Oral and Dental Management Prior to Cancer Therapy
Chemotherapy Patients
Assessment of Hematopoietic Stem Cell Transplant Patients
Severity of oral complications in cancer patients can be reduced significantly
when an aggressive approach to stabilizing oral care is initiated prior to
treatment.[1-3] Primary preventive measures, such as appropriate nutritional
intake, effective oral hygiene practices, and early detection of oral lesions
are important pretreatment interventions.
The involvement of a dental team experienced with oral oncology may reduce the
risk of oral complications via either direct examination of the patient or in
consultation with the community-based dentist. The evaluation should occur as
early as possible prior to treatment.[4-6] The examination allows the dentist
to determine status of the oral cavity prior to cancer therapy, and to initiate
necessary interventions that may reduce oral complications during and after
that therapy. Ideally, this examination should be performed at least 1 month
prior to cancer treatment to permit adequate healing from any required invasive
oral procedures. A program of oral hygiene should be initiated with emphasis
on maximizing patient compliance on a continuing basis.
Chemotherapy Patients
Oral evaluation and management of patients scheduled to undergo myeloablative
chemotherapy should occur as early as possible prior to initiation of
therapy (refer to the list on Oral Disease Stabilization Prior to Chemotherapy and/or Hematopoietic Stem Cell Transplantation below). To maximize outcomes, the oncology team should clearly
advise the dentist as to the patient’s medical status and oncology treatment
plan. In turn, the dental team should delineate and communicate a plan of care
for oral disease management before, during, and after cancer therapy.[6]
Oral Disease Stabilization Prior to Chemotherapy and/or Hematopoietic
Stem Cell Transplantation
- Data provided by oncology to dental medicine:
- Underlying disease:
- Cancer: type, stage, prognosis.
- Aplastic anemia status, complete blood cell count (CBC).
- Other.
- Type of transplant:
- Autologous.
- Allogeneic:
- Matched.
- Mismatched related.
- Mismatched unrelated.
- Syngeneic.
- Nonmyeloablative.
- Planned date of transplant.
- Conditioning regimen:
- Chemotherapy.
- Total-body irradiation.
- Current hematologic status and immunologic status.
- Present medications.
- Other medical considerations:
- Splenectomy.
- Cardiac disease (including murmurs).
- Pulmonary disease.
-
Indwelling venous access line.
- Data provided by dental
medicine to oncology:
- Dental caries (amount/severity).
- Number of teeth requiring
restorations.
- Endodontic disease.
- Teeth with pupal infection.
- Teeth requiring endodontic treatment.
- Periodontal disease status.
- Number of teeth requiring
extraction.
- Other urgent care required.
- Time necessary to complete
stabilization of oral disease.
The overall goal is to complete a comprehensive oral care plan that eliminates
or stabilizes oral disease that could otherwise produce complications during
or following chemotherapy. Achieving this goal will most likely reduce risk of
oral toxicities with resultant reduced risk for systemic sequelae, reduced cost
of patient care, and enhanced quality of life. If the patient is unable to
receive the medically necessary oral care in the community, the oncology team
should assume responsibility for oral management.
Specific interventions are directed to:
- Mucosal lesions.
- Dental caries and endodontic disease.
- Periodontal disease.
- Ill-fitting dentures.
- Orthodontic appliances.
- Temporomandibular dysfunction.
- Salivary abnormalities.
Guidelines for dental extractions, endodontic management, and related
interventions can be utilized as appropriate.[7,8] Antibiotic
prophylaxis prior to invasive oral procedures may be warranted in the context
of central venous catheters; the current American Heart Association (AHA)
protocol for infective endocarditis and oral procedures is frequently utilized
for these patients.
Management Guidelines Relative to Invasive Dental Procedures
Medical Status
|
Guideline
|
Comments
|
Patients with chronic
indwelling venous
access lines
(e.g., Hickman). |
AHA prophylactic antibiotic recommendations (low risk). |
There is no clear scientific proof detailing infectious risk for these lines
following dental
procedures. This
recommendation is
empiric. |
Neutrophils
|
|
Order CBC with
differential. |
>2,000/mm3 |
No prophylactic antibiotics. |
|
1,000–2,000/mm3 |
AHA prophylactic antibiotic
recommendations (low risk). |
Clinical judgment is critical. If infection is present or
unclear, more
aggressive antibiotic
therapy may be
indicated. |
<1,000/mm3 |
Amikacin 150 mg/m2 1 hour
before surgery; ticarcillin
75 mg/kg IV ½ hour before
surgery.
