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    Oral Complications of Chemotherapy and Head/Neck Radiation (PDQ®): Supportive care - Health Professional Information [NCI] - Oral and Dental Management Before Cancer Therapy

    Table 4. Oral Complications of Hematopoietic Stem Cell Transplantation

    Transplant Phase Oral Complication
    GVHD = graft-versus-host disease.
    Phase I: Preconditioning Oral infections: dental caries, endodontic infections, periodontal disease (gingivitis, periodontitis), mucosal infections (i.e., viral, fungal, bacterial).
    Gingival leukemic infiltrates.
    Metastatic cancer.
    Oral bleeding.
    Oral ulceration: aphthous ulcers, erythema multiforme.
    Temporomandibular dysfunction.
    Phase II: Conditioning Neutropenic Phase Oropharyngeal mucositis.
    Oral infections: mucosal infections (i.e., viral, fungal, bacterial), periodontal infections.
    Hemorrhage.
    Xerostomia.
    Taste dysfunction.
    Neurotoxicity: dental pain, muscle tremor (e.g., jaws, tongue).
    Temporomandibular dysfunction: jaw pain, headache, joint pain.
    Phase III: Engraftment Hematopoietic Recovery Oral infections: mucosal infections (i.e., viral, fungal, bacterial).
    Acute GVHD.
    Xerostomia.
    Hemorrhage.
    Neurotoxicity: dental pain, muscle tremor (e.g., jaws, tongue).
    Temporomandibular dysfunction: jaw pain, headache, joint pain.
    Granulomas/papillomas.
    Phase IV: Immune Reconstitution Late Posttransplant Oral infections: mucosal infections (i.e., viral, fungal, bacterial).
    Chronic GVHD.
    Dental/skeletal growth and development alterations (pediatric patients).
    Xerostomia.
    Relapse-related oral lesions.
    Second malignancies.
    Phase V: Long-term Survival Relapse or second malignancies.
    Dental/skeletal growth and development alterations.

    Phase I: Before Chemotherapy

    Oral complications are related to current systemic and oral health, oral manifestations of underlying disease, and oral complications of recent cancer or other medical therapy. During this period, oral trauma and clinically significant infections, including dental caries, periodontal disease, and pulpal infection, should be eliminated. Additionally, patients should be educated relative to the range and management of oral complications that may occur during subsequent phases. Baseline oral hygiene instructions should be provided. It is especially important to note whether patients have been treated with bisphosphonates (e.g., patients with multiple myeloma) and to plan their care accordingly.

    Phase II: Neutropenic Phase

    Oral complications arise primarily from direct and indirect stomatotoxicities associated with high-dose chemotherapy or chemoradiotherapy and their sequelae. Mucositis, xerostomia, and those lesions related to myelosuppression, thrombocytopenia, and anemia predominate. This phase is typically the period of high prevalence and severity of oral complications.

    Oral mucositis usually begins 7 to 10 days after initiation of cytotoxic therapy and remains present for approximately 2 weeks after cessation of that therapy. Viral, fungal, and bacterial infections may arise, with incidence dependent on the use of prophylactic regimens, oral status prior to chemotherapy, and duration/severity of neutropenia. Frequency of infection declines upon resolution of mucositis and regeneration of neutrophils. This phenomenon appears to be more a temporal relation than a causative one, based on the predominant evidence. Despite the initial marrow recovery, however, the patient may remain at risk for infection, depending on status of overall immune reconstitution.

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