CDA Essentials 2016 • Volume 3 • Issue 8

31 Volume 3 Issue 7 | S upporting Y our P ractice Leukemia is a malignant disease affecting the bone marrow that causes the production of large numbers of immature blood cells. The classification of leukemia is based upon the duration (acute or chronic) and cell type that it affects (lymphocyte, monocyte or myelocyte). While the etiology of the disease is unknown, factors such as genetic mutations, inherited susceptibility, tobacco and alcohol consumption by the parents, infections, as well as exposure to chemicals, radiation and non-ionizing electromagnetic and electric fields may play a role in its development. A diagnosis is usually made after careful physical examination, complete blood cell count and bone marrow biopsy. If confirmed, treatment normally consists of chemotherapy, radiation and bone marrow transplant. Oral Findings Patients with leukemia often present with generalized gingival bleeding and hyperplasia. They are more susceptible to opportunistic infections and may present with bone alterations. One of the most consistent findings is gingival swelling due to leukemic infiltration. Cancer treatments also lead to further complications such as oral mucositis that typically follows chemotherapy and radiation. The developing dentition as well as orofacial growth can also be affected. During the induction phase of treatment, it has been noted that the oral health status of the child can deteriorate as a result of the change in quality and quantity of saliva produced. Other studies have shown that patients treated for acute lymphoblastic leukemia have greater incidences of agenesis, microdontia, tapering roots as well as short roots. For children treated with bone marrow transplantation, complications such as graft-versus-host disease may occur. Other oral manifestations may include erythema, xerostomia, mucosal ulcerations, erosion and lichenoid changes. Rare issues such as leukemic infiltration in the mandible, trismus, oral aspergillosis and mucormycosis have also been reported. Dental Management Prior to cancer treatment A thorough dental examination must be performed. • Any teeth with a questionable prognosis should be extracted 10–14 days prior to chemotherapy. • Scaling and other preventive measures including fluoride or pit-and- fissure applications should be completed. • Teeth with caries should be temporized and final restorations should be placed once the patient is in remission. • Patients and parents should be instructed and educated in proper oral hygiene care (brushing, flossing, gentle gum massage). During cancer treatment Complications such as mucositis, xerostomia and infections may develop. • In situations where the child complains that brushing their teeth is painful, a chlorhexidine (CHX) rinse can help to prevent oral mucositis. • 0.12% CHX rinse for 1 minute, twice a day • Fungal infections can be treated with nystatin. • Nystatin suspension 100,000 units, 4 times a day (Nystatin and chlorhexidine should not be used together as they inhibit the action of the other. There should be a sufficient time gap between the two medications.) • Cold sores caused by the herpes simplex virus are also common and can be treated topically with acyclovir. • Xerostomia can be treated with the use of saliva substitutes and sugar- free chewing gum. After cancer treatment Once in remission, children can be treated like any other healthy patient, unless invasive treatment is required. In this latter situation, bloodwork may be considered. • Patients should continue brushing with fluoridated toothpaste rather than using a CHX rinse. • For any patients with dental anomalies, enamel hypoplasia, disturbances in tooth development or maturity, other treatments (including esthetic restorations, orthodontic appliances or endodontic treatments) may be necessary. Some studies have shown that children treated for leukemia may be at a higher risk for developing mucoepidermoid carcinoma and squamous cell carcinoma secondary to an allogenic bone marrow transplant. As such, dental professionals may play a role in the long-term observation of these patients. Reference 1.KholoudA,AlaizariAA,TarakjiB,PetroW,HussainKA,AltamimiMAA.DentalConsiderations forLeukemicPediatricPatients:AnUpdatedReview forGeneralDentalPractitioner.  MaterSociomed. 2015Oct;27(5):359-62.