dental management chemotherapy

7/29/2019 Dental Management Chemotherapy

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AMERIC AN ACADEM Y OF PEDIATRIC DENTISTRY

IL i dU II pJicaUIii ikai \ l i3u) .Originating CommitteeClinical Affairs Co mm itteeReview Counci lCouncil on Clinical AffairsAdopted1986Revised1991,1997,1999, 2001, 2 0 0 4 , 2 0 0 8Reaffirmed1994

PurposeThe American Academy of Pdiatrie Dentistry recognizes thatthe pdiatrie dental professional plays an important role in thediagnosis, prevention, stabilization, and treatment of oral anddental problems that can compromise the child's quality of lifebefore, during, and after cancer treatment. Dental interventionwith certain mod ifications must be done p romp tly and efficient-ly, with attention to the patient's medical history, treatmentprotocol, and health status.Chemotherapy and/or radiotherapy for the treatment ofcancer or in preparation for hematopoietic cell transplantation(HCT) may cause many acute and long-term side effects in theoral cavity. Furthermore, because ofthe immunosuppression thepatients experience, any existing or potential sources of oral/dental infections and or soft tissue trauma can compromise themedical treatment, leading to morbidity, mortality, and higherhospitalization costs. It is imperative that the p dia trie dentist befamiliar with the oral manifestations of the patient's underlyingcondition and the treatment differences for patients undergoingchemotherapy only and those who will receive an HC T.MethodsThis guideline is based on a review of the current dental andmedical literature related to dental management of pdiatriepatients receiving chemotherapy, hematopoietic cell transplant-ation, and/or radiation. A MEDLINE search was conductedusing the terms "pdia trie cancer", "pdiatrie oncology", "hemato-poietic cell transplantation", "bone marrow transplantation","mucositis", "stomatitis", "chemotherapy", "radiation therapy","acute effects", "long-term effects", "dental care", "pdiatriedentistry", and "clinical practice guidelines". Expert opinionsand best current practices were relied upon when sufficientscientific data were not available.

BackgroundThe most frequently documented source of sepsis in theimmunosupp ressed cancer p atient is the mouth; therefore, earlyand d efinitive dental intervention, including comp rehensiveoral hygiene measures, reduces the risk for oral and associatedsystemic complications.'"" All patients with cancer should havean oral examination before initiation of the oncology therapy,and treatment of preexisting or concomitant oral disease is es-sential to minimize comp lications in this pop ulation.^ The key tosuccess in m aintai ning a hea lthy oral cavity during cancer thera-py is patient compliance. The child and the parents should beeducated regarding the possible acute side effects and the long-term sequelae of cancer therapies in the oral cavity.''*''^'''''^Younger patients present more oral problems than adults.''Because there are many oncology and HCT protocols, everypatient should be managed on an individual basis and appro-priate consultations with physicians and other dental specialistsshould be sought before dental care is instituted.'RecommendationsDental and oral care before the initiation of cancer therapyObjectivesThe object ives of a dental /oral examinat ion before cancertherapy starts are two-fold"':1. to identify and stabilize or eliminate existing and poten-tial sources of infection and local irritants in the oralcavitywithout needlessly delaying the cancer treatmentor inducing complications; and2. to educate the patient and parents about the importanceof optimal oral care in order to minimize oral problems/

discomfort before, during, and after treatment and aboutthe possible acute and long-term effects of the therapy inthe oral ca vity and the craniofacial complex.


