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 Author's personal copy

Dent Clin N Am 52 (2008) 19–37

Dental Treatment Planning

and Management in the Patient
Who Has Cancer
Michael T. Brennan, DDS, MHSa,*,
Sook-Bin Woo, DMD, MMScb,c,
Peter B. Lockhart, DDSa
a
Department of Oral Medicine, Carolinas Medical Center, PO Box 32861,
Charlotte, NC 28232, USA
b
Division of Oral Medicine and Dentistry, Brigham and Women’s Hospital,
75 Francis Street, Boston, MA 02115, USA
c
Harvard School of Dental Medicine, 188 Longwood Avenue, Boston, MA 02115, USA

The management of dental disease before and during cancer therapy

poses many challenges to the dental practitioner. Cancer therapy has numer-
ous potential short-term and long-term oral complications that may require
modification of dental management strategy. Dental treatment may also
require modification in situations where it must be delivered expeditiously
and there is little time to institute an ideal treatment plan. For example,
patients first diagnosed with acute leukemia begin induction chemotherapy
within days of their diagnosis and will not have sufficient time for elective
therapy and elimination of all sources of dental disease. During chemother-
apy when white blood cell (WBC) counts are low, a dentist may elect to treat
a dental infection with antibiotics rather than an extraction. In spite of this,
pretherapy dental evaluation consisting of a good history, examination, and
oral radiographs provide a baseline assessment that may be helpful if prob-
lems occur during cancer therapy.

Dental management of a patient in preparation for cancer therapy

The need for conducting a pretreatment oral evaluation depends on the
cancer diagnosis and planned cancer therapy. Patients diagnosed with solid

* Corresponding author.
E-mail address: mike.brennan@carolinas.org (M.T. Brennan).

0011-8532/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2007.10.003 dental.theclinics.com
 Author's personal copy

20 BRENNAN et al

tumors (such as breast, prostate, lung, or colon cancersdthe most common

cancers in the United States) are not typically evaluated. Patients who are
most frequently seen before chemotherapy or radiation are those who are
at the highest risk for developing short-term and long-term complications
as outlined above. These include the following:
(1) Patients undergoing chemotherapy followed by hematopoietic stem
cell transplantation (HSCT) [1]. Conditioning regimens for HSCT
are generally myeloablative and place the patient at high risk for infec-
tious complications during the period of pancytopenia. Autologous
HSCT is used to treat lymphoma, multiple myeloma and some meta-
static solid tumors to the marrow. In this procedure, the patient’s
own stem cells are collected before conditioning, and then reinfused
to reconstitute the marrow that has been ablated by chemotherapy.
Allogeneic HSCT is generally performed in patients with leukemia or
bone marrow failure syndromes such as aplastic anemia where the dis-
eased marrow is replaced by healthy marrow from a donor. Following
allogeneic HSCT, patients may be immunosuppressed in the long term
because of prophylaxis for chronic graft-versus-host disease (GVHD),
slow immune reconstitution, and treatment for chronic GVHD.
(2) Patients who require head and neck radiation therapy. Head and neck
cancers that are typically treated with head and neck radiation therapy
include squamous cell carcinoma, salivary gland malignancies, and
lymphoma. Radiation at therapeutic doses induces long-term irrevers-
ible damage to the salivary glands, connective tissues, vasculature, and
healing potential of the jawbones, and in particular the mandible.
The following are the goals of dental management before the start of can-
cer therapy.

Eliminate or stabilize oral disease to minimize local and systemic

infection during and after cancer therapy
Short term
Cytoreductive therapy generally leads to low WBC counts and in partic-
ular low neutrophil counts (neutropenia), which increases susceptibility to
infection, in particular bacterial infections. Since most odontogenic infec-
tions such as caries, periodontal infection and third molar infections are
usually of bacterial origin, elimination of potential sources of infection
from the oral cavity is a key strategy to prevent new infections or exacer-
bation of existing chronic infections [2]. Ideally, all patients should be
returned to a stable, if not perfect state of dental health before cytoreduc-
tive therapy.
Mucosal injury or mucositis is a common side effect of cancer therapy
and removal of sharp edges of teeth or restorations may help to reduce
trauma to the mucosa and reduce the severity of mucositis and attendant
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DENTAL TREATMENT IN THE PATIENT WHO HAS CANCER 21

pain and discomfort. Furthermore, ulcers of mucositis may act as a gateway

for ingress of oral bacteria in profoundly myelosuppressed individuals with
the potential for bacteremia and septicemia [3]. The frequency of viridans
streptococci in neutropenic patients has become more common, with Strep-
tococcus mitis being the most common species identified [4,5]. Up to one
third of viridans streptococci–infected patients can develop shock syndrome
[6].

