Dental Management of Pediatric Patients Receiving Chemotherapy, Radiation

Oral/dental assessment Management Before Initial evaluation PMH PDH Oral/dental assessment Preventive strategy Oral hygiene Diet Fluoride Trismus prevention Education Dental care Dental procedure During After

General Management- Before the cancer therapy Objective To Identify, stabilise & eliminate existing & potential source infection & irritants in oral cavity to communicate with the oncology team -patient’s oral health status, plan, and timing of treatment. To educate the patient and parents about the importance of optimal oral care to minimise oral problems/discomfort before, during, and after treatment the possible acute and long-term effects of the therapy

General Management- Before the cancer therapy 1-Initial evaluation PMH Disease/condition(type, stage, prognosis), treatment protocol (conditioning regimen, surgery, chemotherapy, radiation, transplant), medications (including bisphosphonates), allergies, surgeries, secondary medical diagnoses, hematological status [complete blood count (CBC)], coagulation status, immunosuppression status, presence of an indwelling venous access line, and contact of oncology team/primary care physician(s). PDH Oral/dental assessment

General Management- Before the cancer therapy Initial evaluation PMH PDH Fluoride exposure,habits, trauma, symptomatic teeth, previous care, preventive practices, oral hygiene, and diet assessment. Oral/dental assessment head, neck, and intraoral examination, OH assessment and training, radiographic evaluation based on history and clinical findings.

General Management- Before the cancer therapy 2-Preventive strategy Oral hygiene Brushing- 2 to 3x/day Floss- only allowed if aptient properly trained Poor OH- alcohol free chlorhexidine Diet Advice parent- non cariogenic diet Fluoride- Toothpaste,gel,varnish,supplement,

General Management- Before the cancer therapy 2-Preventive strategy d) Trismus prevention who receive radiation therapy to the masticatory muscles daily oral stretching exercises/physical therapy should start before radiation is initiated and continue throughout treatment. e) Education importance of optimal care – minimise problem/ discomfort

General Management- Before the cancer therapy 3-Dental Care (haematological consideration) absolute neutrophil count –(antibiotic prophylaxis) >2,000/mm3: no need for antibiotic prophylaxis 1000 to 2000/mm3: Use clinical judgment1based on the patient’s health status and planned procedures. Some authors1,5 suggest that antibiotic coverage (dosed per AHA recommendations) <1,000/mm3: defer elective dental care.

General Management- Before the cancer therapy 3-Dental Care (haematological consideration) platelet count-( >75,000/mm: no additional support needed. 40,000 to 75,000/mm3: platelet transfusions may be considered pre- and 24 hours post-operatively. Local-ized procedures to manage prolonged bleeding may include sutures, hemostatic agents, pressure packs, and/or gelatin foams is needed. <40,000/mm3: defer care. other coagulation test

General Management- Before the cancer therapy 4-Dental procedure Should be completed before start cancer tx- ideally Prioritizing procedure when all dental needs cannot be treated before cancer therapy is initiated. Prioritize: infections, extractions, periodontal care (eg,scaling, prophylaxis), and removal sources of tissue irritation .

General Management- Before the cancer therapy Dental procedure Pulp therapy No studies for safety of performing pulp therapy in primary teeth before starting chemotherapy and/or radiotherapy. Choose extraction – avoid infection later Endodontic tx Symptomatic non-vital permanent teeth should receive RCT at least one week before initiation of cancer therapy if not possible- extract

General Management- Before the cancer therapy Dental procedure Orthodontic appliances and space maintainer Poorly fitting – abrade mucosa risk of microbial invasion to deeper tissue. Should be removed in poor OH patient Simple,non-irritating appliance can e used if OH good Periodontal consideration

General Management- Before the cancer therapy Dental procedure Extraction removed ideally two weeks (or at least seven to 10 days) before cancer therapy ) Nonrestorable teeth, root tips, teeth with periodontalpockets greater than six millimeters, symptomatic impacted teeth, and teeth exhibiting acute infections,significant bone loss, involvement of the furcation, or mobility.