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Initial evaluationMedical history review: should include, but not be limited to,type of disease/condition, treatment protocol, medications (in-cluding bisphosphonates), allergies, surgeries, secondary medicaldiagnoses, and immunosuppression status. For HGT patients,include type of transplant, matching status, donor, con ditioningprotoco l, and graft versus host disease (GVHD) prophylaxis. Th eAmerican Heart Assocation (AHA) recommends that antibioticprophylaxis for nonvalvular devices, including indwelling vascularcatheters (ie, central lines) is indicated only at the time of place-men t of these devices in order to prevent surgical site infection s.'''The AHA found no convincing evidence that microorganismsassociated with dental procedures cause infection of nonvalvulardevices at any time after imp lanta tion .''Th e infections occurringafter device implantation most often are caused by staphyloccalGram-negative bacteria or other microorganisms associated withsurgical imp lantation or other active infections. T h e A H A furtherstates that immunosuppression is not an independent risk factorfor nonvalvular device infections; immunocompromised hostswho have those devices should receive antibiotic prophylaxis asadvocated for immu nocom petent hosts.'^ Consultation with thechilds physician is recommended for management of patientswith nonvalvular devices.Dental history review: includes information such as habits, trau-ma, symptomatic teeth, previous care, preventive practices, etc.Oral/dental assessment: should include thorough head, neck,and intraoral examinations, oral hygiene assessment and train-ing, and radiographie evaluation based on history and clinicalfindings.Preventive strategiesOral hygiene: Oral hygiene includes brushing of the teeth andtongue 2 to 3 times daily with regular soft nylon brush or electrictoothbrush, regardless of the hematological status.''''*'"'*Ultrasonic brushes and dental floss should be allowed only ifthe patient is properly trained.''^ Patients with poor oral hygieneand/or periodontal disease may use chlorhexidine rinses dailyuntil the tissue health improves or mucositis develops. The highalcohol content of commercially-available chlorhexidine mouth-wash may cause discomfort and dehydrate the tissues in patientswith mucositis; thus, an alcohol-free solution is indicated in thissituation.Diet: Dental practitioners should encourage a non-cariogenicdiet and advise patients/parents about the high cariogenic po-tential of dietary supplements rich in carbohydrate and oralpdiatrie medications rich in sucrose.Fluoride: Preventive measures include t h e u s e offluoridated ooth-paste, fluoride supplements if indicated, neutral fiuoride gels/rinses, or applications of fluoride varnish for patients at risk forcaries and/or xerostomia. A brush-on technique is convenientand may increase the likelihood of patient compliance withtopical fluo ride therapy.*

Trismus prevention/treatment: Patients who receive radiationtherapy to the masticatory muscles may develop trismus. Thus,daily oral stretching exercises/physical therapy should startbefore radiation is initiated and c ontinue th rougho ut treatment.Therapy for trismus may include prosthetic aids to reduce theseverity of fibrosis, trigger-point injections, analgesics, mtiscle-relaxants, and other pain management strategies.^''"Reduction of radiation to healthy oral tissues: In cases of radia-tion to the head and neck, the use of lead-lined stents, prosthe-s e s , and shields, as well as salivary gland sparing techniques (eg,3-dimensional conformai or intensity modulated radiotherapy,concomitant cytopro tectants, surgical transfer of salivary glands),should be discussed with the radiation oncologist.Education: Patient/parent education includes the importance ofoptimal oral care in order to minimize oral problems/discomfortbefore, during, and after treatment and the possible acute andlong-term effects ofthe therapy in the craniofacial complex.Dental careHematological considerations:

1 . Absolute neutrophil count (ANC) >l,OOO/mm': no need for antibiotic prophylaxis.'However, some authors suggest that antibiotic coverage(dosed per AHA recommendations") may be prescribedwhen the AN C is between 1,000 and 2,000/m m^ If infec-tion is present or unclear, more aggressive antibiotic therapymay be indicated and should be discussed with the medicalteam


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therapies (eg, radiotherapy, surgery). The patient's bloodcounts normally start falling 5 to 7 days after the b eginningof each cycle, staying low for approximately 14-21 days,before rising again to normal levels for a few days until thenext cycle begins. Ideally, all dental care should be com pletedbefore cancer therapy is initiated. When that is not feasible,temporary restorations may be placed and non-acute dentaltreatment may be delayed until the patient's hematologicalstatus is stable,'*'"'"

2. Prioritizing procedures: When all dental needs cannot betreated before cancer therapy is initiated, priorities shouldbe infections, extractions, periodontal care (eg, scaling,prophylaxis), and sources of tissue irritation before thetreatment of carious teeth, root canal therapy for permanentteeth, and replacement of faulty restorations.'" The risk forpulpal infection and pain determine which carious lesionsshould be treatedfirst.*Incipient to small carious lesions maybe treated withfluoridesand /or sealants until definitive carecan be accomplished.' It is importan t for the practitioner tobe aware that the signs and symptom s of periodon tal diseasemay be decreased in immunosuppressed patien ts.'

