Wednesday, December 14, 2016

Dental care in the pediatric cancer patient

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Semantha Charles                                             Date: 12/14/16
Article Title: Dental care in the pediatric cancer patient.
Authors: da Fonseca, M.A.
Journal: Pediatr Dent
Date: 2004
Major Topic: Pediatric cancer patient
Type of Article: recommendations
Main Purpose: Recommendations for the dental care of the pediatric oncology patient.


  • Declines in mortality for childhood cancer are due to early diagnosis and improvements in therapy.
  • Incidence of childhood cancer is the greatest in the first year of life with a second peak at 2 to 3 years of age followed by a decline until age 9 and then steadily increasing through adolescence.
  • Boys are affected more than girls except in the first year of life. White children show a 30% higher frequency than blacks particularly during the first 5 years of life.
  • Acute lymphoid leukemia (ALL) is the most common malignancy, followed by CNS tumors then sarcomas.
  • The most common head, neck, and intraoral manifestations of ALL at the time of diagnosis are lymphadenopathy, sore throat, laryngeal pain, gingival bleeding, and oral ulceration. This is due to leukemic infiltrates.
  • Oral and dental infections may complicate the oncology treatment as well as delay it, leading to morbidity and an inferior quality of life for the child. Early and radical dental intervention reduces the frequency of problems, minimizing the risk for oral and associated systemic complications.
  • A good medical history is recommended. Most patients have a central line, which may dictate the use of antibiotics against endocarditis.
  • Myelosuppression may cause prolonged bleeding due to certain medications. Significant bleeding in unlikely to occur with a level >20,000/mm3.
  • ANC <1,000/mm3 – dental work should be deferred.
  • If spontaneous gingival bleeding is present, the physician must be notified because it may be a sign of internal hemorrhage.
  • Some patients may complain of paresthesias due to leukemic infiltration of the peripheral nerves or dental pain mimicking irreversible pulpitis. This is a side effect of vincristine and vinblastine, common chemotherapeutic agents.
  • The patient's blood counts normally start falling 5 to 7 days after the beginning of each treatment cycle, staying low for approximately 14 days before rising again.
  • Overall, routine dental care can be done when the ANC is >l,OOO/mm and platelet count is >50,000mm3.  
  • Some recommend that endocarditis prophylaxis be prescribed when ANC is 1,000 and 2,000/mm3 and optional platelet transfusions be considered pre and 24 hours postoperatively when the level is between 40,000 an 75,000/mm3. During immunosuppression all elective dental treatment should be avoided.
  • For patients who need a platelet transfusion before dental treatment, it is important to note that the peak concentration of platelets is achieved 45 to 60 minutes following transfusion.
  • Orthodontic treatment may start of resume after completion of all therapy and after at least every 2 year disease-free survival. A panoramic radiograph should be obtained every 12 to 18 months to monitor the dental changes.
Dr. Sapir remarks are:
The article is old (2004), and some of the recommendations have changed over the years. For instance the author advice SBE prophylaxis whenever a central line was placed. Current guidelines require it only at time of surgical placement. Secondly, he states that elective treatment can be done with ANC>1000. However, currently the guidelines do require clinical judjement when ANC is 1000-2000. Lastly, while the use of Chlorhexidine is recommended for the treatment and prevention of gingival disease and oral candidiasis, It is no longer recommended for mucositis!.

Old drugs, new uses

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Nicholas Paquin                                                                           Date: 12/14/2016
Mentor: Dr. Slowikowski

Article Title: Old Drugs, New uses
Author(s): Marcio da Fonseca, DDS and Paul Casamassimo, DDS
Journal: Pediatric Dentistry
Date: 2011
Major Topic: Re-applications of available medications with unexpected benefits or therapeutic side effects.
Type of Article: Literature review
Main Purpose: To understand what medications our patients may be taking and the reasoning may be different from traditional use.
Key Points: The use of anti-epileptic medications, thalidomide, IV immunoglobulin hydroxyurea, methotrexate, botulinum toxin, bisphosphontaes and aspirin have off-label therapeutic uses in pediatric patients that pediatric dentists should be aware of.

-        Unanticipated benefits in breakthrough care from clinical trials of AEDs for non-epileptic conditions in children and adolescents. The study suggests it will also become more frequent in the near future.

-        Hydroxyurea – Patients may be immunocompromised after use, a consult with the hematologist with an understanding of the patients blood counts must be obtained prior to dental treatment.

