Clinical guideline on dental management of pediatric patients

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					1    Clinical guideline on dental management of pediatric patients receiving
2    chemotherapy, hematopoietic cell bone marrow transplantation, and/or
3    radiation

 4   Originating committee
 5   Clinical Affairs Committee
 6   Review Council
 7   Council on Clinical Affairs
 8   Adopted
 9   1986
10   Reaffirmed
11   1994
12   Revised
13   1991, 1997, 1999, 2001, 2004

14   Purpose
15   The pediatric patient who is beginning, currently is receiving, or has received
16   chemotherapy, a bone marrow transplant (BMT), and/or radiation requires special
17   consideration and altered oral/dental treatment schemes due to the systemic impact of
18   any of these cancer treatments. The American Academy of Pediatric Dentistry
19   recognizes that the dental professional plays an important role in the diagnosis,
20   prevention, stabilization, and treatment of oral and dental problems that can
21   compromise the child's quality of life before, during, and after the cancer treatment.
22   Dental intervention with certain modifications must be done promptly and efficiently,
23   with attention to the patient's medical history, treatment protocol, and health status.
24           Pediatric patients undergoing chemotherapy and/or radiotherapy for the
25   treatment of cancer or in preparation for hematopoietic cell transplantation (HCT) may
26   present many acute and long-term side effects in the oral cavity. Furthermore, because
27   of the immunosuppression they experience, any existing or potential oral/dental
28   infections and trauma can compromise the medical treatment, leading to morbidity,
29   mortality, and higher hospitalization costs. It is also imperative that the dentist be
30   familiar with the oral manifestations of the patient's underlying condition and the
31   treatment differences between patients undergoing chemotherapy only and those who
32   will receive an HCT.

33   Methods
34   This guideline is based on a review of the current dental and medical literature related
35   to on dental management of pediatric patients receiving chemotherapy, hematopoietic
36   cell transplantation, and/or radiation. A MEDLINE search was conducted using the
37   terms “pediatric cancer”, “pediatric oncology”, “hematopoietic cell transplantation”,
38   “bone marrow transplantation”, “mucositis”, “stomatitis”, “chemotherapy”, “radiation
39   therapy”, “acute effects”, “long-term effects“, “dental care“, “pediatric dentistry“, and
40   “clinical practice guidelines”. Expert opinions and best current practices were relied
41   upon when sufficient scientific data were not available.

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42   Background/Literature Review
43   The level of a child’s oral health can be a significant determinant in the outcomes of any
44   of these cancer treatments. A child who is immunosuppressed is at high risk for
45   septicemia due to oral infections. The eradication of active and potential sites of infection
46   prior to initiation of chemotherapy, bone marrow transplantation and/or radiation is
47   paramount. Therefore, it is highly recommended that an oral/dental examination and
48   treatment be a part of the precancer treatment protocols at all institutions providing
49   those type of services.
50   These guidelines are general recommendations for the management of the pediatric
51   cancer patient. Since there are a myriad of protocols for chemotherapy, BMT and
52   radiation, oral/dental care must be provided in consultation with the oncologist and, if
53   necessary, tailored to the individual patient. There are few “absolute” guidelines in the
54   care of these patients, but the literature supports the following.
55   The most frequently documented source of sepsis in the immunosuppressed cancer
56   patient is the mouth; therefore, early and radical dental intervention, including
57   aggressive oral hygiene measures, reduces the risk for oral and associated systemic
58   complications.1-13 In a consensus conference on oral complications of cancer therapies
59   sponsored by the National Institutes of Health in 1989, the most important
60   recommendations were that all patients with cancer should have an oral examination
61   before initiation of the oncology therapy, and that treatment of pre-existing or
62   concomitant oral disease was essential to minimize oral complications in this
63   population. 6 The underlying success in maintaining a healthy oral cavity during cancer
64   therapy is patient compliance. Thus, the child and the caretakers should be educated
65   regarding the possible acute side effects and the long-term sequelae in the oral cavity.1-
66   6,8,14,15 Younger patients present more oral problems than adults.2 Because there are many

67   oncology and HCT protocols, every patient should be dealt with on an individual basis
68   and appropriate consultations with physicians and other dental specialists should be
69   sought before dental care is instituted.5

70   Recommendations
71   Hematologic guidelines
72   The following are general hematologic guidelines. Specific guidelines should be
73   established between the pediatric dentist and oncology service.
74   1.     Elective dental procedures:

75          a.      Absolute neutrophil count (ANC) >1,000/mm3.

