Chemotherapy and Dental

Management
 Management of tumors

Surgery Radiotherapy Chemotherapy

OR combination of them together

Surgery and radiation remain the primary mode of
treatment for most tumors as surgical resection
removes the bulk of malignant tissue and radiation
localize the morbidity to the specific area of the body.
Chemotherapeutic treatments alone are unable to match the
success of surgery or radiation but are being indicated in
some cases.

1- when surgery is contraindicated because of the patient

medical state.

2-used in combination with radiotherapy in treatment of

tumors in inoperable areas.
3- used to reduce the size of the tumor after surgery when
complete tumor resection can’t be done.

4- it is used as a supplemental treatment to attack micro

metastasis following surgery and radiation
treatment .”Adjuvant chemotherapy”

5-maintenance chemotherapy is used in low doses to assist

in prolonging remission.
Mechanism of action:

Anticancer chemotherapy currently involves the use of drugs

that avoid proliferation of the tumor cells and/or cause their
destruction, taking advantage of the characteristically
shortened cell cycle of these cells.

The main problem posed by such treatment is the lack of

selectivity of most antineoplastic drug substances, since they
also act upon normal cells with an accelerated cell cycle, such
as bone marrow cells, hair follicle cells and the epithelial cells
of the gastrointestinal tract and oral epithelium.
Cell cycle
Name Action Indication Side effect

Alkylating agent Effective during DNA -Lymphoma -Nausea

synthesis -Leukemia -vomiting
-leukopenia
-Thrombocytopenia

Nitrosureas Inhibit DNA repair -Brain tumor -Bone marrow toxicity.

-Lung disease .
Antimetabolities cell cycle specific, once -osteogenic sarcoma . -Anemia .
the cell incorporates -head and neck cancer. -Stomatitis .
these substance, it is no
longer capable of
division.

Plant alkaloids prevent DNA replication -kaposi sarcoma. -Xerostomia .

-Lung cancer . -Anemia .
- Leukemia.

Hormones -Breast cancer. -Pain joint .

-Fatigue.
Biologic agents Make cancer cells more -Lymphoma . -Immune imbalance .
recognizable to immune - Head and neck -Hypersensitivity
system cancers . reactions .
Some of the most frequent side effects:
1-Bone marrow suppression, resulting in leukopenia
(observable in peripheral blood towards day 10 after the
start of chemotherapy).

2-Thrombocytopenia (after 10-14 days) and anemia (less

frequent and slower in developing).

3- Nausea and vomiting.

4- hair loss (alopecia).

5-hand-foot syndrome (clinically characterized by painful,

symmetrical erythema of the palms and soles, often
preceded by paresthesias in the affected zones).
Oral side effects of chemotherapy:

The direct effect of the oral manifestations of

chemotherapy are secondary to tissue necrosis and
desquamation

The indirect effect arise from a decreased number and

function of platelets and neutrophils and may be
exacerbated by preexisting conditions unrelated to cancer
such as peridontal disease and caries.
Oral side effects of chemotherapy:
1-Mucositis.
2- Infections.
3-Neurological and dental alterations.
4-Xerostomia (dry mouth).
5-Bleeding tendency.
6-Osteonecrosis.

The soft tissues of the lips, the oral mucosa, tongue,

soft palate and the pharyngeal mucosa are the most
affected areas.
 1-Oral mucositis:

Oral mucositis is a painful inflammation of the mucous

membrane lining. It manifests clinically first by thinning
of oral tissues leading to erythema. As these tissues
continue to thin, ulceration eventually occurs.
Early studies showed that about 85% of patients receiving
chemotherapy have some oral complications.

1- Because of its high turn over rate .

2-Because its subjected to trauma as a

consequence of mastication.

3-Exposure to thermal and chemical stimuli.

4-oral cavity hosts a several micro-
-organisms with the potential to cause
infection and delay healing
Risk factors:

1-Age:
Younger patient are more likely to have ulceration than
older patients under same
treatment but younger
patients tend to heal more
quickly .

2-Poor nutritional status has an impact on how treatment

is tolerated by the patient and how quickly he or she
recovers from therapy.
3-Poor oral hygiene, caries with associated periapical
pathology, and periodontal disease all are associated with an
increased risk of developing OM.

4-Type of malignancy:
Patients with hematologic tumors tend to have more
ulceration than do patients who are being treated for a solid
tumor.
5- Use of radiotherapy:

Concomitant use of radiation will further exacerbate the

effect of chemotherapy on the structures of oral cavity.
EFFECT:

-Inflammation and ulceration of the mucous membranes;

can increase the risk for pain, oral and systemic infection,
and nutritional compromise.
Stages of oral
mucositis
1.Initiation

2.Up-regulation and message generation

3.amplification and signaling

4.ulceration

5.healing
1-Initiation :

caused by direct damage of DNA and other cell components

leading to production of reactive oxygen and free radicals
which leads to further tissue damage.
2-up regulation and massege regeneration:

DNA breakage and reactive oxygen from the Initiation stage

1-activate production of TNFα, IL-1β, and IL-6, which results
in tissue damage and apoptosis.

