Chemotherapy, Hematopoietic Cell Transplantation, and/or Radiation

Resident’s Name: Joanne Lewis Date: December 18, 2009

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

Background

- The most frequently documented source of sepsis in the immunosuppressed cancer patient is the mouth.

- Early and radical dental intervention, including aggressive oral hygiene measures, reduces the risk for oral and associated systemic complications.

Recommendations

- All patients with cancer should have an oral examination before initiation of the oncology therapy.

- Existing or potential sources of infection need to be identified and treated.

- Parents and other caregivers need to be educated about the importance of optimal hygiene and oral care during and after treatment.

- Patients who receive radiation therapy to the masticatory muscles may develop trismus. Daily stretching oral exercises should start before radiation and continue throughout treatment.

- Hematological considerations:

o Absolute neutrophil count (ANC) - <1,000/mm3 defer elective dental care. Emergency dental care should be discussed with the patient’s physician and may require hospitalization.

o Platelet count – 40,000-75,000/mm3 may need to consider platelet transfusion. <40,000/mm3 defer elective dental care.

- Ideally, all dental treatment should be accomplished before cancer therapy is initiated. If dental work is needed once cancer therapy is started, treat between chemotherapy cycles - the patient’s hematological status is usually the most stable in the few days between treatment cycles.

- Dental care should be aimed at preventing infection and may need to be more aggressive for these patients. Primary teeth with pulpal involvement should be extracted, rather than treated with a pulpotomy. Permanent teeth needing endo should only be saved if the RCT can be performed in a single visit; otherwise, extract. Orthodontic appliances may need to be removed if OH is poor or if the cancer treatment protocol is putting the patient at risk for developing mucositis. There are no clear recommendations for the use of prophylactic antibiotics for extractions. If the patient will or has received radiation to the face, caution should be taken due to the risk of osteoradionecrosis.

- During cancer treatment, if moderate to severe mucositis develops, the patient may use a foam toothbrush soaked in aqueous chlorhexadine for brushing; the use of a regular toothbrush should be resumed as soon as the mucositis improves.

- Oral hygiene needs to be impeccable during cancer treatment. Xerostomia may develop; fluoride rinses and gels are highly recommended.

- Patients who have experienced chronic or severe mucositis should be watched closely for malignant transformation of their oral mucosa.

- Orthodontic care may start or resume after all treatment is complete and after at least a 2-year disease-free survival.

- If a child is planned for hematopoietic cell transplantation (HCT), all dental treatment must be completed before the transplant.

- There will be prolonged immunosuppression following the transplant; elective dentistry will need to be postponed until immunological recovery has occurred.