76          b.      Platelet count >40,000/mm3.
77   2.     Emergency dental procedures: May be performed with any hematologic status
78   to remove sources of infection if done in coordination with the oncology service.
79   Consider platelet replacement if the platelet count is <40,000/mm3.
80   3.     Preventive dental procedures:

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 81          a.     Daily tooth-brushing and flossing when the ANC >500/mm3 and platelet
 82          count >20,000/mm3.
 83          b.    Dental hygiene with a moist gauze or toothette        only when ANC
 84          <500/mm3 and/or platelet count <20,000/mm3.
 85   Antibiotic prophylaxis guidelines
 86   Refer to Guideline on Antibiotic Prophylaxis for Patients at Risk (see pages 107-108). The
 87   following are general antibiotic prophylaxis indications:

 88   1.     Patient has an ANC <500/mm3 and/or white blood cell count (WBC)
 89   <2,000/mm3.
 90   2.     Patient has a central venous catheter.
 91   3.     Patient is taking long-term immunosuppressive drugs (eg, cyclosporine,
 92   prednisone).
 93   Management
 94   Objectives
 95   1.     Decrease the morbidity and mortality due to infection.
 96   2.     Decrease the morbidity due to hemorrhage.
 97   3.     Facilitate the patient’s nutritional status.
 98   4.     Improve the patient’s comfort.
 99   5.    Increase the education of the patient, family and physician relative to the
100   importance of maintaining oral health and the methods to achieve it.
101           Management of the pediatric cancer patient can be divided into 3 phases of care.
102   Although the overall management of these patients is a continuum of assessment and
103   treatment decisions, they can be roughly divided into phases based on time and
104   hematological status. Each presents unique potential oral problems and opportunities
105   for treatment.
106   Phase 1: The period of time from the medical diagnosis/admission to the initiation of
107   chemotherapy/radiation. The child has active disease and hematological changes
108   related to the disease.
109   Phase 2: A period lasting approximately 30 to 45 days after chemotherapy induction,
110   bone marrow transplantation and/or radiation. This period represents the most intense
111   therapy. Significant myelosuppression and immunosuppression is the result of
112   chemotherapy/radiation.
113   Phase 3: Post chemotherapy, BMT and/or radiation, the long term follow-up for which
114   may last anywhere from a year to a lifetime.

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      pediatric patients receiving cancer therapy
115   Phase I
116   Assessment and diagnosis
117   Ideally, the oral assessment of the pediatric patient should occur 7 to 10 days prior to the
118   initiation of chemotherapy/radiation. Oftentimes, however, this is not possible due to
119   the medical status of the child and treatment options may be limited. Every effort should
120   be made to educate the oncology service as to the importance of early intervention and
121   to encourage them to make the dental referral as early as possible.
122   1.     Review the child’s health history, particularly as related to the child’s current
123   disease.
124   2.     Review current blood data with particular attention to WBC, differential, ANC
125   and platelet count.
126   3.      Review the proposed chemotherapy/BMT/radiation protocol, making special
127   note of treatment cycles, agents, dosages and, in the case of BMT, human leukocyte
128   antigen matching.
129   4.     Complete a thorough head, neck, oral and dental examination.
130   5.     Make panoramic and bitewing radiographs as basic screening films. Additional
131   radiographs should be based on clinical findings.
132   6.      Give standard oral hygiene instructions, with emphasis on instructions
133   specifically related to chemotherapy and/or radiation.
134   7.     Formulate a treatment plan in coordination with patient, family and oncologist.
135   Treatment
136   Treatment should only be provided in consultation with the oncologist and after careful
137   review of blood lab data (see hematologic guidelines on previous page). Consideration
138   must be given to antibiotic prophylaxis.
139   1.     Complete a dental scaling and polishing.
140   2.     Apply a fluoride gel in the standard manner.
141   3.     Restore carious teeth and replace defective restorations.
142   4.      Institute pulp therapy as indicated. Pulpotomy and pulpectomy are preferable to
143   extraction if no breakdown of periradicular supporting tissues is present.
144   5.       Extract teeth with acute or chronic infections and breakdown of periradicular
145   supporting tissues. Ideally, all extractions should be done 5 to 7 days prior to the
146   initiation of chemotherapy/radiation.
147   6.     Manage soft tissue lesions related to disease conservatively and symptomatically.
148   7.     Remove all orthodontic appliances and removable prostheses.
149   8.     Initiate an antimicrobial rinse (eg, chlorhexidine) 2 to 3 times per day beginning 2
150   days prior to the start of chemotherapy/radiation.

