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
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!.