REFERENCE MANUAL V 37 / NO 6 15 / 16

Guideline on Dental Management of Pediatric

Patients Receiving Chemotherapy, Hematopoietic
Cell Transplantation, and/or Radiation Therapy
Originating Committee
Clinical Affairs Committee

Review Council
Council on Clinical Affairs

Adopted
1986

Reaffirmed
1994

Revised
1991, 1997, 1999, 2001, 2004, 2008, 2013

Purpose pediatric dentistry, AND practice guideline; Field: all; Limits:

The American Academy of Pediatric Dentistry (AAPD) recog- within the last 10 years, humans, English, clinical trials, birth
nizes that the pediatric dental professional plays an important through age 18. Sixty one thousand four hundred thirty two
role in the diagnosis, prevention, stabilization, and treatment articles matched these criteria. One hundred thirty three papers
of oral and dental problems that can compromise the child’s were chosen for review from this list and from the references
quality of life before, during, and after cancer treatment. within selected articles. When data did not appear sufficient
Dental intervention with certain modifications must be done or were inconclusive, recommendations were based upon
promptly and efficiently, with attention to the patient’s expert and/or consensus opinion by experienced researchers
medical history, treatment protocol, and health status. and clinicians.
Chemotherapy and/or radiotherapy for the treatment of
cancer or in preparation for hematopoietic cell transplantation Background
(HCT)* may cause many acute and long-term side effects in A multidisciplinary approach involving oncologists, nurses,
the oral cavity. Furthermore, because of the immunosuppres- social workers, dieticians, dentists and other related health
sion that patients experience, any existing or potential sources professionals is essential in caring for the child before, during
of oral/dental infections and/or soft tissue trauma can com- and after any cancer therapy.1 The oral cavity is highly
promise the medical treatment, leading to morbidity, mortality, susceptible to the effects of chemotherapy and radiation and
and higher hospitalization costs. It is imperative that the pedi- is the most frequently documented source of sepsis in the
atric dentist be familiar with the medical history as well as oral immunosuppressed cancer patient.1 For these reasons, early
manifestations of the patient’s underlying condition and the and definitive dental intervention, including comprehensive
treatment differences for patients undergoing chemotherapy oral hygiene measures, reduces the risk for oral and associated
and/or radiotherapy and those who will receive HCT. systemic complications.1-13
Acute oral sequelae as a result of cancer therapies and HCT
Methods regimens are common in children. 2 Oral and associated
This guideline is and update of the previous document adopted systemic complications may include pain, mucositis, oral
in 1986 and last revised in 2008. The revision included a new ulcerations, bleeding, taste dysfunction, secondary infections
systematic literature search of the PubMed® electronic data- (eg, candidiasis, herpes simplex virus), dental caries, salivary
base using the parameters: Terms: pediatric cancer, pediatric gland dysfunction (eg, xerostomia), neurotoxicity, mucosal
oncology, hematopoietic cell transplantation, bone marrow fibrosis, post-radiation osteonecrosis, soft tissue necrosis,
transplantation, mucositis, stomatitis, chemotherapy, radiother- temporomandibular dysfunction (eg, trismus), craniofacial
apy, acute effects, long-term effects, dental care, oral health, and dental developmental anomalies, and oral graft versus
host disease (GVHD).1,2,14
* The term HCT is also referred to as hematopoietic stem cell transplantation (HSCT).

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All patients with cancer should have an oral examination surgical implantation or other active infections.18,19 Due to
prior to initiation of the oncology therapy.1 Prevention and the risk of antibiotic adverse events, development of drug
treatment of pre-existing or concomitant oral disease is essential resistance among oral flora, spectrum of non-oral bacteria
to minimize complications in this population.6 The key to causing catheter-related infections, and lack of evidence from
success in maintaining a healthy oral cavity during cancer clinical trials, antibiotic prophylaxis is not necessary for
therapy is patient compliance. The child and the parents patients with an indwelling central venous catheter who are
should be educated regarding the possible acute side effects undergoing dental procedures. 18,19 Immunosuppression is
and the long-term sequelae of cancer therapies in the oral not an independent risk factor for nonvalvular device in-
cavity.2-6,8,15-17 Because there are many oncology and HCT fections; immunocompromised hosts who have those devices
protocols, every patient should be managed on an individual should receive antibiotic prophylaxis as advocated for
basis; consultations with the patient’s physicians and, when immunocompetent hosts. 18-21 Consultation with the child’s
appropriate, other dental specialists should be sought before physician is recommended for management of patients with
dental care is instituted.5 nonvalvular devices.

