Hodgkin Lymphoma Quiz

WBC Disorders

• White blood cells (WBCs) are the primary defense against microbial infections and vital to the immune response.
• Defects in WBCs can cause delayed healing, infection, and mucosal ulceration.
• WBCs make up approximately 1% of the total blood volume in healthy adults.
• Only 5% of WBCs circulate in the peripheral blood.

White Blood Cell Count (WBC 1)

• Normal circulating WBC count ranges from 4400 to 11,000/microL in adults.
• Normal differential count consists of:
  • Neutrophils: 50% to 60%
  • Eosinophils: 1% to 3%
  • Basophils: less than 1%
  • Lymphocytes: 20% to 34% (T lymphocytes, B lymphocytes, Natural killer cells)
  • Monocytes: 3% to 7%

White Blood Cell Function (WBC 3)

• Neutrophils defend the body primarily against bacteria through phagocytosis and enzymatic destruction.
• Eosinophils and basophils are involved in inflammatory and allergic reactions.
• Eosinophils combat parasitic infections.

Leukocytosis

• Leukocytosis is an increase in circulating WBCs to more than 11,000/microL.
• Physiologic leukocytosis is caused by exercise, pregnancy, and emotional stress.
• Pathologic leukocytosis is caused by infection, neoplasia, and necrosis.
• Pyogenic infections increase neutrophils.
• Tuberculosis, syphilis, and viral infections increase lymphocytes.
• Protozoal infections increase monocytes.
• Allergies and parasitic infections increase eosinophils.

Leukopenia

• Leukopenia is a reduction in circulating WBCs (less than 4400/microL).
• Leukopenia can result from infection (viral), drugs, and chemotherapy.

Pancytopenia

• Pancytopenia is a reduction in all blood elements (WBC, RBC, platelets).
• Pancytopenia is caused by bone marrow suppression, such as aplastic anemia and chemotherapy.

Leukemia and Lymphoma

• Patients with leukemia or lymphoma are severely ill if not properly identified and treated.
• Patients are immunosuppressed, increasing risk of serious infections.
• Patients often bleed easily due to thrombocytopenia.

Leukemia (1)

• Leukemia (cancer of the WBCs) is characterized by a significant increase in immature leukocytes.
• Leukemia affects bone marrow and circulating blood.
• Exists in acute and chronic forms.

Leukemia (2)

• Myeloproliferative disorders include acute myeloid leukemia (immature myeloid cell malignancy) and chronic myeloid leukemia (mature myeloid cell malignancy).
• Lymphoproliferative disorders include acute lymphoblastic leukemia (immature lymphoid cell malignancy) and chronic lymphocytic leukemia (mature lymphoid cell malignancy).

Leukemia (3)

• Leukemia occurs in all races and at any age, but is more common in men.
• Leukemia is more common in adults than in children, and more than half of cases occur after age 65.
• Acute myeloid leukemia is a common type of leukemia in adults.
• Acute lymphoblastic leukemia is a common type in those younger than 19.

Risk of Leukemia

• Risk factors include family history, high doses of ionizing radiation, infections with specific viruses (e.g., Epstein-Barr virus), cigarette smoking, and exposure to electromagnetic fields.

Lymphomas (1)

• Lymphoma is a cancer of the lymphoid organs and tissues.
• Lymphomas are classified by cell type (B cell, T cell, plasma cell) and appearance (small cell, large cell).
• Classified by clinical behavior (low, intermediate, high grade).

Lymphomas (2)

• Initial signs of these diseases often occur in the mouth and head/neck region.
• Intraoral lymphoma most often involves Waldeyer's Ring (soft palate, oropharynx), but salivary glands and mandible can also be affected.
• Intraoral lymphomas present as rapidly expanding or chronic, unexplained swellings in the head/neck, palate, gingiva, buccal sulcus, or floor of the mouth.
• Prompt evaluation with biopsy is needed for diagnosis.

Lymphomas (3)

• Common lymphoma types include Hodgkin lymphoma, Non-Hodgkin lymphoma, Burkitt lymphoma and multiple myeloma.

Hodgkin Lymphoma (1)

• Hodgkin lymphoma is a malignant neoplasm of B-lymphocytes, mainly in lymph nodes, characterized by Reed-Sternberg cells.
• Micrograph(Field stain) can show the cells.
• Diagnosis includes,hematology,oncology, symptoms such as fever, night sweats, weight loss, enlarged non painful lymph nodes
• Risk factors include Epstein-Barr virus, family history, and HIV/AIDS.
• Treatment involves chemotherapy, radiation therapy, stem-cell transplant, and immunotherapy.
• Five-year survival rate is around 88% (US).

Non-Hodgkin Lymphoma

• Includes all lymphomas except Hodgkin's lymphoma.
• Often a B-cell origin.
• Are malignant neoplasms of lymphoid cells.
• Occur in many kinds and places.

Burkitt Lymphoma

• Aggressive non-Hodgkin B-cell lymphoma involving bone and lymph nodes.

Multiple Myeloma

• Characterized by overproduction of malignant plasma cells, creating multiple tumor masses throughout the skeletal system.