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      pediatric patients receiving cancer therapy
151   Dental and Oral Care Before the Initiation of Cancer Therapy
152   Objectives: The objectives of a dental/oral examination before cancer therapy starts are
153   two-fold:
154   1. to identify and stabilize or eliminate existing and potential sources of infection, local
155      irritants, and irregular surfaces that may complicate the cancer therapy and HCT
156      without needlessly delaying the cancer treatment or inducing complications; and
157   2. to educate the patient and caretakers about the importance of optimal oral care in
158      order to minimize oral problems/discomfort during and after treatment and about
159      the possible acute and long-term effects of the therapy in the craniofacial complex.
160   Initial evaluation
161   Medical history review should include, but not be limited to, type of cancer, treatment
162   protocol, medications, allergies, and immunosuppression status. For HCT patients,
163   include type of transplant, conditioning protocol, and Graft versus Host Disease
164   (GVHD) prophylaxis. The presence of an indwelling venous catheter (ie central line)
165   dictates the need for endocarditis prophylaxis following the American Heart Association
166   (AHA) recommendations16; however, this recommendation is empirical.5,10
167   Dental history review includes information such as habits, trauma, symptomatic teeth,
168   previous care, preventive practices, etc.
169   Oral/dental assessment should include thorough head, neck, and intraoral examinations,
170   oral hygiene assessment and training, and radiographic evaluation based on history and
171   clinical findings.
172   Preventive strategies
173   Oral hygiene includes brushing of the teeth and tongue 2 to 3 times daily with regular
174   soft brush or electric toothbrush, regardless of the hematological status.4,5,8,9,13,17
175   Ultrasonic brushes and dental floss should be allowed only if the patient is properly
176   trained.1,8 Patients with poor oral hygiene and/or periodontal disease can use
177   chlorhexidine rinses daily until the tissue health improves or mucositis starts. The high
178   alcohol content can cause discomfort and dehydrate the tissues.
179   Diet: Dental practitioners should encourage a non-cariogenic diet and advise caretakers
180   about the high cariogenic potential of dietary supplements rich in carbohydrate and oral
181   pediatric medications rich in sucrose.
182   Fluoride: Preventive measures include the use of fluoridated toothpaste, fluoride
183   supplements if indicated, neutral fluoride gels/rinses, or applications of fluoride varnish
184   for patients at risk for caries and/or xerostomia. A brush-on technique is the most
185   convenient technique making patients more compliant.8
186   Trismus prevention/treatment: Patients who receive radiation therapy to the masticatory
187   muscles may develop trismus. Thus, daily stretching oral exercises/physical therapy
188   should start before radiation is initiated and continue throughout treatment. Therapy
189   also may include prosthetic aids to reduce the severity of fibrosis, trigger-point
190   injections, analgesics, muscle-relaxants, and other pain management strategies.3,5,10

