Outcomes of Dental Extractions in the Neutropenic Patient

Abstract

Oral and maxillofacial surgeons are frequently consulted in the hospital setting for the evaluation of neutropenic patients. Often they are asked to rule out an odontogenic source of infection in the setting of fevers of unknown origin. If a possible odontogenic source is detected, a decision must be made as to what is the best management for these medically compromised patients. There is a paucity of data regarding the effect of severe neutropenia on outcomes following dental extractions. Our study retrospectively reviewed outcomes in neutropenic patients undergoing dental extractions at Mayo Clinic. IRB approval was obtained prior to chart review. Search criteria included all patients undergoing extractions who also had concurrent diagnoses of neutropenia, pancytopenia, aplastic anemia, or malignant neoplasms of the lymphatic and hematopoietic tissues. Chart review was then performed to identify patients who were neutropenic (< 1.5 × 109/L) at the time of dental extraction. Complications including local infection, delayed healing, bleeding, bacteremia, and fever were recorded. Preliminary chart reviews of 200 patients, who underwent extractions between 2007 and 2010, revealed 27 patients that met full inclusion for this study. Descriptive statistical analysis was performed using JMP 8.0 software. Patient demographics were: 14 males/13 females, mean age 53.7 years (range 6-93). The mean absolute neutrophil count at the time of extractions was 0.633 × 109/L (range 0-1.48), and mean platelet count was 94.9 (range 21-389). Clinical findings pre-extractions included: 63% of patients with radiographic caries, 74% with radiographic periapical radiolucencies, 44% with radiographic evidence of local periodontal disease, 48% with clinical caries, 52% with pain on percussion, 22% with clinical evidence of dental abscess, and 56% with complaints of spontaneous oral pain. Mean number of teeth extracted per patient was 2.96 (range 1-11) with 48% coded as simple extractions, 44% as surgical extractions, and 7% as extractions of impacted teeth. Median post-operative follow up was 163 days (range 4-1,404). Post-operative complications were found in 5/27 cases including 2 patients with delayed healing (although both patients had a history of BRONJ), 2 with pain after healing, and 1 with minor transient bleeding. No local infections were noted at the extraction sites. Three patients had pre-operative fever, of which two had resolution of fever within seven days of extractions. This retrospective study revealed no significant complications following dental extractions in neutropenic patients. Specific antibiotic regimens were not controlled for, although most patients received wide-spectrum antibiotics during the post-operative period as part of their medical management. Of five patients with post-operative complications, three consisted of pain or minor transient bleeding while the other two represented delayed healing in patients with a BRONJ history. The lack of local post-operative infection in this study is notable. Although this preliminary review lacks sufficient sample size for definitive conclusions, it appears that the benefits associated with extraction of indicated teeth in severely neutropenic patients may outweigh the associated risks. A broader study, with larger sample size, is underway to better characterize outcomes following dental extractions in the severely neutropenic patient population.