2-Macrophages activation, activates MMPs ( matrix

metalloprotenase) that cause direct tissue injury.
3-Amplification and signaling phase :

There are multiple positive feedback loops are

activated that increase the number and level of
activating signals for cell injury and death .

1-Thinning and atrophy of the epithelium .

2-Marked degeneration of collagen .
Clinically:

1- Erythema.

2- Patient at this stage is asymptomatic or mild symptomatic.

4-Ulceration phase :

Damage and destruction of the basal cells

Loss of continuity of oral mucosa.

Clinically:

1-These process initially seen as leukoplakia over the

oral mucosa progresses over a two week period to
erythema and ulceration.
2- The ulcerated surfaces collect debris and become
vulnerable to secondary infections .

3-At this phase patients will be most symptomatic

PAIN
LOSS OF
FUNCTION

INFLAMMATION
5-Healing phase:

It consists of a renewal of epithelial proliferation and

differentiation as white blood cell counts normalize
oral mucositis assessment scales according to world health
organization:

Grade 0: none.
Grade 1: soreness and erythema with pain but no ulceration.
Grade 2 :erythema and ulcers patient still able to eat sold
. food.
Grade 3: liquid diet only.
Grade 4 : oral nutrition is not possible (parenteral nutrition
. or tube feeding).
 2-Infection:
viral, bacterial, and fungal; results from bone marrow
suppression, xerostomia, and/or damage to the mucosa
from chemotherapy or radiotherapy.
Signs of infection:

1- Temperature of 38C or higher.

2- chills and shakes.

3-Areas of redness or tenderness.

4-sore throat .

5- protective coughing.

6-Itching and burning sensation.

 3-neurological and dental alterations:
-Altered tooth development, craniofacial growth, or
skeletal development in children secondary to
radiotherapy and/or high doses of chemotherapy before
age 9.

- Neurotoxicity: persistent, deep aching and burning pain

that mimics a toothache, but for which no dental or
mucosal source can be found.
 4-Xerostomia/salivary gland dysfunction:
Dryness of the mouth due to thickened, reduced, or absent
salivary flow; increases the risk of infection and
compromises speaking, chewing, and swallowing.
Medications other than chemotherapy can also cause
salivary gland dysfunction. Persistent dry mouth increases
the risk for dental caries.
 5- Bleeding tendency:

Oral bleeding from the decreased platelets and clotting

factors associated with the effects of therapy on bone
marrow.
 6- Development of osteonecrosis :
Blood vessel compromise and necrosis of bone exposed to
high-dose radiation therapy; results in decreased ability to
heal if traumatized.
 Dental Management

Before During After

chemotherapy chemotherapy chemotherapy
Dental treatment before, during and after
chemotherapy:
1-Before chemotherapy:
A− The dentist should consult the oncologist to determine
the current condition of the patient and the type of treatment
planned.

.
B− Exhaustive examination of
the oral cavity with
radiographic evaluation:

- discard periapical lesions

and/or bone alterations, and
the evaluation of periodontal
health.

-Identify and treat existing

infections, carious and other
compromised teeth, and tissue
injury or trauma.

-Extract nonrestorable teeth.

c− Teeth that are non-viable or present a poor prognosis
should be removed: Teeth that are non-viable or present a
poor prognosis (pericoronitis, extensive caries, advanced
periodontal disease and periapical disorders)

a- Minor surgery: al least two weeks before chemotherapy.

b- Major surgery: 4-6 weeks before chemotherapy. The

operation should be minimally traumatic in order to secure
good and rapid healing.
D − Denture fitting should be checked, with readjustment or
removal of those prostheses that proved to be traumatic
E− General prophylactic measures:
1-calculus removal

2- Rinses with 0.12% chlorhexidine.

3-Sealing of cracks and fissures in

recently erupted molars and
premolars is advised
 4-Dental fluorization .
a high-potency fluoride gel,
delivered via custom gel-applicator
trays, is recommended. patients
should start a daily 10-minute
application of a 1.1% neutral pH
sodium fluoride gel or a 0.4%
stannous fluoride gel.

Patients with porcelain crowns or resin or glass ionomer

restorations should use a neutral pH fluoride. Be sure that the
trays cover all tooth structures without irritating the gingival
or mucosal tissues.
F-Remove orthodontic bands and brackets if highly
stomatotoxic chemotherapy is planned or if the
appliances will be in the radiation field.

