The objective of this presentation to improve removable prosthodontic therapy during chemotherapy to improve the patient's quality of life, enhance nutrition by reducing oral irritation and ulceration, and control the oral microbial populations associated with chemotherapy and the wearing of a denture. During chemotherapy what all thing, let a dentist know well it helps to provide information regarding the what all to use or not use .

1. and its Prosthodontics Implication

2. Article references
 Chaveli López B, Gavaldá Esteve C, Sarrión Pérez MG.
Dental treatment considerations in the chemotherapy
patient. J Clin Exp Dent. 2011;3(1):e31-42
 Lopez BC, Esteve CG, Perez MGS. Dental treatment
considerations in the chemotherapy patient. J Clin Exp
Dent 2010;3:31-42.

3. Topics to be covered.......
 DEFNITION
 TYPES
 ETIOPATHOGENESIS
 TOXIC EFECT OF CHEMOTHERAPY
 GENERAL SIDE EFFECT
 ORAL SIDE EFFECT
 TREATMENT

4. CHEMOTHERAPY
 Chemotherapy is a type of cancer treatment, that
uses one or more anti-cancer drugs as part of a
standardized chemotherapy regimen.
 Chemotherapy may be given with a curative intent it
may aim to prolong life or to reduce symptoms
(palliative chemotherapy).

5. TYPES
 Alkylating agents : eg cyclophosphamide
 Antimetabolites : eg 5-Fluorouracil
 Anti-microtubule agents : eg vincristine
 Topoisomerase inhibitors : eg doxorubicin
 Cytotoxic antibiotics : eg bleomycin

6. The chemotherapeutic agents most
commonly used in head and neck
malignancies are
• Bleomycin,
• Cisplatin,
• Methotrexate,
• 5-fluorouracil,
• Vinblastine
• Cyclophosphamide

7. AIM
 The aim of this discussion is to isolate and describe
the oral side effects arising only from chemotherapy
and focus on the dentist’s contribution to their
management.

8. Etiopathogenesis:
Antineoplastic drugs can act upon the tissues either
directly or indirectly.
The direct side effects of such drugs start with the primary
oral tissue damage caused by their indiscriminate effect
upon the cell replication cycle, such as for example in the
oral mucosa, where these cytotoxic agents destroy the
proliferating basal cells of mucosal layer

9. The indirect side effects in turn are caused
by non-oral actions that have a collateral
impact upon the oral cavity, such as bone
marrow suppression, the loss of tissue
immune cells, and the loss of salivary
protective element.

10. TOXIC EFFECT OF CHEMOTHERAPY
 Many drugs target rapidly proliferating cells; however,
they have the same action upon rapidly proliferating
normal tissues such as bone marrow, intestinal
mucosa, oral mucosa, hair follicles, and gonads.
 Particularly in the oral mucosa, they destroy the basal
cells of the mucosal layer, and their replacement or
turnover is affected resulting in mucosal ulceration.

11. The main problem posed by such
treatment is the lack of selectivity of
most antineoplastic drug substances,

12. General side effects of chemotherapy
• Bone marrow suppression
• Alopecia
• Hand-foot syndrome (clinically characterized
by painful, symmetrical erythema of the palms
and soles)
• Most of the side effects gradually disappear
after the end of treatment
• Some cases permanent damage may be
observed at cardiac (myocardiopathy),
pulmonary (fibrosis), renal (chronic renal
failure) or reproductive level (sterility)

13. Oral complications of chemotherapy
• Mucositis,
• Neurotoxicity,
• Susceptibility to infections
• Dental related problem
• Salivary and taste alterations
• Osteonecrosis.

14. •Mucositis usually appears 4-7 days after the start of
highdose
•It in turn disappears 2-4 weeks after the withdrawl of
cytotoxic chemotherapy
• The drugs most often associated with the development of
mucositis are doxorubicin, bleomycin,
fluorouracil and methotrexate

15. Tongue necrosis due to chemotherapy with a nucleoside metabolic
inhibitor in a patient with acute myeloblastic leukaemia

16. MANAGEMENT
Oral hygiene protocols recommend dental intervention
before chemotherapy, which included the use of dental
floss and oral rinses.
• Sterile water or physiologic saline solution seems to be
more effective than chlorhexidine.
• In addition, rinses with povidone iodine reduce the
severity of OM.
• Anti-inflammatory agents, such as benzydamine, are
used for both prevention and management of OM.