Recommendations Dental history review: includes information such as fluoride

Dental and oral care before the initiation of cancer therapy exposure, habits, trauma, symptomatic teeth, previous care,
Objectives preventive practices, oral hygiene, and diet assessment.
The objectives of a dental/oral examination before cancer
therapy starts are three-fold:16,17 Oral/dental assessment: should include thorough head, neck,
• To identify and stabilize or eliminate existing and poten- and intraoral examinations, oral hygiene assessment and
tial sources of infection and local irritants in the oral training, and radiographic evaluation based on history and
cavity—without needlessly delaying the cancer treatment clinical findings.
or inducing complications.
• To communicate with the oncology team regarding Preventive strategies
the patient’s oral health status, plan, and timing of Oral hygiene: Oral hygiene includes brushing of the teeth
treatment. and tongue two to three times daily with regular soft nylon
• To educate the patient and parents about the importance brush or electric toothbrush, regardless of the hematological
of optimal oral care in order to minimize oral problems/ status.5,8,9,13,21,22 Ultrasonic brushes and dental floss should be
discomfort before, during, and after treatment and about allowed only if the patient is properly trained.8 Patients with
the possible acute and long-term effects of the therapy in poor oral hygiene and/or periodontal disease may use chlorhex-
the oral cavity and the craniofacial complex. idine rinses daily until the tissue health improves or mucositis
develops.4 The high alcohol content of commercially-available
Initial evaluation chlorhexidine mouthwash may cause discomfort and dehydrate
Medical history review: should include, but not be limited to, the tissues in patients with mucositis; thus, an alcohol-free
disease/condition (type, stage, prognosis), treatment proto- chlorhexidine solution is indicated in this situation.
col (conditioning regimen, surgery, chemotherapy, radiation,
transplant), medications (including bisphosphonates), allergies, Diet: Dental practitioners should encourage a non-cariogenic
surgeries, secondary medical diagnoses, hematological status diet and advise patients/parents about the high cariogenic
[complete blood count (CBC)], coagulation status, immuno- potential of dietary supplements rich in carbohydrates and
suppression status, presence of an indwelling venous access oral pediatric medications rich in sucrose.4
line, and contact of oncology team/primary care physician(s).1
For HCT patients, include type of transplant, HCT source Fluoride: Preventive measures include the use of fluoridated
(ie, bone marrow, peripheral stem cells, cord blood stem toothpaste or gel, fluoride supplements if indicated, neutral
cells), matching status, donor, conditioning protocol, date of fluoride gels/rinses, or applications of fluoride varnish for
transplant, and presence of GVHD or signs of transplant patients at risk for caries and/or xerostomia. 4,8 A brush-on
rejection. The American Heart Association (AHA) recommends technique is convenient and may increase the likelihood of
that antibiotic prophylaxis for nonvalvular devices, including patient compliance with topical fluoride therapy.8
indwelling vascular catheters (ie, central lines) is indicated only
at the time of placement of these devices in order to prevent Trismus prevention/treatment: Patients who receive radiation
surgical site infections.18-20 The AHA found no convincing therapy to the masticatory muscles may develop trismus. Thus,
evidence that microorganisms associated with dental proce- daily oral stretching exercises/physical therapy should start
dures cause infection of nonvalvular devices at any time after before radiation is initiated and continue throughout treat-
implantation. 18-20 The infections occurring after device ment. Therapy for trismus may include prosthetic aids to reduce
implantation most often are caused by staphyloccal Gram- the severity of fibrosis, trigger-point injections, analgesics,
negative bacteria or other microorganisms associated with muscle-relaxants, and other pain management strategies.3,5,10