3 . Pulp therapy in primary teeth: Although there have beenno studies to date that address the safety of performingpulp therapy in primary teeth prior to the initiation ofchemotherapy and/or radiotherapy, m any clinicians chooseto provide a more definitive treatment in the form ofextraction because pulpal/periapical/furcal infections duringimmunosuppression periods can have a significant impacton cancer treatment and become life-threatening.''*" Teeththat already have been treated pulpally and are clinically andradiographically sound present minimal risk.4. Endodontic treatment in permanent teeth: Symptomaticnon-vital permanent teeth should receive root canal treat-ment at least 1 week before initiation of cancer therapyto allow sufficient time to assess treatment success beforethe chemotherapy.''" If that is not possible, extraction isindicated. Extraction is also the treatment of choice for teeththat cannot be treated by definitive endodontic treatment ina single visit. In that case, the extraction should be followedby antibiotic therapy (penicillin or for penicillin-allergicpatients, clindamycin) for abou t 1 week.'''"' Asymptomaticendod ontic needs in permanen t teeth may be delayed untilthe hematological status ofthe patient is stable.'""' It isimportant that the etiology of periapical lesions associatedwith previously endodontically treated teeth be determinedbecause they can be due to a number of factors includingpulpal infections, inflammatory reactions, apical scars, cysts,and malignancy.* If a periapical lesion is associated with anendodontically treated tooth and no signs or symptoms ofinfection are present, there is no need for retreatment orextraction since the radiolucency likely is due to an apicalscar.2"

5. Orthod ontic appliances and space maintainers: Poorly-fittingappliances can abrade oral mucosa and increase the risk ofmicrobial invasion into deeper tissues.' Appliances should be

removed if the pa tient has poor oral hygiene and/or the treat-ment protocol or HCT conditioning regimen carries a riskfor the developmen t of moderate to severe mucositis. Simpleappliances (eg, band and loops, fixed lower lingual arches)that are not irritating to the soft tissues may be left in placein patients who present good oral hygiene.''* Removableappliances and retainers that fit well may be worn as long astolerated by the patient who maintains good oral care.''"'^'Patients should be instructed to changes appliance soakingsolutions daily and routinely clean appliance cases with anantimicrobial solution to prevent contamination and reducethe risk of appliance-associated oral infections.' If bandremoval is not possible, vinyl mouth guards or orthodonticwax should be used to decrease tissue trauma.^

6. Periodontal conside rations: Partially erupted molars canbecome a source of infection because of pericoronitis. Theoverlying gingival tissue should be excised if the dentistbelieves it is a potential risk and if the hematological statuspermits.*'" Patients should have a periodontal assessmentand appropriate therapy prior to receiving bisphosphonatesas part of cancer treatment.^^'^^ If the patient has hadbisphosphonates and an invasive periodontal procedure isindicated, risks must be discussed with the patient, parents,and physicians prior to the procedure.

7. Extractions: There are no clear recommendations for the useof prophylactic antibiotics for extractions. Recommendationsgenerally have been empiric or based on anecdotal experi-ence. Surgical procedures must be as atraumatic as possible,with no sharp bony edges remaining and satisfactory closureof the wo und s.''*'"'^ If there is docum ented infectionassociated with the tooth, antibiotics- ideally chosen withthe benefit of sensitivity testing- should be administeredfor about 1 week.'''"''^ To minimize the risk of developm ent of osteonecrosis orosteoradionecrosis, patients w ho will receive bisphosphonatesor radiation to the jaws as part of the cancer treatmentmust have all oral surgical procedures completed beforethose measures are instituted.^^' ' If the patient has receivedbisphosphonates or radiation to the jaws and an oral surgicalprocedure is necessary, risks must be discussed with thepatient, parents, and physician prior to the procedure. Loose prima ry teeth should be allowed to exfoliatenaturally, and the patient should be counseled to not playwith them in order to avoid bacteremia. When the patientcannot comply with this recommend ation, the teeth shouldbe removed if the hmatologie parameters allow. Nonrestorable teeth, root tips, teeth with periodontalpockets >6 mm, symptomatic impacted teeth, and teethexhibiting acute infections, significant bone loss, involve-ment ofthe furcation, or mobility should be removed ideally2 weeks (or at least 7 to 10 days) before cancer therapy isinitiated to allow adequate healing .''''*'"'" Some practitioners prefer to extract all third molarsthat are not fully erupted, particularly prior to HCT, whileothers favor a more conservative approach, recomm ending