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191   Reduction of radiation to healthy oral tissues: In cases of radiation to the head and neck, the
192   use of lead-lined stents, prostheses, and shields, as well as beam-sparing
193   procedures, should be discussed with the radiation oncologist.
194   Education: Patient/caretaker education includes the importance of optimal oral care in
195   order to minimize oral problems/discomfort during and after treatment and the
196   possible acute and long-term effects of the therapy in the craniofacial complex.
197   Dental care
198   Hematological considerations:
199   1. Absolute neutrophil count (ANC)
200       •   >1,000/mm3 no need for antibiotic prophylaxis.10 However, some authors
201           suggest that antibiotic coverage (AHA recommendations) may be prescribed
202           when the ANC is between 1,000 and 2,000/mm3.5 If infection is present or
203           unclear, more aggressive antibiotic therapy may be indicated and should be
204           discussed with the medical team.
205       •   < 1,000/mm3: defer elective dental care until the ANC rises. In dental emergency
206           cases, discuss antibiotic coverage beyond endocarditis prophylaxis with medical
207           team before proceeding with treatment. The patient may need hospitalization for
208           dental management.12
209   2. Platelet count5,10
210       •   >75,000/mm3: no additional support needed but be prepared to treat prolonged
211           bleeding by using sutures, hemostatic agents, pressure packs, gelatin foams, etc.
212       •   40,000 - 75,000/ mm3: platelet transfusions may be considered pre- and 24 hours
213           post-operatively
214       •   < 40,000/ mm3: defer care. In dental emergency cases, contact physician before
215           proceeding. Consider platelet transfusion and hospital admission for treatment.
216   3. Other coagulation tests may be in order for individual patients.
217   Dental procedures
218   1. In general terms, most oncology/hematology protocols (exclusive of HCT, which
219      will be discussed later) are divided into phases (cycles) of chemotherapy, in addition
220      to other therapies (radiotherapy, surgery, etc). The patient's blood counts normally
221      start falling 5 to 7 days after the beginning of each cycle, staying low for
222      approximately 14-21 days, before rising again to normal levels for a few days until
223      the next cycle begins. Ideally, all dental care should be completed before cancer
224      therapy starts. But, when that is not feasible, temporary restorations can be placed
225      and non-acute dental treatment can be delayed until the patient's hematological
226      status is stable, usually in the few days between treatment cycles.5,8,10,11
227   2. Prioritizing procedures: When all dental needs cannot be treated before cancer
228      therapy is initiated, priorities should be infections, extractions, periodontal care
229      (scaling, prophylaxis), and sources of tissue irritation before the treatment of carious
230      teeth, root canal therapy for permanent teeth, and replacement of faulty
231      restorations.10 The risk for pulpal infection and pain determine which carious lesions

