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.

Guidelines on Record Keeping and Informed Consent

Guideline on Record Keeping and Informed Consent.

Kris Hendricks, Lit Review 12/18/09

Records

Just copy the appendixes and use them. See, how easy was that?

Purpose: assist practitioners in creating a comprehensive patient record, but this is not meant to be the “standard of care”

Each patient should have an individual record, most of this seems intuitive at this point so there isn’t much to say.

In order to not overlook important details in your records, use the appendixes included to make sure your records have all needed elements.

Everything that is done, every correspondence, every mediation used, basically everything must be recorded.

In depth medical and dental histories and risk assessments too.

Informed Consent

Process of informing pt or custodial parent/guardian with relevant info regarding dx and tx needs so an educated decision can be made.

The ADA code of ethics says: “the dentist must inform the patient of the proposed treatment, and any reasonable alternatives, in a manner that allows the patient to become involved in treatment decisions.”

Every person has the legal right to determine what happens to his or her own body.

States differ on their interpretation and expectations of informed consent. \

As we know the accompanying person of a minor patient may or may not legally be able to give informed consent.

Some states require written consent before treating a patient, but even if not mandated, it’s a smart idea.

Some states will allow oral conversations documented in the medical record.

Consent form should include proposed therapy, risks, benefits and possible alternative therapy.

Forms should utilize simple words and phrases. The lay person --or in the case of some parents extra-lay person—should be able to understand the forms.

Courts have decided that the use of overly broad terms like “all treatment deemed necessary by the doctor” are too unspecific and do not constitute informed consent.

There are lists of essential elements in the handbook.

Forms need to be procedure specific, and you will need different forms for different procedures.

Additional consent for protective stabilization and sedation should be used separately.

Policy on the Management of Patients with Cleft Lip/Plalate and other craniofacial anomalies

Policy on the Management of Patients with Cleft Lip/Plalate and other craniofacial anomalies

Reference Manual: 2009-10

AAPD endorses the statements of the American Cleft Palate-Craniofacial Association (ACPA). In 1991 parameters of care were listed for these patients
1. Management of these patients is best provided by an interdisciplinary team of specialists.
2. Care is best provided by a team with experience in treating a number of patients with craniofacial abnormalities.
3. Best time for a initial evaluation is within the first few weeks of life
4. The team should make every effort to assist the family in adjusting to the birth of the child with various anomalies and the future demands and stress placed on the family.
5. The family should be well informed about treatment decisions and options should be given to encourage participation in these decisions.
6. The team approach to treatment planning recommendations is necessary
7. Care recommended by the team should be provided at the local level as best as possible, and more complex procedures reserved for major medical centers that have experienced providers.
8. Team must be sensitive to extrinsic demographic factors.
9. The team must monitor short-term and long-term outcomes of care.
10. Outcomes must account for satisfaction, psycho-social well-being of the patient as well as the effects on growth, function and appearance.

Dental specialists should also coordinate care between pediatric dentists and orthodontic, oral and maxillofacial surgery and prosthodontic specialists.