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extraction of third molars at risk for pulpal infection or thoseassociated with significant periodontal infection, includingpericoronitis.*

Dental and oral care during immun osupression periodsObjectivesThe objectives of a dental/oral care during cancer therapy arethree-fold:

1 . to maintain optimal oral health during cancer therapy;2 . to manage any oral side effects that may develop as aconsequence of the cancer therapy; and3 . to reinforce the patient and parents' education regarding theimportance of optimal oral care in order to minimize oralproblems/discomfort during treatment.

Preventive strategiesOral hygiene; Intensive oral care is of paramount importancebecause it reduces the risk of developing moderate/severe mucosi-tis without causing an increase in septicemia and infections inthe oral cavity.''^ Thrombocytopenia should not be the soledeterm inant of oral hygiene as patients are able to brush withou tbleeding at widely different levels of platelet count.*'" Patientsshould use a soft nylon brush 2 to 3 times daily and replace it ona regular (every 2-3 months) basis.* Fluoridated toothpaste maybe used b ut, if the patient does not tolerate it during periods ofmucositis due to oral burning or stinging sensations, it may bediscontinued and the patient should brush with water alone. Ifmoderate to severe mucositis develops and the patient cannottolerate a regular soft nylon toothb rush or an end-tufted brush,foam brushes or super soft brushes soaked in chlorhexidine maybe used.''' Otherwise, foam or super soft brushes should bediscouraged because they do not allow for effective cleaning.'"The use of a regular brush should be resumed as soon as themucositis improves.* Brushes should be air-dried between uses.*Electric or ultrasonic brushes are acceptable if the patient iscapable of using them without causing trauma and irritation.'*If patients are skilled atflossingwithout traumatizing the tissues,it is reasonable to continue flossing throughout treatment.*Toothpicks and water irrigation devices should not be used whenthe patient is pancytopenic to avoid tissue trauma.*'Diet: Dental practitioners should encourage a non-cariogenicdiet and advise patients/parents about the high cariogenic po-tential of dietary supplements rich in carbohydrate and oralpdiatrie medications rich in sucrose.Fluoride: Preventive measures include the use of fluorida tedtoothpaste, fluoride supplements if indicated, neutral fluoridegels/rinses, or applications offluoridevarnish for patients at riskfor caries and/or xerostomia. A brush-on technique is conve-nient, familiar, and simple and may increase the likelihood ofpatient compliance with topical fluoride therapy.*Lip care: Lanolin-based creams and ointments are more effectivein moisturizing and protecting against damage than petrolatum-based p roducts.*"

