case presentation: katarina witt

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CASE PRESENTATION: KATARINA WITT Dent 6122 March 13, 2008 R Garni B Germain B Gray J Grittner A Gunderson B Haasken D Halberg C Halligan

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Dent 6122 March 13, 2008 R Garni B Germain B Gray J Grittner A Gunderson B Haasken D Halberg C Halligan. case presentation: katarina witt. Patient presentation. Patient history. Medical findings. I believe she has the flu!. Patient presentation. - PowerPoint PPT Presentation

Transcript of case presentation: katarina witt

Page 1: case presentation:  katarina witt

CASE PRESENTATION: KATARINA WITT

Dent 6122 March 13, 2008R Garni B Germain B Gray J Grittner A Gunderson B Haasken D Halberg C Halligan

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PATIENT PRESENTATION17 year old female

No significant Medical Hx

Chief Complaint

• “Bleeding Gums”

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PATIENT HISTORYYoung healthy athletic high school student

Physical exam six weeks prior with NSF

Dental exam and prophy three weeks prior

“Hasn’t felt very good lately” and has had “very little energy”

Came in because normal dentist was on vacation

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MEDICAL FINDINGSRapid onset of symptoms

• Fatigue• Enlarged lymph nodes

Physician differential diagnosis:

• Flu I believe she has the flu!

“Physician”

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PATIENT PRESENTATIONHead and neck exam

• Enlarged, non-tender cervical lymph nodes

Intraoral Exam

• Hypertrophic, erythematous, and edematous gingiva• Spontaneous gingival bleeding• Petechiae on soft palate• Not much plaque• No deep perio pockets

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WHAT IS GOING ON WITH KATRINA?Prolonged “Flu-like” symptoms• Fatigue

• Enlarged lymph nodesPetichiae

Bleeding gingiva

Suggest systemic disease

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QUESTIONS TO ASKHave you taken aspirin lately?

Is there a history of bleeding disorders in your family?

Have any of your family or friends been diagnosed with mono lately?

Have you had any rashes lately?

Did you get a flu shot this year?

Have you experienced any nausea, vomitting, or unexplained weight loss?

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QUESTIONS TO ASKHave you had any bone or joint pain recently?

Have you been thirsty a lot lately?

Have you experienced fever, chills, or clamminess lately?

Has your lack of energy start just recently?

Have you noticed a lot of bruises lately? Do you bruise easily?

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PATIENT SYMPTOMSNo aspirin.

No history of mono.No nausea, vommitting or weight loss.

I did get a flu shot this year.No fever.

No bone/joint pain or swelling.I have been thirsty and cold recently.

Fatigue began suddenly.I have been bruising easily lately.

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LAB TESTSCBC and WBC differential

Peripheral blood and bone marrow smear

Lab tests to confirm AML• Cytochemical staining• Immunophenotyping• Cytogenetic analyses• 20% WBC are myeloblasts

Hemoglobin hematocrit

Platelet count

Monospot

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CONSULTATIONConsultation with a physician may be necessary to:

• Obtain lab results• Confirm said patient history• Determine if patient had been previously diagnosed with anemia or a bleeding disorder• Discuss final diagnosis

Consultation with usual dentist may be necessary to:

• Discuss patient condition at previous appointments

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RED BLOOD CELL DISEASESRBC Diseases

MicrocyticIron Deficiency Anemia

Thalassemias

Lead Poisoning

NormocyticRenal

Failure/Anemia associated w/

Chronic Diseases

Aplastic Anemia

Hemolytic Anemia

Sickle Cell

Anemia

Glucose-6-phosphate

dehydrogenase deficiency

MacrocyticPernicious Anemia

Folate Deficiency

Hypothryroidism

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WHITE BLOOD CELL DISEASESWBC Diseases

Leukemia (Bone Marrow Origin)

Acute Leukemias (Rapid onset, All ages,

Immature Cells)

AML

ALL

Chronic Leukemias (Slow Onset, Adults,

Mature Cells)

CML

CLL

Lymphoma (Lymph Node origin)

Hodgkin (Reed-Sternberg Cells, Contiguous spread, Better

Prognosis)

Non-Hodgkin (B-Cell has a better prognosis than T-Cell)

Plasma Cell Disorders

Myelomas

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LEUKEMIANeoplasm of myeloid white blood cells

Uncontrolled proliferation of bone marrow space

Subsequent increase of myeloid WBC in peripheral blood

Etiology• Viruses• Genetic factors• Radiation• Chemical agents

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AML VS. ALL

AML

• Immature neoplastic malignancy of myeloid cells

• Usually in younger adults• Bleeding, anemia, poor healing,

and infection• Fatigue, bone pain• Enlargement of spleen, lymph

nodes, tonsils, and gingiva• At least 20% myeloblasts in bone

marrow or peripheral blood

ALL

• Immature neoplastic malignancy of lymphoid cells

• Common in young children (2-4 years old)

• Symptoms related to anemia, thrombocytopenia, fever, and neutropenia

• Higher propensity toward CNS involvement and cranial nerve deficiencies

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DIAGNOSIS & ASA PATIENT STATUS

ASA PS III

Age , Sex & Health

Level of

Control

Signs & Sympto

ms

Diagnosis: AML

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AAntibiotics:

• Antibiotic treatment can be used to prevent post operative infections when Severe Neutropenia is present (WBC below 2000 or neutrophil count is below 500)• 2g of Penicillin one hour before dental treatment and 500mg four times a day for a week post dental treatment

• Antibiotic prophylaxis is also recommended for Patients with Hodgkin’s lymphoma who have had a splenectomy are at an increased risk for bacterial infection is recommended for the 1st 6 months after surgery for invasive procedures

Analgesics:• For patients with Mucositis and Ulcerations, topical anesthetics can be applied to relieve patient of pain.

