Published: May 2003
The most appropriate time to schedule dental treatment during chemotherapy is after patients' blood counts have recovered, usually just prior to their next scheduled round or course of chemotherapy. If oral surgery is required, it should be scheduled to allow 7-10 days of healing prior to the anticipated date of bone marrow suppression. It is imperative that the dentist seek consultation with the oncologist prior to any dental procedure, including prophylaxis. Blood work should be ordered the day before the dental treatment to document hematologic status.
Important Information Includes:
Hemorrhage may be a complication when the platelet count is <50,000/mm3 or with abnormal clotting factors (PT, PTT, fibrinogen).
Absolute Neutrophil Count*
Risk of infection and septicemia is high when the absolute neutrophil count is <1,000/mm3. Patients receiving immunosuppressive chemotherapy will usually reach their "nadir" (the lowest blood counts) 7 14 days after initiation of therapy.
Dental treatment can be performed after the neutrophil count has begun to rise from the nadir and has reached a level of 1,000/mm3 or above. If a dental procedure is necessary and the neutrophil count is less than 1,000/mm3, the oncologist must be consulted concerning antibiotic coverage. Extensive invasive oral procedures should not be performed if the absolute neutrophil count will be <1,000/mm3 within 10-14 days of the oral procedure.
Normal Complete Blood Count
|Red blood cells||4.2 – 6.0 million/mm3|
|Hemoglobin||12 – 18 g/dl|
|Hematocrit||36 – 52%|
|Platelets||150,000 – 450,000/mm3|
|White blood cells||4,000 – 11,000/mm3|
|"Segs" (or Polys or PMNS)||40 – 60 %|
|"Bands"||0 – 5 %|
|Eosinophils||1 – 3%|
|Basophils||0 – 1 %|
|Lymphocytes||20 – 40 %|
|Monocytes||2 – 8 %|
* Absolute Neutrophil Count – total WBC x (% "Segs" + % "Bands")
Indwelling Central Venous Catheter
Some patients are given chemotherapy through a catheter placed in a major vein. Because catheters may become colonized with bacteria that enter the blood during dental procedures, it is recommended that these patients receive the American Heart Association endocarditis prophylactic antibiotic regimen prior to an invasive dental procedure, including dental prophylaxis. Physician consultation is recommended.
Oral Hygiene Care
Excellent oral hygiene must be maintained. An oral hygiene program must be individualized for each patient and modified throughout therapy according to his or her medical status.
To foster compliance the patient must understand the risks of septicemia from poor oral hygiene. The patient should be taught a very gentle but effective toothbrushing technique.
During periods of neutropenia and/or thrombocytopenia (ANC < 1000/mm3 and/or platelet count of <50,000/mm3) optimum plaque control measures may necessitate gentle oral lavage, increased baking soda-saline rinses, toothbrush bristles softened in hot water or the use of a super-soft toothbrush. Sponge Toothettes, gauze and/or cotton tipped applicators do not adequately remove plaque and should be supplemented with other measures. Dipping a sponge Toothette in chlorhexidine rinse may increase effectiveness. Regular toothbrushing and flossing should resume as soon as possible. Toothbrushes should be changed frequently and/or disinfected in chlorhexidine. During periods of severe neutropenia, the patient should also be cautioned about eating crunchy or sharp foods that may damage friable oral tissues. Toothpicks should not be used.
Alcohol-based mouthwashes and full-strength peroxide solutions or gels should not be used due to their drying and irritating effects. Use of all diluted peroxide solutions should be limited to the removal of adherent debris; long-term use may disrupt the normal oral flora. Peroxide solutions are acidic and, if used, should be followed by a neutralizing rinse, such as a bicarbonate water solution.
The prophylactic use of chlorhexidine rinse may be helpful in suppressing bacterial colonization but should not replace mechanical removal of plaque with a toothbrush. The patient should be monitored closely and evaluated regularly to determine the benefit of the rinse versus the risk for irritation and/or drying of tissues.
The mouth may be rinsed with a baking soda-saline solution and followed by a plain water rinse several times a day. The solution is prepared by mixing 1-2 tsp(s) of baking soda and 1/2 tsp of salt with one quart of water. The salt may be eliminated according to patient preference. This solution may be put in a disposable irrigation bag and hung overhead to allow the solution to flow through the mouth. The solution must not be swallowed.
Patients who experience frequent emesis should be encouraged to rinse thoroughly with a baking soda and water solution. Brushing the teeth without first neutralizing the gastric acids in the mouth may result in etching of the enamel.
Edentulous patients must not wear dentures while they sleep or when their dentures irritate ulcerated mucosal tissues. Dentures must be brushed daily with a denture brush and soaked in an antimicrobial cleanser or mild detergent. An effective soaking solution for dentures without metal parts is made by mixing one-teaspoon chlorine bleach, two teaspoons Calgon water softener and one cup of water. After brushing and soaking, the dentures should be rinsed well and stored in clean water or a fresh chlorhexidine solution. Edentulous patients should cleanse their tongue and oral tissues with gauze or a soft toothbrush.
Measures for the prevention of tooth demineralization are required only when xerostomia persists for longer than six weeks. It is recommended that a 1.1% neutral pH sodium fluoride or 0.4% unflavored stannous fluoride be brushed on the teeth or applied in custom-made gel applicator trays. A neutral pH fluoride gel should be used by patients with porcelain crowns. Acidulated fluoride should not be used (refer to page 9 for gel application directions).
Routine Dental Care
Routine dental care may be provided as the patient's hematologic status permits.
Culture all suspicious lesions for infection (bacterial, fungal and/or viral). Prescribe treatment in cooperation with the oncologist. Exfoliative cytology or ELISA may be performed for rapid identification of the herpes virus. If positive, acyclovir may be administered to prevent progression of the lesions. For fungal infections, patients should be aware that topical antifungal agents are efficacious only when in contact with the lesions and are used for the prescribed time period. Use of a sugar-free antifungal should be considered if extended use is necessary or if the patient is caries-prone.
If bands are not removed prior to chemotherapy, soft wax or a plastic mouthguard may cover them during periods of oral inflammation or ulceration.
Dental Management – Following Chemotherapy
At the completion of all planned courses of chemotherapy, closely monitor the patient until all side effects of therapy have resolved, including immunosuppression. The patient may then be placed on a normal dental recall schedule. Since these patients may need to undergo additional myelosuppressive therapy if they relapse in the future, it is very important to maintain optimal oral health.
Children should receive close lifetime follow-up, with specific attention to growth and development patterns.