CDA Essentials 2016 • Volume 3 • Issue 7 - page 31

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Leukemia isamalignantdiseaseaffecting thebonemarrow that causes theproductionof largenumbersof immatureblood cells. The classificationof leukemia is
basedupon theduration (acuteor chronic)and cell type that itaffects (lymphocyte,monocyteormyelocyte).While theetiologyof thedisease isunknown, factors
suchasgeneticmutations, inherited susceptibility, tobaccoandalcohol consumptionby theparents, infections, aswell asexposure to chemicals, radiationand
non-ionizingelectromagneticandelectricfieldsmayplaya role in itsdevelopment.
Adiagnosis isusuallymadeafter careful physical examination, completeblood cell countandbonemarrowbiopsy. If confirmed, treatmentnormally consistsof
chemotherapy, radiationandbonemarrow transplant.
Oral Findings
Patientswith leukemiaoftenpresentwithgeneralizedgingivalbleedingand
hyperplasia. Theyaremoresusceptible toopportunistic infectionsandmay
presentwithbonealterations.Oneof themostconsistentfindings isgingival
swellingdue to leukemic infiltration.
Cancer treatmentsalso lead to furthercomplicationssuchasoralmucositis
that typically followschemotherapyand radiation.Thedevelopingdentition
aswellasorofacialgrowthcanalsobeaffected.During the induction
phaseof treatment, ithasbeennoted that theoralhealthstatusof the
childcandeteriorateasa resultof thechange inqualityandquantityof
salivaproduced.Other studieshaveshown thatpatients treated foracute
lymphoblastic leukemiahavegreater incidencesofagenesis,microdontia,
tapering rootsaswellasshort roots.
Forchildren treatedwithbonemarrow transplantation, complicationssuch
asgraft-versus-hostdiseasemayoccur.Otheroralmanifestationsmay
includeerythema, xerostomia,mucosalulcerations,erosionand lichenoid
changes.Rare issuessuchas leukemic infiltration in themandible, trismus,
oralaspergillosisandmucormycosishavealsobeen reported.
DentalManagement
Prior to cancer treatment
A thoroughdental examinationmustbeperformed.
• Any teethwithaquestionableprognosis shouldbeextracted10–14
daysprior to chemotherapy.
• Scalingandotherpreventivemeasures includingfluorideorpit-and-
fissureapplications shouldbe completed.
• Teethwith caries shouldbe temporizedandfinal restorations should
beplacedonce thepatient is in remission.
• Patientsandparents shouldbe instructedandeducated inproperoral
hygiene care (brushing, flossing, gentlegummassage).
During cancer treatment
Complications suchasmucositis, xerostomiaand infectionsmaydevelop.
• In situationswhere the child complains thatbrushing their teeth is
painful, a chlorhexidine (CHX) rinse canhelp topreventoralmucositis.
• 0.12%CHX rinse for1minute, twiceaday
• Fungal infections canbe treatedwithnystatin.
• Nystatin suspension100,000units, 4 timesaday
(Nystatinand chlorhexidine
shouldnotbeused together
as they inhibit
theactionof theother. There shouldbea sufficient timegapbetween the two
medications.)
• Cold sores causedby theherpes simplexvirusarealso commonand
canbe treated topicallywithacyclovir.
• Xerostomia canbe treatedwith theuseof saliva substitutesand sugar-
free chewinggum.
After cancer treatment
Once in remission, children canbe treated likeanyotherhealthypatient,
unless invasive treatment is required. In this latter situation, bloodwork
maybe considered.
Patients should continuebrushingwithfluoridated toothpaste rather
thanusingaCHX rinse.
For anypatientswithdental anomalies, enamel hypoplasia,
disturbances in toothdevelopmentormaturity, other treatments
(includingesthetic restorations, orthodonticappliancesor
endodontic treatments)maybenecessary.
Some studieshave shown that children treated for leukemiamaybeat a
higher risk fordevelopingmucoepidermoid carcinomaand squamous cell
carcinoma secondary toanallogenicbonemarrow transplant.As such,
dental professionalsmayplaya role in the long-termobservationof these
patients.
Reference
1.KholoudA,AlaizariAA,TarakjiB,PetroW,HussainKA,AltamimiMAA.DentalConsiderations forLeukemicPediatricPatients:AnUpdatedReview forGeneralDentalPractitioner. 
MaterSociomed.2015Oct;27(5):359-62.
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