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      pediatric patients receiving cancer therapy
232      should be treated first.8 Incipient to small caries can be treated with fluorides and
233      sealants until definitive care can be accomplished. 5 It is also important to be aware
234      that the signs and symptoms of periodontal disease can be decreased in
235      immunosuppressed patients.5
236   3. Pulp therapy in primary teeth: Although there have been no studies to date that
237      address the safety of performing pulp therapy in primary teeth prior to the initiation
238      of chemotherapy and/or radiotherapy, many clinicians choose to provide a more
239      radical treatment in the form of extraction because pulpal/periapical/furcal
240      infections during immunosuppression periods can have a significant impact on
241      cancer treatment and become life-threatening. 5,8,11 Teeth that already have been
242      treated pulpally and are clinically and radiographically sound present minimal risk.
243   4. Endodontic treatment in permanent teeth: Symptomatic non-vital permanent teeth
244      should receive root canal treatment at least 1 week before initiation of cancer therapy
245      to allow sufficient time to assess treatment success before the chemotherapy. 5,10 If
246      that is not possible, extraction is indicated. Extraction is also the treatment of choice
247      for teeth that cannot be treated by definitive endodontic treatment in a single visit. In
248      that case, the extraction should be followed by antibiotic therapy (penicillin or
249      clindamycin for penicillin-allergic patients) for about 1 week. 5,10,12 Asymptomatic
250      endodontic needs in permanent teeth can be delayed until the hematological status
251      of the patient is stable.10,11,18 It is important that the etiology of periapical lesions
252      associated with previously endodontically treated teeth be determined because they
253      can be caused by a number of factors including pulpal infections, inflammatory
254      reactions, apical scars, cysts, and malignant lesions. 8 If a periapical lesion is
255      associated with an endodontically treated tooth and no signs or symptoms of
256      infection are present, there is no need for retreatment or extraction since the
257      radiolucency is likely due to an apical scar.18
258   5. Orthodontic appliances and space maintainers: Appliances should be removed if the
259      patient has poor oral hygiene and/or the treatment protocol or HCT conditioning
260      regimen carries a risk for the development of moderate to severe mucositis, except
261      for smooth appliances such as band and loops and fixed lower lingual arches.1,8
262      Removable appliances and retainers that fit well may be worn as long as tolerated by
263      the patient who shows good oral care.5,8,19 If band removal is not possible, vinyl
264      mouth guards or orthodontic wax should be used to decrease tissue trauma.8
265   6. Periodontal considerations: Partially erupted molars can become a source of
266      infection because of pericornitis. The overlying gingival tissue should be excised if
267      the dentist believes it is a potential risk and if the hematological status permits. 8,10
268   7. Extractions: There are no clear recommendations for the use of prophylactic
269      antibiotics for extractions. Recommendations generally have been empiric or based
270      on anedoctal experience. Particular attention should be given to extraction of
271      permanent teeth in patients who will receive or have received radiation to the face
272      because of the risk of osteoradionecrosis. Surgical procedures must be as atraumatic
273      as possible, with no sharp bony edges remaining and satisfactory closure of the
274      wounds.5,8,10-12 If there is documented infection associated with the tooth, antibiotics,
275      ideally chosen with the benefit of sensitivity testing, should be administered for
276      about 1 week.5, 8,10,12

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      pediatric patients receiving cancer therapy
277        •   Loose primary teeth should be left to exfoliate naturally and the patient should
278            be counseled to not play with them in order to avoid bacteremia. If the patient
279            cannot comply with this recommendation, the teeth should be removed if the
280            hematologic parameters allow.
281        •   Impacted teeth, root tips, teeth with periodontal pockets >6 mm, teeth exhibiting
282            acute infections, significant bone loss, involvement of the furcation, or mobility,
283            and non-restorable teeth should be removed ideally 2 weeks (or at least 7 to 10
284            days) before cancer therapy starts to allow adequate healing.1,5,8,10,11
285        •   Some practitioners prefer to extract all third molars that are not fully erupted,
286            particularly prior to HCT, while others favor a more conservative approach,
287            recommending extraction of third molars at risk for pulpal infection or those
288            associated with significant periodontal infection, including pericoronitis.9
289        •   If a permanent tooth cannot be extracted for medical reasons ( ie., severe
290            thrombocytopenia) , then the crown should be amputed above the gingiva and
291            root canal therapy should be initiated on the remaining root fragment to
292            minimize the risk of disseminating infection through the systemic circulation.
293            The root canal chamber should be sealed with an antimicrobial medicament.5
294            Antibiotics should follow for 7 to 10 days afterwards with the extraction
295            subsequently done when the patient's hematological status is normal.5
297   Phase II
298   Assessment and diagnosis
299   1.      Patients should be followed and regularly assessed for the development of oral
300   lesions secondary to the chemotherapy/radiation.
301   2.       Monitor mouth care and consult with nursing staff, if necessary.
302   3.       Keep the oncologist apprised of any oral problems.
303   Treatment
304   1.       Elective oral/dental treatment should be avoided.
305   2.    Biopsy or dental treatment for eradication of sites of infection should only be
306   done with the approval of the oncologist.
307   3.       Continue antimicrobial rinses (2 to 3 times per day).
308   4.       In head and neck radiation cases, provide appropriate fluoride application.
309   5.       Provide symptomatic care for mucositis and stomatitis as needed.