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Reduction of radiation to healthy oral tissues: In cases of to other therapies (eg, radiotherapy, surgery). The patient’s
radiation to the head and neck, the use of lead-lined stents, blood counts normally start falling five to seven days after
prostheses, and shields, as well as salivary gland sparing tech- the beginning of each cycle, staying low for approximately
niques (eg, three-dimensional conformal or intensity modulated 14 to 21 days, before rising again to normal levels for a
radiotherapy, concomitant cytoprotectants, surgical transfer few days until the next cycle begins. Ideally, all dental care
of salivary glands), should be discussed with the radiation should be completed before cancer therapy is initiated.
oncologist. When that is not feasible, temporary restorations may be
placed and non-acute dental treatment may be delayed
Education: Patient/parent education includes the importance until the patient’s hematological status is stable.1,5,8,10,11
of optimal oral care in order to minimize oral problems/ • Prioritizing procedures: When all dental needs cannot be
discomfort before, during, and after treatment and the possible treated before cancer therapy is initiated, priorities should
acute and long-term effects of the therapy in the craniofacial be infections, extractions, periodontal care (eg, scaling,
complex.1 prophylaxis), and sources of tissue irritation before the
treatment of carious teeth, root canal therapy for perma-
Dental care nent teeth, and replacement of faulty restorations.10,14
Hematological considerations14: The risk for pulpal infection and pain determine which
• Absolute neutrophil count (ANC): carious lesions should be treated first.8 Incipient to small
— >2,000/mm3: no need for antibiotic prophylaxis;1,10 carious lesions may be treated with fluoride and/or
— 1000 to 2000/mm3: Use clinical judgment1 based on sealants until definitive care can be accomplished.5 It is
the patient’s health status and planned procedures. important for the practitioner to be aware that the signs
Some authors1,5 suggest that antibiotic coverage (dosed and symptoms of periodontal disease may be decreased in
per AHA recommendations19) may be prescribed when immunosuppressed patients.5
the ANC is between 1,000 and 2,000/mm3. If infec- • Pulp therapy in primary teeth: Although there have been
tion is present or unclear, more aggressive antibiotic no studies to date that address the safety of performing
therapy may be indicated and should be discussed pulp therapy in primary teeth prior to the initiation of
with the medical team; and chemotherapy and/or radiotherapy, many clinicians
— <1,000/mm3: defer elective dental care. In dental choose to provide a more definitive treatment in the form
emergency cases, discuss antibiotic coverage (antibiotic of extraction because pulpal/periapical/furcal infections
prophylaxis versus antibiotic coverage for a period during immunosuppression periods can become life-
of time) with medical team before proceeding with threatening.5,8,11,14 Teeth that already have been treated
treatment. The patient may need hospitalization for pulpally and are clinically and radiographically sound
dental management.12 should be monitored periodically for signs of internal
• Platelet count5,14: resorption or failure due to pulpal/periapical/furcal in-
— >75,000/mm3: no additional support needed; fections.
— 40,000 to 75,000/mm3: platelet transfusions may be • Endodontic treatment in permanent teeth: Symptomatic
considered pre- and 24 hours post-operatively. Local- non-vital permanent teeth should receive root canal
ized procedures to manage prolonged bleeding may treatment at least one week before initiation of cancer
include sutures, hemostatic agents, pressure packs, therapy to allow sufficient time to assess treatment suc-
and/or gelatin foams; and cess before the chemotherapy.5,10,14 If that is not possible,
— <40,000/mm3: defer care. In dental emergency cases, extraction is indicated. Extraction is also the treatment
contact the patient’s physician to discuss supportive of choice for teeth that cannot be treated by definitive
measures (eg, platelet transfusions, bleeding control, endodontic treatment in a single visit. In that case, the
hospital admission and care) before proceeding. In extraction should be followed by antibiotic therapy
addition, localized procedures (eg, microfibrillar (penicillin or, for penicillin-allergic patients, clindamycin)
collagen, topical thrombin) and additional medica- for about one week.5,10,12 Endodontic treatment of asymp-
tions as recommended by the hematologist/oncologist tomatic non-vital permanent teeth may be delayed until
(eg, aminocaproic acid, tranexamic acid) may help the hematological status of the patient is stable.10,11,14,23 It
control bleeding.1 is important that the etiology of periapical lesions associ-
• Other coagulation tests may be in order for individual ated with previously endodontically treated teeth be de-
patients. termined because they can be due to a number of factors
including pulpal infections, inflammatory reactions,
Dental procedures: apical scars, cysts, and malignancy.8 If a periapical lesion
• In general terms, most oncology/hematology protocols is associated with an endodontically treated tooth and no
(exclusive of HCT, which will be discussed later) are signs or symptoms of infection are present, there is no
divided into phases (cycles) of chemotherapy, in addition need for retreatment or extraction since the radiolucency
likely is due to an apical scar.23

