Scheduling extraction if neutrophil Perform extraction at least 10 days prior to count expected to decrease <500 neutrophil count becoming <500 cells/mm3 cells/mm3
Day of extraction, if absolute Consider use of a broad-spectrum neutrophil count < 1,500 cells/mm3 prophylactic antibiotic regimen
30 minutes prior to extraction, if Administer random donor or histocompati-
platelet count < 40,000 cell/mm3 bility-matched platelets (as available)
During extraction Minimize surgical trauma, with alveolec-
tomies as necessary to achieve primary
closure with multiple interrupted sutures
Minimize use of hemostatic packing agents within extraction sites
Adapted with permission from The Chemotherapy Source Book, 15 copyright Lippincott Williams & Wilkins, 2007
ventions in patients scheduled to receive high-dose chemotherapy. However, procedures associated with dental extractions have been used by clinicians for many years, based on historical retrospective studies. 22, 23 Guidelines for dental extractions in patients scheduled to undergo myelosuppressive chemotherapy are outlined in Table 3.
After extraction
New trends in oncology practice based on “targeted” therapies. Targeted cancer therapies, including monoclonal antibodies, are being utilized with increasing frequency in clinical oncology practice. 24 For example, potential targets of monoclonal antibodies are growth factor receptors, signaling kinases, and transcription factors. 24 These novel molecular approaches are in turn causing a change in expression of toxicities among various cancer cohorts, including diarrhea and oral mucosal
ulceration. 24 The potential impact on immune response and wound healing relative to oral toxicities requires additional study.
In some cases, oral mucositis necessitates chemotherapy dose reduction or schedule modifications in order to reduce severity of future oral mucosal injury. For example, among patients undergoing chemotherapy for solid tumors or lymphomas, dose reduction was twice as common after treatment cycles for patients with mucositis than for those without mucositis. 16 This compromise in optimal dosing schedule can affect tumor response and thus patient survival. In addition, oral mucositis can contribute to increased Figure 4. Lower left lingual area healthcare costs associated with of peridontium in a patient on (a) extended hospital stays, (b) antineoplastic therapy need for total parenteral nutrition, (c) infection management, and (d) nutritional support. 13
Dental management of patients taking antineoplastic agents. It is important that the oncologist and dentist maintain clear communication in order to provide maximum preventive and therapeutic management. Elements of the health professional consultation include both the patient’s medical status and an integrated oncology/dental management plan (relative to oral disease before, during, and after cancer treatment). 14 Management suggestions relative to invasive dental procedures in patients currently receiving antineoplastic therapy are outlined in Table 2.
Bisphosphonates
Management of cancer patients may also include bisphosphonates to control metastatic bone lesions through impairment of osteoclast function. 6 A severe complicating factor is BIONJ with associated osteomyelitis, although most BIONJ patients exhibit osteonecrosis without osteomyelitis. 5, 6 Maxillary, mandibular, and soft-tissue lesions, secondary to long-term bisphosphonate use in patients with cancer, have been increasingly reported in the literature. 25-28 Over time, the accumulation of compromised bone matrix can lead to pain and clinically evident bone exposure that can be difficult to manage clinically (Figure 4). 28 Since there are currently no evidence-based guidelines for treatment of BIONJ, prevention may be the best approach to managing this complication. 26
Increasing compromised bone matrix can lead to pain
and clinically evident bone exposure.
Reprinted from Migliorati, J Clin Oncol,
28 with permission
from American Society of Clinical Oncology, copyright
2003
A limited number of studies address guidelines for dental extractions, endodontic management, and related inter-
Steroids
Topical or systemic steroid therapy is indicated for a wide variety of systemic and oral mucosal disorders. Common uses for systemic steroids include endocrine disorders (primary or secondary adrenal insufficiency), rheumatic disorders (rheumatoid arthritis), collagen diseases (sys-
References:
Archives