Dental care of the Pediatric Cancer Patient 01/29/2010

Resident: J. Hencler
Date: 01/29/2010

Article title: Dental care of the Pediatric Cancer Patient
Author: Marcio A. da Fonseca, DDS, MS
Journal: Pediatric Dentistry-26:1 Pg 53-57

Major topic: Dental care and the pediatric cancer patient
Type of Article: Literature review
Main Purpose: Dental care recommendations

Key points in the article discussion:
Oral/dental infections may complicate or delay cancer tx. Dental consultation on a newly diagnosed patient should be done asap so enough time is available to complete dental tx before cancer therapy begins.

Take a thorough medical hx and consult with PCP/Oncologist. Antibiotic prophylaxis should be considered due to possible lowered immune state or presence of central line, catheter, or port.

Check patient’s hematologic status. Patients with platelet count <20,000 have increased bleeding risk. Elective dental work should be deferred in patients with absolute neutrophil count <1,000. Routine dental tx can be done when ANC >1,000 and platelet count is >50,000. AB prophylaxis should be considered with ANC between 1000 and 2000. Platelet transfusion should be considered when count is between 40,000 and 75,000. Peak concentration of platelets is reached 45-60 mins after transfusion so dental tx should be conducted at this time if possible. During immune suppression all elective dental tx should be avoided.

Aggressive OH should be conducted throughout cancer tx. Patients with poor OH or PD disease can use chlorhexidine rinses daily. The pediatric cancer patient has high caries risk due to nutritional supplements (high carb), fungal rinses with high sucrose such as nystatin, and frequent vomiting (enamel demin).

Dental tx priorities should be infections, EXTs, PD care and souces of infection before tx of caries, RCT permanent teeth, and replacement of defective restorations. SC/RP before cancer tx begins if time allows and EXTs are favorable over pulp therapy. During immune suppression swelling and purulent exudates may not be observed so radiographic exam is important to determine odontogenic infections.

Fixed ortho and space maintainers should be removed in patients with poor OH. Removable appliances may be worn in the patient with good OH.

Partially erupted molars can be a source of infection due to pericoronitis. Overlying gingival should be excised. Loose primary teeth should be left to exfoliate naturally. EXTs ideally should be completed 3 wks before cancer tx initiation. Osteoradionecrosis risk in patients who have undergone radiation to face and have had EXT is elevated and needs to be addressed.

Patient in maintenance phase and prognosis is good, dental procedures can be done routinely. Must still check blood count and need for AB prophylaxis.

Summary of conclusions: Key to maintaining healthy OH during cancer tx is compliance. It is important to educate parent about importance of oral care to minimize discomfort, a healthy diet, potential cariogenicity of pediatric medications and nutritional supplements, and effects of cancer tx on craniofacial growth and dental development. The role of the pediatric dentist in the hematology/oncology team is a very important one.

Assessment of article: Good article. All information is pertinent and useful to a pediatric dentist in clinical situations.