Long term
Radiation therapy to the head and neck has the potential for increased
caries risk and reduced healing capacity (especially of the bone) in the
long term [7]. Elimination of dental disease by judicious restorative dentistry
and periodontal treatments, and extraction of teeth with questionable prog-
nosis are important preventive strategies to avoid future dental extractions,
an important risk factor for postradiation osteonecrosis. Custom trays for
prescription fluoride applications are often fabricated for patients since life-
long fluoride therapy helps to minimize radiation-induced dental caries. Pa-
tients treated with intravenous (IV) bisphosphonates are at risk for
developing bisphosphonate-related osteonecrosis of the jaws [8,9]. Because
invasive dental procedures such as extractions are a risk factor for this con-
dition, elimination of dental disease to reduce the necessity for such dental
procedures in the long term is an important aspect of patient management.
Patients who undergo allogeneic hematopoietic stem-cell transplantation
may develop chronic GVHD (see the article by Schubert and Correa else-
where in this issue). This disease may result in painful mucosal ulcerations,
increased caries rates, hyposalivation, and sometimes fibrosis, limiting
mouth opening. Similar to patients with radiation-induced salivary gland
hypofunction, caries even when incipient must be treated and dental treat-
ment should not be deferred.

Identify issues specific to the cancer diagnosis

A thorough examination of the mouth for oral involvement of the pri-
mary tumor such as leukemic infiltrates (especially in the gingiva) and jaw
involvement from multiple myeloma should be performed. Such oral in-
volvement that may not have been noted previously may change the stage
of the patient’s disease and impact future cancer therapy.

Educate the patient regarding short-term and long-term

oral complications from cancer therapy
This provides an opportunity to educate the patient about the role of
dental health in systemic disease. Patients should be informed about why
a dental evaluation is important before cancer therapy, what to expect dur-
ing cancer therapy (such as mucositis and xerostomia), and measures that
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22 BRENNAN et al

can be taken to minimize side effects of therapy. The importance of long-

term follow-up should also be stressed, especially with respect to postradia-
tion caries and osteonecrosis, bisphosphonate-related osteonecrosis of the
jaws, and chronic GVHD in the appropriate patient population. Written in-
formation is usually helpful for patients and many cancer centers provide
such information for patient education. The National Institutes of Health
provides information and pamphlets free of charge at the following Web
site: https://cissecure.nci.nih.gov/ncipubs/searchResults.asp?subject2¼
CopingþwithþCancer.

Pretreatment evaluation and treatment planning

The pretreatment evaluation for patients with cancer requires a thorough
understanding of the cancer diagnosis and stage, and should include a review
of systems, current medications, drug allergies, and social and family history,
in addition to a comprehensive oral examination (Box 1). Communication
with the patient’s oncologist with regard to previous and planned cancer ther-
apy helps the dentist and dental specialist to plan and schedule dental treat-
ment appropriately.
The logistics of a pretreatment evaluation can be complicated by many
factors. For patients who prefer to be treated by their own dentist or
who may not be able to travel to the cancer center for dental treatment,
an off-site dental evaluation program may be used [10]. In this type of pro-
gram, the dentist performs the entire evaluation and treatment planning
guided by written instructions from the dental oncology service. All treat-
ment is provided by the dentist or dental specialist in the community.
Although this has been used primarily for patients scheduled for HSCT,
the same program may be used for any of the other patient populations dis-
cussed above. Off-site evaluations save time, are preferred by many patients,
save hospital resources, and are well-accepted by dentists in the community
who welcome the opportunity to play an important role in their patients’
cancer care.