Repeat both 6 hours
postoperatively.
|
If organisms are known or suspected, appropriate adjustments should be made based on sensitivities. |
Platelets*
|
|
Order platelet count
and coagulation tests. |
>75,000/mm3 |
No additional support needed. |
|
40,000–75,000/mm3 |
Platelet transfusions are
optional; consider
administering preoperatively
and 24 hours later. Additional
transfusions are based on
clinical course. |
Utilize techniques to promote establishing and maintaining control of bleeding (i.e., sutures, pressure packs, minimize trauma). |
<40,000/mm3 |
Platelets should be transfused
1 hour before procedure, immediately obtain
platelet count, transfuse
regularly to maintain counts
above 30,000–40,000/mm3 until
initial healing has occurred. |
In addition to above, consider using hemostatic agents (i.e., microfibrillar collagen, topical thrombin).
Monitor sites
carefully.
|
CBC = complete blood cell count; IV = intravenous.
|
*Assumes that all other coagulation parameters are within normal limits and
that platelet counts will be maintained at or above the specified level until
initial stabilization/healing has occurred.
|
Assessment of Hematopoietic Stem Cell Transplant Patients
Stages of assessment have been described relative to the hematopoietic stem cell transplant patient (see the table below on Oral Complications of Hematopoietic Stem Cell Transplantation).[6] This model provides a useful classification for neutropenic cancer
patients in general. Type, timing, and severity of oral complications
represent the interaction of local and systemic factors that culminate in
clinical expression of disease. Correlating oral status with systemic
condition of the patient is thus critically important.
In recent years, selected conditioning regimens characterized by reduced intensity for myelosuppression have been utilized in patients. These regimens may or may not result in reduced severity of oral complications, including mucositis and infection risk. The guidelines listed in the table below can be adjusted to reflect these varying degrees of risk, based on the specific conditioning regimen to be used.
Oral Complications of Hematopoietic Stem Cell Transplantation
Transplant Phase
|
Oral Complication
|
GVHD = graft-versus-host disease.
|
Phase I: Preconditioning
|
Oral infections: dental caries, endodontic infections, periodontal disease (gingivitis, periodontitis), mucosal infections (i.e., viral, fungal, bacterial). |
Gingival leukemic infiltrates. |
Metastatic cancer. |
Oral bleeding. |
Oral ulceration: aphthous ulcers, erythema multiforme. |
Temporomandibular dysfunction. |
Phase II: Conditioning Neutropenic Phase |
Oropharyngeal mucositis. |
Oral infections: mucosal infections (i.e., viral, fungal, bacterial), periodontal infections. |
Hemorrhage. |
Xerostomia. |
Taste dysfunction. |
Neurotoxicity: dental pain, muscle tremor (e.g., jaws, tongue). |
Temporomandibular dysfunction:
jaw pain, headache, joint pain. |
Phase III: Engraftment
Hematopoietic Recovery |
Oral infections: mucosal infections (i.e., viral, fungal, bacterial). |
Acute GVHD.
|
Xerostomia.
|
Hemorrhage. |
Neurotoxicity:
dental pain,
muscle tremor (e.g., jaws, tongue).
|
Temporomandibular dysfunction: jaw pain, headache, joint pain. |
Granulomas/papillomas. |
Phase IV: Immune
Reconstitution
Late Posttransplant |
Oral infections: mucosal infections (i.e., viral, fungal, bacterial). |
Chronic GVHD. |
Dental/skeletal growth and development
alterations (pediatric patients). |
Xerostomia. |
Relapse-related oral lesions. |
Second malignancies. |
Phase V: Long-term Survival |
Relapse or second malignancies. |
Dental/skeletal growth and development
alterations. |
Phase I: Prior to Chemotherapy
Oral complications are related to current systemic and oral health, oral
manifestations of underlying disease, and oral complications of recent cancer
or other medical therapy.
During this period, oral trauma and clinically significant infections, including
dental caries, periodontal disease, and pulpal infection, should be eliminated.
Additionally, patients should be educated relative to the range and management
of oral complications that may occur during subsequent phases. Baseline oral
hygiene instructions should be provided.
Phase II: Neutropenic Phase
Oral complications arise primarily from direct and indirect stomatotoxicities
associated with high-dose chemotherapy or chemoradiotherapy and their sequelae.
