淋巴瘤患者的口腔治疗

恶性淋巴瘤是发生于淋巴结和淋巴结以外的淋巴组织以及单核巨噬细胞系统的恶性肿瘤，是一种全身性疾病，但其主要病变及临床表现可局限于某一特定部位。病理上，可将其分为霍奇金淋巴瘤和非霍奇金淋巴瘤；在发生部位上，可分为结内型和结外型¹。

目前对于淋巴瘤患者主要的治疗方式包括：单抗、化疗、放疗、肾上腺皮质激素以及造血干细胞移植。以下内容是来自单篇文章²的观点，可以作为参考：

Type of Treatment	Dental Recommendations
Pre-lymphoma treatment assessment (prechemotherapy cycles, monoclonal antibodies and pre-radiotherapy)	• A dental assessment prior to starting lymphoma treatment is recommended to ensure that patients are dentally fit. The general dental practitioner in primary care can carry this out after liaison with the patient’s haematooncologist and special care dentists, if required, about the suggested treatment plan. • Periodontal treatment (ie scaling and root surface debridement), restorative treatment and adjustment of ill-fitting dentures are essential. • Dental extraction of teeth with poor prognosis at least 10–14 days prior to chemotherapy cycles and MABs is recommended. Otherwise, it is recommended to wait until the next cycle of chemotherapy and manage any dental infection with antibiotics with/without pulp extirpation. • Dental care providers should check platelets and neutrophil counts prior to dental treatment. No dental extraction for patients with platelet counts below 50 x 09/L, and no regional block injection for patients with platelet counts below 30 x 109/L. Liaison with the haemato-oncology team is necessary for platelets transfusion. Conscious sedation is not recommended for patients with haemoglobin below 10g/dl. Again, liaison with haemato-oncology team is necessary. • Antibiotic prophylaxis for patients with neutrophil counts below 2 x 109/L is recommended to reduce possible septicaemia (granulocyte colony-stimulating factor) might be considered by the haemato-oncologist prior to dental procedures. • Topical anti-fungal agents (ie Nystatin 100,000 U/ml) 4 times per day for oral candidiasis and aciclovir 200 mg three times per day could be prescribed for herpes simplex viral infection as a prophylactic. • Dry mouth advice involves advising patients to take sips of water, use sugar-free chewing gum and saliva substitute. • Diet advice at this stage is important. Patients should consider soft diet and avoid rough and spicy food, acidic fruit and salt. • Advice to avoid alcohol and smoking. • Oral hygiene instructions to include using a soft toothbrush with alcohol-free mouthrinse. • Advise patients to register with the local general dental practitioner, if they are not registered. A referral letter to patient’s GDP should include patient’s medical history, treatment received and the importance of future follows up every 3–6 months. • All dental treatment should be planned in liaison with patient’s haemato-oncologist.
During chemotherapy cycles or radiotherapy	• Dental treatment is not recommended at this stage and urgent dental care should be managed with antibiotics and analgesics with/without pulp extirpation. • If dental extraction is necessary, it should be carried out in secondary care setting in liaison with the haematooncology team as patients might require blood transfusion at this stage. • Emphasizing oral hygiene instructions and maintaining good oral hygiene are essential. • Mucositis will complicate maintaining good oral hygiene, advise to use soft toothbrushes or sponge toothbrush with alcohol-free mouthrinse. Topical gel (ie Lidocaine) or 15% benzydamine hydrochloride (15 ml every 8 hours and up to three weeks) could be considered to help reduce pain. • Anti-fungal or anti-viral infections can be prescribed for the treatment of fungal and viral infections.
Pre-HSCT treatment	• Dental assessment is necessary and it is similar to pre-lymphoma treatment assessment, but it should be carried out in secondary care centre. • Patient education about side-effects of immunosuppressive agents (ie ciclosporin and tacrolimus) such as gingival hyperplasia and the importance of maintaining good oral hygiene to reduce gingival enlargement.
Post-HSCT	• No dental treatment recommended in the first six months post-HSCT, while urgent dental care should be managed with antibiotic or analgesic with/without pulp extirpation. If dental extraction is necessary it should be carried out in secondary care centre after liaison with the haemato-oncology team. • Six months post-HSCT, patients can receive dental treatment in primary care centre. • Anti-fungal or anti-viral infections can be prescribed for the treatment of fungal and viral infections, but liaison with haemato-oncology team is important at this stage in patients taking immunosuppressive agents (ie ciclosporin or tacrolimus) to avoid drug interaction. • HSCT patients are at high risk of developing oral squamous cell carcinoma and early referral to secondary care centre is essential. • Pathological findings, tooth mobility with sudden displacement and oral bleeding could be a clinical scenario of a relapsing lymphoma and patients need urgent referral to a specialist centre.

1. 张震康, 俞光岩 editor. 口腔颌面外科学. 北京大学出版社, 2013 ↩

2. Abed, Hassan, Najla Nizarali, and Mary Burke. "Oral and dental management for people with lymphoma." Dental Update 46.2 (2019): 133-150. ↩