Presenting symptoms
Cancer patients can present with a wide range of oral symptoms and
a thorough review of the CHaracter, Location, Onset, Radiation, Intensity,
Duration, and Exacerbating factors (CHLORIDE is a useful mnemonic) of
these symptoms helps the dentist arrive at a diagnosis. Distinguishing
between acute infections of pulpal versus periodontal origin, or temporo-
mandibular joint (TMJ) versus odontogenic origin is vital in arriving at
an appropriate treatment plan. Importantly, patients may experience pain
directly related to their cancer. Patients with squamous cell carcinoma in
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DENTAL TREATMENT IN THE PATIENT WHO HAS CANCER 23

Box 1. Pretreatment evaluation

Review recent medical history
Past medical history
Medications
Drug allergies
Social history
Family history
Review current cancer diagnosis
Previous cancer treatment
Planned cancer treatment
Past dental history
Frequency of past visits, including hygiene
History of extractions, periodontal surgery, endodontics,
pain, swelling, bleeding, ulcers
Present oral complaint
Character, location, onset, radiation, intensity, duration,
and exacerbating factors of the complaint
Management of current oral complaints
Oral examination
Extraoral
Observe for asymmetries, swelling, or skin lesions
Palpate for nodes, salivary glands, temporomandibular
joint, muscles of mastication, and neck muscles
Intraoral
Remove appliances: examine for fit, function,
and aesthetics
Evaluate for soft tissue abnormalities
Examine teeth for plaque, calculus, caries, mobility,
faulty restorations, fractures
Radiographs
Panoramic radiograph and full-mouth radiographic series
Examine for bone loss, caries, root tips, impactions, calculus,
periapical/furcation radiolucencies, fractures
Laboratory values
Complete blood count + WBC differential
prothrombin time/international normalized ratio/partial
thromboplastin time

the oral cavity often experience pain from the tumor and this must be differ-
entiated from pain of odontogenic origin [11].
A history of extractions, periodontal surgery, and endodontic therapy
together with a history of previous pain, swelling, or bleeding should be
obtained in case these areas become symptomatic during cancer therapy.
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24 BRENNAN et al

Laboratory values
A recent complete blood count (CBC) must be obtained on patients with
leukemia, myeloma, and marrow failure syndromes such as aplastic anemia
before examination of the patient. The CBC should be evaluated in the context
of the patient’s disease. A high neutrophil count in a patient with acute myeloid
leukemia does not necessarily indicate an infection, but is typical of the disease.
Since many of these neutrophils are not functional, the patients will still be
highly susceptible to infection. Marrow involvement by primary malignancy
such as leukemia or metastatic disease reduces the volume of ‘‘normal’’ hema-
topoietic elements resulting in neutropenia, thrombocytopenia, and anemia
[12,13].

Necessity for antibiotic prophylaxis

Another consideration for cancer patients is the concern regarding infec-
tions with indwelling catheters such as Hickman lines. The rate of blood-
stream infection with Hickman catheters has been reported as 4.7
episodes per 1000 catheter-days [14], with neutropenia an important risk fac-
tor for catheter-related infections [15]. A Cochrane review of antimicrobial
prophylactic antibiotics before insertion of long-term tunneled central ve-
nous catheters in oncology patients found administration of an antibiotic
before catheter insertion did not significantly decrease catheter infection,
but that flushing the catheter with vancomycin and heparin did have a pos-
itive overall effect [16]. There is no guideline regarding the necessity for
antibiotic prophylaxis before invasive oral procedures as there is no clear
link between dental procedure–related bacteremia and catheter infection.
However, antibiotic prophylaxis before invasive oral procedures may be rec-
ommended for patients with central venous catheters; the current American
Heart Association protocol for prevention of infective endocarditis follow-
ing oral procedures is frequently used for these patients.

Clinical examination
Patients with squamous cell carcinoma presenting for preradiation ther-
apy evaluation may have healing surgical sites both extra- and intraorally.
The clinician must be empathetic in the presence of oral discomfort and
take care to minimize trauma to the soft tissues during the examination.

Extraoral examination
The head and neck examination should consist of an inspection for asym-
metries, swellings, or skin lesions, followed by palpation of the lymph nodes
of the submental, submandibular, and cervical chains. Lymph nodes should
be evaluated for the presence of pain to palpation, mobility, or fixation. A
lymph node that is fixed and nonpainful is a common finding in metastatic
tumors to the node while a freely movable and tender node is more likely to
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DENTAL TREATMENT IN THE PATIENT WHO HAS CANCER 25

represent an infectious or inflammatory process. Salivary glands, the tempo-

romandibular joint (TMJ) area, muscles of mastication, and neck muscles
should be palpated to provide baseline information.

