SAKINAH MOHD SALEH MOHD AZIZUL MOHD ATAN ABDULLAH ZAHID AZHARI NUR AMALINA ZULKEPRE NURMARZURA ABDUL LATIF AHMAD ZULKHAIRI RESALI NURUL ASMAT ABDUL RAHMAN MANAGEMENT OF MEDICALLY COMPROMISED PATIENTS

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.

ONCOLOGY AETIOLOGY

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

ONCOLOGY CLINICAL PRESENTATION

Clinical presentations: Incidence 2 nd leading cause of death

Clinical presentations Incidence of childhood cancer CancerIncidence leukemia30.2 Central nervous system21.7 lymphoma10.9 neuroblastoma8.2 Soft tissue sarcoma7.0 Renal tumor6.3 Bone tumor4.7 others11.0 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. Cancer diagnosis in children is often delayed because the presenting symptoms tend to be nonspecific and resemble those of benign conditions.

1. LEUKEMIA 2. NON-HODGKIN’S LYMPHOMA 3. NEUROBLASTOMA Common disease of childhood cancer

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 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% Rare in childhood, accounts for <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 featuresInvestigations Fatigue and weight loss Anaemia Purpura Infection and febrile episodes. Hepatosplenomegaly and lymphadenopathy Bone pain 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 Preventive strategy Oral hygiene Diet Fluoride Trismus prevention Education Dental procedure During After

General Management- Before 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 Preventive strategy Oral hygiene Diet Fluoride Trismus prevention Education Dental care Dental procedure During After

General Management- Before 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 Management- Before 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 Management- Before 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 Management- Before the cancer therapy 2-Preventive strategy a) Oral hygiene Brushing- 2 to 3x/day Floss- only allowed if aptient properly trained Poor OH- alcohol free chlorhexidine b) Diet Advice parent- non cariogenic diet c) Fluoride- Toothpaste,gel,varnish,supplement,

General Management- Before 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 Management- Before 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 authors 1,5 suggest that antibiotic coverage (dosed per AHA recommendations) <1,000/mm3: defer elective dental care.

General Management- Before 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 Management- Before 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 Management- Before 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 Management- Before 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 Management- Before 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 After A. Preventive strategies 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 1. Guideline on Dental Management of Pediatric Patients Receiving Chemotherapy, Hematopoietic Cell Transplantation, and/or Radiation 2. Handbook of Pediatric Dentistry, A Cameron, R Widmer

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