Case Conference: How would you treat this 73-year old patient on chemotherapy?
Dr. Linda Lee presents the case of a 73-year old female patient who is undergoing chemotherapy.
Dr. Linda Lee DDS, MSc. Dipl. ABOP, FRCD(C), Oral Pathology/Medicine
Dr. Lee is Associate Professor, Faculty of Dentistry, University of Toronto Staff Dentist, Princess Margaret Cancer Centre, University Health Network. Dr. Lee received her DDS degree in 1977 from the University of Toronto and her Certificate in Oral Pathology, Indiana University School of Dentistry Master of Science, Indiana University.
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For any pulpally compromised or unrestorable teeth, I would send the patient to an endodontist for non-surgical endodontic therapy. The Position Statement by the AAE Special Committee on Bisphosphonates recommends non-surgical endodontic treatment for teeth that would have been considered for extraction in the absence of high-potency bisphosphonate use. For teeth that are non-restorable, the AAE recommends crown resection and restoration as for an overdenture after the non-surgical endodontic therapy is completed. Teeth that are restorable and do not have signs or symptoms of pulpal compromise may be conventionally restored as usual. Routine home use of neutral fluoride trays and other caries management strategies could be implemented as well. Because the most questionable teeth (26 and 36) are molar teeth with calcified-appearing canals, I believe that referral to an endodontist would help ensure the greatest chance of positive response to the endodontic treatment. I am not an endodontist myself, but I would want the best possible outcome for this unfortunate patient undergoing palliative care.
I agree with Elaine. The oral condition of this patient needs to be stabilized as soon as possible in a short window of time, in a very conservative and highly preventive palliative manner to avoid any painful complications. Extractions are to be avoided at all cost. Preventive endodontic treatments on the compromised molars (26-36) if necessary only, followed by temporization of the teeth would be my approach, in the short term and depending on the severity of the mets. All other restorable decay should be eliminated with indirect pulp capping if necessary to avoid any possible pulpal infections with permanent or again temporary restorations. Highly preventive oral hygiene regimen would be recommended with daily chlorhexidine , fluoride rinse and saliva replacement therapy specially before bedtime. The need for a bruxism splint should also be carefully evaluated since these patients are often in pain and highly stressed; daily clenching and nocturnal bruxism stress on those bridges and crowns causing micro fractures at the restoration -tooth junctions followed by decay in an already highly acidic dry oral environment. Bi-monthly follow-ups would be my approach to supervise the stability or reoccurrence of problems.You do not want this patient to have accelerated rampant decay.