-        Methotrexate – the drug may induce or exacerbate a wide variety of oral lesions, ranging from nonhealing ulcers to destructive lymphoma-like lesions. It may be necessary to replace it early with another agent in patient with persistent mucositis that does not respond to treatment. Consults regarding the patient’s immune status should be obtained prior to invasive dental procedures.
-        Bisphosphonates – use in children remains controversial due to inadequate long-term efficacy and safety data. Avoiding oral surgical procedures, especially in patients have had or are being given IV bisphosphonates is a must. Oral bisphosphates are at a considerably lower risk of BRONJ than IV. Insufficient evidence that implant placement, extractions and other surgical treatments should be routinely avoided in patients on oral bisphosphonates. However, oral use of more than 3 years may relate to development of BRONJ. BRONJ has not been reported in children. Many bisphosphonates are taken every few weeks or months, so some parents may not remember that they took it if not specifically asked. Bisphosphonates can inhibit tooth movement which can pose a problem for orthodontic therapy which is dependent on osteoclastic activity to move teeth.

-        Acetylsalicylic acid – rarely causes significant hemorrhage, except in the presence of an underlying hemostatic defect or in children also treated with anticoagulants or thrombolytic therapy. Therefore, it is clear that pediatric dentists can proceed with oral surgical procedures in children and adolescents taking aspirin w/o any modification of care. We should not order the patient to stop taking it before dental procedures, a consult with the pediatrician or prescribing physician is needed if the pediatric dentist is concerned with potential for hemorrhage.
Dr. Slowikowski – 
1)     Because of off label use of medication, you can’t assume the patient is taking a prescribed medication for its intended use.  Making it important to ask the parents why they are taking the medication especially if there is no indication for them on the health history.  Asking about medications can help complete a health history since parents often forget to mention or think their child’s health issues are not related to dentistry.
2)     Keeping current with pediatric medicine is important but also contacting the physician with any questions will help to provide complete care to the patient.

An Overview of Chronic Oral Graft-Vs-Host Disease Following Pediatric Hematopoietic Stem Cell Transplantation

