MANAGEMENT OF MEDICALLY COMPROMISED PATIENTS

1. MANAGEMENT OF MEDICALLY COMPROMISED PATIENTS SAKINAH MOHD SALEH 1090041 MOHD AZIZUL MOHD ATAN 1090042 ABDULLAH ZAHID AZHARI 1090043 NUR AMALINA ZULKEPRE 1090044 NURMARZURA ABDUL LATIF 1090045 AHMAD ZULKHAIRI RESALI 1090046 NURUL ASMAT ABDUL RAHMAN 1090048

2. GROUP 3: ONCOLOGY Discuss the aetiologies, clinical presentations, problems related to dental management and general management of patients with this medical problem.

3. Introduction • Cancer is a complex illness that requires clinical care by a physician or other health care professional. • Survival rate for childhood cancers : 72%, adult cancers: 60%. What is cancer? • Cancer is an abnormal growth of cells. Cancer cells rapidly reproduce despite restriction of space, nutrients shared by other cells or signals sent from the body to stop reproduction. Cancer cells are often shaped differently than healthy cells, they do not function properly and they can spread to many areas of the body. Oncology is the study of cancer and tumors. 

4. AETIOLOGY ONCOLOGY

5. The factors involved may be genetic, environmental or constitutional characteristics of the individual. • Lifestyle factors : -smoking, high-fat diet and working with toxic chemicals • Genetics: • genetic mutation, exposure to chemicals near a family's residence, a combination of these factors or simply coincidence. • genetic disorders (i.e., Wiskott-Aldrich and Beckwith-Wiedemann syndrome) • Exposure: -viruses such as the Epstein-Barr virus (EBV) and human immunodeficiency virus (HIV). - environmental such as pesticides, fertilizers, and power

6. CLINICAL PRESENTATION ONCOLOGY

7. Clinical presentations: Incidence 150 new cases per I million US children 2nd leading cause of death

8. Clinical presentations • Incidence of childhood cancer Recent trends in childhood cancer incidence and mortality in the United States. J Nati Cancer Inst 1999;91:1051-8

9. Clinical presentations Cancer diagnosis in children is often delayed because the presenting symptoms tend to be nonspecific and resemble those of benign conditions.

10. Oncologic Emergencies Refer to oncologist

11. TumorLysis Syndrome (TLS) • Lysis of tumor cells releases electrolytes & urea cycle products resulting in hyperuricemia, hyperkalemia,hyperphosphatemia & resultant hypocalcemia • Severe TLS seen with large tumor burden including (but not limited to): • Burkitt’s Lymphoma • Acute Lymphoblastic Leukemia with WBC count >100,000/mm3 • AML • Neuroblastoma • TLS Labs: minimum daily up to every 6hrs as resources allow • Urea & Electrolytes • Calcium • Magnesium • Phosphate • Uric Acid • Maintain urine output at > 2.5 ml/kg/hr • Hemodialysis reserved for severe TLS, prevention of severe disease will obviate requiring this invasive & expensive intervention

12. Specific Management • Hyperuricemia Management • Hydration with 3000 ml/m2/day with fluids not containing potassium (e.g. D5 1/2NS) • Consider adding 40 mEq NaHCO3/L to aid in uric acid excretion • Need to monitor calcium & phosphate several times daily if adding NaCO3,where this is not feasible,do not add NaHCO3to fluids • Allopurinol 100 mg/m2/dose PO given three times daily • Max dose 600 mg/day for age <10 yrs, 800 mg/day for >10 yrs • Rasburicase: currently not available in the resource-limited setting

13. Hyperkalemia • ECG: T wave elevation (peaked T wave), loss of P wave, widened QRS complex • Avoid potassium in fluids to help prevent this complication • Stop any potassium supplementation if present • Dextrose 0.5 g/kg with 0.3 units insulin/gm dextrose, infuse over 2 hours • Kayexalate 1 g/kg/dose PO four times daily • 1 g/kg lowers potassium by 1 mEq

14. Hyperphosphatemia/Hypocalcemia • Remove NaHCO3 from fluids if Ca x PO4>60 • Where calcium & phosphate levels cannot be checked several times daily, do not add NaHCO3 to fluids • Hyperphosphatemia -treat with aluminum hydroxide 25 mg/kg/dose four times daily & avoid foods containing large amounts of phosphate • Hypocalcemia: 10% calcium gluconate 500 mg/kg IV infusion through a central line • Maximum dose 2000 mg/dose • Monitor calcium level closely including ionized calcium where available

