This document discusses dental management of pediatric patients receiving chemotherapy or radiotherapy. It outlines that cancer therapy can cause oral complications and a preventive regimen is necessary. It recommends completing all dental work before therapy starts. During therapy, it advises oral hygiene, managing infections and mucositis, and avoiding dental procedures. Following therapy, it suggests monitoring patients periodically for risks like caries and osteonecrosis. The goal is to educate patients and minimize oral issues through preventive care before, during, and after cancer treatment.

1. Management of Pediatric
Patients Receiving
Chemotherapy or Radiotherapy
General Pediatrics Course Prof. Eman Hamze
By: Riwa kobrosli
Ms1-Pediatric Dentistry

2. Introduction
Role of dentist
Preventive and Clinical Regimen
Prior to cancer therapy
During cancer therapy
Following cancer therapy
Patient Information Leaflet
References
Outline

3. Introduction
Cancer is one of the leading causes of morbidity and mortality
worldwide.
Cancer is the second leading cause of death globally.
Oral and associated systemic complications may occur as a sequelae
of immunosuppressive therapy including: pain, mucositis, oral
ulcerations, bleeding, taste dysfunction, secondary infections (e.g.,
candidiasis, herpes simplex virus), dental caries, salivary gland
dysfunction and others.
A clear pathway of care is necessary to prevent or minimize oral
complications.
RCS Oncology Guideline Update V36 - 2018
The Oral Management of Oncology Patients requiring radiotherapy, Chemotherapy and / or Bone Marrow Transplantation

4. A symptomatic treatment only
can be provided
What
should we
do as a
dentist?

5. The more we know about cancer the more lives we can save

6. Chemotherapy and radiotherapy
treatments
can affect patient mouth

8. Dental and oral care before therapy
Ideally, all dental care should be completed before
immunosuppressive therapy is initiated.
When that is not feasible, temporary restorations may be placed
and non-acute dental treatment may be delayed until the patient’s
hematological status is stable.
Prior the cancer therapy, an oral/dental assessment including
radiographs, must be undertaken.

9. Aims of pretreatment assessment
Identifying and stabilize or eliminate existing and potential
sources of infection and local irritants in the oral cavity.
Communicating with the medical team regarding the patient’s oral
health status, plan, and timing of treatment.
Educating the patient and parents about:
-The importance of optimal oral hygiene care to minimize oral
problems during cancer therapy.
-The possible effects of the therapy in the oral cavity and the
craniofacial complex.

10. Preventive and Clinical Regimen
Preventive and clinical strategies that should be taken are:
Oral Hygiene instructions.
Chlorhexidine “alcohol-free” and Periodontal treatment.
Dietary Advice.
Restoration of carious lesions.
Removal of trauma “sharp edges and poorly-fitting appliances” that
increase the risk of microbial invasion .
Trismus prevention/treatment.
Taking impressions to construct applicator trays and intra-oral
radiation stents “reduction of radiation to healthy oral tissues”.

11. Preventive and Clinical Regimen
Instructions to remove prosthesis during cancer therapy at least at
night, and clean it daily with antibacterial solution.
Extraction of teeth with doubtful prognosis no less than ten days
prior to commencement of cancer therapy (weak recommendation).
Antibiotic prophylaxis / hematological support prior to invasive oral
procedure with the oncologist
Orthodontic treatment should be discontinued and fixed appliances
removed.
Simple appliances (e.g., band and loops, fixed lower lingual arches) not
irritating the soft tissues may be left in good oral hygiene patients.

12. Endodontic treatment before therapy
In primary teeth:
Teeth needing pulp therapy  better to be extracted because
pulpal/periapical/furcal infections during immunosuppression periods
can become life-threatening.
Teeth already treated pulpally and are clinically and radiographically
sound  monitor for signs of internal resorption or infections.

13. Endodontic treatment before therapy
In permanent teeth:
Symptomatic non-vital teeth  root canal treatment at least one week
before therapy. If not possible  extraction.
Teeth that cannot be treated in a single visit  extraction + antibiotic.
Asymptomatic non-vital teeth  delayed until the hematological status
of the patient is stable.
Periapical lesion in endo treated tooth with no signs or symptoms of
infection  no retreatment nor extraction “ scar ”.

14. Osteonecrosis
Patients who will receive radiation to the jaws or bisphosphonate
treatment as part of the cancer therapy must have all oral surgical
procedures completed before those measures are instituted.
To minimize the risk of development of osteonecrosis,
osteoradionecrosis, or bisphosphonate-related osteonecrosis of the jaw
(BRONJ).