17. Recent studies have shown that only a few interventions are effective
in the prevention and treatment of OM.
Cryotherapy proves to be an effective choice for patients receiving
chemotherapy.
On the other hand, cryotherapy is contraindicated in patients
treated with oxaliplatin, to eliminate the possibility of neurological
side effects such as mandibular stiffness

18. •According to certain reports, zinc sulfate may restrict the extent of OM
• Polaprezinc suspension proved to be effective in preventing OM after high dose
chemotherapy course.

19. Fungal infections:
Bone marrow suppression,
Oral mucosal lesions and salivary alterations contribute to the
development of Candida albicans infection . The
most common presentations are pseudomembranous
candidiasis, followed by erythematous candidiasis.
treatment of these conditions involves the use of
topical and/or systemic antifungal agents eg fluconazole
In case the patient wears removable dentures, the dentures should
be disinfected in nystatin, chlorhexidine solution, or diluted sodium
hypochloride for at least 20-30 min every day. The patient must not
wear the dentures during the night.

21. Neurotoxicity
A number of chemotherapeutic agents such as vincristine
and vinblastine are able to cause direct neurotoxicity.
Patients may experience deep and palpitating mandibular
pain that tends to subside one week after concluding
chemotherapy.
Topical fluorides or special desensitizing toothpaste may
prove to be efficient in restricting the symptoms.

22. Dysgeusia
During chemotherapy, patients may experience an
unpleasant ,metallic taste due to diffusion of the
chemotherapeutic agent into the oral cavity.
• Agents associated with taste defects are cisplatin,
doxorubicin, 5-fluorouracil, levamisole, doxecatel,
paclitaxel, cyclophosphamide, or carboplatin.
Alterations in taste have been recorded in 26% of the patients receiving crizotinib. The
replacement of crizotinib with alectinib, which is also an alkylating inhibitor, showed
promising results.

23. Hyposialia and xerostomia
effect of chemotherapy on the salivary glands,
• transient and reversible.
It appears particularly with the use of adriamycin,
and can cause oral functional problems, especially
in relation to speech and mastication

24. Alterations in salivary components during
chemoterapy
• increase in the levels of peroxidase and amylase,
• reduction in total secreted immunoglobulins A and G,
• presence of the chemotherapeutic drug also
•patients should drink abundant water and
• use sugar-free sweets or chewing gum to increase
salivation.
• sialogogues such as pilocarpine,
•bromhexine or bethanechol can be used.

25. chemotherapy has a systemic effect.
The developing odontogenic cells are susceptible to
chemotherapy, even when far removed from
the tumor site.
Minicucci et al. (2003) detected delays
in dental development, hypoplasia and microdontia in
children receiving chemotherapy

26. Age below 5 year chemotherapy is containdicated
Chemotherapy is responsible for certain dental anomalies
such as microdontia, enlargement of the dental pulp
chamber, tooth developmental retardation, or root
malformations.
Enamel hypoplasia and discoloration are the most
common defects.
Studies in animals revealed dental anomalies caused by agents such
as vinblastine, vincristine, doxorubicin, and cyclophosphamide.

27. Bleeding tendency
Bleeding is due to alterations resulting from thrombocytopenia
( bone marrow aplasia).
Clinically, patients my present petechiae, ecchymosis,hematomas or
diffuse bleeding
Routine CBC test ,platlet count<50000 dental surgical procedure is
not done
If less than 20000 then gingival bleeding can see eaisly
,vastibule,soft palate,lower lip most suseptible for hemmorrage
Treatments of choice in the event of bleeding comprise
the use of vasoconstrictors such as topical epinephrine,
Muco-adherent tissue protectors such as the cyanoacrylates

28. Osteonecrosis
Osteonecrosis of the jaw (ONJ) is observed in patients
treated with bisphosphonates (BPs)
• Inhibit bone resorption
• iv route given
• treatment for bone metastases in cancer patients,
• malignant hypercalcemia ,
•multiple myeloma

30. Bisphosphonate drugs
•The most commonly used in North America are
pamidronate (90 mg infused over 2 hours every 3
to 4 weeks)
•zoledronate (4 mg infused over 15 minutes).

31. . In summary, in the absence of debilitating ONJ
lesions, conservative therapy with optimal oral
hygiene, topical antibiotic rinses, and systemic
antibiotics are advised as needed for pain or
infection.
For non-responsive ONJ lesions, surgery is an
option and includes ostectomy of the affected
area with resection margins that extend into
adjacent normal-appearing bone.
Soft tissue closure should be tension-free with no
underlying sharp edges of bone that could lead to
a mucosal breakdown.

32. Prosthodontic implication
Discontinuing the drug before dental
treatment has not been demonstrated to
reduce the risk of osteonecrosis, as the drug
has been shown to persist in human bone for
up to 12 years.