Department of Pediatric Dentistry

Lutheran Medical Center


Resident’s Name: John Diune   Mentor’s Name: Dr. Silva    Date: 12/14/2016

Article Title: An Overview of Chronic Oral Graft-Vs-Host Disease Following Pediatric Hematopoietic Stem Cell Transplantation
Author(s): Marcio A. da Fonseca DDS MS, Cahterine Hong BDS MS
Journal: Pediatric Dentistry
Date: Mar/Apr 2008
Major Topic: Medically compromised patients
Type of Article: Review article
Main Purpose: Purpose: Review of the pathogenesis, prevention, and treatment of pediatric chronic GVHD, focusing on its oral manifestation and dental management in children.
Key Points: (2 lines Max): 1)  Mouth can be major or ONLY site of cGVHD presentation – pediatric dentists must be able to recognize conditions
2) patients who survive HSCT at least 10 years at 8.3x risk of new solid cancer (mainly squamous cell carcinomas of skin and oral cavity
3) Research on management of pediatric oral cGVHD almost non-existent
Acute Graft-Vs-Host Disease (aGVHD) – distinctive syndrome of dermatitis, hepatitis, and enteritis developing within 100 days of allogeneic HSCT
Chronic Graft-Vs-Host Disease (cGVHD) – tends to be a more pleiotropic (diverse effects) syndrome generally developing after 100 days
·         20% of patients receiving matched sibling transplants develop disease
·         40% of patients receiving matched unrelated donor recipients develop disease
GVHD thought to be due to improper recovery of the immune system leading to recognition of T cells as foreign, impaired T and B cell production, impaired antibody production, and functional asplenia.
·         Thus clinical manifestations of cGVHD closely resemble that of autoimmune diseases.
cGVHD can be categorized as:
a)      “De novo” – occurs by itself
b)      “Quiescent” or “Interrupted” – present after resolution of aGVHD
c)       “Progressive” – evolve from aGVHD
cGVHD most common clinicopathological staging:
a)      Limited
b)      Extensive
Most significant risk-factors for developing cGVHD:
1)      Patient age 10 years or older
2)      Donor age 5 years or older
3)      Female donor to male recipient
4)      Use of total body irradiation as part of transplant conditioning regimen
5)      Diagnosis of hematologic malignancy
6)      Previous aGVHD
cGVHD course and prognosis:
-          Major cause of death is:
o   infectious complications
o   progressive organ failure from GVHD involvement
-          risk of new solid cancers – mainly Squamous Cell Carcinomas of skin and oral cavity
o   risk is higher
§  for HSCT recipients younger <10 yo at time of transplant
§  particularly males
§  receive high-dose total body irradiation
§  have cGVHD
§  receive prolonged immunosuppressive therapy
cGVHD prevention and treatment: Best approach to reduce GVHD-related mortality is prevention
1)      interference with T cell activation and function
a.       cyclosporine and tacrolimus most common agents to prevent disease
2)      interference with T cell proliferation
a.       methotrexate and mycophenolate mofetil (MMF) most commonly used
3)      Reduction of T cell numbers
a.       Alemtuzumab and antithymocyte globulin used in vivo
4)      Interference with cytokine function
a.       Corticosteroids – but can increase risk of infections
Supportive care:
1)      Local measures
a.       Physical therapy to reduce contractures
b.      Deep tissue massage for deep cutaneous sclerosis
c.       Optimal oral care with fluoride
2)      Prophylaxis against infections
3)      Protein and carbohydrate dietary supplements to prevent weight loss due to increased metabolic activity and diminished intestinal absorption
4)      Use of sunblock to avoid activation of GVHD by the sun
Oral and Dental Aspects:
-          Mouth can be major or ONLY site of cGVHD presentation
-          Oral cGVHD often starts with xerostomia and/or oral sensitivity
-          Risk of development of Oral Squamous Cell Carcinomas
-          Presentations
o   Atrophy and erythema or lichenoid lesions of buccal and labial mucosa
o   Oral pain not limited to ulcerations
o   Erosive lesions (often covered by heavy grayish pseudomembrane) associated with lichenoid abnormalities of lateral tongue and posterior buccal mucosa
o   Patients with severe liver dysfunction and elevated bilirubin levels showed jaundice of oral mucosa
Pediatric oral cGVHD findings (study of 22 children):
-          Erythematous > Reticular and Ulcerative forms
-          Mouth pain
-          Xerostomia
-          Avoidance of certain foods
-          Atrophic glossitis
-          Gross caries
-          Soft tissue fibrosis
-          Mucoceles
-          Soft tissue growths (such as pyogenic granulomas)
Treatment of oral cGVHD and its sequelae:
-          Pediatric oral cGVHD treatment almost non-existent – based on adult therapies
-          Scope is:
o   Treatment of specific lesion
o   Pain control
o   Relief of xerostomia
o   Maintenance of oral health
-          Treatment of disease:
o   Reticular lesions rarely need treatment
o   Erythematous and ulcerative lesions need AGGRESSIVE therapy
§  Systemic immunosuppressive agents
§  Topical steroid preparations can be used in addition if not completely resolved
·         General guidelines for topical steroid use
o   Infants – 1/5th of adult dose
o   Children – 2/5th of adult dose
o   Adolescents – 2/3rd of adult dose
·         Within 2 weeks follow-up all patients on topical steroids to monitor adverse effects (such as opportunistic fungal infections)
·         Patients should receive prophylaxis against candidiasis
o   Chlorhexidine oral rinse
o   Systemic antifungal agents (triazoles) more effective than topical
§  Careful with drug interactions
-          Pain control:
o   Topical anesthetics – 2% viscous lidocaine
o   Non-narcotics to start
o   Progress to opiates as needed
-          Relief of Xerostomia:
o   Bland rinses (saline or sodium bicarbonate)
o   Sugarless candy/gum
o   Special toothpastes, Gels, Mouthwashes, Saliva substitues
o   Bedside humidifier
o   Fresh and lightly acidic fruits
o   Slices of cold cucumber or tomato or apple
o   NOT recommended for children – Muscurinic agonists
-          Maintenance of good oral hygiene
o   At risk for caries:
1)      Hyposalivation
2)      Loss of protective saliva
3)      Perioral fibrosis and oral pain - limits hygiene
4)      High caloric diet due to weight loss
5)      Decreased mobility of tongue – oral clearance issues
6)      Frequent consumption of soft foods
o   Fluoride supplementation
o   Xylitol
o   Routine dental treatment ONLY if immunologically competent
§  Need to assess Platelet and absolute neutrophil count (ANC)
§  Apply same principles as immunosuppressed hematology/oncology patients
It is essential to communicate frequently and effectively with the patient’s oncologist to stay up to date with platelet and ANC values. AHA guidelines for SBE prophylaxis do not apply to these patients. Patients can have widely variable clinical presentations and blood test results, making each case an entity unto itself. Do not be tempted to paint these patients with a broad brush, except when it comes to prevention and comfort measures for xerostomia.
Frequent recall is essential for high-risk patients. SDF should be considered when mucositis and metal allergy can be ruled out in high-risk or active-caries patients. They are undergoing frequent medical appointments that may be saving their lives. Dental appointments add to the burden of care for the patients and their parents. If caries can be medically managed and arrested rather than surgically treated, it should be considered as a legitimate alternative.
Assessment of Article:  Level of Evidence/Comments: III – expert opinion