Intraoral examination
A systematic approach to the oral cavity is important to avoid missing
more subtle pathologic processes. The soft tissues of the buccal mucosa, floor
of mouth, tongue, palate, and oropharynx should be examined for erythema,
ulceration, erosions, mucosal hemorrhages, swellings, or other lesions. The
saliva expressed from the major salivary glands should be examined for pres-
ence, color, and consistency. The presence of cloudy and thick saliva may rep-
resent a chronic bacterial infection of the salivary gland(s).
Patients with leukemia, especially acute monocytic or myelomonocytic
leukemia may present with leukemic infiltration of the oral cavity [17]. These
patients may have boggy, swollen gingiva that bleed when brushing or upon
palpation during the clinical examination (Fig. 1). Petechiae and ecchymoses
may develop with decreased platelet counts (thrombocytopenia) [12].
Patients may also present with opportunistic infections because of their
immunocompromised status. These include candidiasis and herpes infec-
tions (such as herpes simplex virus [HSV] or varicella zoster virus) and their
presentation may be abnormal in this population [18–20]. For example,
intraoral HSV may present like aphthous ulcers on the nonkeratinized sites
rather than on typical keratinized mucosa. Candidal infections may have
different clinical presentations ranging from a typical white plaque that
can be removed with gauze (pseudomembranous candidiasis or ‘‘thrush’’),
to red lesions (erythematous candidiasis), to hyperplastic lesions that cannot
be removed with gauze, to cracking at the corners of mouth (angular chei-
litis). Deep fungal infections may present as solitary lesions. Culture or biopsy
may be indicated depending on the clinical appearance and differential

Fig. 1. Leukemic involvement of the maxillary and mandibular gingiva. (Courtesy of Sook-Bin
Woo, DMD, Boston, MA.)
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26 BRENNAN et al

diagnosis of the lesion(s) (see the article by Lerman and colleagues elsewhere
in this issue).
Periodontal probing depths and assessment of tooth mobility should be
performed, bearing in mind that the patient may be neutropenic or throm-
bocytopenic. Bacteremia from dental probing has been estimated to occur in
10% to 40% of patients, and appears to be related to the severity of gingival
and periodontal disease [21,22]. One study examined the impact of both
periodontal probing and dental scaling on development of fever and/or bac-
teremia in patients before chemotherapy. The results found no difference in
the incidence of fever or bacteremia in the probing/scaling group compared
with a noninvasive oral examination group [23]. Negative outcomes of peri-
odontal probing in immunosuppressed patients with cancer has not been
thoroughly evaluated; therefore, it still remains unclear if the bacteremia
from periodontal probing alone can increase the risk of bacteremia and sep-
ticemia while a patient is neutropenic. The potential for bleeding complica-
tions with markedly low platelet count (eg, !20,000 cells/mL) may limit
periodontal probing in some patients [24].
The teeth should be examined for caries, failing restorations, and loss of
vitality. Teeth with large restorations and crowns may be asymptomatic and
yet have necrotic pulps and the potential to develop an abscess during or fol-
lowing cancer therapy. The retention, stability, and tissue health under
removable appliances should also be evaluated. Patients should be told
that they may have to discontinue wearing full and partial dentures to avoid
soft tissue trauma during cancer therapy.

Radiographic examination
Ideally, the dentist should evaluate a full-mouth series (FMS) of radio-
graphs and a panoramic radiograph taken within the preceding 6 months
for dental and osseous pathology. Patients with head and neck cancer
may have limited ability to tolerate a full oral and radiographic examination
because of pain and limited opening, either from the cancer or from surgery.
In a study of 65 patients who were to undergo HSCT, carious lesions, peri-
odontal disease, and faulty restoration were detected more commonly in the
FMS, while findings such as detection of third molars, neoplasms, and mul-
tiple myeloma were detected more commonly in the panoramic radiograph
[25]. These findings show the importance of obtaining an FMS and pano-
ramic radiograph for situations where odontogenic infections need to be
accurately diagnosed because of potential serious consequences. In patients
with multiple myeloma, a panoramic radiograph should always be taken to
evaluate for jaw involvement (Fig. 2).
However, obtaining an FMS is not always possible because of time and
resource constraints. As stated in the preceding paragraph, patients with
head and neck cancer may have limited ability to tolerate a full oral and
radiographic examination because of pain and limited opening, either
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DENTAL TREATMENT IN THE PATIENT WHO HAS CANCER 27

Fig. 2. Radiolucencies representing involvement of the left mandible by multiple myeloma.

(Courtesy of Nathaniel S. Treister, DMD, DMSc, Boston, MA.)

from the cancer or from surgery. In such situations, a panoramic film with
bitewings and selected periapical films is the minimal requirement. Previ-
ously obtained dental radiographs from the patient’s dentist may also be
used as long as the radiographs are no more than 6 months old.