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• Orthodontic appliances and space maintainers: Poorly- are best managed by a dental specialist in coordination
fitting appliances can abrade oral mucosa and increase the with the oncology team in the hospital setting.
risk of microbial invasion into deeper tissues.5 Appliances Loose primary teeth should be allowed to exfoliate
should be removed if the patient has poor oral hygiene naturally. Nonrestorable teeth, root tips, teeth with perio-
and/or the treatment protocol or HCT conditioning dontal pockets greater than six millimeters, symptomatic
regimen carries a risk for the development of moderate to impacted teeth, and teeth exhibiting acute infections,
severe mucositis.14 Simple appliances (eg, band and loops, significant bone loss, involvement of the furcation, or
fixed lower lingual arches) that are not irritating to the soft mobility should be removed ideally two weeks (or at least
tissues may be left in place in patients who present good seven to 10 days) before cancer therapy is initiated to
oral hygiene.8,14 Removable appliances and retainers that allow adequate healing.5,8,10,11,14
fit well may be worn as long as tolerated by the patient Some practitioners prefer to extract all third molars
who maintains good oral care.5,8,24 Patients should be that are not fully erupted, particularly prior to HCT,
instructed to clean their appliance daily and routinely while others favor a more conservative approach, recom-
clean appliance cases with an antimicrobial solution to mending extraction of third molars at risk for pulpal
prevent contamination and reduce the risk of appliance- infection or those associated with significant pathology,
associated oral infections.5 If band removal is not pos- infection, periodontal disease, or pericoronitis or if the
sible, vinyl mouth guards or orthodontic wax should be tooth is malpositioned or non-functional.8,28,29
used to decrease tissue trauma.8
• Periodontal considerations: Partially erupted molars can Communication:
become a source of infection because of pericoronitis. The It is vital that the dentist communicate the comprehensive
overlying gingival tissue should be excised if the dentist oral care plan with the oncology team. Information to be
believes it is a potential risk and if the hematological shared includes the severity of dental caries (number of teeth
status permits.8,10 Patients should have a periodontal as- involved and which teeth need immediate treatment), endo-
sessment and appropriate therapy prior to receiving bis- dontic needs (pulpal versus periapical infection), periodontal
phosphonates as part of cancer treatment.25-27 Extraction status, number of teeth requiring extraction, soft tissue path-
is the treatment of choice for teeth with a poor prognosis ology, and any other urgent care needed. Furthermore, it is
that cannot be treated by definitive periodontal therapy. important for the dentist to discuss with the oncology team
If the patient has had bisphosphonates and an invasive how much time is needed for the stabilization of oral disease as
periodontal procedure is indicated, risks must be discussed this will also affect the timing of the treatment or conditioning
with the patient, parents, and physicians prior to the protocols.1
procedure.
• Extractions: There are no clear recommendations for the Dental and oral care during immunosupression periods
use of prophylactic antibiotics for extractions.14 Recom- Objectives
mendations generally have been empiric or based on The objectives of a dental/oral care during cancer therapy are
anecdotal experience. Surgical procedures must be as three-fold:
atraumatic as possible, with no sharp bony edges remain- 1. To maintain optimal oral health during cancer therapy.
ing and satisfactory closure of the wounds.5,8,10-12 If there 2. To manage any oral side effects that may develop as a
is documented infection associated with the tooth, consequence of the cancer therapy.
antibiotics (ideally chosen with the benefit of sensitivity 3. To reinforce the patient and parents’ education regarding
testing) should be administered for about one week.5,8,10,12 the importance of optimal oral care in order to minimize
To minimize the risk of development of osteone- oral problems/discomfort during treatment.
crosis, osteoradionecrosis, or bisphosphonate-related
osteonecrosis of the jaw (BRONJ), patients who will Preventive strategies
receive radiation to the jaws or bisphosphonate treatment Oral hygiene: Intensive oral care is of paramount importance
as part of the cancer therapy must have all oral surgical because it reduces the risk of developing moderate/severe mu-
procedures completed before those measures are cositis without causing an increase in septicemia and infections
instituted.25-27 If the patient has received bisphosphonates in the oral cavity.1-13,24 Thrombocytopenia should not be the
or radiation to the jaws and an oral surgical procedure sole determinant of oral hygiene as patients are able to brush
is necessary, risks must be discussed with the patient, without bleeding at widely different levels of platelet count.8,9
parents, and physician prior to the procedure. In patients Patients should use a soft nylon brush two to three times daily
undergoing long-term potent, high-dose intravenous and replace it on a regular (every two to three months) basis.8,13,24
bisphosphonates, there is an increased risk of BRONJ Fluoridated toothpaste may be used but, if the patient does
after a tooth extraction or with periodontal disease,25-27 not tolerate it during periods of mucositis due to oral burning
although most of the evidence has been described in the or stinging sensations, it may be discontinued and the patient
adult population.26 Patients with a high risk of BRONJ should switch to mild-flavored non-fluoridated toothpaste. If