310   Dental and Oral Care During Immunosuppression Periods
311   Objectives: The objectives of a dental/oral care during cancer therapy starts are three-
312   fold:
313   1. to maintain optimal oral health during cancer therapy;

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      pediatric patients receiving cancer therapy
314   2. to manage any oral side effects that may develop as a consequence of the cancer
315      therapy; and
316   3. to educate the patient and caretakers about the importance of optimal oral care in
317      order to minimize oral problems/discomfort during treatment.
318   Preventive strategies
319   Oral hygiene: Intensive oral care is of paramount importance because it reduces the risk
320   of developing moderate/severe mucositis without causing an increase in septicemia and
321   infections in the oral cavity.1-12 Thrombocytopenia should not be the sole determinant of
322   oral hygiene as patients are able to brush without bleeding at widely different levels of
323   platelet count.8,9,13 Patients should use a soft nylon brush 2 to 3 times daily. 8 Fluoridated
324   toothpaste can be used but, if the patient does not tolerate it during periods of mucositis,
325   it can be discontinued and water or saline solution can be substituted. If moderate to
326   severe mucositis develops and the patient cannot tolerate a regular toothbrush or an
327   end-tufted brush, foam brushes or super soft brushes soaked in aqueous chlorhexidine
328   can be used, although they do not provide efficient cleaning.9,17 The use of a regular
329   brush should be resumed as soon as the mucositis improves.8 Brushes should be air-
330   dried between uses.8 Electric or ultrasonic brushes are acceptable if the patient is capable
331   of using them without causing trauma and irritation.1,8 If patients are skilled at flossing
332   without traumatizing the tissues, it is reasonable to continue flossing throughout
333   treatment.8 Toothpicks and water irrigation devices should be avoided when the patient
334   is pancytopenic.8,10
335   Diet: Dental practitioners should encourage a non-cariogenic diet and advise caretakers
336   about the high cariogenic potential of dietary supplements rich in carbohydrate and oral
337   pediatric medications rich in sucrose.
338   Fluoride: Preventive measures include the use of fluoridated toothpaste, fluoride
339   supplements if indicated, neutral fluoride gels/rinses, or applications of fluoride varnish
340   for patients at risk for caries and/or xerostomia. A brush-on technique is the most
341   convenient technique making patients more compliant.8
342   Lip care: Lanolin-based creams and ointments are more effective in moisturizing and
343   protecting against damage than petrolatum-based products.8,11
344   Education: Patient/caretaker education includes the importance of optimal oral care in
345   order to minimize oral problems/discomfort during treatment and the possible acute
346   and long-term effects of the therapy in the craniofacial complex.
347   Dental Care Only conservative emergency dental care should be provided during
348   immunosuppression, and only after consultation with the medical team in regards to
349   platelet and antibiotic therapy. Patients who are using plant alkaloid chemotherapeutic
350   agents (vincristine, vinblastine) may present deep, constant pain (mostly in the
351   mandible) in the absence of odontogenic pathology.5,8,10 The pain resolves with
352   discontinuation of the drugs and no treatment is necessary. The patient should be seen
353   not less often than every 6 months for an oral health evaluation during treatment,
354   preferably in times of stable hematological status and always after reviewing the
355   medical history and the need for endocarditis coverage if a central line is still in place.
356   Management of oral conditions related to cancer therapies

