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.

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.

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.

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

1. 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. 
   
   
2. Sonis ST, Woods PD, White BA: Oral complications of cancer therapies. Pretreatment oral assessment. NCI Monogr (9): 29-32, 1990.  [PUBMED Abstract]
   
   
3. Epstein JB: Infection prevention in bone marrow transplantation and radiation patients. NCI Monogr (9): 73-85, 1990.  [PUBMED Abstract]
   
   
4. 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]
   
   
5. 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. 
   
   
6. 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. 
   
   
7. 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]
   
   
8. 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]
   
   

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