Antihistamines:• Some solutions of antihistamines, for ex: Benzydamine, have local anesthetic properties and can be used to protect ulcerated

surface of mucosa from being irritated

Antiseptics and Antimicrobials:• Antiseptic and Antimicrobial rinses that are nonalcoholic are recommended for the prevention of oral infections, cleansing of

ulcers, and to help promote healing of intraoral ulcerations.

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B

Bleeding:

• Uncontrolled leukemia patients may experience serious bleeding problems after any surgical procedure and may have problems with healing of surgical wounds.• Patient’s gingival may be boggy and bleed easily from poor oral hygiene or minor trauma due to thrombocytopenia.• Treatment of gingival bleeding include:

• Plaque control measures• Chlorhexidine rinse• Thrombin/microfibrillar collagen sponge• Antifibrinolytic rinse• Chemotherapy

• If local measures not enough to manage bleeding, platelet transfusion may be done.• Platelet count should be 50,000/mm prior to invasive dental procedures.

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C

Complications:

• Patients who are undergoing chemotherapy or radiotherapy are susceptible to many oral complications including:• Mucositis• Neutropenia• Infection• Excessive bleeding• Graft-versus-host disease• Alterations in growth and development

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DDrugs

• Antibiotic prophylaxis for neutropenia and hodgkin lymphoma (discussed above)• Vincristine (a chemotherapy drug) can cause paresthesia• Cyclosporine is sometimes given during bone marrow transplants and a side effect of this drug is gingival

overgrowth

Dental Management

• Gather proper medical and familial history and conduct a thorough head and neck lymph node exam• Obtain lab test results from M.D. (WBC, Hb or hematocrit level, platelet count, etc.) and get a medical consult before any dental treatment to review the patient’s current status• For patients with characteristic signs and symptoms, consult an M.D. before treatment and no treatment should be rendered for patients with acute symptoms• Undiagnosed leukemia patients may experience delayed wound healing, be prone to infections and bleed excessively• Once a patient has been diagnosed, the dentist should take an active role in treatment planning with the M.D.• The primary goal of dental treatment should be to eliminate disease prior to chemotherapy commencement and extractions should be done 10-14 days before chemotherapy is started • Emphasize and educate the patient about the importance of excellent oral hygiene

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DDrugs

• Antibiotic prophylaxis for neutropenia and hodgkin lymphoma (discussed above)• Vincristine (a chemotherapy drug) can cause paresthesia• Cyclosporine is sometimes given during bone marrow transplants and a side effect of this drug is gingival

overgrowth

Dental Management

• Gather proper medical and familial history and conduct a thorough head and neck lymph node exam• Obtain lab test results from M.D. (WBC, Hb or hematocrit level, platelet count, etc.) and get a medical consult before any dental treatment to review the patient’s current status• For patients with characteristic signs and symptoms, consult an M.D. before treatment and no treatment should be rendered for patients with acute symptoms• Undiagnosed leukemia patients may experience delayed wound healing, be prone to infections and bleed excessively• Once a patient has been diagnosed, the dentist should take an active role in treatment planning with the M.D.• The primary goal of dental treatment should be to eliminate disease prior to chemotherapy commencement and extractions should be done 10-14 days before chemotherapy is started • Emphasize and educate the patient about the importance of excellent oral hygiene

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D

Dental Management Continued: Oral complications of chemotherapy:

• 1) Mucositis and Ulcers (discussed above)• 2) Neutropenia and infection:• Inability to protect against oral bacteria resulting in acute gingivitis• Oral mucosal ulcerations and periodontal destruction with loss of attachment• Opportunistic infections are common (esp candidiasis)• Recurrent herpes simplex virus is common with chemotherapy and can be Treated with:

• Oral hygiene instruction• Frequent scaling• Antimicrobial rinses• Antifungal medication for candidiasis• Antiviral medication for HSV antibody-positive patients

• 3) Bleeding (discussed above)• 4) Restricted growth of jaw if chemotherapy given during childhood resulting in micrognathia, retrognathia and/or malocclusion.

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E

Emergency

• Excessive bleeding, anemia, poor healing, and infection after surgical procedures are some emergencies that could occur in the dental chair.

• To treat such conditions you should be able to control bleeding, minimize secondary wound healing, and keep the surgical field as sanitary as possible.

• This should reduce the chance of emergency with a patient with acute leukemia.

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PHARMACOLOGY EXAM ANSWERS1 C

2 C

3 C

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39 C

40 C Good Luck!