Dental Management in Leukemia

• Leukemic patients, especially those with undiagnosed disease, may experience serious bleeding problems after surgery, healing problems, and postoperative infection.
• Dentists should identify these patients before treatment.

Diagnosis/Questions

• Questions on family history of blood disorders and cancer
• Evaluate weight loss, fever, enlarged lymph nodes, and bleeding tendencies
• Complete clinical examination needed, including inspection of head, neck, mouth, oropharynx, cervical, and supraclavicular lymph nodes.
• Awareness of supraclavicular lymph node enlargement as a possible sign of malignancy.
• Evaluate cranial nerves to check for possible invasive neoplasms.
• Radiographic studies like panoramic films are needed to check for oral conditions.
• Blood tests to obtain WBC count, hemoglobin, and platelet count.

Treatment Planning Modifications

• Three main phases:
  • Pre-treatment assessment and preparation
  • Oral health care during medical therapy
  • Post-treatment management

Pre-treatment Assessment (1)

• Minimize or eliminate oral diseases prior to chemotherapy.
• Dentist needs to know specific diagnosis, severity of disorder, and type of medical treatment.

Pre-treatment Assessment (2)

• Oral hygiene instructions (fluoride gels) and non-cariogenic diet.
• Eliminating sources of mucosal/periodontal disease.
• Caries elimination.
• Root canal therapy or tooth extraction for pulpal disease.
• Radiographic review/Inspection/identification of potential/undiagnosed disease, impacted teeth to clear oral cavities.

Extraction

• Extraction consideration in patients on chemotherapy :
  • Periodontal pocket depth > 5mm
  • Periapical Inflammation
  • Non-functional tooth
  • Partially erupted tooth
• Scheduling considerations regarding extraction and start of chemotherapy : A 3-week wait between extraction and chemo-radio-therapy initiation
• Platelet count should be at least 50,000/microL before performing invasive procedures.

Oral Complications during Medical Therapy (1)

• Mucositis: Inflammation of oral mucosa, especially in young patients undergoing chemotherapy.
• Affects replication-active epithelial cells and usually begins 7-10 days after chemo, resolving after chemo ceases.

Oral Complications during Medical Therapy (2)

• Breakdown of epithelial barrier leading to oral ulcerations
• Potentially secondarily infected
• Use antiseptic rinses (chlorhexidine) and oral topical/systemic analgesics.
• Using Orabase to protect ulcers from surface irritation

Neutropenia and Infection

• Patients with neutropenia can develop acute gingival inflammation and mucosal ulcerations, leading to periodontal destruction when oral hygiene is poor.
• Periodontal therapy, oral hygiene instructions, frequent scaling, and antimicrobial therapy are beneficial.

Oral Infection

• Oral infection is less common in patients with chronic leukemia because of healthier cells.
• Still, in later stages, infection can become problematic.
• Severe cases include opportunistic bacterial, fungal and viral infections.
• Splenectomy further increases risk of bacterial infection.

Opportunistic Infections

• Infections like acute pseudomembranous candidiasis are usually treated by antifungal medications.
• Unusual fungal infections like mucormycosis are treated with potent antifungal agents.
• Herpes Simplex Virus infections might have prolonged healing compared to other populations. Acyclovir may be used for prevention.

Bleeding

• Submucosal hemorrhage could occur in small or large areas.
• Bleeding can be from minor trauma (e.g., tongue biting) and thrombocytopenia.
• Severe gingival bleeding is exacerbated by poor oral hygiene management.
• Efforts to improve oral hygiene and/or topical measures (like gelatin sponge with thrombin) are recommended to reduce/manage bleeding.
• Platelet count of at least 50,000/microL is needed before dental procedures.

Growth and Development

• Chemotherapy affects growing and developing teeth, jaws, and facial bones – this is especially pronounced during childhood but less so in adults.
• Results of such therapy can be micrognathia, retrognathia, malocclusion, or altered teeth-roots (e.g., shorten or blunted roots, dilacerations, calicification abnormalities, pulp enlargement, microdontia).

Post-treatment Management (1)

• Patients in remission can receive indicated dental treatment, although emergencies are often handled separately.
• Patients with advanced disease or certain conditions (like Hodgkin lymphoma or splenectomy and bacterial infection after) receive only emergency dental care.
• Antibiotic prophylaxis is recommended for invasive procedures for at least the first 6 months after splenectomy.

Post-treatment Management (2)

• Typical presentation includes severely painful non-healing extraction socket/bone exposure.
• Necrotic bone can be asymptomatic for weeks so requires routine observation.
• Treatment focuses on managing symptoms with local debridement (bone and wound irrigation with antiseptics) and suitable antibiotics.

Treatment Planning Development

• Early intervention is key- Treat infections and related complications promptly.
• Non-surgical options are preferred over surgery.
• Limit extractions to a single quadrant or limited procedures to one quadrant.
• Two-month wait period recommended between surgical interventions.
• Antibiotic coverage should be present during extraction and the healing period.

Additional Notes

• Bisphosphonates, a type of drug, can result in osteonecrosis of the jaw, which is a serious complication.
• This risk is higher in patients receiving intravenous bisphosphonates for a year or more, particularly after tooth extractions.