Myth or Truth: Is active periodontal care not safe during chemotherapy or radiation?
Drs. Debbie Saunders and Joel Epstein dispel the myth about providing periodontal care for patients undergoing chemotherapy or radiation.
Dr. Debbie Saunders is a Dentist and Medical Director of the Dental Oncology Program, Health Science North, in the North East Cancer Center. She is also Assistant Professor in the Norther Ontario School of Medicine.
Dr. Joel Epstein is Professor and Medical Director Cancer dentistry at the Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Health System in Los Angeles and the Division of Otolaryngology and Head and Neck Surgery in City of Hope.
Highlights
There is often confusion about whether patients that are undergoing cancer treatment should continue active periodontal care. There are no contraindications or safety issues concerned with patients having ongoing and routine periodontal care during active chemotherapy. For patients having radiation treatment, it is recommended that dentists consult with the dental specialist at the cancer centre.
Periodontal pathogens that lie in deeper pockets (4mm and more) can cause periodontal abscesses. Often, patients undergoing cancer treatments take medications that can cause mouth sores/mucositis. The mucositis can extend into the periodontal pockets and create open portals for bacteremias.
The timing of periodontal care should be 1 or 2 days prior to or 1 week after the chemotherapy session. This will ensure that the patient’s blood counts are not compromised and that the patient is comfortable. Dentists should educate patients on the importance of continuing periodontal therapy during their cancer treatments and the need to share their chemotherapy and radiation schedules with the practitioner so that timing is optimized. Additionally, practitioners should ask for blood work to ensure that the platelet, total white cells, especially neutrophils and hemoglobin counts are in acceptable ranges to provide treatment without the need for antibiotic prophylaxis or an increased risk of bleeding.
Watch the video conversation
I must admit that I disagree with many of the statements in this clip especially regarding chemotherapy and “active” periodontal therapy.
I think that we should consider the type of chemotherapy – myelosuppressive vs. targeted or hormonal with the former being of the most concern. Patients undergoing this type of chemotherapy are generally feeling unwell, often with nausea and vomiting and oral mucositis. At our cancer centre, we weigh the benefits vs. the risk of the procedure as well as the patient’s overall feeling of wellness. There is no evidence that chronic periodontal disease with bone loss WITHOUT periodontal abscess formation requires treatment prior to or during chemotherapy. Periodontal abscess would require active treatment – and would most likely entail extraction.
The timing stated as “..1 week after the chemotherapy session” is inaccurate as this is the most likely time of the nadir in myelosuppressive chemotherapy and is potentially dangerous from a bleeding and infection risk standpoint.
The complete blood count numbers need to be individualized as we are all well aware that periodontal disease with a normal platelet count results in profuse bleeding with scaling. Given, even a platelet count of 75 may predispose to more bleeding and gingival bleeding is not only difficult to control but will increase nausea and vomiting.
In general, we see that “active” periodontal therapy is an elective procedure; if possible, to be done prior to cancer therapy. For some chemo regimens, however, (e.g. Dana Farber protocol for ALL) where the treatment involves 3 yrs of chemotherapy, if the patient feels well, the optimal time for an elective procedure would be prior to the next cycle of chemo where the blood counts have recovered.
There are many factors to consider in treating patients undergoing myelosuppressive chemotherapy and trying to rid “periodontal pathogens that lie in deeper pockets,..” is lower on the priority list. How long would these deeper pockets stay “clean”? Is this worth the risk to the patient?
Dental treatment for each cancer patient must be individualized taking into account the diagnosis, type of chemotherapy, blood counts, dental IQ, ability to keep their teeth clean and dental symptoms. There can be no facts or myths to dispel.