Page 31 - GP Fall 2022_Neat

neck. It was not painful or tender, “ I just to link episodic joint pain in the TMJ to any-

felt my neck and I knew it wasn’t right.” thing further? At the time the patient was Dr. Joseph DiDonato,
At this point, the patient scheduled a visit also concerned that she might have had a III is in private prac-
with her primary care physician to discuss reaction to the COVID vaccination. Is there tice in Rochester, NY.
her other developing symptoms. She had anything more that could have beenbe done He received his dental
knee soreness and found walking up and given the circumstances? In this case, the degree from New York
down stairs painful. She still had the lymph- patient did seek medical attention within ten University College of
adenopathy in her neck. When asked if she or twenty days for other ongoing symptoms, Dentistry. He has served
should get her second COVID shot her PCP but what if the patient hadn’t? as President of the New
advised her to go ahead and that the lymph- York State Academy of General Dentist-
adenopathy may be related to the COVID The treatment for ATL involves killing ex- ry and currently serves as Treasurer.
vaccination. Her PCP advised Motrin and isting blood stem cells contributing to the
ice for the joint pain. Within a few days, her line of T-lymphocytes by chemotherapy
knee started feeling better. and radiation. This also includes eliminat-
ing the cells that may be in the brain and
The day after the PCP visit the patient re- spinal cord. After this, the patient receives
ceived her second dose of the COVID vac- a stem cell transplant from a sibling which
cine. Some time after this she noticed pain is intended to repopulate the stem cells lost
in other joints, moving from joint to joint, during treatment. In some forms of ALL, a
including a swollen finger with redness and targeted approach can be employed. This
a swollen elbow with decreased mobility. involves using drugs such as monoclonal
She noticed swollen lymph nodes in various antibodies, that target just the cancer cells
locations. and leave the healthy cells alive.

Approximately ten days after the first PCP The latest avenue of treatment for some
visit she returned to follow up on the new forms of cancer is immunotherapy in which
symptoms. At this second visit, a complete the patient’s immune system is marshaled to
blood count revealed an increased number find and kill cancer cells. The patient’s own
of lymphoblasts. She was instructed to see T-cells are removed from the body and in the
a hematologist. Within three days she was lab special chemical receptors are added to
seen by a specialist and a bone marrow bi- the surface of the cells. This is done by add-
opsy was done to confirm the diagnosis of ing a new gene to the cell genome to code
acute lymphoblastic leukemia (ALL). for a new protein on the cancer cell surface.
This is called CAR T-cell therapy (chime-
The patient was admitted to the hospital for ric antigen receptor). The newly enhanced
chemotherapy, radiation therapy, and a stem T-cells are now specifically equipped to go
cell transplant from a sibling donor. Prior to after the cancer cells because they have a
radiation therapy, the oncologist requested a receptor designed to attach to the surface of
dental exam to rule out active infection. the cancer cells.

Discussion Speeding up the identification and access to
Because dental visits tend to be more fre- care by identifying clinical signs and symp-
quent than routine medical visits, patients toms is an essential goal during oral hygiene
will often disclose health concerns to a den- screening. Identifying cancer at its earliest
tal provider. The question becomes what clinical appearance is a goal all clinicians
kinds of information is actionable and how should strive to achieve.
far should a patient complaint be pursued.
We know that the warning signs of systemic References:
disease can often be discovered during an 1.M. Plummer, C. de Martel, J. Vignat, J.
oral exam and counseling patients to seek Ferlay, F. Bray, S. Franceschi
medical care can be a very important ser- Global burden of cancers attributable to in-
vice. In many cases, patients need to hear fections in 2012: a synthetic analysis
from a respected party that they should not Lancet Glob. Health, 4 (2016), pp. e609-e616
delay seeking treatment. https://www.sciencedirect.com/science/arti-
cle/pii/S2211124719311933#bib3
The presentation of episodic TMJ pain
without an offending factor is not unusual. 2. National Cancer Institute https://www.
Patients can often present with localized cancer.gov/types/leukemia/patient/adult-
trauma to individual teeth or soreness to the all-treatment-pdq.last access January 2022.
myo-facial complex that is self-limiting and 3. Matsuoka, M., Jeang, KT. Human T-cell
resolves without intervention. The critical leukemia virus type 1 (HTLV-1) infectivity
step is to ask ourselves if we have done a and cellular transformation. Nat Rev Cancer
complete survey, could we have detected 7, 270–280 (2007). https://doi.org/10.1038/
any further clues? In this case, how would nrc2111.
a finding of lymphadenopathy, a solitary 4. https://creativecommons.org/licenses/by-
node in the neck, in a patient with no sign of sa/3.0>, via Wikimedia Commons.
dental disease, be processed? Is it possible
www.nysagd.org l Fall 2022 l GP 31