Dental Management of Leukemia Patients: An Overview

Introduction

Leukemia, a type of blood cancer, poses unique challenges for both patients and healthcare providers. As dental health plays a crucial role in overall well-being, it becomes essential to understand the specific considerations and management strategies for dental care in leukemia patients. This article provides an overview of the dental management of leukemia patients, highlighting the importance of comprehensive oral health care and the measures to ensure optimal treatment outcomes and enhanced quality of life.

What Is Leukemia?

Leukemia is a form of cancer affecting the white blood cells (WBC). WBC-forming cells, the myeloid, and the lymphoid cells tend to exhibit hyperplastic changes that produce either immature or abnormally shaped WBCs. This results in a deterioration of the normal hematopoietic functions of blood.

Leukemia is divided mainly into two forms based on clinical characteristics:

Acute Leukemia: Acute leukemia is a fatal condition and if misdiagnosed or not treated in time can lead to severe complications such as gastrointestinal bleeding, pulmonary hemorrhage, or severe blood infections and sometimes death. Most untreated patients, especially in acute leukemia, usually face fatality within or less than one year.

Leukemia is further divided into lymphocytic and myelocytic forms based on cell histology.

• Acute Lymphoid Leukemia (ALL): It is much more prevalent amongst younger children; it contributes to nearly 50 percent of all global neoplasms and 80 percent of the leukemias occurring in childhood. The prognosis is considered poor, especially in patients older than 30 years.

• Acute Myeloid Leukemia (AML): In contrast to the lymphoid form, the incidence of the myeloid form usually increases in older individuals after the sixth decade of life, primarily as per case reports among people older than 65 age. Current cancer research also suggests that the incidence of AML has been on the rise over the past decade.

What Are the Oral Manifestations of Leukemia?

Acute leukemia has a set of oral manifestations in particular. The dentist has a significant role in identifying clinical symptoms that would be identified and reported to the physician or the oncologist. This is because oral manifestations of acute leukemia are common.

Oral complications include-

• Gingival enlargement (frequent in AML).

• Arthritis of the temporomandibular joint (again common in AML).

• Osteolytic lesions (spots of bone damage) occur more in the mandible or lower jaw.

Referring such lesions on observation by dentists to the hematologist would be ideal, as misdiagnosis can result in fatal consequences when ignored. According to Stafford et al., dentists should recognize the oral manifestations of leukemic patients, which would be helpful in an early diagnosis.

What Are the General Symptoms of Leukemia?

Leukemia is a type of cancer that affects the blood and bone marrow, leading to abnormal production of white blood cells. The symptoms of leukemia can vary depending on the type of leukemia and its stage. Common symptoms of leukemia may include:

• Fatigue and Weakness: Patients with leukemia often experience extreme tiredness and weakness, even after minimal physical activity.
• Fever and Infections: Leukemia impairs the body's ability to fight infections, leading to frequent or severe infections and persistent fever.
• Easy Bruising and Bleeding: Leukemia can reduce the number of platelets in the blood, leading to easy bruising, bleeding gums, and nosebleeds.
• Paleness: Anemia, a condition where there are too few red blood cells, can cause paleness of the skin and mucous membranes.
• Enlarged Lymph Nodes and Spleen: Leukemia may cause swelling of the lymph nodes, especially in the neck, armpits, and groin, as well as an enlarged spleen.
• Bone and Joint Pain: Some leukemia patients may experience bone pain or tenderness due to the accumulation of leukemia cells in the bone marrow.
• Weight Loss and Loss of Appetite: Leukemia can lead to a reduced appetite and unintentional weight loss.
• Abdominal Discomfort: Enlargement of the liver or spleen may cause discomfort or pain in the abdomen.
• Night Sweats: Some leukemia patients may experience excessive sweating, particularly at night.

It is essential to note that these symptoms can be caused by various other health conditions as well, and the presence of these symptoms does not necessarily indicate leukemia. If any of these symptoms persist or raise concerns, it is crucial to consult a healthcare professional for a proper evaluation and diagnosis. Early detection and prompt treatment are critical for better outcomes in leukemia patients.