Osteoporosis: An Increasing Concern in Pediatric Dentistry

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Amir Yavari (Mentor: Dr. Kiang)                                     Date: 12/14/2016
Article Title:  
Osteoporosis: An Increasing Concern in Pediatric Dentistry
Author(s):  Marcio A. da Fonseca
Journal: Pediatric Dentistry
Date: 2011
Major Topic: Osteoporosis, Primary and Secondary Bone Disease, Measuring Bone Mineral Density, Treating Osteoporosis in Children:
Type of Article: Literature Review
Main Purpose:
With increasing numbers of children affected by low bone density and osteoporosis, the topic has become an important issue in contemporary pediatrics.
Bone fractures are the most common reason for hospitalization between 10 and 14 year olds.
Factors, such as lifestyle, diet, chronic illness and medications can affect bone mineral density.
Osteoporosis is classically defined in adults as a systemic skeletal disease characterized by: 1- Low bone mass; 2- Alteration of ultra-structural quality of bone; 3- Deterioration in trabecular architecture; 4- Increased cortical porosity; 5- Reduced cortical thickness and 6- Decreased bone width.  
Osteoporosis is often difficult to define in children as they are constantly changing in size and shape with increases in bone mass and density.
Greatest bone mass acquisition tends to mirror height velocity and is greatest during puberty.  Any disruption of this growth would lead to an increased risk of adult osteoporosis and fractures. Excess of deficiencies in GH, TH, PTH, and sex steroids can also lead to decreased bone mineral density.

- Primary Bone disorders:
Heritable Disorders of connective tissue: Idiopathic juvenile osteoporosis, osteogenesis imperfecta, Marfan syndrone, Ehler-Danlos, Bruck, osteoprosis pseudoglioma syndrome, homocystinuria
- Secondary Bone disorders:
Inflammatory Diseases: Inflammatory bowel disease, celiac disease, juvenile idiopathic arthritis, CF, Lupus, dermatomyositis
Chronic Immobalization: CP, neuromuscular disorders, epidermolysis, spina bifida, spinal cord injury
Endocrine Disturbances: Turner syndrome, anorexia, hypogonadism, GH deficiency, DM I, hyperthyroidism, Cushings, delayed puberty
Hematologic-oncologic disorders: Childhood cancer, thalassemia, sickle cell disease
Inborn Errors of Metabolism: Pr intolerance, glycogen storage diseases, galactosemia, Gaucher disease
Iatrogenic Etiologies: Glucocorticoids, anticonvulsants, chemotherapy, cyclosporine, acrolimus, bone/cranial radiation
Others: Chronic renal disease, steroid, dependent asthma

Measuring Bone Mineral Density: 
DEXA (dual energy X-ray absorptiometry): Diagnostic tool in the management of adult osteoporosis. DEXA doesn’t distinguish between cortical and trabecular bone + Does not differentiate between body types for a certain age (i.e. short kids vs. tall).
DEXA is beneficial to use as a monitor during tx.

Treating Osteoporosis in Children: Anticipatory guidance regarding healthy lifestyle  (physical activity, diet, no drugs/alcohol) is of great importance to prevent bone loss and should start from an early age. In severe cases of low bone mineral density, promoting calcium and Vit D intake coupled with weight-bearing physical activity can provide benefits with minimal risk.

Implications of Osteoporosis in Dental Treatment: 
Getting a full medical history is important.
Dentist should be careful when using restraints with child diagnosed with osteoporosis as bone fractures may result.
Extractions should be done carefully as to avoid any unnecessary jaw fractures.
Dentists should be aware of the patient’s current therapy. Bisphosphonate therapy may lead to BRONJ. Elimination of all potential sources of odontogenic and mucosal infection must be done before the patient starts therapy with bisphosphonates.
There are no reported cases of BRONJ developing from primary tooth extraction. However, it is always important to consult with the child’s physician prior to any surgical therapy.
Bisphosphonates can also inhibit tooth movement: posing a problem for Ortho therapy (reduced osteoclasts). It is suggested that Ortho tx be avoided in patients with high risk, such as those patients receiving or have received IV Bisphosphonate.

-       As a pediatric dentist we need to review the health history all the time. Any time that we have primary bone disease, there is a possibility of bone injury or fracture. Be carful during patient movements, positioning on the dental chair, and doing the procedure.
-       It is important what is the underlining cause and whether or not it is would change the treatment.
-       Bisphosphonate drugs have a long half-life time and it is important to have proper consulting with the pediatrician.

Assessment of Article:  Level of Evidence/Comments: