Note: last updated before 2010

RATIONALE FOR DENTAL EVALUATION ANTECEDING CHEMOTHERAPY

1. A thorough oral evaluation is important in that some dental interventions can diminish the potential for oral and/or systemic complications secondary to the stomatotoxic and hematotoxic side effects of many oncologic chemotherapy regimens. Such an evaluation is particularly beneficial for patients afflicted with hematologic neoplasms.
2. The aim of the examination involves the identification of dental or periodontal conditions that could exacerbate mucositis, contribute to a hemorrhagic event, or serve as a nidus of infection during each chemotherapeutic course. Although the information gleaned in the examination should be used to counsel the patient regarding a comprehensive oral and maxillofacial treatment plan, it is immediately used for the development of a strategy to eliminate or allay those conditions that place the patient at risk during neutropenic or thrombocytopenic periods.

CLINICAL REGIMEN ANTECEDING CHEMOTHERAPY

1. Radiographic Evaluation
   1. Intraoral radiography
      1. Provides greatest image resolution for dental and periodontal evaluation
      2. Indications
         1. Full mouth intraoral radiographic series (FMX) when portions or all of the dentition is, upon presentation, considered healthy enough to potentially retain
         2. Selected intraoral radiographs to bolster panoramic radiographic evidence of maxillary or mandibular tumoral invasion
   2. Panoramic Radiography
      1. Provides expansive imaging of the maxillomandibular complex
      2. Provides poorer resolution of images when compared to intraoral radiography
      3. Provides less patient radiation exposure when compared to a FMX
      4. Indications
         1. Assessment of maxillary or mandibular primary solid tumoral invasion
         2. Assessment of maxillary or mandibular metastatic tumoral invasion
         3. Provide oral surgical information
   3. Extraoral and intraoral examination
      1. Palpation and observation of the soft tissues of the neck, face, and oral cavity
      2. Dental, periodontal, and radiographic assessment
         1. Existing restorations
         2. Carious lesions
         3. Periapical lesions
         4. Gingival sulci
            1. Depths of mesiofacial, mesiolingual, midfacial, midlingual, distofacial, and distolingual areas
            2. Dental mobility
   4. Dental intervention
      1. Dental prophylaxis
      2. Amalgam, composite resin, or interim restorative material, restoration of carious teeth
      3. Odontoplasty for teeth with sharp surfaces capable of traumatizing mucosal surfaces
      4. Removal of orthodontic hardware capable of traumatizing mucosal surfaces
      5. Removal of ill-fitting, removable prostheses capable of traumatizing mucosal surfaces
      6. Fabrication of fluoride gel carriers for patients whose chemotherapeutic regimen can be expected to cause xerostomia
         1. Fluoride gel application in fluoride gel carriers
            1. 0.4% stannous fluoride or 1.1% neutral sodium fluoride prescription
            2. Five-minute application over dentition following the home care regimen delineated below
            3. Expectoration following fluoride gel carrier removal
            4. NPO for 30 minutes following fluoride gel carrier removal
            5. Utilization of the fluoride gel until xerostomia subsides
      7. Extraction indications (7 to 14 postoperative days are typically required for the elimination of infections and the epithelization of OS wounds before the initiation of chemotherapy)
         1. Acutely infected periodontal lesions
         2. Acutely infected endodontic lesions
         3. Nonrestorable teeth
         4. Impacted teeth communicating with the oral cavity
         5. Mobile primary teeth
      8. Home care instructions to be followed when neutrophil counts are >1,000 per mm3 and platelet counts are >50,000 per mm3
         1. Routine brushing and flossing
      9. Home care instructions to be followed when neutrophil counts are <1,000 per mm3 and platelet counts are <50,000 per mm3
         1. Warm saline and soda solution rinses QID
            1. 0.5 teaspoon salt
            2. 1 to 2 teaspoon(s) baking soda
            3. 1 quart water
         2. Cease flossing
         3. Institute the use of toothettes for gentle mechanical plaque removal
      10. A daily chlorhexidine regimen can also diminish plaque accumulation.

CLINICAL REGIMEN DURING CHEMOTHERAPY

1. Although dental intervention is typically suspended during chemotherapeutic sequences, windows of opportunity exist between consecutive courses of chemotherapy during which limited dental therapy may be rendered. These opportunities coincide with those periods during which the patient has not suffered serious myelosuppression or has recovered from it to such an extent that he/she is no longer at great risk for hemorrhage or infection. In addition to the week anteceding the initiation of a cycle of chemotherapy, minimally invasive periodontal and dental procedures may usually be safely rendered during the first four or five days of each cycle. If, however, any question exists with respect to a patient's vulnerability, hematologic laboratory values should be obtained no greater than 24 hours prior to the initiation of the dental care.
2. For neutropenic individuals (<1,000 per mm3) whose dental care cannot be deferred, antibiotic prophylaxis is necessary to stave off the potential for septicemia. A consultation with the medical oncologist is beneficial for determining an appropriate antibiotic or combination of therapeutic agents in addition to an appropriate delivery route, dosage, and duration of administration.
3. Thrombocytopenic patients (<50,000 per mm3) whose dental care cannot be deferred should be considered candidates for preoperative platelet transfusions, particularly when their dental intervention involves exodontia. This decision should also be made in consultation with the medical oncologist.
4. The American Heart Association's prophylactic endocarditis recommendations should be followed for dental patients whose chemotherapeutic agents are being delivered via a central venous catheter.

CLINICAL REGIMEN FOLLOWING CHEMOTHERAPY

1. Patients who have completed all of their chemotherapeutic courses can engage in a routine dental recall program once all of the side effects of chemotherapy subside.