It is recommended that intravenous sedation should be considered only in a hospital setting. (Bryant C, Boyle C. Sickle cell disease, dentistry and conscious sedation. Dent Update. 2011 Sep;38(7):486-8, 491-2). The presence of angular cheilitis in the patient with iron-deficiency anemia suggests the possibility of a candidiasis which can be effectively managed with the anti-fungal medications previously described.

Another important consideration for the dentist treating the patient with Plummer-Vinson syndrome (and Fanconi syndrome) is that these conditions are linked to the development of oral squamous cell carcinoma. Hence, increased vigilance should include close inspection of the tongue during recall examination. Likewise, in the patient with painless oral swellings, gingival bleeding, recurrent viral (e.g. HSV-1) or fungal (e.g. candidiasis) oral infection, and/or lymphadenopathy without obvious cause, systemic hematologic disease should be considered and medical evaluation strongly recommended concomitant with the provided dental treatment.

Leukemia and Platelet Disorders

Bleeding and infection are the conditions of greatest concern in the dental management of the leukemic patient.  Medical consultation is imperative prior to dental treatment of the patient with leukemia or other blood diseases.

Oral Mucositis

Dentists in the hospital setting may be asked to co-manage patients with oral mucositis arising secondary to high-dose chemotherapy or graft-versus-host disease (GVHD) following hematopoietic stem cell transplantation. Peterson and Schubert, et al, provide an excellent chapter that reviews management strategies that can be considered best practice in the care of these patients (Peterson D, Schubert M, Silverman S, Eversole R. Blood Dyscrasias. In Essentials of Oral Medicine. Editors: Sol Silverman, L.Roy Eversole, Edmond L Truelove. BC Decker, Inc. 2001, Hamilton, London).

For mild mucositis bland rinses containing 0.9% normal saline or sodium bicarbonate solution; mucosal coating agents such as antacid or kaolin solution; or water soluble lubricating agents and artificial salivas can improve patient comfort. Film coating agents such as Zilactin or polyvinylpyrrolidone-sodium hyaluronate gel (Gelclair) (Vokurka S, Skardova J, Hruskova R, Kabatova-Maxova K, Svoboda T, Bystricka E, Steinerova K, Koza V. The effect of polyvinylpyrrolidone-sodium hyaluronate gel (Gelclair) on oral microbial colonization and pain control compared with other rinsing solutions in patients with oral mucositis after allogeneic stem cells transplantation. Med Sci Monit. 2011 Oct;17(10):CR572-6) can reduce discomfort in focal areas of ulceration. For more generalized mucositis associated with moderate pain they recommend topical anesthetics such as viscous lidocaine, dyclonine rinse or spray, benzocaine sprays or gels, or diphenhydramine solutions to be used as frequently as necessary.  Systemic analgesics will also need to be supplied to supplement the topical measures.  The use of the above topicals may alter chewing and swallowing so should not be used immediately prior to eating.

Several recent studies provide evidence for a number of other approaches to managing mucositis. A recent drug trial of benzydamine hydrochloride, chlorhexidine, and povidone iodine in patients undergoing radiotherapy for head and neck malignancy suggests that the development of severe mucositis and subsequent oral pain can be muted by the use of benzydamine hydrochloride (0.15%). (Roopashri G, Jayanthi K, Guruprasad R. Efficacy of benzydamine hydrochloride, chlorhexidine, and povidone iodine in the treatment of oral mucositis among patients undergoing radiotherapy in head and neck malignancies: A drug trail. Contemp Clin Dent. 2011 Jan;2(1):8-12).

And in another trial (RCT) assessing the efficacy of Palifermin  (Kepivance - which is comprised of a human recombinant keratinocyte growth factor (KGF)), used to manage mucositis, data analysis suggests that the product may reduce the duration of severe oral mucositis and reduce the incidence of xerostomia.  However, when compared with placebo the results were not significant. (Le QT, Kim HE, Schneider CJ, Muraközy G, Skladowski K, Reinisch S, Chen Y, Hickey M, Mo M, Chen MG, Berger D, Lizambri R, Henke MPalifermin reduces severe mucositis in definitive chemoradiotherapy of locally advanced head and neck cancer: a randomized, placebo-controlled study. J Clin Oncol. 2011 Jul 10;29(20):2808-14). Triclosan oral rinse (triclosan 0.03% W/V) has also been shown to be effective in managing mucositis (Satheeshkumar PS, Chamba MS, Balan A, Sreelatha KT, Bhatathiri VN, Bose T. Effectiveness of triclosan in the management of radiation-induced oral mucositis: a randomized clinical trial. J Cancer Res Ther. 2010 Oct-Dec;6(4):466-72).

National standards produced by NIH for managing oral mucositis have been published for the health professional and for patients and can be found at:

Oral complication of chemotherapy and Head/Neck radiation (PDQR)

Best practice guidelines for managing the patient with multiple myeloma that include recommendations regarding mucositis as well as bisphosphonate-induced osteonecrosis of the jaw can be found at: Guidelines for supportive care in multiple myeloma 2011 (Snowden JA, Ahmedzai SH, Ashcroft J, D'Sa S, Littlewood T, Low E, Lucraft H, Maclean R, Feyler S, Pratt G, Bird JM; Haemato-oncology Task Force of British Committee for Standards in Haematology and UK Myeloma Forum.  Guidelines for supportive care in multiple myeloma 2011. Br J Haematol. 2011 Jul;154(1):76-103)  Best practice guidelines for the management of all oncology patients includes a thorough pre-treatment dental examination that includes jaw imaging to rule out dental pathology before initiation of intravenous high-dose bisphosphonate therapy.  If invasive dental treatment is necessary it should be completed in advance of delivery of the drug and other dental procedures should be delayed for three to six months after completion of this drug treatment to prevent complications.

Canadian consensus practice guidelines for biphosphonate associated osteonecrosis of the jaw

In patients with GVHD oral infection risk, including periodontal disease, is increased so dental management should include comprehensive dental hygiene strategies that include good home care and dental prophylaxis and careful monitoring for bacterial, viral, and fungal infection. Limited data suggests that the administration of topical medication such as cyclosporine or psoralen-ultra violet A (PUVA) may help to reduce GVHD symptoms.

Submitted by Jeff Burgess DDS MSD