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moderate to severe mucositis develops and the patient cannot Oncology has published guidelines for treatment of mucos-
tolerate a regular soft nylon toothbrush or an end-tufted itis.13,30 The most common prescriptions for management of
brush, foam brushes or super soft brushes soaked in chlor- mucositis include good oral hygiene, analgesics, non-medicated
hexidine may be used.9,17 Otherwise, foam or super soft brushes oral rinses (eg, 0.9 percent saline or sodium bicarbonate
should be discouraged because they do not allow for effective mouth rinses four to six times/day), and parenteral nutrition
cleaning.9,22 The use of a regular brush should be resumed as as needed. 1,7,13 Mucosal coating agents (eg,Amphojel ® ,
soon as the mucositis improves.8,13,30 Brushes should be air- Kaopectate®, hydroxypropylmethylcellulose) and film-forming
dried between uses.8 Electric or ultrasonic brushes are accept- agents (eg, Zilactin® and Gelclair®) also have been suggested.1
able if the patient is capable of using them without causing The use of palifermin, also known as keratnocyte growth
trauma and irritation.8 If patients are skilled at flossing without factor-1, for prevention of oral mucositis associated with
traumatizing the tissues, it is reasonable to continue flossing HCT and oral cryotherapy as prophylaxis and treatment to
throughout treatment.8 Toothpicks and water irrigation devices decrease mucositis recently have been recommended.1,13,30
should not be used when the patient is pancytopenic to avoid Palifermin has been observed to decrease the incidence and
tissue trauma.8,10 duration of severe oral mucositis in patients undergoing
conditioning with high-dose chemotherapy, with or without
Diet: Dental practitioners should encourage a non-cariogenic radiotherapy, followed by HCT.7 The guidelines, however, did
diet and advise patients/parents about the high cariogenic not recommend the use of sucralfate, antimicrobial lozenges,
potential of dietary supplements rich in carbohydrate and oral pentoxifylline, and granulocyte–macrophage-colony stimu-
pediatric medications rich in sucrose.4 lating factor mouthwash for oral mucositis.13,30
There is limited, but encouraging, evidence to support the
Fluoride: Preventive measures include the use of fluoridated use of low-level laser therapy to decrease the duration of
toothpaste or gel, fluoride supplements if indicated, neutral chemotherapy-induced oral mucositis; further studies are
fluoride gels/rinses, or applications of fluoride varnish for pa- required to evaluate the efficacy and develop specific recom-
tients at risk for caries and/or xerostomia. A brush-on tech- mendations.30-32 Appropriate protocol must be followed when
nique is convenient, familiar, and simple and may increase the using low-level laser therapy to prevent contamination and
likelihood of patient compliance with topical fluoride therapy.8 occupational risks to the child and dental team.
Studies on the use of chlorhexidine for mucositis have given
Lip care: Lanolin-based creams and ointments are more effec- conflicting results. Most studies have not demonstrated a pro-
tive in moisturizing and protecting against damage than phylactic impact, although reduced colonization of candidial