Education: Patient/parent education includes reinforcing the im-portance of optimal oral hygiene and teaching strategies to m an-age soft tissue changes (eg, mucositis, oral bleeding, xerostomia)in order to minimize oral problems/discomfort during trea tmentand the possible acute and long-term effects ofthe therapy in thecraniofacial complex.Dental careDuring immunosuppression, elective dental care must not beprovided. If a dental emergency arises, the treatme nt plan shouldbe discussed with the patient's physician who will make recom-mendations for supportive medical therapies (eg, antibiotics,platelet transftisions, analgesia). The patien t should be seen every6 months (or in shorter intervals if there is a risk of xerostomia,caries, trismus, and/or chronic oral GVHD) for an oral healthevaluation during treatment, in times of stable hematologicalstatus and always after reviewing the medical history. If a centralline is still in place and an invasive dental procedure is planned,consultation with the oncologist is recomm ended.'^Man ageme nt of oral conditions related to cancer therapiesMucositis: Mucositis care remains focused on palliation of symp-toms and efforts to reduce the influence of secondary factorson mucositis.''"'^ The Multinational Association of SupportiveCare in Cancer/International Society of Oral Oncology haspublished guidelines (which are updated regularly) for treat-ment of mucositis.'^'' Studies on th e use of chlorhexidine formucositis have given conflicting results. Most studies have notdemon strated a prophylactic im pact, although reduced coloniza-tion of candidial species has been shown.''' '* P atient-con trolledanalgesia has been helpful in relieving pain associated withmucositis, reducing the requirement for oral analgesics. Thereis no significant evidence of the effectiveness or tolerabilityof mixtures containing topical anesthetics (eg, "Philadelphiamouthwash", "m agic mouthw ash").^''The use of topical anesthe-tics often is recommended for pain management although thereare no studies available to assess the benefit and potential fortoxicity. Lidocaine use may obtund or diminish taste and thegag reflex and/or result in a burning sensation, in addition topossible cardiovsascular and C NS effects. Local application maybe useful for painful ulcers.'Oral mucosal infections: The signs of inflammation and infectionmay b e greatly diminished during neutropenic periods. Thus , theclinical appearance of infections m ay differ significantly from thenormal.''" Close monitoring ofthe oral cavity allows for timelydiagnosis and treatment of fungal, viral, and bacterial infectionsProphylactic nystatin is not effective for the prevention and/ortreatm ent of fungal infections.'' '' Ora l cultures and/o r biopsiesof all suspicious lesions should be performed and prophylacticmedications should be initiated until more specific therapy canbe prescribed.'^*'2Oral bleeding: Oral bleeding occurs due to thrombocytopeniadisturbance of coagulation factors, and/or damaged vascularintegrity. Management should consist of local approaches (eg


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pressure packs, antifibrinolytic rinses, gelatin sponges) and sys-temic measures (eg, platelet transfusions, aminocaproic acid).''^'^''"Dental sensitivity/pain: Tooth sensitivity could be related todecreased secretion of saliva during radiation therapy and thelowered salivary p H . ' ' ' " Patients who are using plant alkaloidchemotherapeutic agents (eg, vincristine, vinblastine) may pres-ent with deep, constan t pain affecting the mandibu lar molarswith greater frequency, in the absence of odontogenic pathol-ogy The pain usually is transient and generally subsides shortlyafter dose reduction and or cessation of chemotherapy.''*"*Xerostomia: Sugar-free chewing gum, or candy, sucking tablets,special dentifrices for oral dryness, saliva substitutes, frequentsipping of water, alcohol-free oral rinses, and/or oral moistur-izers are recommended. '^^ Placing a humidifier by bedside atnight may be useful.'" Saliva stimulating drugs are not approvedfor use in children. Fluoride rinses and gels are recommendedhighly for caries prevention in these patients.Trismus: Daily oral stretching exercises/physical therapy mustcontinue during radiation treatment. Managem ent of trismusmay include prosthetic aids to reduce the severity of fibrosis,trigger-point injections, analgesics, muscle relaxants, and otherpain management strategies.''''"Dental and oral care after the cancer therapy is completed(exclusive o f HC T)ObjectivesThe objectives of a dental/oral examination after cancer therapyends are two-fold:

1. to maintain optimal oral health; and2. to reinforce to the patient/parents the importance of

optimal oral and dental care for life.Preventive strategiesOral hygiene: Patients must brush their teeth 2 to 3 times dailywith a soft nylon toothbrush . Brushes should be air-driedbetween uses.' Patients shouldflossdaily.Diet: De ntal practitioners should encourage a non-cariogenic dietand advise patients/parents about the high cariogenic potentialof dietary supplements rich in carbohydrate and oral pdiatriemedications rich in sucrose.Fluoride: Preventive measures include the use of fluo rida tedtoothpaste, fluoride supplements if indicated, neutral fluoridegels/rinses, or applications offluoridevarnish for patients at riskfor caries and/or xerostomia. A brush-on technique is conve-nient, familiar, and simple and may increase the likelihood ofpatient compliance with topical fluoride therapy.*Lip care: Lanolin-based creams and o intments are more effectivein moisturizing and protecting against damage than petrolatum-based products.*'"

