Oral Manifestations in Patients with Aplastic Anemia 7/31/09 - Boboia

LUTHERAN MEDICAL CENTER
Dental Residency Program
Literature Review Form

Resident: Boboia Date: 7/31/09
Article title: Oral Manifestations in Patients with Aplastic Anemia
Author(s): Brennan et al.
Journal: Oral Surgery, Oral Medicine, Oral Pathology, Oral Medicine
Volume #; Number; Page #s): 92:5
Year: 2001
Type of Article: Review
Main Purpose: Characterize the prevalence and risks of oral complications in patients with aplastic anemia (AA)
What is it?
-Rare hematologic disorder characterized by a failure of hematopoietic precursor cells in bone marrow to produce adequate number of blood cells
-Pts will demonstarte signs and symptoms related decreased blood oxygen carrying capacity (fatigue, tachycardia, weakness)
-Thrombocytopenia (¯ platelets) cause tendency for bruising / bleeding
-Leukopenia (¯wbc) predisposes pts to bacterial and fungal infections that are often times fatal
Cause:
Underlying cause is unknown; some cases are associated with exposure to environmental toxins (benzene), tx. with certain drugs (chloramphenicol), or infection with certain viruses (non-A, B, C, or G hepatitis); a few genetic disorders (Faconi’s anemia) are also associated with this
Subjects and Methods: 79 patients with AA evaluated and treated from 1993 to 1999 were compared with control subjects (66 schizophrenic patients seen at the NIH dental clinic 1993 to 1999). These controls were demographically well matched to the study subjects patients having similar hospital stays (usually 2-6 months for a protocol visit); all controls did not have a known hematologic or immune deficiency; in addition the control group had dental treatment completed as inpatients.
Data collection and Definition of Oral Manifestations:
-Included a review of medical and dental charts by 3 investigators
-Dental disease was documented for cases and control subjects as follows:
1) Current and past dental health status was documented with respect to DMFT (a score of one for missing restored or diseased tooth and 0 for for healthy tooth). Max DMFT was 28 – 3rds not included
2) Because of pancytopenia in AA patients periodontal status was assessed by alveolar bone height; intpx bone height assessed from orthopantomographs
Risk factors for oral complications in AA pt group:
Cyclosporine treatment within the previous 6 months
Prednisone treatment within the previous 6 months
Disease duration
Labs: WBC, absolute lymphocyte, monocyte, and neutrophil counts, Hct, Hgb, RBC, and platelet count

Dental Management Issues:
Dental treatment was provided for cases and controls during hospitalization; the following were documented: Predental treatment prophylaxis (usually platelet transfusions or abx or both), type of dental tx., hemorrhagic episodes > 48 hrs after dental tx., Hg levels before and after exts, infections or febrile after exts, bacteremia during hospital stay.
Results:
Patients with AA have an increased chance of presenting with petechiae, gingival hyperplasia, spontaneous gingival bleeding, and herpetic ulcertations when compared with control subjects.
Petechiae: 27% - labial and buccal mucosa, ventral tongue, palate, and gingiva
Gingival hyperplasia: 16% - common on mandibular anterior teeth
Spontaneous gingival bleeding: 16% - all 4 quads
HSV ulcerations: 16% - primarily on lips
Discussion:
- Petechia hemorrhages most common finding in AA group however no independent variables (lab values, etc) were predictive of their presence
- Gingival bleeding is another very common manifestation which also did not correlate to any other independent variable – likely caused by other oral factors (plaque,etc)
Gingival hyperplasia – 34% of AA pts. treated with cyclosporine had this
HSV – a total 28% of AA pts had HSV lesions either at baseline or during tx
Periodontal disease / bone loss – no increase in risk for the AA group compared to control
Conclusions:
- AA pts. should have routine dental examinations and tx. when appropriate
- Exts or more invasive dental tx for pts with pancytopenia should be done in a hospital setting; in this study 3/10 pts undergoing exts required at least one or more infusion of platelets or packed RBC within 4 days of dental procedures; hemorrhagic events are related to the type pt procedure rather then the degree of transfusion dependence.
Assessment of article: Good study / Review