Treatment planning
Treatment planning is guided by several principles that include evaluat-
ing the following: (1) risk of infection during neutropenia, (2) risk of osteo-
necrosis, and (3) risk of infection/bleeding following dental procedures. An
important principle in treatment planning for chemotherapy is asking this
question: What is the likelihood of the patient developing an infection
when he or she has no white cells if I do not treat this tooth/condition? In
patients who are about to undergo radiation therapy or start IV bisphosph-
onate therapy, the question is: What is the likelihood that this tooth will re-
quire extraction within the next few years? Before performing procedures,
an important question to ask is: Is this patient at risk for infection or bleed-
ing after the procedure? A CBC should be obtained before beginning proce-
dures, especially surgical procedures or a dental scaling.
In general, all carious teeth should be restored and a scaling and prophy-
laxis should be performed; extractions should be performed as soon as pos-
sible to allow for maximal healing time [26]. Only the most superficial
occlusal caries may be deferred, and only if there is no alternative. After can-
cer therapy has been completed, some patients still suffer severe morbidities
and may develop even more complications that may make originally innoc-
uous carious lesions turn into rampant caries especially after radiation or
with chronic GVHD [7,27]. Patients may develop fibrosis and experience
trismus that make it difficult to open their mouths even for routine restor-
ative dentistry [28,29].
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28 BRENNAN et al

A thorough debridement of plaque and calculus before cancer therapy

should decrease gingival inflammation and has the potential to decrease
the risk of oral mucositis. Previous studies have demonstrated a potential
role of good oral hygiene for the management of oral mucositis [30].
The timing of dental treatment must take into account when cancer
therapy will occur (see Case Study 1 later in this article). In patients
who are candidates for autologous HSCT, dental treatment must be
avoided during the 3 days when stem cells are harvested so as to min-
imize contamination of the harvest with circulating bacteria. Surgical
procedures such as extractions must take into account the WBC nadir,
the period when WBC counts are at their lowest during chemotherapy.
A surgical procedure is best completed at least 1 week before chemo-
therapy to allow approximately 2 weeks of healing before the WBC na-
dir, which often occurs 7 to 14 days after the start of chemotherapy,
depending on the chemotherapy regimen [31]. If this time is not avail-
able, the dentist and oncologist must weigh the risk of an infection dur-
ing cancer treatment versus the risk of poor healing going into cancer
treatment.
For the patient with head and neck cancer scheduled to receive radiation
therapy, concern for impaired healing must also be taken into consideration.
Radiation reduces bone-remodeling activity with a reduction in the number
of cells and progressive fibrosis [7]. Invasive dental procedures may lead to
poor healing and infection [32]. Allowing for 3 weeks of healing time after
extractions is ideal in patients who require radiotherapy. Because of numer-
ous factors that may delay therapy in patients with head and neck cancer,
a shorter time than 3 weeks between dental procedures and radiotherapy
is more commonly available [33]. Thus, similar to the patients undergoing
chemotherapy, the dentist and oncologist must consider the risk of infection
versus poor healing during and after radiotherapy if less than 3 weeks is
available.
The patient’s cancer stage and prognosis must be taken into consider-
ation for treatment planning. The dental treatment plan for a patient with
a poor prognosis who is receiving palliative cancer therapy or for a patient
with a prognosis of less than 6 months may include removal of symptomatic
teeth with active infection, simple restorative dentistry, and dental prophy-
laxis, and should not include placement of extensive fixed prosthesis and
dental implants. Supplemental fluoride is a mainstay of caries control in
patients with hyposalivation such as seen in radiation-induced salivary
gland dysfunction or chronic GVHD. The use of custom-fabricated fluoride
gel carriers improves delivery of fluoride to the teeth, although compliance
of a custom tray may be limited [34,35]. If the cost of a fabricating a custom
tray is too prohibitive, brush-on prescription fluoride gels (such as 1.1%
sodium fluoride gel) may be used [36]. Newer fluoride-releasing systems
are currently being investigated, and may be a future option for patients
with head and neck cancer [37].
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DENTAL TREATMENT IN THE PATIENT WHO HAS CANCER 29

