Oral and Dental Management Before Cancer Therapy
The overall goal is to complete a comprehensive oral care plan that eliminates or stabilizes oral disease that could otherwise produce complications during or following chemotherapy. Achieving this goal will most likely reduce risk of oral toxicities with resultant reduced risk for systemic sequelae, reduced cost of patient care, and enhanced quality of life. If the patient is unable to receive the medically necessary oral care in the community, the oncology team should assume responsibility for oral management.
It is important to realize that dental treatment plans need to be realistic relative to type and extent of dental disease and how long it could be before resumption of routine dental care. For example, teeth with minor caries may not need restoration before cancer treatment begins, especially if more conservative disease stabilization strategies can be used (e.g., aggressive topical fluoride protocols, temporary restorations, or dental sealants).
Specific interventions are directed to:
- Mucosal lesions.
- Dental caries and endodontic disease.
- Periodontal disease.
- Ill-fitting dentures.
- Orthodontic appliances.
- Temporomandibular dysfunction.
- Salivary abnormalities.
Guidelines for dental extractions, endodontic management, and related interventions (see Table 3) can be used as appropriate.[6,7] Antibiotic prophylaxis prior to invasive oral procedures may be warranted in the context of central venous catheters; the current American Heart Association (AHA) protocol for infective endocarditis and oral procedures is frequently used for these patients.
Table 3. Management Guidelines Relative to Invasive Dental Procedures
CBC = complete blood cell count; IV = intravenous.
a Assumes that all other coagulation parameters are within normal limits and that platelet counts will be maintained at or above the specified level until initial stabilization/healing has occurred.
|Medical Status || Guideline || Comments|
|Patients with chronic indwelling venous access lines (e.g., Hickman). || AHA prophylactic antibiotic recommendations (low risk). ||There is no clear scientific proof detailing infectious risk for these lines following dental procedures. This recommendation is empiric.|
|Neutrophils || ||Order CBC with differential. |
|>2,000/mm3||No prophylactic antibiotics.|| |
|1,000-2,000/mm3|| AHA prophylactic antibiotic recommendations (low risk). || Clinical judgment is critical. If infection is present or unclear, more aggressive antibiotic therapy may be indicated.|
|<1,000/mm3||Amikacin 150 mg/m2 1 h presurgery; ticarcillin 75 mg/kg IV ½ h presurgery. Repeat both 6 h postoperatively. ||If organisms are known or suspected, appropriate adjustments should be based on sensitivities.|
|Plateletsa|| ||Order platelet count and coagulation tests.|
|>60,000/mm3|| No additional support needed.|| |
|30,000-60,000/mm3||Platelet transfusions are optional for noninvasive treatment; consider administering preoperatively and 24 h later for surgical treatment (e.g., dental extractions). Additional transfusions are based on clinical course.|| Utilize techniques to promote establishing and maintaining control of bleeding (i.e., sutures, pressure packs, minimize trauma).|
|<30,000/mm3||Platelets should be transfused 1 h before procedure; obtain an immediate postinfusion platelet count; transfuse regularly to maintain counts >30,000-40,000/mm3 until initial healing has occurred. In some instances, platelet counts >60,000/mm3 may be required.||In addition to above, consider using hemostatic agents (i.e., microfibrillar collagen, topical thrombin). Aminocaproic acid may help stabilize nondurable clots. Monitor sites carefully. |