Monday, December 11, 2017

Dental care of the pediatric cancer patient


Article Title: Dental care of the pediatric cancer patient
Author(s): Marcio A. da Fonseca
Journal: Pediatric Dentistry
Date: 2004; 26: 53-57
Major Topic: Dental management of children with cancer
Type of Article: Literature review
Main Purpose: This article aimed to discuss recommendations for dental care of the pediatric oncology patient.
Key Points: It is very important to be knowledgeable about the oral implications of cancer and its treatment because physicians and nurses involved in the patient’s care rarely discuss these issues.
·      Cancer is the leading cause of disease-related death in children <14 years in the USA
·      Cancers incidence is greatest the 1st year of life with a 2nd peak at 2-3 years followed by a decline to age 9 and then an increase through adolescence
·      Boys > girls
·      Most common pediatric cancers: ALL > CNS tumors > sarcomas
·      Radiation therapy
o   Given over several weeks in a series of equal-sized fractions usually spaced by 24 hours to allow repair of normal tissues
·      Acute Lymphoid Leukemia
o   Most common childhood cancer
o   75% of childhood leukemias. Peaks at 4 years
o   Craniofacial manifestations: lymphadenopathy, sore throat, laryngeal pain, gingival bleeding, oral ulceration
o   4 phases of treatment
§  Remission induction: usually 28 days; 3-4 drugs (vincristine, prednisone, L-aspariginase)
§  CNS preventive therapy/prophylaxis because CNS can act as reservoir for leukemic infiltrates (normal chemotherapeutics can’t cross blood-brain barrier). Cranial irradiation and/or weekly intrathecal injection
§  Consolidation or intensification: intensified treatment to minimize drug cross-resistance and minimize remaining leukemic cells.
§  Maintenance: 2.5-3 years to suppress leukemic growth
·      Central Line: indwelling catheter inserted into the right atrium of the heart for obtaining blood samples and administering drugs
o     Antibiotic prophylaxis is NOT needed for these patients
·      Increased bleeding risk in patients with liver tumor or dysfunction
·      Prothrombin time: measures extrinsic pathway
·      Partial thromboplastin time: measures intrinsic pathway
·      Platelet Counts
o   Normal: 140,000-340,000/mL
o   >75,000/mL – no additional support needed
o   40,000-75,000/mL – consider platelet transfusion pre-op and 24 hours post-op
o   <40,000/mL – defer elective treatment; contact physician about emergency treatment (platelet transfusion, bleeding control, hospital admission)  
o   Platelet concentration peaks 45-60 minutes after transfusion
·      Absolute Neutrophil Count (ANC)
o   >2000/ml – no antibiotic needed
o   1000-2000/ml – use clinical judgment about using antibiotics
o   <1000/ml – defer elective treatment and discuss antibiotic coverage with physician if emergency treatment is needed
·      Toothbrushing is OK even though many medical and dental providers think it increases risk of bacteremia and bleeding
o   Patients can brush without bleeding at various platelet levels
o   Good oral hygiene decreases risk of mucositis without increasing risk of septicemia and oral infections
o   Avoid sponges, foam brushes, supersoft brushes because they do not provide effective mechanical cleaning unless the patient has severe mucositis
o   Air dry brushes between uses
o   Use dentifrice without heavy flavoring agents because they can irritate tissues
·      Avoid toothpicks and water-irrigating devices when neutropenic
·      Consider prescribing chlorhexidine for patients with poor oral hygiene or periodontal disease
·      Many pediatric medications have high amounts of sucrose
·      Nystatin should not be prescribed as prophylaxis for Candida infections in immunosuppressed patients
·      Vomiting is a common side effect of cancer treatment. Patients should rinse with tap water or bland solutions to remove gastric acid which is irritating to oral tissues and may cause enamel decalcification  
·      Notify physician of spontaneous gingival bleeding because it may be a sign of internal hemorrhage
·      Patients may experience paresthesia due to leukemic infiltration around peripheral nerves
·      Vincristine and vinblastine can cause pain that mimics irreversible pulpitis but will go away within a few days after stopping the drug.
·      Blood counts start falling 5-7 days after the beginning of each treatment cycle, staying low for approximately 14 days before rising again.
·      No pulpal treatment in primary teeth à only extractions because pulpal and periapical infections can have serious effects on cancer treatment when the patient is immunosuppressed.
·      May perform RCT on nonvitial, symptomatic teeth if there’s at least 7 days before cancer treatment. Extract if this cannot be done.
·      May delay endodontic treatment in neutropenic patients with asymptomatic teeth with periapical involvement  
·      Signs of infection like swelling and purulent exudate may be masked when patient is immunosuppressed.
·      Fixed orthodontic appliances and space maintainers should be removed if patient has poor hygiene.
·      Removable appliances and retainers may be worn if the patient has good hygiene
·      Consider removing gingival tissue if concerned that gingival tissue over partially erupted molars are at risk of pericoronitis
·      Loose primary teeth may be left to exfoliate if the patient does not play with them to avoid bacteremia. Extract loose primary tooth if the patient is not compliant
·      Ideally extract teeth 3 weeks before cancer treatment and at least 4-7 days before of: impacted teeth, root tips, partially erupted third molars, teeth with periodontal pockets >5mm, teeth with acute infections, nonrestorable teeth
·      If medical status of patient does not allow extraction, may consider amputating crown above the gingiva followed by root canal treatment with antimicrobial medicament and then providing antibiotics for 7-10 days.
·      Orthodontic treatment may be started 2 years after disease-free survival. Recommended to use appliances that minimize risk of toot resorption, use lighter forces, terminate treatment earlier than normal, choose simplest method for treatment needs, and do not treat the mandible.

Remarks:
1- Dated article
Assessment of Article:  Level of Evidence/Comments: III

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