Awareness Needed for Successful Dental Management of CAD Patients, Report Highlights

The case report of a patient with cold agglutinin disease (CAD) who developed chronic inflammation of the gums (periodontitis) highlights the need for dentists to be aware of CAD signs and symptoms.

The study, “Cold agglutinin disease and its implications for dental treatment,” was published in the journal Special Care in Dentistry.  

Primary CAD, an autoimmune disorder where the body wrongly attacks its own red blood cells, can be classified as a secondary disorder when the disease is a consequence of an underlying condition, such as infections (e.g., influenza or HIV), other autoimmune diseases or blood cancers such as lymphoma.

Oral manifestations of CAD, such as ulceration and pale color in the mouth tissue, are mainly associated with anemia.

Here, authors report a case of a 75-year-old man with CAD who received dental management over a three-year period.

The patient was referred to a dedicated dental hematology practice in London over concerns that he might develop acute dental infections that could make his CAD worse.

He was diagnosed with CAD in 2005. Eight years later, in 2013, he developed a type of non-Hodgkin’s lymphoma (called lymphoplasmacytic lymphoma). However, he had additional medical conditions, including type 2 diabetes (under control), underactive thyroid gland (hypothyroidism) and had pale white patches develop on the skin, a condition called vitiligo. No other diseases were reported on his family medical history.

He was given rituximab (sold under the brand name Rituxan in the U.S., and MabThera in Europe, among others) an approved therapy for various types of non-Hodgkin’s lymphoma; the chemotherapy Soliris (eculizumab, by Alexion), an anti-C5 protein antibody, which has the ability to block hemolysis and is used as a rescue therapy for severe CAD.

The patient complained about receding gums that had become smaller over a one-year period. He said he experienced pain intermittently but with increasing intensity in his lower gums.

A clinical exam confirmed overall horizontal bone loss in the mouth, between 20% and 70%, and additional signs that confirmed a diagnosis of chronic periodontitis (gum disease). He also had an abscess laterally located to his lower jaw tooth that required immediate removal.  

Blood tests performed at the hospital revealed significant anemia, and a low white blood cell count.

The tooth was removed to avoid further infection and eliminate pain. During the procedure, the room’s temperature was adjusted to 22 degrees Celsius (about 72 degrees Fahrenheit).

In periodontitis, an inflammatory condition of the gums and deep tooth, gums are usually sore, swollen and bleed easily, causing significant discomfort. It is caused by bacteria accumulation that triggers a strong inflammatory response.

In order to avoid the periodontitis progression and prevent severe infections, the patient was given advice for oral hygiene that included the use of interdental brushes. He was also advised to reduce his intake of foods and drinks with sugar.

He recovered without complications from the local surgery, and was followed and treated non-surgically to manage his periodontitis.

“After three years of regular dental management and additional input from a hygienist where (gum) pocket depths were closely monitored, the patient’s clinical periodontal condition had stabilized. There was a significant improvement in his oral hygiene, with reduced soft and hard deposits,” they stated.

“Although CAD is rare, dental practitioners should have an awareness of the signs and symptoms of the disease, as they present with anemia, as well as associated comorbidities,” they said.

“This case demonstrates the impact of comorbidities as well as importance of a multidisciplinary approach when planning dental care,” the study concluded.