Education: Th e importance of optimal oral and dental care forlife must be reinforced. It is also important to emphasize theneed for regular follow-ups w ith a dental professional, especiallyfor patients who are at risk for or have developed GV HD and/orxerostomia and those less than 6 years of age during treatmentdue to potential dental developmental problems caused bycancer therapies.Dental carePeriodic evaluation: The patient should be seen at least every6 months (or in shorter intervals if issues such as chronic oralGVHD, xerostomia, or trismus are present). Patients who haveexperienced moderate or severe mucositis and/or chronic oralGVHD should be followed closely for malignant transforma-tion of their oral mueosa (eg, oral squamous cell carcinoma) .""^^Orthodontic treatment: Orthodontic care may start or resumeafter completion of all therapy and after at least a 2 year disease-free survival when the risk of relapse is decreased and the patientis no longer using immunosuppressive drugs.-" A thoroug h assess-ment of any dental developmental disturbances caused by thecancer therapy must be performed before initiating orthod ontictreatment. The following strategies should be considered whenproviding orthodontic care for patients with dental sequelae:(1) use appliances that minimize the risk of root rsorption,(2) use lighter forces, (3) terminate treatment earlier thannormal, (4) choose the simplest method for the treatment needs,and (5) do not treat the lower jaw.^*However, specific guidelinesfor orth odontic management, including optimal force and pace,remain undefined. Patients who have used or will be givenbisphosphonates in the future present a challenge for orthodon-tic care. Although bisphosphonate inhibition of tooth move-ment has been reported in animals, it has not been quantifiedfor any dose or duration of therapy in humans.^' Consultationwith the patients parents and physician regarding the risks andbenefits of orthodontic care in this situation is recommended.Oral surgery: Consultation with an oral surgeon and/or perio-dontist and the patient's physician is recommended for non-elective oral surgical and invasive periodontal procedures inpatients who have used or are using bisphosphonates or thosewho received radiation therapy to the jaws in order to devisestrategies to decrease the risk of osteonecrosis and osteoradio-necrosis, respectively. Elective invasive procedures should beavoided in these patients.^*Xerostomia: Sugar-free chewing gum or candy, special denti-frices for oral dryness, saliva substitutes, frequent sipping ofwater, alcohol-free oral rinses, and/or oral moisturizers arerecommended.*'^^ Placing a humidifier by bedside at night maybe useful'". Saliva stimulating d rugs are not approved for use inchildren. Fluoride rinses and gels are recommended highly forcaries prevention in these patients.


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Trismus: Daily oral stretching exercises/physical therapy shouldcontinue after radiation therapy is finished in order to prevent orameliorate trismus. Management of trismus may include pros-thetic aids to reduce the severity of fibrosis, trigger-point injec-tions, analgesics, muscle-relaxants, and other pain managementstrategies.^''-'"Hematopoietic cell transplantationSpecific oral complications can be correlated with phases ofPhase I: Pre-transplantationThe oral complications are related to the current systemic andoral health, oral manifestations of the underlying condition,and oral complications of recent medical therapy. Most of theprinciples of dental and oral care before the transplant are similarto those discussed for pdiatrie cancer."' The 2 major differencesa r e : 1) In HCT, the patient receives all the chemotherapy and/ortotal body Irradiation in just a few days before the transplant,and 2) there will be prolonged imm unosuppression followingthe transplant. Elective dentistry will need to be postponed untilimmunological recovery has occurred, which may take as long as9 to 12 months after HCT, or longer if chronic GVHD or othercomplications are present.''^ Therefore, all dental treatment mustbe completed before the patient becomes immunosuppressed.Phase II: Gonditioninglneutropenic phaseIn this phase, which encompasses the day the patient is admittedto the hospital to begin the transplant conditioning to 30 dayspost-HC T, the oral complications are related to the con ditioningregimen and supportive medical therapies.' Mucositis, xerosto-mia, oral pain, oral bleeding, opportunistic infections, and tastedysfunction may be seen. Th e pa tient shou ld be followed closelyto monitor and manage the oral changes and to reinforce theimportance of optimal oral care. Dental procedures usually arenot allowed in this phase due to the patient's severe imm unosup -pression.Phase III: Initial engrafhnent to hematopoietic reconstitutionThe intensity and severity of complications begin to decreasenormally 3 to 4 weeks after transplantation. Oral fungal infec-tions and herpes simplex virus infection are most notable. OralGVHD can become a concern for allogeneic graft recipients. Adental /oral examination should b e performed and invasive dentalprocedures, including dental cleanings and soft tissue curettage,should be done only if authorized by the HCT team becauseof the patient's continued immunosuppression.^ Patients shouldbe encouraged to optimize oral hygiene and avoid a cariogenicdiet. Attention to xerostomia and oral GVHD manifestationsis crucial. HCT patients are particularly sensitive to intraoralthermal stimuli between 2 and 4 months post-transplant.' Themechanism is not well understood, but the symptoms usuallyresolve spontaneously within a few months. Topical applicationof neutral fluoride or desensitizing toothpastes helps reducethe symptoms.'