G− The patient should be informed of the

complications of treatment (e.g., mucositis).
 During chemotherapy
management of

Xerostom Bleeding
Mucositis Infection Pain
ia tendency
2-During chemotherapy:
Treatment of the complications of chemotherapy (mucositis,
xerostomia…) .
1- mucosistis:
Strict dental hygiene is indicated:
1-Using a soft toothbrush replacing toothbrushes, every
4 hours and at bed time.

2-Routinely flossing.
3-Salt/soda gargles (½
teaspoonful of salt and 1
teaspoonful of baking soda in
a quart of water).
Every (2-4)hours

Note:
If your toothpaste is too irritating, you can use a
solution made by dissolving 1 teaspoon of salt in 4 cups
of water, or mixing 1 teaspoon baking soda in 2 cups of
water.
4-Dietary changes (frequent small, high-calorie, high-
protein meals and supplemental drinks, with adequate
fluid intake).

5-Avoidance of hot, spicy, coarse foods, beverages with a

high acid content or carbonation, and alcoholic drinks.
Avoid candy, gum, and soda unless they are sugar-free.
6-Smoking cessation;
and antidepressant medications.

7-Calcium/phosphate oral rinse

(Caphosol, EUSA Pharma) at the
beginning of chemoradiation to
alleviate oral discomfort and dryness,
in addition to cleaning and
lubricating the oral mucosa.
8- Coating Agents:
The goal of coating agents is to cover the ulcerated
tissue of mucositis, thereby acting like an intraoral
bandage.
Some may contain topical anesthestics, which are short
acting, but the effective function is long-term coverage
e.g. Sucralfate suspension and hydroxpropyl cellulose
gel.
9-Laser Therapy. Low energy laser therapy has been proposed
as a treatment to prevent or lessen oral mucositis

10- Anticholinergic drug, has been shown to reduce the

severity and frequency of oral mucositis by causing salivary
stimulation which speed the healing of mucositis because
epidermal growth factor (EGF) is present in saliva. EGF plays
a critical role in normal wound healing.
2- Xerostomia:
-Sip water frequently.

-Suck ice chips or sugar-free candy.

-Chew sugar-free gum.

-Use a saliva substitute spray or gel or

a prescribed saliva stimulant if
appropriate.

-Avoid glycerin swabs(oil base can

promote infection).
3-Pain management:

1- Provide topical anesthetics

(orajel / orabase)

2− Analgesics:
-paracetamol (panadol)
- metamizol (novalgin).
-Narcotics can be used in
case of sever pain.

3− NO NSAID.
 4-Cepacol Lozenges, Chloraseptic spray and lozenges,
or the use of tea (particularly chamomile) for swishing
and gargling may be of some help

5-In mild cases, ice pops, water ice, or ice chips may
help numb the area, but most cases require more
intervention for relief or pain.
4-Infection:

− Antibiotics:
Dose adjustment is required according to the
observed creatinine clearance values in patients with kidney
problems.

-Drugs metabolized by kidney like amoxicillin ,penicillin G,

metronidazol …etc, if the creatinine clearance less than 10
ml/min the dose need to be given at longer time interval.
NOTE:
1-Great caution is required with the administration of drugs,
since all antineoplastic agents cause bone marrow
suppression to one degree or other, as well as variable liver
toxicity, nephrotoxicity, and gastrointestinal disorders .
2-Narcotics for pain will cause constipation, and
appropriate stool softeners will need to be taken with
them.
3-Due to the interactions that occur between non-steroidal
anti-inflammatory drugs (NSAID) and immunosuppressors
e.g.
-with corticosteroids (used to control pain): risk of
. gastric ulcer.
-with cyclosporine: nephrotoxicity.
-with methotrexate (to decrease risk of gastric ulcer
. with omeperazol): risk of bleeding.

So,it is contraindicated ,
and also due to its
effect on the platelet
which can increase the
risk of bleeding.
5-Bleeding tendency:
No elective dental treatment should be carried out. ONLY
emergency dental care.

The oncology team have to conduct blood work 24 hours

before dental treatment to determine whether the patient’s
platelet count, clotting factors, and absolute neutrophil
count are sufficient to recommend oral treatment. Postpone
oral surgery or other oral invasive procedures if:
1-platelet count is less than 75,000/mm 3 or abnormal
clotting factors are present.
2-absolute neutrophil count is less than 1,000/mm 3 (or
consider prophylactic antibiotics)
3-After chemotherapy:

A− Insist on the need for routine systematic oral hygiene.

B− Use of chlorhexidine rinses and fluorization.

C− Elective dental treatment.