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      pediatric patients receiving cancer therapy
357   Mucositis: Mucositis care remains focused on palliation of symptoms and efforts to
358   reduce the influence of secondary factors on mucositis.5,10,12 There is a variety of
359   protocols available.1,3-10,12 Most studies do not demonstrate a prophylactic impact of
360   chlorhexidine on mucositis.7,12
361   Oral mucosal infections: The signs of inflammation and infection may be greatly
362   diminished during neutropenic periods. Thus, the clinical appearance of infections may
363   differ significantly from the normal.1,10 Close monitoring of the oral cavity allows for
364   timely diagnosis and treatment of fungal, viral, and bacterial infections. Prophylaxis
365   with nystatin for fungal infections is not effective.5,20 Oral cultures and/or biopsies of all
366   suspicious lesions should be done and prophylactic medications should be initiated until
367   more specific therapy can be prescribed.1,5,8-12
368   Oral bleeding: Oral bleeding occurs due to thrombocytopenia, disturbance of coagulation
369   factors, and damaged vascular integrity. Treatment should consist of local approaches
370   (pressure packs, antifibrinolytic rinses, gelatin sponges, etc) and systemic measures
371   (platelet transfusions).
372   Dental sensitivity/pain: Tooth sensitivity could be related to decreased secretion of saliva
373   during radiation therapy and the lowered salivary pH.5,8,10
374   Xerostomia: Sugar-free chewing gum, candy, suckling tablets, special dentifrices for oral
375   dryness, saliva substitutes, frequent sipping of water, bland oral rinses, and/or oral
376   moisturizers are recommended.8,21 Saliva stimulating drugs are not approved for use in
377   children. Fluoride rinses and gels are recommended highly for caries prevention.
378   Phase III
379   Assessment and diagnosis
380   1.     Place the child on a 3-month recall for the first 12 months after cancer treatment
381   and 6 months thereafter, or as indicated by the individual patient’s needs/susceptibility
382   to dental disease.
383   2.      At recall visits, review current medications to determine if the child continues to
384   receive immunosuppressive or myelosuppressive drugs.
385   3.     At recall visits, review current blood data to assess the child’s return to a normal
386   hematologic status. Particular attention should be paid to the WBC, differential, ANC
387   and platelet count.
388   4.     Provide oral/dental exams, dental prophylaxis and fluoride therapy.
389   5.    Educate the patient and parents about the possible long-term sequelae of
390   chemotherapy and radiation on the craniofacial complex.
391   Treatment
392   1.      Provide restorative and periodontal therapy to return the patient to an optimal
393   state of dental health.
394   2.     Provide symptomatic care for any residual/long-term oral lesions.
395   3.     Restart or initiate orthodontic treatment as indicated.

396   Dental and Oral Care After the Cancer Therapy is Completed (Exclusive of HCT)

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      pediatric patients receiving cancer therapy
397   Objectives: The objectives of a dental/oral examination after cancer therapy ends are
398   two-fold:
399   1. to maintain optimal oral health; and
400   2. to educate the patient and caretakers about the importance of optimal oral care in
401      order to minimize oral problems/discomfort after treatment and about the possible
402      acute and long-term effects of the therapy in the craniofacial complex.
403   Preventive strategies
404   Oral hygiene: Patients should resume normal tooth brushing 2 to 3 times daily. Brushes
405   should be air-dried between uses.8 Patient should continue/resume daily flossing.
406   Diet: Dental practitioners should encourage a non-cariogenic diet and advise caretakers
407   about the high cariogenic potential of dietary supplements rich in carbohydrate and oral
408   pediatric medications rich in sucrose.
409   Fluoride: Preventive measures include the use of fluoridated toothpaste, fluoride
410   supplements if indicated, neutral fluoride gels/rinses, or applications of fluoride varnish
411   for patients at risk for caries and/or xerostomia. A brush-on technique is the most
412   convenient technique making patients more compliant.8
413   Lip care: Lanolin-based creams and ointments are more effective in moisturizing and
414   protecting against damage than petrolatum-based products.8,11
415   Education: Patient/caretaker education includes the importance of optimal oral care in
416   order to minimize oral problems/discomfort after treatment and the possible acute and
417   long-term effects of the therapy in the craniofacial complex.
418   Dental Care
419   Periodic evaluation: The patient should be seen at least every 6 months (sooner if more
420   imperative issues such as xerostomia and trismus are present). Patients who have
421   experienced chronic or severe mucositis should be followed closely for malignant
422   transformation of their oral mucosa (eg, oral squamous cell carcinoma).22
423   Orthodontic treatment: Orthodontic care may start or resume after completion of all
424   therapy and after at least a 2 year disease-free survival when the risk of relapse is
425   decreased and the patient is no longer using immunosuppressive drugs19 A thorough
426   assessment of any dental developmental disturbances caused by the cancer therapy
427   must be done before initiating orthodontic treatment. The following strategies should be
428   considered to provide orthodontic care for patients with dental sequelae: (1) use
429   appliances that minimize the risk of root resorption, (2) use lighter forces, (3) terminate
430   treatment earlier than normal, (4) choose the simplest method for the treatment needs,
431   and (5) not treat the lower jaw.23 However, specific guidelines for orthodontic
432   management, including optimal force and pace, remain undefined.
433   Oral surgical procedures such as an extraction or excisional biopsy may require pre-
434   operative and post-operative hyperbaric oxygen to avoid osteomyelitis if the patient has
435   had previous cranial radiation therapy to the involved maxillary or mandibular area.

