Wednesday, April 22, 2015

Pediatric Bone Marrow Transplantation: Oral Complications and Recommendations for Care

Title: Pediatric bone marrow transplantation: oral complications and recommendations for care
Classic 100

The paper discusses the important and unique role that pediatric dentistry has in the multiprofessional BMT team to help bring about a successful outcome through the prevention and tx of acute or al complications often seen in these patients. BMT results in immunosuppression and problems in the oral cavity, which can become life threatening and increase hospital stay, pt discomfort, and tx costs.

BMT Overview:
·      BMT has become the tx of choice for patients with disease affecting BM directly or indirectly. Donor stem cells provide recipient with new hemopoietic and immune system response. The BMT replaces marrow in patients with: 1. Hematological malignancies (leukemia) 2. Hematatologic disorders (aplastic and sickle cells anemia) 3. Congenital immunodeficiencies (severe combined immuno def. disorders such as Wiskott-Aldrich syndrome). 4. Lipidoses 5. Metabolism errors (Hurlers Syndrome).

·      BMT is also used as marrow to support patients needing chemo/radiation therapy for solid tumors and receive autologous transplants using BM.

·      Allogenic BM is used in patients with hematologic malignancies which come from three main sources: 1. Iliac crest aspirations 2. Peripheral circulating blood (PBSC) 3. Umbilical cord blood (UCB)

Pre-transplant oral/dental evaluation:
·      Goal: to eliminate and prevent potential problems to insure successful BMT. According to PIzzo and Schimpf, bolster host defense mechanisms, preserve body’s natural defense, reduce environmental organisms and endogenous microflora
·      Review of Md Hx: underlying disease, time of diagnosis, types of tx patient has received, complications, surgeries, hospitalizations, ER visits, past episodes of infections, current hematological status, allergies, meds, review of systems.
o   Transplant details: type, donor, preoperative regiment, GVHD, pediatric BMT meds
o   Was a central line placed: If so establish if any AHA prophylaxis is necessary.
·      Hematological Status
o   Know patients blood counts
o   Before Dental Tx you should know patients # of platelets and ANC
§  Thrombocytopenia: platelets <100kmm3, moderate bleeding risk <50kmm3
§  Neutropenia: ANC <1500 cells/mm3 when ANC <1000 cells/mm3 NO ELECTIVE DENTAL TX
Dental Tx:
o   Oral hygiene dental rehab should be aggressive as possible before transplant because patients may not experience dental tx for one year after BMT
o   Dental consult should be one of first in work-up schedule to allow enough time to coordinate services
o   Dental rehab should be scheduled with other medical procedures
o   Eliminate active infection potential sources of problems when low # of granulocytes
o   Fever in immunosuppressed pts requires prompt assessment and antibiotics
o   Dental scaling, cleaning, and carious lesions should be taken care of promptly
o   Pulpotomies/pulpectomies in primary teeth are not advocated –ext
o   Endo tx in one visit
o   Smooth enamel fractures, leave loose primary teeth and remove all fixed ortho appliances.
Oral Hygiene
o   Problems most likely when pt noncompliant with good OH
o   Many BMT teams believe toothbrushing increases risk of bacteremia/bleeding and advocate discontinuation of OH with a regular TB when pt is neutropenic
o   Sponges of foam brushes “toothettes’ are not effective to remove plaque and debris and should be discouraged
o   BID TB with atramatic flossing
o   Rinses: Saline, Sodiumbicarbs for four to six times daily
o   Do not use hydrogen peroxide – delays healing
o   Chlorhexidine rinses BID if poor OH
Oral Complications
o   Mucositis
§  Oral mucosa affected bc of rapid cell turnover
§  Severity based on drug doses schedules, duration of tx and impairment of renal and hepatic fxn
§  Tissue changes noted between 4-7 days and lasts from 10-14 days
§  Nonkeratinized surfaces of buccal/labial mucosa, lateral/ventral tongue and soft palate
§  Morbidity includes dysphagia, poor nutrition, increased discomfort, difficult speech, oral bleeding and secondary infections
§  Pain Management of Mucositis
·      Patient controlled analgesia
·      Viscous lidocaine hydrochloride (2%) and dyclonine hydrochloride (0.5 or 1%) are common topical anethesthics to be used for at least three minutes
o   Gargling not advised as loss of gag reflex can cause aspiration of saliva and mucous tissues
·      Ice packs on cheeks and throat, popsicles and ice chips/drinks
o   Oral Bleeding
§  Thrombocytopenia – bruising petechiae, purpura and oozing are complicated by the presence of irritants such as plaque, calculus, ortho bands.
§  Spontaneous bleeding: platelets <20kmm3 (avoid elective surgical procedures and IA blocks)
o   Infections:
§  Most common: Candida albicans and treated with nystatin and clotrimazole troches
§  Most frequent viral: Herpes (HSV) and if pts test positive then prophylactic acyclovir
§  Cytomegalovirus infection can happen
o   Xerostomia and Taste Disturbances
§  Salivary dysfunction can be increased by: use of oxygen support, anticholinergic meds, GVHD, mouth breathing
§  Saliva is thick and viscous
§  Saliva stimulated by sugar free gum, candy and drinks
§  Avoid high sugar and cab drinks
o   Acute GVHD
§  Transplanted T-lymphocytes recognize histocompatiblity antigens of host tissue as foreign, causing injury
§  Occurs within 100d post-BMT w/median onset 19d
§  Most common oral changes in GVHD: erythema (dorsal/ventral tongue, FOM, gingival, labial mucosa)
§  Acute GVHD suspected when mucosal changes appear, worsen, or persist beyond day 21 post BMT

