Oral and Dental Management Before Cancer Therapy
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.|
|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.|
Assessment of Hematopoietic Stem Cell Transplant Patients
Stages of assessment have been described relative to the hematopoietic stem cell transplant patient (see Table 4). This model provides a useful classification for neutropenic cancer patients in general. Type, timing, and severity of oral complications represent the interaction of local and systemic factors that culminate in clinical expression of disease. Correlating oral status with systemic condition of the patient is thus critically important.
Selected conditioning regimens characterized by reduced intensity for myelosuppression have been used in patients. These regimens have generally been noted to significantly reduce the severity of oral complications early posttransplant, especially for mucositis and infection risk. The guidelines listed in Table 4 can be adjusted to reflect these varying degrees of risk, based on the specific conditioning regimen to be used.