      Clinical guideline on dental management of    11                                   CCA 1.G
      pediatric patients receiving cancer therapy
436   Hematopoietic Cell Transplantation
437   Specific oral complications can be correlated with phases of HCT:8,14,15
438   Phase I: Pre-transplantation
439   The oral complications are related to the current systemic and oral health, oral
440   manifestations of the underlying condition, and oral complications of recent medical
441   therapy.
442   Dental and oral care before the transplant: Most of the principles are similar to those
443   discussed for pediatric cancer. The 2 major differences are: 1) in HCT, the patient
444   receives all the chemotherapy and/or total body irradiation in just a few days before the
445   transplant, and 2) there will be prolonged immunosuppression following the transplant.
446   Elective dentistry will need to be postponed until immunological recovery has occurred,
447   which may take as long as 9 to 12 months after HCT, or longer if chronic GVHD or other
448   complications are present.5,8 Therefore, all dental treatment must be completed before
449   the child is admitted in order to eliminate disease that could lead to complications
450   during and after the transplant.
451   Phase II: Conditioning/neutropenia
452   The oral complications are related to the conditioning regimen and medical therapies,
453   approximately to day 30 post-transplant.8 Mucositis, xerostomia, oral pain, oral
454   bleeding, opportunistic infections, and taste dysfunction can be seen. The patient should
455   be followed up closely during the hospitalization period to monitor and treat the oral
456   changes and reinforce the importance of optimal oral care. Dental care usually is not
457   allowed in this phase.
458   Phase III: Initial engraftment to hematopoietic reconstitution
459   The intensity and severity of complications begin to decrease normally 3 to 4 weeks after
460   transplantation. Oral fungal infections and herpes simplex virus infection are most
461   notable. Oral GVHD can become a concern for allogeneic graft recipients. A dental/oral
462   examination should be performed and invasive dental procedures, including dental
463   cleanings and soft tissue curettage, should be done only if authorized by the HCT team
464   because of the patient's continued immunosuppression.8 Patients should be encouraged
465   to continue optimal oral hygiene and avoid a cariogenic diet. Attention to xerostomia
466   and oral GVHD treatment, including topical application of steroids or cyclosporine, and
467   oral psoralen and ultraviolet A therapy, are a must. HCT patients are particularly
468   sensitive to thermal stimuli between 2 and 4 months post-transplant.8 Topical
469   application of neutral fluoride helps reduce the sensitivity.
470   Phase IV: Immune reconstitution/ late post-transplantation
471   After day 100 post-HCT, the oral complications predominantly are related to the chronic
472   toxicity associated with the conditioning regimen, including salivary dysfunction,
473   craniofacial growth abnormalities, late viral infections, oral chronic GVHD, and oral
474   squamous cell carcinoma.8 Regular dental examinations with radiographs can be done
475   routinely, but invasive dental treatment should be avoided in patients with profound
476   impairment of immune function.8 Orthodontic treatment considerations are the same as
477   discussed in the previous section.

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      pediatric patients receiving cancer therapy
478   References
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      pediatric patients receiving cancer therapy

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