Dental and oral care during immunosupression periods The objectives of a dental/oral care during cancer therapy: to maintain optimal oral health during cancer therapy to manage any oral side effects that may develop as a consequence of the cancer therapy to reinforce the patient and parents’ education regarding the importance of optimal oral care in order to minimize oral problems/discomfort during treatment

Management Before During A. Preventive strategies B. Dental care C. Mx of oral conditions related to cancer therapies After

A. Preventive strategies Oral hygiene Diet Fluoride Lip care Education

1.Oral hygiene Use a soft nylon brush 2 to 3 times daily and replace it on a regular (every 2-3 months) basis. If cannot use brush, foam brushes or super soft brushes soaked in chlorhexidine may be used Fluoridated toothpaste may be used but, if the pt does not tolerate it (mucositis) ,it may be discontinued and the patient should brush with water alone The use of a regular brush should be resumed as soon as the mucositis improves Brushes should be air-dried between uses Electric or ultrasonic brushes are acceptable (if capable of using without causing trauma and irritation) Flossing is reasonable to do, tooth picks not allowed Mucositis-oral burning or stinging sensations

2.Diet Should encourage a non-cariogenic diet Advise patients/parents about the high cariogenic potential of dietary supplements rich in carbohydrate and oral pediatric medications rich in sucrose

3.Fluoride Fluoride gels/rinses, or applications of fluoride varnish for patients at risk for caries and/or xerostomia.

4.Lip care Lanolin-based creams and ointments more effective in moisturizing and protecting against damage

5.Education Reinforcing the importance of optimal oral hygiene Teaching strategies to manage soft tissue changes (eg, mucositis, oral bleeding, xerostomia) minimize oral problems/discomfort during treatment

B. Dental care During immunosuppression, elective dental care must not be provided. Emergency tx- discuss with the patient’s physician supportive medical therapies (antibiotics, platelet transfusions, analgesia) Monitor every 6 months (or in shorter intervals if there is a risk of xerostomia, caries, trismus)

C. Management of oral conditions related to cancer therapies Mucositis Oral mucosal infections Oral bleeding Dental sensitivity/pain Xerostomia Trismus

Mucositis use of topical anesthetics often is recommended for pain management. Local application may be useful for painful ulcers use of chlorhexidine (reduced colonization of candidial species )

Oral mucosal infections Close monitoring oral cavity allows for timely diagnosis and tx of fungal, viral, and bacterial infections Oral cultures and/or biopsies of all suspicious lesions Prophylactic medications should be initiated until more specific therapy can be prescribed

Oral bleeding Systemic measures Local measures Platelet transfusions Aminocaproic acid Local measures Pressure packs Antifibrinolytic rinses Gelatin sponges

Dental sensitivity/pain Related to decreased secretion of saliva during radiation therapy and the lowered salivary pH Pts who are using plant alkaloid chemotherapeutic agents (vincristine, vinblastine) may present with deep, constant pain affecting the mandibular molars with greater frequency The pain usually is transient and generally subsides shortly after dose reduction and/or cessation of chemotherapy.

Trismus Daily oral stretching exercises/physical therapy must continue during radiation treatment Prosthetic aids to reduce the severity of fibrosis Analgesics Muscle relaxants

Management Before During After A. Preventive strategies B. Dental care C. Mx of oral conditions related to cancer therapies

Dental and oral care after the cancer therapy is completed Objectives to maintain optimal oral health to reinforce to the patient/parents the importance of optimal oral and dental care for life.

A. Preventive strategies Oral hygiene Diet Fluoride Lip care Education need for regular follow-ups (potential dental developmental problems after radiotherapy)

B. Dental care Periodic evaluation Orthodontic treatment Oral surgery should be seen at least every 6 months (or in shorter intervals) moderate or severe mucositis and/or chronic oral GVHD should be followed closely for malignant transformation Orthodontic treatment Oral surgery

Orthodontic treatment May start/resume after completion of all therapy and after at least a 2 year disease-free survival when the risk of relapse is decreased the patient is no longer using immunosuppressive drugs Consultation with the patient’s parents and physician regarding the risks and benefits of orthodontic care Patients who have used or will be given bisphosphonates present a challenge for orthodontic care (inhibition of tooth movement ) Few strategies in Ortho TX: use appliances that minimize the risk of root resorption use lighter forces terminate treatment earlier than normal choose the simplest method for the treatment needs do not treat the lower jaw

Oral surgery Non-elective oral surgical and invasive periodontal procedures Consultation with an oral surgeon/periodontist & physician is recommended to decrease the risk of osteonecrosis and osteoradionecrosis Elective invasive procedures should be avoided

C. Management of oral conditions related to cancer therapies Xerostomia Trismus