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level: Leukemia and lymphoma

Questions and Answers List

level questions: Leukemia and lymphoma

QuestionAnswer
Acute leukiemaiAn 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 presentationsMarrow 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 leukemiaChronic 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 byLichenoid inflammation Sclerosis Salivary gland dysfunction Predisposition to HSV and secondary oral cancers
Prophy for candidafluconazole
Prophy for HCVAciclovir
Lymphoma general symptoms‘B symptoms’ § Unintentional weight loss of 10% over 6 months § Fevers greater than 38 degrees § Night sweats (drenching)
Intraoral presentations of lymphomaGum swelling § Dental abscesses § Osteonecrosis § Mucosal lesions
Systemic signs of lymphomaCervical 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 mouthDental 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 txKetoacidosis □ 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
PTHStimulates osteoclasts to release more serum calcium
Vit DRegulates calcium and phosphate in the body
Hyper PTHParathyroid 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 causesHypoplasia 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 muchCortisol/ hydrocortisone or too many glucocorticoids
Dental implications of cushings§ Osteoporosis § Gums bleed easily § Infections (periodontitis, candidiasis)
What causes addisons diseaseAdrenal 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
Neutrophilswould 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 manifestationAngular stomatitis apthous ulceration glosisits
normocytic anaemiaormocytic 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
antithromboticsapixaban, warfarin
Complications of CKDand 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 causetubular 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 ADHIf 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 whatVasocontricts
Aldosterone does whatInc 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