Wednesday, January 3, 2018

Management of Oral Infection in Cancer Patients

Management of Oral Infection in Cancer Patients                     
Resident: Wayne Dobbins                                                                                     Date: 1/3/2018
Article Title: Management of Oral Infection in Cancer Patients
Author(s): Lerman MA, Laudenbach J, Marty FM, Baden LR, Treister NS
Journal: Dent Clin N Am 52 (2008) 129-153
Date: 2008
Major Topic: Oral Infection
Type of Article: Review
Main Purpose: Overview of medical complications seen with oral infections in cancer patients
Key Points:
Oral infections in cancer patients are complicated by a number of factors, all of which must be considered during treatment. Reduced inflammatory response is often seen in immunocompromised cancer patients, thus the presence of any symptoms at all may be indicative of an infection that would be far more evident in a healthy patient.

Odontogenic infection
·                      A reduced inflammatory response may be noted, thus large restorations, endodontically treated teeth, and other potential sites of infection must be monitored closely; ie. a previously asymptomatic root canaled tooth with adequate apical seal may become symptomatic in an immunocompromised patient. Periapical infections may progress aggressively, for instance by progressing into osteomyelitis or penetrating a sinus space.
·         Osteomyelitis presents with a moth-eaten appearance of the bone, with pain, suppuration, fistula formation, and bone sequestration possible, and BRONJ (MRONJ) is a risk. Osteomyelitis can be treated with long term, broad spectrum antibiotics, adequate surgical debridement, and hyperbaric O2, while being continuously monitored for spread, which can lead to cavernous sinus thrombosis or Ludwig’s angina.

Periodontal Infection
·                     Inflammation and swelling may or may not be absent in the immunocompromised patient, thus plaque and calculus, probing depths, changes in periodontal health, and radiographic assessment are key to early detection. Periodontal infection may progress rapidly, leading to bacteremia, and may not respond well to periodontal treatment. ANUG is also a concern.
·        Pericoronitis may also progress rapidly, with or without pain and swelling, and lead to ulceration, necrosis, and bacteremia. It should be treated aggressively, with soft tissue resection or tooth extraction.

·         Unilateral, painful, indurated, erythematous swelling of the parotid, most often caused by ascending bacteria (ie S. aureus), and may cause suppuration from the Stensen Duct. Risk factors include myelosuppression (bone marrow making too few blood cells to replace the blood cells that have worn out) and reduced salivary flow. Differential diagnoses include neoplasm and sialolith. Parotitis can be treated with antibiotics, rehydration, warm compress, and OH.

·                    Oral mucositis is a risk factor for bacteremia in hematopoetic cell transplant patients, and is often caused by gram positive rods such as S. viridans. Bacteremia can progress to cytopenic fever and toxic shock syndrome.

Fungal Infection
·                    Deep fungal infections are rare but can cause non-healing ulcerative lesions.   Oropharyngeal candidiasis is very common – normally found as a commensual organism in 34+% of healthy patients, and progressing to an infection when left unchecked. Pseudomembranous candidiasis, erythematous candidiasis, hyperplastic candidiasis, and angular chelitis are all expressions of candidiasis infection.
·        Risk factors: salivary gland hypofunction, neutropenia, antibiotic use and dentures.

Viral Infection
·                    Herpes Virus: HSV-1 is a common oral virus, with 60+% of healthy individuals exposed and about 1% converting to primary herpetic gingivostomatitis. It can remain latent in CN V, with recurrent episodes triggered by illness, stress, hormones, trauma, immunosuppression, etc. Normally presenting as small vesicles (most often on the lower lip) that appear after a prodromal period, rupture, and then heal. In an immunocompromised patient these ulcers may be larger, may appear on any mucosal surface, and may fail to heal becoming sites at risk for secondary infections.
·         Varicella: Immunosuppression, radiation, and cytotoxic drugs may cause a recurrence of varicella infection, presenting with or without pain, as unilateral vesicles confined to a nerve dermatome, which may lead to scarring or post-herpetic neuralgia.

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