Phase IV: Immun e reconstitution/ late posttransplantationAfter day 100 post-HCT, the oral complications predominantlyare related to the chronic toxicity associated with the conditioning regimen, including salivary dysfunction, craniofacial growthabnormalities(especially in patients less than 6 years ofage at thetime of treatment), late viral infections, oral chronic GVHDand oral squamous cell carcinoma.* Periodic dental examinationswith radiographs can be performed, but invasive dental treat-ment should be avoided in patients with profound impairmentof immu ne functio n.'Con sultation with the patient's physicianand parents regarding the risks and benefits of orthodontic careis recommended.R e f e r e n c e s

1 . Barker GJ. Current practices in the oral management ofthe patient undergoing chemotherapy or bone marrowtransplantation. Support Care Cancer 1999;7(l):17-20.2 . Sonis S, Kunz A . Impact of improved dental services on thefrequency of oral complications of cancer therapy for patientswith non-head-and-neck malignancies. Oral Surg Oral M edOral Pathol 1988; 65(l):19-22 .3 . Scully C, Epstein J B . Oral health care for the cancer patientEurJ Cancer B Oral Oncol 1996;32B(5):281-92.4 . Toth BB, Martin JW, Fleming TJ. Oral and dental careassociated with cancer therapy. Cancer Bull 1991;43:397-

4 0 2 .5 . Schubert MM, Epstein JB, Peterson DE. Oral complica-tions of cancer therapy. In: Yagiela JA, Dow d FJ, Neidle EA

e d s . Pharmacology and Therapeutics for Dentistry. 5* edSt. Louis Mo: Mosby-Year Book Inc; 2004 ;797-8 13.6. National Institutes of Hea lth, National Canc er InstituteConsensus Development Conference on Oral Complicationsof Cancer Therapies: Diagnosis, Prevention, and TreatmentNational Cancer Institute Monograph N o . 9. Bethesda, MdNational Institutes ofHealth; 1990.

7 . Epstein J B , Schubert M M . Oral mucositis in myelosuppressive cancer therapy. Oral Surg Oral Med Oral Pathol OraRadiol Endod 1999;88(3):273-6.8. Schubert MM , Peterson DE , Lloid M E . Oral complicationsIn: Blume KG, Forman SJ, Appelbaum RF, eds. ThomasHem atopoietic Cell Transplantation, 3"* ed. Maiden, Mass

Blackweli Science, Inc; 2004:911-28.9. Bavier A R . Nursing management of acute oral complicationsof cancer. Consensus Development Conference on OraComplications of C ancer Therapies: Diagnosis, Preventiona n d Treatment. National Cancer Institute Monograph N o . 9Bethesda, Md: National Institutes ofHealth; 1990:23-128

1 0 . Little JW, Falace DA, Miller CS, Rhodus NL. DentaManagement of the Medically Compromised Patient, 7'ed., St. Louis, Mo: Mosby; 2008:433-61,

1 1 . Semba SE, Mealy BL, Hallmon W W Dentistry and thecancer patient: Part 2: Oral health management of thechemotherapy patient. Compend 1994;15(11):13781380-7; quiz 1388.