Dental treatment during cancer therapy

The management of oral mucositis from chemotherapy and radiation
therapy is discussed in articles by Lalla and colleagues and Fischer and Ep-
stein elsewhere in this issue. Despite the best efforts to eliminate dental dis-
ease before cancer therapy, acute infection from an odontogenic or
periodontal source may occur during the cytopenic stage of cancer chemo-
therapy. This section will only discuss the management of acute dental infec-
tions during cancer therapy. The goal of dental treatment during this period
is to treat the infection and symptoms while trying as far as possible to avoid
an invasive procedure because of neutropenia and thrombocytopenia, and
sometimes severe mucositis.
The usual signs of infection, such as pain, redness, swelling, and/or puru-
lence may be less pronounced or absent during neutropenia. Neutropenia and
thrombocytopenia during chemotherapy are usually contraindications for
invasive dental procedures until blood counts return to safer levels (eg,
when the absolute neutrophil count is O1000/mL and platelet count is
O50,000/mL). Patients with dental infections during neutropenia can be
treated with appropriate antibiotics and pain medications until counts im-
prove even if the offending tooth is identified, to avoid bacteremia, poor heal-
ing, and infection of the surgical site [38] (see Case Study 2 later in this article).
Dental treatment such as incision and drainage of abscesses or extractions
may be necessary in cases of a spreading infection not controlled by antibi-
otics or if airway compromise occurs. Biopsies of suspicious oral lesions
may also be required to rule out an infectious etiology (eg, invasive fungal in-
fection). When an invasive dental procedure is indicated during thrombocy-
topenia and neutropenia, a platelet transfusion before the procedure (to bring
the platelet count up to 50,000/mL) and systemic antibiotics are indicated.
Careful local management of the surgical site with resorbable gelatin sponges
and primary closure of the wound is required for effective hemostasis. Other
adjunctive measures to control bleeding include topical thrombin and tra-
nexamic acid (an anti-fibrinolytic agent) mouthwash [39,40].

Dental management of patients with a history of cancer

Patients may be seen by their dentist before cancer therapy and return to
their dentist for continued follow-up and routine dental care. However, den-
tists may also see new patients in their practice who have been treated for
cancer.
The goals of management in both these populations are the following:
(1) maintain good oral health by routine maintenance dental treatment.
Patients should be on a follow-up and maintenance program as with any
other patient without cancer, with a frequency dictated by the patient’s den-
tal needs. For patients new to the practice, the same concepts introduced in
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30 BRENNAN et al

the pretreatment evaluation section would apply. They should be thoroughly

evaluated to determine the type of cancer and therapy rendered, recurrences
and treatment regimens for recurrences, current cancer status (ie, remission
versus recurrence), and long-term medical and maxillofacial side effects of
cancer therapy.
(2) identify and manage oro-dental issues specific to the patient’s cancer
diagnosis.
Possible long-term side effects will be more pronounced for patients
who have received head and neck radiotherapy, such as xerostomia and
hyposalivation, increased caries incidence, postradiation osteonecrosis
(see article by Fischer and Epstein elsewhere in this issue), dysgeusia, tris-
mus and chronic fungal infections (see article by Lerman and colleagues
elsewhere in this issue). Patients presenting after radiotherapy should be
closely evaluated for radiation caries, which are commonly located in
the incisal and cervical portion of the tooth [7]. Compliance with oral hy-
giene and fluoride use should be closely monitored and appropriate recom-
mendations made based on deficiencies. Frequent follow-up visits are
especially important to identify early carious lesions. Patients with a history
of metastatic cancer or multiple myeloma should be asked if they have
ever been treated with IV or oral bisphosphonates. Because IV bisphosph-
onates may be given only monthly or bimonthly, patients may not include
this on a current medication list. These patients are at risk for bisphosph-
onate-related osteonecrosis of the jaws (see article by Ruggerio and Woo
elsewhere in this issue). Preventive and routine dental care to identify
and treat sites of infection early will help to minimize the future need
for invasive dento-alveolar surgery. Continued routine follow-up is impor-
tant to identify early areas of osteonecrosis so appropriate intervention can
be provided [9].
Approximately 50% of patients develop chronic GVHD after allogeneic
HSCT (see article by Schubert and Correa elsewhere in this issue) with at-
tendant problems of mucosal lichenoid mucositis, hyposalivation, and
sometimes trismus. Patients should be followed closely for dental disease
and for management of mucosal disease.
(3) monitor for recurrences and second primary tumors.
The local recurrence rate for oral cavity squamous cell carcinoma is
approximately 30%, while the occurrence of second primary cancers after
treatment for laryngeal cancer has been estimated at 17% to 18% [41,42].
An understanding of soft tissue changes as a result of fibrosis from previous
surgeries or radiotherapy helps differentiate these changes from recurrent
cancer. The distinction may be subtle since both can present as tissue
induration.
Additionally, an increased risk of second primary cancers of the head and
neck has been identified for survivors of soft tissue sarcoma, neuroblastoma,
and leukemia [43]. Squamous cell carcinomas are the most common second
primary solid malignancy after allogeneic HSCT [44]. As such, a careful and
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DENTAL TREATMENT IN THE PATIENT WHO HAS CANCER 31

comprehensive soft tissue examination should be performed for all patients

at follow-up dental visits.