16. Dental and oral care during therapy
Hygienist Support.
Oral and Denture Hygiene regimen + Antibacterial Mouthwash + fluoride.
Management of Infections: topical antibacterial (neocyn), Anti-viral
(cyclovir), Antifungal (nystatin) for oral candida.
Mucositis: reduce the severity and control oral discomfort.
Xerostomia: reduce the effect (saliva substitutes, moisturize lip, fluids).
Dentures / Obturators: removable prostheses may become difficult to
wear and may need to be left out.
Control bleeding: by topical hemostatic agents.

17. Dental and oral care during therapy
Foam swabs / Gauze: If the mouth is too painful for cleaning with a soft
toothbrush, the tissues can be cleaned with gauze moistened with alcohol-
free chlorhexidine mouthwash
Dietary Advice:
- avoid food which irritate the oral mucosa (hard, high sugar, caffeine).
- Eat soft bland not hot food.
- Fluid intake to keep mouth moist.
- Well balanced diet high in proteins, vitamins B & C.
Dental Treatment: avoided during cancer therapy.

18. Dental treatments during therapy
The patient’s blood counts normally start falling five to seven days
after the beginning of treatment cycle, staying low for
approximately 14 to 21 days, before rising again to normal levels for
a few days until the next cycle begins.
Prioritizing procedures: When all dental needs cannot be treated
before therapy is initiated, priorities should be:
 Infections  extractions  periodontal care  treatment of
carious teeth  root canal therapy for permanent teeth  and
replacement of faulty restorations.

19. Dental and oral care during therapy
Pain and the risk for pulpal infection determine which carious lesions
should be treated first.
Incipient to small carious lesions may be treated with fluoride and
sealants until definitive care can be accomplished.
Patients requiring an organ transplant will be best able to tolerate dental
care at least three months after transplant when overall health improves.
It is important for the practitioner to be aware that the signs and
symptoms of periodontal disease may be decreased in immunosuppressed
patients
During head and neck radiotherapy: place mouth block.

20. Try to schedule dental work
a few days prior to chemo
therapy, this is the time when
the patient feels best.
After treatment they are weak.

21. Osteonecrosis
If the patient has received bisphosphonates or radiation to the jaws
and an oral surgical procedure is necessary, risks must be discussed
with the patient, parents, and physician prior to the procedure.
In patients undergoing long-term potent, high-dose intravenous
bisphosphonates, there is an increased risk of BRONJ after a tooth
extraction or with periodontal disease.

23. Dental and oral care following therapy
Monitor periodically.
Dental Caries Risk assessment.
Gingival / Periodontal Risk: Bone marrow transplant patients on
cyclosporine may need more frequent hygienist support if gingival
hyperplasia is a side
Preventive Advice and Fluoride supplementation.
Xerostomia control.
Smoking Cessation.

24. Dental and oral care following therapy
Abnormal Blood counts: Patients on maintenance chemotherapy or with
persistent hemato-oncology disease may need blood tests pre-operatively
if invasive treatment is planned.
Herpes Labialis: can be a chronic problem and requires timely
management. Topical aciclovir may be effective.
Limited Mouth Opening: jaw exercises.
Growth and Development: should be closely monitored. Survivors of
childhood cancer are at risk of dental developmental abnormalities.
Dental Extractions: risk of osteoradionecrosis and / or medication-
related osteonecrosis of the jaw.

25. Dental and oral care following therapy
Orthodontics: remove to reduce dental caries susceptibility, root
stunting, risk of osteonecrosis and inhibiting effect of bisphosphonates
on orthodontic tooth movement.
Dentures/removable appliances: discontinued if the mouth becomes
painful and advice must be sought.
Obturators: Unlike dentures, obturators should not be left out at night
for the six months following treatment.

26. Osteonecrosis
Following a diagnosis of ORN it is recommended that oral trauma is
minimised, and a high standard of oral hygiene is established.
Local measures are employed to relieve symptoms including topical /
systemic analgesia.
High dose systemic antibiotics are prescribed if there are symptoms of
persistent infection.
Surgical excision of exposed necrotic bone with primary mucosal
closure may become necessary.
In some cases, the use of hyperbaric oxygen therapy (HBOT) may be a
beneficial adjunct to surgical interventions (under clinical trial).

27. Dental treatment following therapy
Dental treatment usually is safe after:
3 months following chemotherapy /
radiotherapy to head and neck.
6 months following total body radiation.

