What are the immediate and long-term considerations for the GP dentist providing dental care to children who have undergone cancer therapy or bone marrow transplantation?”
This question was submitted by a general dentist: What are the immediate and long term considerations for the GP dentist providing dental care to children who have undergone cancer therapy or bone marrow transplantation?”
Dr. Carol Janik and Caroline Fulop provided this initial response.
The focus of this article is to provide practitioners with guidance on the clinical considerations for pediatric patients who have undergone cancer therapy or bone marrow transplantation. For more information on patients who have been diagnosed and are planned to initiate treatment or those patients currently undergoing therapy please consider referral to a hospital pediatric dentist and reference the following article for current guidelines published by the American Academy of Pediatric Dentistry (AAPD) from which the content of this article has been sourced:
After the completion of cancer therapy, the primary dental treatment objectives are:
- To maintain optimal oral health
- To educate the patient and their caregivers regarding the importance of optimal lifelong oral health care
- To inform the patient and their caregivers about possible long-term effects of the therapy in the craniofacial complex and address any dental issues that may arise
The major focus of oral health care for children who have undergone cancer therapy is prevention. This begins with education where the importance of lifelong optimal oral health care is emphasized. Regular follow-ups with a dentist are required, especially for those patients who developed or were at risk of developing Graft vs Host Disease (GVHD), xerostomia, or who were younger than 6 years of age when undergoing treatment. This is due to potential developmental issues secondary to cancer treatment.
Targeted preventive considerations involve:
ORAL HYGIENE – Brushing 2-3 times daily with a soft brush. Daily flossing.
DIET – A non-cariogenic diet should be encouraged. Counseling regarding the high cariogenicity of dietary supplements and pediatric oral medications should be performed.
FLUORIDE – Daily use of fluoridated toothpaste is indicated. Fluoride supplementation may be suggested after assessment of individual fluoride exposure. Neutral Fluoride gels/rinses may be prescribed for home use. Professional fluoride varnish application is indicated especially for patients at elevated risk of caries and/or xerostomia.
LIP CARE – Lanolin-based creams and ointments are preferred over petroleum-based products for moisturizing and protective properties.
Considerations for ongoing dental care:
FOLLOW-UP: Patients should be evaluated at minimum every 6 months and more frequently if sequelae such as chronic GVHD, xerostomia, or trismus are present. Close monitoring for malignant transformation of the oral mucosa in patients who experienced moderate to severe mucositis or GVHD during treatment is essential. Regular consultation with the patient’s physician is essential, and dental treatment may require a multidisciplinary approach involving a team of specialists to address individual needs.
ORTHODONTIC TREATMENT – Orthodontic treatment may begin or resume after all cancer therapy is complete, a minimum two-year disease-free period has passed, and the patient is no longer taking immunosuppressive medications. A history of or potential bisphosphonate use should be determined. A thorough assessment for developmental disturbances caused by cancer therapy must be performed before orthodontic treatment is initiated. The general practitioner may facilitate interactions between the patient’s caregivers, the physician, and the orthodontist to incorporate potential orthodontic therapy into the overall dental treatment plan and evaluate the risks and benefits of treatment.
ORAL SURGERY – Consultation between the patient’s physician and the oral surgeon and/or periodontist is recommended for all patients who have taken or are presently taking bisphosphonates or have undergone radiation therapy to the jaws prior to non-elective procedures. This is done to minimize risk of bisphosphonate-induced osteonecrosis and osteoradionecrosis. Elective procedures should not be performed in this patient population. Those patients at high risk should be managed with the support of the oncology team in a hospital setting.
XEROSTOMIA – Sugar-free chewing gum, lozenges, alcohol-free oral rinses, and specialized products for oral dryness are recommended. Drugs to stimulate salivary flow are not approved for use in children. Fluoride therapy is recommended for caries prevention in xerostomic patients.
TRISMUS – Daily oral stretching and physical therapy should continue after radiation therapy is finished to prevent or improve trismus. Further management of trismus may be explored through consultation with an oral medicine specialist.
DEVELOPMENTAL SEQUELAE – Usually occur among children who were under 6 years of age when receiving cancer treatment. These may include:
- Tooth agenesis
- Crown disturbances (size, shape, enamel hypoplasia, pulp chamber anomalies)
- Root disturbances (early apical closure, blunting, change in shape or length)
- Reduced mandibular length
- Reduced alveolar process height
The severity of the anomaly depends on the age and stage of development when treatment was administered. Treatment planning for and execution of restorative dental procedures may be influenced by these developmental anomalies.
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