15. Hyperleukocytosis • Defined as WBC > 100,000/mm3 • High risk for pulmonary & CNS complications due to viscosity & stasis • IV fluid rate 3600 ml/m2/day • Monitor WBC counts along with TLS labs • Monitor pulse oximetry for evidence of pulmonary complications, continuous monitoring where possible • Do not transfuse above Hg 8.5 g/dL as pRBC or whole blood may increase viscosity • May transfuse platelets for active bleeding or platelets <50,000/mm3 • Although not available in resource-limited settings, leukopheresis is recommended if possible

16. Space occupying lesions • Mediastinal mass/upper airway lesion • Avoid sedation • Elevate head of bed • Avoid procedures that may compromise airway & consult anesthesia for procedures • Obtain diagnostic tissue with the least invasive method-e.g. Peripheral lymph node biopsy preferred over thoracotomy to biopsy chest mass • May need emergency chemotherapy and/or radiation therapy as a lifesaving measure, even prior to full diagnostic work-up

17. Intracranial mass/spinal cord compression • Intracranial pressure elevation can be treated with dexamethasone; mannitol can be added for severe cases • Dexamethasone up to 4 mg IV every 4 hours can be given for cerebral edema • Where required, substitution with hydrocortisone or prednisone can be done, but effects on cerebral edema are much less potent as compared to dexamethasone • Any central nervous system involvement by tumor requires immediate involvement of neurosurgery • May need emergency chemotherapy and/or radiation therapy as a lifesaving measure, even prior to full diagnostic work-up.

18. Problems related to dental management • Mainly as a result of cancer therapy; radiotherapy or chemotherapy • Oral problems pain, mucositis, oral ulceration, bleeding, taste dysfunction, increase risk of infection (2°), dental caries, xerostomia, osteonecrosis, trismus, neurotoxicity. • Late complicationsalterations of shape (microdontia, macrodontia, taurodontia), number (anodontia) and root formation (root shortening and blunting of the roots, root stunting) of the teeth. • Head and neck radiotherapy abnormalities in the growth and maturation of the craniofacial skeleton structures.

19. Dental Management of Pediatric Patients Receiving Chemotherapy, Radiation

21. General Management- Before the cancer therapy Dental procedure • Should be completed before start cancer tx- ideally • Prioritizing procedure • when all dental needs cannot be treated before cancer therapy is initiated. • Prioritize: infections, extractions (7-10 d), periodontal care (eg,scaling, prophylaxis), and removal sources of tissue irritation . • Pulp therapy • Choose extraction – avoid infection later • Endodontic tx • At least 1 week b4 therapy (if symptomatic), extract if not possible • Ortho • Perio

23. A. Preventive strategies • Oral hygiene – mechanical plaque removal • Diet • Fluoride • Lip care – moisture for prevent damage • Education – reinforce proper OH

24. B. Dental care • During immunosuppression, elective dental care must not be provided. • Emergency tx- discuss with the patient’s physician • supportive medical therapies (antibiotics, platelet transfusions, analgesia) • Monitor every 6 months (or in shorter intervals if there is a risk of xerostomia, caries, trismus)

25. C. Management of oral conditions related to cancer therapies • Mucositis – topical anaesthetic • Oral mucosal infections – prophylaxis • Oral bleeding – systemic & local measures • Dental sensitivity/pain & Xerostomia • Trismus – muscle relaxant

27. A. Preventive strategies • Oral hygiene • Diet • Fluoride • Lip care • Education • need for regular follow-ups (potential dental developmental problems after radiotherapy)

28. B. Dental care • Periodic evaluation • should be seen at least every 6 months (or in shorter intervals) • moderate or severe mucositis and/or chronic oral GVHD should be followed closely for malignant transformation • Orthodontic treatment • Light force • Oral surgery • Only minor procedure

29. Oral surgery • Non-elective oral surgical and invasive periodontal procedures • Consultation with an oral surgeon/periodontist & physician is recommended • to decrease the risk of osteonecrosis and osteoradionecrosis • Elective invasive procedures should be avoided

30. C. Management of oral conditions related to cancer therapies • Xerostomia • Trismus

31. References Guideline on Dental Management of Pediatric Patients Receiving Chemotherapy, Hematopoietic Cell Transplantation, and/or Radiation

32. Thank you