Dental Care of the Pediatric Patient with Splenic Dysfunction

Author: Da Fonseca and Hirsch

Journal: Pediatric Dentistry-24:1, 2002

Purpose: To review the risks of splenic dysfunction and its implications for dental care delivery for pediatric patients.

Background: The spleen makes up about 25% of the body’s lymphoid tissues, receiving 5% of the blood volume per minute and pooling around 30% of the circulating platelets. In the first years of life, before specific immunity has developed, phagocytosis of encapsulated organisms (ie S. pneumonia, H. influenza type B, and N. meningitides) takes place exclusively in the spleen. The spleen plays a large role in the generation of immune mediators involved in clearing bacteria and other mediators of phagocytosis. The spleen also recycles the iron released by the breakdown of red blood cells, sending it back to the bone marrow to use in the production of new cells. Therefore, asplenic and hyposplenic patients present a high risk for infection.

Splenic Dysfunction: Congenital absence of the spleen can be observed in children with severe organ malformation (ie. complex cyanotic heart defects, dextrocardia, heterotrophic abdominal organs). Functional hyposplenism is most commonly a part of gastrointerstinal, immunologic, inflammatory, infiltrative and hematologic diseases. Traumatic rupture of the spleen, with consequent life-threatening hemorrhage, is the most common reason for splenectomy. Healthy patients, however, who had a splenectomy due to trauma have the lowest risk of serious infections as a result of implanted splenic remnants or the presence of an accessory spleen.

Prevention of Infection: If a splenectomy is being contemplated, particularly in young children, immunization against a small number of organisms is advised. In children undergoing chemotherapy and/or radiationtherapy, it is best to delay immunization for at least 6 months after treatment is completed. Also, as the risk of infection is greatest within the two years after a splenectomy, most practitioners prescribe oral PenVK 250 mg twice daily.

Pediatric Dental Considerations: Parents must be reminded that an odontogenic infection needs to be ruled out in cases of fever of unknown origin and has a potential to be life threatening, regardless if indication and timing of the splenectomy. Children undergoing chemotherapy/radiotherapy who have a splenectomy as part of the therapy or as a staging procedure, must have a complete blood count done before dental treatment. As of the time this article was published, there were no proven benefits or recommendations for the use of antibiotic prophylaxis in splenectomized patients receiving invasive dental procedures. Antibiotic prophylaxis prior to dental treatment is not indicated for healthy asplenic patients nor for those who had splenectomy due to trauma. A medical consultation should be performed when treating patients who are immunosuppressed, in poor health or who had a splenectomy within the past two years, especially in young children.