Mucositis, xerostomia, and those lesions related to myelosuppression,
thrombocytopenia, and anemia predominate. This phase is typically the period
of high prevalence and severity of oral complications.
Oral mucositis usually begins 7 to 10 days after initiation of cytotoxic
therapy, and remains present for approximately 2 weeks after cessation of
that therapy. Viral, fungal, and bacterial infections may arise, with
incidence dependent on the use of prophylactic regimens, oral status prior to
chemotherapy, and duration/severity of neutropenia. Frequency of infection
declines upon resolution of mucositis and regeneration of neutrophils. The
patient may remain at risk, however, depending on status of overall immune
reconstitution.
Xerostomia secondary to anticholinergic drugs and taste dysfunction is
initially detected in this phase; the toxicity typically resolves within 2 to 3
months.
Phase III: Hematopoietic Recovery
Frequency and severity of acute oral complications typically begin to decrease
approximately 3 to 4 weeks after cessation of chemotherapy. Healing of
ulcerative oral mucositis in the setting of marrow regeneration contributes to
this dynamic. Although immune reconstitution is developing, oral mucosal
immune defenses may not be optimal. Thus, the patient remains at risk for
selected infection, including candidal and herpes simplex virus infections. Mucosal bacterial infections during this phase occur less
frequently unless: engraftment is delayed or the patient has acute graft-versus-host disease (GVHD) or is
receiving GVHD therapy.
The hematopoietic stem cell transplant patient represents a unique cohort at this point. For example, risk
for acute oral GVHD typically emerges during this time in allogeneic graft
recipients.
Phase IV: Immune Reconstitution/Recovery from Systemic Toxicity
Oral lesions are principally related to chronic chemotherapy-associated or
chemoradiation therapy–associated toxicity. Late viral infections and xerostomia
predominate. Mucosal bacterial infections are infrequent unless the patient
has severe chronic GVHD. Risk exists for graft failure, cancer relapse, and
second malignancies. The hematopoietic stem cell transplant patient may develop oral manifestations of
chronic GVHD during this period.
Phase V: Long-term Survival
Long-term survivors of cancer treated with high-dose chemotherapy alone or
chemoradiotherapy will generally have few significant permanent oral
complications.
Risk for radiation-induced chronic complications is related to the total dose
and schedule of radiation therapy. Xerostomia is the most frequently reported
oral complication of total-body irradiation. Other significant complications
include craniofacial growth and developmental abnormalities in pediatric
patients, and emergence of second malignancies of the head/neck region.
References
-
Beck SL: Prevention and management of oral complications in the cancer patient. In: Hubbard SM, Greene PE, Knobf MT, eds.: Current Issues in Cancer Nursing Practice. Philadelphia, Pa: J.B. Lippincott Company, 1990, pp 27-38.
-
Sonis ST, Woods PD, White BA: Oral complications of cancer therapies. Pretreatment oral assessment. NCI Monogr (9): 29-32, 1990.
[PUBMED Abstract]
-
Epstein JB: Infection prevention in bone marrow transplantation and radiation patients. NCI Monogr (9): 73-85, 1990.
[PUBMED Abstract]
-
Woo SB, Matin K: Off-site dental evaluation program for prospective bone marrow transplant recipients. J Am Dent Assoc 128 (2): 189-93, 1997.
[PUBMED Abstract]
-
Schubert MM, Epstein JB, Peterson DE: Oral complications of cancer therapy. In: Yagiela JA, Neidle EA, Dowd FJ: Pharmacology and Therapeutics for Dentistry. 4th ed. St. Louis, Mo: Mosby-Year Book Inc, 1998, pp 644-55.
-
Schubert MM, Peterson DE, Lloid ME: Oral complications. In: Thomas ED, Blume KG, Forman SJ, eds.: Hematopoietic Cell Transplantation. 2nd ed. Malden, Mass: Blackwell Science Inc, 1999, pp 751-63.
-
Williford SK, Salisbury PL 3rd, Peacock JE Jr, et al.: The safety of dental extractions in patients with hematologic malignancies. J Clin Oncol 7 (6): 798-802, 1989.
[PUBMED Abstract]
-
Overholser CD, Peterson DE, Bergman SA, et al.: Dental extractions in patients with acute nonlymphocytic leukemia. J Oral Maxillofac Surg 40 (5): 296-8, 1982.
[PUBMED Abstract]
Back to Top
< Previous Section | Next Section > |