| Acute leukiemai | An acute life threatening condition
Incidence of around 5 cases per 100,000 every year
Two types: Acute Myeloid Leukaemia (AML) – most common in adults
Acute Lymphoblastic Leukaemia (ALL) – most common in children
Requires treatment within hours/days of diagnosis - risk of death from bleeding / infection if delay |
| Acute leukemia presentations | Marrow failure
Anaemia: fatigue, SOB, headaches, palpitations
Leukopenia (low WBC count): infections, mouth ulcers
Neutropenia is the biggest concern
Thrombocytopenia: purpura, bleeding, bruising
Hyperviscosity due to leucocytosis
Headaches
Breathlessness
Visual blurring
Confusion
Leukaemic infiltration
AML can cause gingival hypertrophy
skin lesions ‘chloromas’
Hepatosplenomegaly |
| 2 main types of leukemia | Chronic lymphocytic leukaemia (CLL)
Chronic myeloid leukaemia (CML) |
| Complications of tx | ○ Mucositis
○ Opportunistic infections
Candida
Herpes simplex virus (HSV)
Bacterial dental abscesses
○ Xerostomia, if radiotherapy used
Oral GvHD |
| Oral GvHD characterised by | Lichenoid inflammation
Sclerosis
Salivary gland dysfunction
Predisposition to HSV and secondary oral cancers |
| Prophy for candida | fluconazole |
| Prophy for HCV | Aciclovir |
| Lymphoma general symptoms | ‘B symptoms’
§ Unintentional weight loss of 10% over 6 months
§ Fevers greater than 38 degrees
§ Night sweats (drenching) |
| Intraoral presentations of lymphoma | Gum swelling
§ Dental abscesses
§ Osteonecrosis
§ Mucosal lesions |
| Systemic signs of lymphoma | Cervical lymphadenopathy
Nasal obstruction
Facial pain
Conductive hearing loss
Visual problems
Cranial nerve palsies
ACNS signs |
| Multiple myeloma | ○ Myel’ – marrow, ‘Oma’ – tumour
○ Malignancy of plasma cells
○ Plasma cells are mature, terminally differentiated B lymphocytes that produce immunoglobulins
○ Plasma cells accumulate in the bone marrow and secrete clonal immunoglobulins into the plasma, resulting in a paraprotein or ‘M protein’ |
| myeloma | - CRABI
○ C = Hypercalcaemia
○ R = Renal impairment
○ A = Anaemia
○ B = Bone pain and destruction (fractures, cord compression)
I = Infection |
| Tx of myeloma | § Chemotherapy
§ Autologous bone marrow transplant
§ IV bisphosphonates for bone protection (and survival benefit)
□ Zoledronic acid (Zometa)
Pamidronate |
| MRONJ lower risk in | □ Pamidronate lower than Zoledronic acid
Oral bisphosphonates |
| Tyrosine derivatives | = thyroid hormones epinephrine |
| Diabetes side effects on mouth | Dental caries
Periodontitis
□ Associated with poor glycaemic control
□ Associated with increased risk of death from cardiovascular and renal disease
□ High levels of CRP correlate inflammation
§ Xerostomia
□ May lead to candida infection
§ Altered taste
§ Parotid gland enlargement
§ Mucosal diseases
□ Lichen planus
□ Lichenoid drug reactions |
| Type 1 diabetes tx | ○ Monitoring of blood glucose is vital
§ Basal bolus: 4 injections daily
§ Mixed insulin: 2-3 injections daily
§ Long acting insulin only: 1-2 injections daily
Pump |
| Diabetes type II tx | ○ 1. Diet and exercise to promote weight loss
○ 2. Oral treatment with drugs
§ Single or combined therapy
○ 3. Insulin
§ In combination with drugs
Full insulin replacement |
| dental treatment with diabetes patients | □ Try not to omit meals or consider reduction of antidiabetic drug or insulin
□ Plan breaks for snacks
□ Regular glucose checks during longer procedures
□ Try to avoid procedures in uncontrolled diabetes (may not be possible)
For major procedures plan ahead and liaise with local diabetes team |
| treatment of hypoglycaemia | □ PO (glycogel, Lucozade)
□ IM (glucagon)
IV (dextrose 10% or 20%) |
| Hyperglycaemia- issues and tx | Ketoacidosis
□ Mainly affects type 1 diabetics
□ Build-up of ketone bodies in blood stream – lowers pH
□ Coma and death
□ Prominent cause of mortality in type 1 diabetes
HHS (hyperosmolar hyperglycaemic state)
□ Affects patients with type 2 diabetes
□ Presentation: very high glucose (>30) and dehydration
Treatment
□ Insulin and IV fluids |
| PTH | Stimulates osteoclasts to release more serum calcium |
| Vit D | Regulates calcium and phosphate in the body |
| Hyper PTH | Parathyroid adenoma
Hyperplasia of all 4 glands
○ High calcium and PTH
○ Bones of the mouth are less radio dense