Tuesday, April 21, 2015

Pediatric Bone Marrow Transplantation: Oral Complications and Recommendations for Care.

Title: Pediatric Bone Marrow Transplantation: Oral Complications and Recommendations for Care.

Abstract: Due to immunosuppression any problems the pediatric patient presents in the oral cavity can be life threatening. The paper discusses the important and unique role that pediatric dentistry has in the multi-professional Bone Marrow Transplantation (BMT) team.

Bone marrow transplantation (BMT)- an overview:
-        BMT used to replace marrow in patients with hematological malignancies or disorders.
-        3 main sources of stem cells used in BMT: iliac crest, peripheral blood, and umbilical cord blood.
-        Human leukocyte antigen tissue typing is done to identify antigens on the short arm of chromosome 6 of potential donors to match the recipient’s.
-        Pt receives combo of high-dose chemotherapy and total body irradiation to eradicate the patient’s immune system to prepare for a transplant.
-        Stages of Bone Marrow Transplantation
o   Stage 1-Pretherapy-education, eliminate/stabilize disease
o   (Day 0) Stage 2- Intratherapy- conditioning, immunosuppression, continued recovery
§  Mucositis, infection, hemorrhage, acute graft vs. host disease (GVHD)
o   (Day +30) Stage 3-Post Therapy
§  Immunosuppression, continued recovery.
·      mucositis, infection, hemorrhage, acute chronic GVHD
o   (Day + 100) Stage 4- Long Term
§  Immunosuppresion to full recovery GVHD
·      Xerostomia, late effects.
The pretransplant oral/dental evaluation (Stage 1)
-        Pediatric dentist’ should identify, eliminate and prevent potential problems that could deem transplant unsuccessful.
Review of medical History
-        Gather information regarding underlying disease, diagnosis, treatment, complications, surgeries, hospitalizations, infection history.
-        Nystatin and clotrimazole, are commonly prescribed in pediatric BMT, have high sugar content. Pediatric dentist should make physicians aware of possible cariogenic potential.
-        Central line venous access for chemotherapeutic agents require antibiotic prophylactic coverage per the AHA.
Hematologic status
-        Platelets, neutrophil count should be assessed.
-        Moderate bleeding risk exists when platelets reach 50,000/mm3
-        ANC <1000/mm3- elective dental treatment should be deferred.
o   Appropriate antibiotic coverage should be discussed with BMT team.
Oral complications during the transplant and early engraftment period (Stage 2)
-        Mucositis
o   Preparative agents are not specifically targeted to malignant cells only and can affect tissues that have a rapid cell turnover like the oral mucosa.  This is done by inhibiting the basal layer to replace superficial cells leading to generalized mucosal inflammation.
o   Can occur 4-7 days after starting medication and can last 10-14 days .
-        Pain management of mucositis
o   Viscous Lidocaine HCL 2% and dyclonine HCL (0.5% or 1.0%).
o   Combination of topical anesthetics and antacids have been suggested.
o   Swallowing anesthetics not recommended since loss of the gag reflex can lead to aspiration.
-        Oral bleeding
o   Occurs due to thrombocytopenia.
o   Bruising, petechiae, purpura and oozing from mucosal surfaces.
o   Spontaneous bleeding occurs 20,000/mm3.
-        Xerostomia and taste disturbances
o   Due to medications with anticholinergic effects, GVHD and mouth breathing.
o   Can last a few weeks to several months.
-        Acute GVHD
o   The use of prophylactic measures against systemic GVHD directly reflects the prevention and treatment or the oral form of the disease.
o    Good oral hygiene, steroid rinses and gels along with treatment for oral infections and topical anesthetics. 
-        Neurotoxicity
o   Plant alkaloid drugs used in the conditioning regimen produce peripheral neuropathy leading to jaw pain and toothaches.
o   Treatment is palliative and symptoms disappear a few days after discontinuing drugs.
-        Summary

o   The paper discussed the unique role that pediatric dentistry has in a multi-professional BMT team.