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12. Sonis S, Fazio RC, Fang L. Principles and Practice of OralMedicine. 2"'' ed.Philadelphia, Pa: W.B. Saunders Co; 1 995:426-54.13 . Borowski B, Benhamou E, Pico JL, Laplanche A, MargainaudJP, Hayat M. Prevention of oral mucositis in patients treatedwith high-dose chemotherapy and bone m arrow transplanta-

tion: A randomised con trolled trial comparing two protocolsof dental care. EurJ Cancer B Oral Oncol 1994;30B(2):93-7.14. da Fonseca MA. Pdiatrie bone marrow transplantation:Oral complications and recommendations for care. PediatrDent 1998;20(7):386-94.15. da Fonseca MA. Long-term oral and craniofacial complica-tions following pdiatrie bone marrow transplantation.Pediatr Dent 2000;22(l):57-62.16. daFonseea M A. Dental care ofthe pdiatrie cancer patient.Pediatr Dent 20 04;26(l):53 -7.17. Baddour LM, Bettman MA, Bolger AF, et al. Nonvalvu-

lar cardiovascular device-related infections. Circ 2003;108(16):2015-3I.18. Ransier A, Epstein JB, Lunn R, Spinelli J. A combinedanalysis of a toothbrush, foam brush, and a chlorhexidine-soaked foam brush in maintaining oral hygiene. Cane Nurs1995;18(5):393-6.19. Wilson W, Taubert KA, Gevitz M, et al. Prevention of in-fective endocarditis: Guidelines from the American HeartAssociation. Circulation e-published April 19, 2007. Available

at: "http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA. 106.183095". Accessed March 30, 2008. CorrectionCirculation. 200 7;l I6:e3 76-e3 77. Available at: "http://circ.ahajournals.org/cgi/content/full/116/15/173 6". AccessedMay 23 , 2008.

20 . Peters E, Monopo li M , Woo SB, Sonis S. Assessment o ftheneed for treatment of postendodontic asymptomatic peri-apical radiolucencies in bone marrow transplant recipients.Oral Surg Oral Med Oral Pathol 1993;76(l):45-8.

21 . Sheller B, Williams B. Ortho dontic management of patientswith hmatologie malignancies. Am J Orthod DentofOrthop 1996;109(6):575-80.22 . Migliorati CA, Casiglia J, Epstein J, Jacobsen PL,Siegel MA, Woo SB. Managing the care of patients withbisphosphonate-associated osteonecrosis. An American

Academy of Oral Med icine position paper. J Am Dent Assoc2005;136(12):1658-68. Erratum in: 2006;137(l):26.23. Ruggiero SL, Fantasia J, Carlson E. Bisphosphonate-relatedosteonecrosis of the jaw: Background and guidelines fordiagnosis, staging and management. Oral Surg Oral MedOral Pathol Oral Radiol Endodont 2006; 102(3) :43 3-4 l.24. Keefe DM, Schubert MM, Elting LS, et al. Updated clin-ical practice guidelines for the prevention and treatmentof mucositis. Cancer 2007;109(5): 820-831. Available at:"http://www .mascc .org/content/125 .htmr'. Accessed June 9,2008.25 . Euvrard S, Kanitakis J, Claudy A. Skin cancers after organ

transplantation. N Engl J Med 2003; 348(17):1681-91.26. Gotzche PC, Johansen HK. Nystatin prophylaxis andtreatment in severely immunocompromised patients.Cochrane Database Syst Rev (2):CD002 033 , 2002.27. Nieuw Amerongen AV, Veerman ECI. Current therapiesfor xerostomia and salivary gland hypofunction associatedwith cancer therapies. Support Care Cancer 2003;ll(4):

226-31.28 . Dahllf G, Jonsson A, Ulmner M , Huggare J. Orrhodontictreatment in long-term survivors after bone marrow trans-plantation. Am J Orthod Dentof Orthop 2001;120(5):459-65.29. Zahrowski JJ. Bisphosphonate treatment: An orthodonticconcern for a proactive approach. Am J Orthod DentofacialOrthop 2007;131(3):311-20.


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