Guideline on Dental Management of Pediatric Patients Receiving Chemotherapy, Hematopoietic Cell

Resident: Roberts

Date: 3/20/2011

Article title: Guideline on Dental Management of Pediatric Patients Receiving Chemotherapy, Hematopoietic Cell Transplantation and or Radiation

Author: Clinical Affairs Committee

Year: Revised 2008

Background:

The most frequently documented source of sepsis in the immunosuppressed cancer patient is the mouth, therefore, early and definitive dental intervention, including comprehensive oral hygiene measures, reduces risk for oral and associated systemic complications.

Recommendations

Examination before initiation of cancer therapy

Two fold objective: 1. to identify and stabilize or eliminate existing and potential sources of infection and local irritants in the oral cavity. 2. To educate the patient and parents about the importance of optimal oral care in order to minimize oral problems/ discomfort before, during, and after treatment and about the possible acute and long term effects of the therapy in the oral cavity and craniofacial complex.

Evaluation should include: type of disease/condition, treatment protocol, medications (including bisphosphonates), allergies, surgeries, secondary medical diagnoses, and immunosuppression status. For Hematopoietic (HCT) patients, include type of transplant, matching status, donor conditioning protocol, and graft versus host disease prophylaxis.

Preventive strategies:

Oral hygeine should include brushing teeth 2x/day with a regular soft nylon brush or electric toothbrush, regardless of the hematological status. Ultrasonic brushes and dental floss should be allowed only if the patient is properly trained. Patients with poor oral hygiene or perio disease may use chlorhexidine daily until tissue health improves or mucositis develops. If mucositis develops then an alcohol free rinse is suggested.

Diet: should be a non-cariogenic diet.

Fluoride: should use fluoride toothpaste and fluoride supplements and gels are acceptable especially if indicated because of xerostomia.

Trismus: Patients who receive radiation therapy to the masticatory muscles may develop trismus. Thus daily stretching should start before treatment and continue throughout to prevent problems.

Hematological considerations:

Absolute Neutrophil Count

>1000/mm3: no need for antibiotic prophylaxis. <1000mm3: defer elective care until the ANC rises.

Platelet count

>75000/mm3: no additional support needed. 40000 to 75000 platelet transfusions may need to be considered, should use supporting agents such as sutures, gel foams etc. <40000: defer care until supportive measures have been taken. Contact physician.