Leukemia patients should also be screened again after diagnosis clinically and radiologically for observing additional oral manifestations that can have a detrimental impact on their treatment or general health (if not treated alongside conventional medicine by the oncologist).

Which Dental Problems Can Occur in Leukemic Patients?

Leukemic patients are at increased risk of developing various dental problems due to the impact of the disease and its treatment on the immune system and oral health. Some common dental problems that can arise in leukemic patients include:

• Oral Infections: Leukemia compromises the immune system, making patients more susceptible to oral infections such as thrush (oral candidiasis), bacterial infections, and viral infections like herpes simplex virus.
• Bleeding Gums: Leukemia can cause low platelet counts, leading to easy bruising and bleeding, including bleeding gums.
• Mucositis: Chemotherapy and radiation treatments for leukemia can cause inflammation and ulceration of the mucous membranes in the mouth, resulting in painful mucositis.
• Dry Mouth (Xerostomia): Certain chemotherapy drugs can reduce salivary flow, leading to dry mouth. This condition increases the risk of dental caries, gum disease, and oral infections.
• Gum Disease (Gingivitis and Periodontitis): Immune system impairment in leukemia patients can make them more susceptible to gum disease, characterized by swollen, red, and bleeding gums.
• Tooth Decay: Dry mouth, changes in diet, and compromised immune function can contribute to an increased risk of tooth decay in leukemic patients.
• Oral Bleeding: Leukemia-related low platelet counts can cause spontaneous bleeding in the oral cavity, affecting the gums, tongue, and other soft tissues.
• Delayed Tooth Eruption: Children with leukemia may experience delayed tooth eruption due to the effects of cancer treatment on tooth development.
• Osteonecrosis of the Jaw (ONJ): Rarely, certain types of cancer treatments, such as bisphosphonates or high-dose steroids, may increase the risk of ONJ, a condition where the jawbone tissue begins to die.
• Oral Ulcerations: Leukemic patients may experience painful oral ulcerations, which can be a side effect of cancer treatments.

Proper oral care and regular dental check-ups are essential for leukemic patients to minimize the risk of these dental problems. Dentists should be informed about the patient's medical history and cancer treatment to provide personalized and safe dental care. Collaboration between oncologists and dentists is crucial to ensure comprehensive care for leukemic patients, addressing their specific oral health needs during and after cancer treatment.

What Are the Dental Management Strategies Employed By the Dentist?

• Gingival enlargement as such in leukemic patients is usually a self-limiting condition according to dental research; It means the inflammatory gingival disease tends to disappear without any specific treatment protocol or periodontal treatment plans.

• But the most common issue in these patients is that the enlarged gingival tissues facilitate more plaque accumulation and food impaction.

• This can further aggravate oral mucosal inflammation and irritation while complicating the maintenance of individual oral hygiene.

• Patients may also be concerned about bleeding while brushing or mouth washing during their daily routine oral hygiene.

• Dentists may also encounter varying degrees of periodontal diseases or chronic periodontitis that secondary clinical features may often aggravate due to a lack of professional aid or irregular dental follow-ups.

• Regular procedures or follow-up like scaling, subgingival debridement, mouth rinsing or washing, extraction of teeth with a hopeless prognosis, and administration of antibiotics when needed should be done.

• Before every dental sitting, a blood test or CBC (complete blood count), preoperative evaluation, and physician's consent would be mandatory to address all dental issues.

Conclusion

Dentists should be able to clearly recognize oral manifestations of leukemia as the dentist sometimes is the first health care professional that discovers acute leukemia in children. To conclude, leukemic patients have specific oral manifestations that ideally need early recognition, especially by the dental surgeon, which would also aid in timely diagnosis with life-saving potential. Any possibility of oral tumors or malignancies, severity in the periodontal disease, and potential osteolytic lesions apart from gingival enlargement should be carefully observed and treated by the dentist or the maxillofacial surgeon.