Case studies
The following are two case studies that demonstrate how a pre–cancer
therapy oral evaluation and treatment plan is arrived at and executed.

Case study 1: patient scheduled for chemotherapy and radiation

L.K. is a 42-year-old male who presented for dental evaluation before
radiotherapy and chemotherapy, having been diagnosed 2 months earlier
with a 3  5 cm squamous cell carcinoma of the right lateral tongue and
floor of mouth. A 2 cm fixed lymph node in the right neck was positive
for metastatic carcinoma. The tumor node metastasis stage was T3 N2a
MO consistent with a Stage III cancer. He had undergone a surgical re-
section of the primary tumor and a neck dissection on the ipsilateral side
1 week prior, and was scheduled for intensity modulated radiotherapy
(IMRT) at 70 GY to the tumor base, and concomitant cisplatin
40 mg/m2 weekly for six doses beginning on day 1 of IMRT. Combined
IMRT and chemotherapy were tentatively scheduled to start 3 to 4 weeks
from the day of the dental examination. The patient reports continued
improvement in postoperative pain and function after his tumor resec-
tion, but did report some postoperative discomfort. Patient reports new
onset pain in area of right temporomandibular joint (TMJ) after surgical
resection.
Past medical history (PMH) included hypertension and gastroesophageal
reflux disease. His medications include hydrochlorothiazide (25 mg daily) and
pantoprazole (40 mg daily). He denied any drug allergies. His social history
reveals a one pack/day smoking history for 30 years and 2 to 3 beers/day
for 25 years.
Past dental history (PDH) was negative for dental pain. However, he had
not received routine dental care for 3 years.
Extraoral examination revealed scarring from his recent neck dissection.
The right TMJ was tender to palpation. There were no salivary gland abnor-
malities and no tenderness to palpation within the muscles of mastication
and neck muscles.
Intraoral examination revealed scar tissue in the left tongue and floor of
mouth resection site. There was generalized gingivitis and plaque on the teeth.
There were 4 mm probing depths associated with the third molars; all other
probing depths were % 3 mm. Caries were present in multiple teeth as follows:
#3 occlusal, #9 facial, #17 occlusal-lingual, #18 mesial, #19 occlusal-distal,
#30 occlusal, #31 occlusal-distal, and #32 occlusal. Pulp testing was com-
pleted on #30, which had a large restoration and the tooth was determined
to be vital. Radiographs confirmed theses findings (Figs. 3 and 4).
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32 BRENNAN et al

Fig. 3. Panoramic radiograph for Case 1.

Assessment
This 42-year-old man who had a resection of a left tongue and floor of
mouth squamous cell carcinoma and who is scheduled with chemotherapy
and radiation had the following findings:
 carious teeth requiring restorations and extractions
 mild periodontal bone loss
 TMJ pain following cancer resection

Treatment plan
1. Third molar extractions. Because of the caries in his third molars and
the potential for long-term side effects of radiation therapy, #17 and
#32 were planned for extraction. The maxillary third molars were also
planned for extraction because of likely supra-eruption without the
opposing teeth.
2. Restorative dentistry. All carious teeth were planned for appropriate
amalgam or composite restorations before cancer therapy.
3. Dental prophylaxis. A dental prophylaxis was also scheduled.
4. Management of TMJ symptoms. He was placed on soft diet and warm
compresses for mild TMJ pain.
Treatment course
Extractions of all third molars were completed first, which allowed for
2 weeks of healing before chemotherapy and radiation. The patient healed

Fig. 4. Full-mouth radiographic series for Case 1. Because of postoperative pain from recent
cancer resection, patient could not tolerate periapical radiographs of mandibular teeth.
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DENTAL TREATMENT IN THE PATIENT WHO HAS CANCER 33

well from the extractions, but canceled his appointment for dental restora-
tions 4 days later because of an exacerbation of pain from the right TMJ and
muscles of mastication. He was treated with cyclobenzaprine 5 mg at bed-
time, soft diet, and warm compresses. One week later, he returned with res-
olution of pain with TMJ and muscles of mastication and had all
restorations completed over two appointments. He started chemotherapy
and radiation as scheduled.