29. Patient Information Leaflet
Reproduced from the Royal College of Surgeons of England / The British Society for Disability and Oral Health Clinical Guidelines - Updated 2018

30. This leaflet gives you information on how to manage the possible side
effects in the mouth due to radiotherapy and chemotherapy
 Radiotherapy can cause side effects in the mouth.
 Your mouth needs to be as healthy as possible before the start of
treatment to avoid problems later.
 Infected teeth and gums can be a risk during cancer treatment.
 You should have a thorough dental check-up and seek advice from a dentist
before cancer treatment starts.
 If you have cancer of the head and neck, this is arranged by the oncology
team when they plan your care.
 Throughout your radiotherapy or chemotherapy your mouth needs careful
monitoring by either a dental hygienist or an appropriately trained nurse.
Patient Information Leaflet
Reproduced from the Royal College of Surgeons of England / The British Society for Disability and Oral Health Clinical Guidelines - Updated 2018

31. How can my mouth be affected by cancer treatment?
 Not everyone will get changes in the mouth during cancer treatment
 About two weeks after the start of radiotherapy and chemotherapy you may
notice changes
 The most common side effects include general soreness and mouth ulcers, dry
mouth, altered / loss of taste and difficulty swallowing and eating.
 These generally improve a couple of weeks after cancer treatment is completed.
How can I help to reduce the impact of therapy on my mouth?
 Brush teeth twice daily using toothpaste, which contains fluoride to prevent
dental decay.
 Keep dentures clean and take them out at night.
 Sugary snacks and drinks can cause dental decay – the dietician may need you to
have these to keep your energy up.
 Use a pain relieving mouthwash if your mouth is sore (ask you dentist).
 Sip water if your mouth is dry – avoid sipping sugary or acidic drinks and sweets.
Patient Information Leaflet
Reproduced from the Royal College of Surgeons of England / The British Society for Disability and Oral Health Clinical Guidelines - Updated 2018

32. side effect
of treatment
Why does this happen during
your cancer therapy?
What can I do? What should I avoid?
Sore mouth • Radiotherapy and
chemotherapy can make the
lining of your mouth thin
• This can make your mouth,
tongue and throat may become
red and sore
• You may also get mouth ulcers
• It can become uncomfortable
to eat, speak, swallow and
brush your teeth.
• Your dentist or doctor can recommend
you a mouthwash to help with the
soreness
• If there is thrush in your mouth, they
can give you medication for this
• Use a brush with a small head to clean
your teeth with a fluoride toothpaste
• If your blood counts are very low, a
soft brush may be used for a limited
period of time
• Strongly flavored
toothpaste or
mouthwash
• Hard food, spicy food
and hot drinks
• Alcohol and tobacco
Dry Mouth • Radiotherapy can damage the
glands which produce saliva
• Saliva moistens the mouth and
protects against tooth decay
and tooth sensitivity.
• The dryness is worse during
treatment but slowly improves.
• Saliva may not return
completely
• Sip water frequently.
• Try and chew sugar-free gum.
• Discuss saliva substitutes with the
dentist / doctor
• Oral gel or lubricant (e.g. (Vaseline,
Cetraben) are useful to coat and
protect the lips and soft tissues.
• Follow the dietitian’s advice regarding
food and drink
• Fizzy drinks, diet
drinks and fruit juice
• Sucking / chewing
sweets
Patient Information Leaflet
Reproduced from the Royal College of Surgeons of England / The British Society for Disability and Oral Health Clinical Guidelines - Updated 2018

33. side effect
of treatment
Why does this happen during
your cancer therapy?
What can I do? What should I avoid?
Altered /
Loss of
taste
• Radiotherapy and
chemotherapy can affect your
taste buds
• A dry mouth can also affect
your taste
• Taste will return after cancer
treatment is completed
• Sip water regularly • Fizzy drinks, diet
drinks and fruit juice
• Sucking / chewing
sweets
Difficulty
swallowing /
eating
• Dryness and soreness of the
mouth makes swallowing
difficult
• This can reduce your
enthusiasm for food and
contribute to weight loss
• Let your oncology team know if this
occurs as they can monitor this and help
• Rinse your mouth with a pain relieving
mouth wash before eating
• Sip water frequently
• Eat moist food / have water with food
• Eat high energy food such as pasta,
bread, and potatoes
• see a dietitian if you are losing weight
• Hard / dry food
• Acidic food
Difficulty
Wearing
Dentures
• Lack of saliva and mouth
soreness can make dentures
difficult to wear.
• See your dentist if your dentures are
painful
• Clean your dentures after each meal, at
least twice daily
• Do not sleep with
your dentures in your
mouth
Patient Information Leaflet
Reproduced from the Royal College of Surgeons of England / The British Society for Disability and Oral Health Clinical Guidelines - Updated 2018

34. o The Royal College of Surgeons of England / The
British Society for Disability and Oral Health
Clinical Guidelines - Updated 2018
The Oral Management of Oncology Patients
requiring radiotherapy, Chemotherapy and / or Bone
Marrow Transplantation.
o MANUAL OF PEDIATRIC DENTISTRY
Dental Management of Pediatric Patients Receiving
immunosuppressive Therapy and/or Radiation
therapy - Updated 2018.

35. ThankYou