Dental treatment planning and management in the patient who has cancer

By Brennan MT, Woo SB, Lockhart PB.

Date: 01/2008
Journal: Dental clinic of North America

Summary: 

The following are the goals of dental management before the start of cancer therapy:

Eliminate or stabilize oral disease to minimize local and systemic infection during and after cancer therapy:

Short term:  Ideally, all patients should be returned to a stable, if not perfect state of dental health before cytoreductive therapy

long term:  the cancer Pt. has a potential for increased caries risk and reduced healing capacity (especially of the bone) in the long term.

      Elimination of dental disease by restorative, endodontic, periodontal treatments, and extraction of teeth with questionable prognosis are important preventive strategies to avoid future dental extractions, an important risk factor for post-radiation osteonecrosis

Identify issues specific to the cancer diagnosis.

•A thorough examination of the mouth for oral involvement of the primary tumor such as leukemic infiltrates (especially in the gingiva) and jaw involvement from multiple myeloma should be performed.

Educate the patient regarding short-term and long-term oral complications from cancer therapy

•what to expect during cancer therapy (such as mucositis and xerostomia), and measures that can be taken to minimize side effects of therapy.

Pretreatment evaluation and treatment planning:

•The pretreatment evaluation for patients with cancer requires a thorough understanding of the cancer diagnosis and stage, and should include a review of systems, current medications, drug allergies.

  • Presenting symptoms:  Patients with squamous cell carcinoma in the oral cavity often experience pain from the tumor and this must be differentiated from pain of odontogenic origin
  • Laboratory values:  A recent complete blood count (CBC) must be obtained on patients with leukemia, myeloma, and marrow failure syndromes such as aplastic anemia before examination of the patient.
  • Necessity for antibiotic prophylaxis: There is no guideline regarding the necessity for antibiotic prophylaxis before invasive oral procedures

Clinical examination:

Extra-oral examination:  A lymph node that is fixed and non-painful is a common finding in metastatic tumors to the node while a freely movable and tender node is more likely to represent an infectious or inflammatory process.

Intraoral examination:  

•Patients with leukemia, especially acute monocytic leukemia may present with leukemic infiltration of the oral cavity. These patients may have swollen gingiva that bleed when brushing or upon palpation during the clinical examination

•Patients may also present with opportunistic infections because of their immunocompromised status. These include candidiasis and herpes infections (such as herpes simplex virus [HSV] or varicella zoster virus).

Radiographic examination: 

Ideally, the dentist should evaluate a full-mouth series (FMS) of radiographs and a panoramic radiograph taken within the preceding 6 months for dental and osseous pathology.

Treatment planning:

•Treatment planning is guided by several principles that include evaluating the following:

(1) risk of infection during neutropenia,

(2) risk of osteonecrosis,

(3) risk of infection/bleeding following dental procedures.

•In general, all carious teeth should be restored and a scaling and prophylaxis should be performed; extractions should be performed as soon as possible to allow for maximal healing time.

•A surgical procedure is best completed at least 1 week before chemotherapy to allow approximately 2 weeks of healing

Dental treatment during cancer therapy:

The goal of dental treatment during this period is to treat the infection and symptoms while trying as far as possible to avoid an invasive procedure because of neutropenia and thrombocytopenia, and sometimes severe mucositis.

Dental management of patients with a history of cancer:

(1) maintain good oral health by routine maintenance dental treatment.

(2) identify and manage oro-dental issues specific to the patient’s cancer diagnosis.

• Possible long-term side effects will be more pronounced for patients who have received head and neck radiotherapy, such as xerostomia and hyposalivation, increased caries incidence, postradiation osteonecrosis.

(3) monitor for recurrences and second primary tumors.