Case 2: patient scheduled for HSCT

J.N. is a 43-year-old woman who presented for dental evaluation before
autologous HSCT for transformed B-cell lymphoma. She was diagnosed
with stage IVB follicular lymphoma 3 years earlier with initial symptoms
of night sweats and weight loss. She was initially treated with cyclophospha-
mide, vincristine, prednisone, and rituximab and received a complete clinical
remission. She continued to feel well until a skin lesion was noted on her left
anterior scalp, which was biopsied and found to be consistent with a large
B-cell lymphoma. She was treated with two cycles of ifosfamide, carbopla-
tin, and etoposide with resolution of the lesion. She was to undergo autol-
ogous HSCT and had donated her marrow several weeks prior.
Her PMH was noncontributory. She is not taking any medications and
has no known drug allergies. She denied tobacco, alcohol or illicit drug use.
PDH was noncontributory. She is seen routinely by her private dentist
every 3 months.
Extraoral examination did not reveal lymphadenopathy, salivary gland
abnormalities, TMJ discomfort or tenderness to palpation in the muscles
of mastication and neck muscles. Her CBC was within normal limits.
Intraoral examination revealed no soft tissue abnormalities of the labial
and buccal mucosa, floor of mouth, ventral and dorsal tongue, and hard and
soft palate. She had excellent oral hygiene with minimal plaque, localized
mild gingivitis, and generalized gingival recession. Deep probing depths
were identified on the distal-lingual of #2 (7 mm) and distal lingual of #15
(7 mm) without evidence of purulence or swelling; other probing depths
measured ! 3 mm. No caries were present. A cracked amalgam restoration
with a distal overhanging margin was identified on #29. Radiographs con-
firmed these findings (Figs. 5 and 6).

Assessment
This 43-year-old woman with relapsed B-cell lymphoma scheduled for
autologous HSCT had the following findings:
 an amalgam restoration on #29 with an overhanging margin
 focal moderate periodontal bone loss with 7-mm pocket depths associ-
ated with #2 and #15
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34 BRENNAN et al

Fig. 5. Panoramic radiograph for Case 2.

Treatment plan
1. Restorative dentistry. The cracked amalgam with overhanging margin
on #29 had a small risk of becoming symptomatic during treatment,
either from dentin exposure or from plaque accumulation and gingivitis
from the defective margin. This restoration was replaced before HSCT
to eliminate this potential source of infection.
2. Dental prophylaxis. A dental scaling was completed before HSCT with
curettage of pockets associated with #2 and 15.

Treatment course
She received a conditioning regimen from day 6 to day 3 of mesna
(2478 mg IV infusion over 24 hours), cyclophosphamide (2478 mg IV infu-
sion over 2 hours), cytosine arabinoside (180 mg IV infusion over 1 hour
twice a day), and etoposide (180 mg IV infusion over 1 hour twice a day).
The autologous stem cells were infused on day 0 following the conditioning
regimen. Four days after infusion during her WBC nadir, she reported
lingering hot and cold sensitivity in the upper right quadrant. On bedside
examination, she was able to localize pain to the upper right first molar
(#3), which was felt to exhibit irreversible pulpitis. There was no swelling

Fig. 6. Full-mouth radiographic series for Case 2.

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DENTAL TREATMENT IN THE PATIENT WHO HAS CANCER 35

or purulence. A decision was made to treat the tooth symptomatically only

since she was already on systemic antibiotics. She also developed grade 2
oral mucositis (erythema without ulceration) of the right buccal mucosa
and mandibular facial gingiva. She was maintained on IV morphine until
her counts improved 11 days after cell infusion. Root canal therapy was
completed through the existing crown of #3 and the patient’s pain resolved.

Summary
The oral cavity has the potential to be a major source of short-term and
long-term complications from cancer therapy. Appropriate evaluation and
elimination of potential sources of oral infection before cancer therapy is
vital because oral bacteria are a known source of bacteremia and septicemia
during cancer therapy. Cancer diagnosis with previous and planned treat-
ment, PMH, PDH, current medications, drug allergies, social history, family
history, laboratory values, extraoral findings, intraoral findings, and radio-
graphic findings must all be evaluated in planning dental treatment for these
complex cases.

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