1. Dental Management of Pediatric Patients Receiving Chemotherapy, Radiation

2. 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

3. 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

4. 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

5. 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.

6. 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,

7. 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

8. 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.

9. 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

10. 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 .

11. 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

12. 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

13. 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.

14. 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

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

16. A. Preventive strategies
Oral hygiene
Diet
Fluoride
Lip care
Education

17. 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

18. 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

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

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

21. 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

22. 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)

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

24. 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 )

25. 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

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

27. 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.

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

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

30. 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.

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

32. 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

33. 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

34. 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

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