○ Central giant cell granulomas from osteoclasts may be present |
| Low PTH or Ca causes | Hypoplasia of the enamel and dentin, short roots, delayed eruption of teeth |
| Osteomalacia = | = softening of bones
§ Deficit of calcium, phosphate and vitamin D
§ Acquired or familial
Rickets (osetomalacia in children): hypocalcification of dentin, enamel and alveolar |
| Cushings is due to too much | Cortisol/ hydrocortisone or too many glucocorticoids |
| Dental implications of cushings | § Osteoporosis
§ Gums bleed easily
§ Infections (periodontitis, candidiasis) |
| What causes addisons disease | Adrenal failure |
| Treatment of addisons | □ Fludrocortisone/ hydrocortisone 3 times every 24 hours
□ (DHEA)
□ Steroid card
□ Sick day rules
§ Prevention of adrenal crisis (can be brought on by high stress)
□ Life threatening complication
□ Severe vomiting and diarrhoea followed by dehydration
□ Low blood pressure and shock
□ Hypoglyceamia
□ Loss of consciousness
§ Treatment: Iv fluids + IV hydrocotrisine
Peri-interventional glucocorticoids |
| Acromegaly | ○ Simulated by low glucose, exercise, sleep
Effects mediated by GH and IGF1
○ Excessive production of GH from anterior pituitary (most of time due to tumour)
accelerated tooth eruption § Larger maxillary sinuses |
| Thyrocytosis | ○ Causes: graves disease, toxic goitre, adenoma, medication
○ Symptoms
§ Weight loss, tachycardia, sweating, tremor
§ Accelerated tooth development in children
§ Potential to malocclusion and demineralisation
§ Avoid epinephrine in LA if possible
○ Diagnoses: high fT3 and fT4, low TSH
○ Treatment:
§ Antithyroid drugs
§ Radioactive iodine
§ Thyroid surgery |
| Neutrophils | would be up in infection such as bacterial infection |
| Lymphocytes- | would suggest a viral infection
If lymphocyte count is very low could suggest HIV |
| Normal haemoglobin levels | § Male: 135-180g/L
§ Female: 115-160g/L
Anaemia is any less than this |
| Pernicous anaemia | § Autoimmune destruction of gastric parietal cells
§ Loss of intrinsic factor necessary for absorption of vitamin B12 from the diet |
| macro and microanaemia- | micro from bleeding dietary or malabsorbtion micro from deficiency e.g. b12 or from thalassema |
| Oral manifestation | Angular stomatitis apthous ulceration glosisits |
| normocytic anaemia | ormocytic anaemia
○ Aplastic aneamia
○ Acute haemolysis
○ Anaemia of chronic disease
Rheumatoid arthritis |
| Pancytopenia | ○ Refers to reduction of all 3 components (RBC, WBC, platelets)
○ Suggests infiltration of bone marrow by pathological process |
| antithrombotics | apixaban, warfarin |
| Complications of CKD | and increased risk for patients undergoing dental procedures
○ Indications for antibiotic prophylaxis
○ Dialysis patients - increased risk of carriage of blood borne viruses, anticoagulation |
| Be aware of the management of patients on long term steroid therapy | ○ Drugs causing gingival hyperplasia
§ Cyclosporine |
| NSAIDs can cause | tubular damage |
| Synthesis and exrection in the kidney | □ Vitamin D
□ Erythropoietin
□ Renin
§ Excretion of drugs and drug metabolites
□ Need to check for reduced dosage if lack of kidney function
◊ E.g. opiods, antibiotics
◊ Need to be aware that some medication may interact with immunosuppressants such as tacrolimus and increase its levels |
| Hypovolemia | § Hypotension (shock)
Organ failure (especially kidneys)
Death |
| fluid oedema | § Oedema
§ Hypoxia
§ ‘heart failure’
Death |
| hypernatremia | § CNS dysfunction
§ Fits
§ Coma
Death |
| hypoNa+tremia | § Nausea and vomiting
§ Cerebral oedema
§ Coma
Death |
| Blood pressure ADH | If you have a change in blood pressure this is sensed by the carotid sensors which sends signals to the hypothalamus and again you get ADH released by the posterior pituitary |
| Angiotensin does what | Vasocontricts |
| Aldosterone does what | Inc sodium retention decreased pottasium retention and brain thirst |
| excess K | § Hyperkalaemia
□ Muscle paralysis
□ Paraesthesia
□ Cardiac arrhythmias
◊ Bradycardia
◊ Complete heart block
◊ VF
□ Metabolic acidosis
Death |
| hypokalaemia | □ Muscle weakness
□ Dyspnoea
□ Paraesthesia
□ Cramps
□ Cardiac arrhythmias
◊ Atrial fibrillation
◊ Ventricular fibrillation
□ Death |
| metabolic acidoisis | □ Confusion
□ Coma
□ Hypotension
□ Arrhythmias
□ Cardiac failure
Hyperventilation |