petrolatum-based products.8,11 species has been shown.7,12,30,33 Chlorhexidine is no longer
recommended for preventing oral mucositis in patients under-
Education: Patient/parent education includes reinforcing the going radiotherapy.13
importance of optimal oral hygiene and teaching strategies Patient-controlled analgesia has been helpful in relieving
to manage soft tissue changes (eg, mucositis, oral bleeding, pain associated with mucositis, reducing the requirement for
xerostomia) in order to minimize oral problems/discomfort oral analgesics. There is no significant evidence of the effec-
during treatment and the possible acute and long-term effects tiveness or tolerability of mixtures containing topical anes-
of the therapy in the craniofacial complex. thetics (eg, Philadelphia mouthwash, magic mouthwash). 30
The use of topical anesthetics has been recommended for pain
Dental care management although there are no studies available to assess
During immunosuppression, elective dental care should not the benefit and potential for toxicity. Topical anesthetics only
be provided. If a dental emergency arises, the treatment plan provide short term pain relief.13 Lidocaine use may obtund or
should be discussed with the patient’s physician who will diminish taste and the gag reflex and/or result in a burning
make recommendations for supportive medical therapies (eg, sensation, in addition to possible cardiovsascular and central
antibiotics, platelet transfusions, analgesia). The patient should nervous system effects.
be seen every six months (or in shorter intervals if there is a
risk of xerostomia, caries, trismus, and/or chronic oral GVHD) Oral mucosal infections: The signs of inflammation and infec-
for an oral health evaluation during treatment, in times of tion may be greatly diminished during neutropenic periods.
stable hematological status and always after reviewing the Thus, the clinical appearance of infections may differ signifi-
medical history. cantly from the normal.10 Close monitoring of the oral cavity
allows for timely diagnosis and treatment of fungal, viral, and
Management of oral conditions related to cancer therapies bacterial infections. Prophylactic nystatin is not effective for
Mucositis: Mucositis care remains focused on palliation of the prevention and/or treatment of fungal infections.5,34 Oral
symptoms and efforts to reduce the influence of secondary cultures and/or biopsies of all suspicious lesions should be
factors on mucositis.5,10,12,30 The Multinational Association performed and prophylactic medications should be initiated
of Supportive Care in Cancer/International Society of Oral until more specific therapy can be prescribed.1,5,8-12

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Oral bleeding: Oral bleeding occurs due to thrombocytopenia, que is convenient, familiar, and simple and may increase the
disturbance of coagulation factors, and/or damaged vascular likelihood of patient compliance with topical fluoride therapy.8
integrity. Management should consist of local approaches (eg,
pressure packs, antifibrinolytic rinses or topical agents, gelatin Lip care: Lanolin-based creams and ointments are more effec-
sponges) and systemic measures (eg, platelet transfusions, tive in moisturizing and protecting against damage than
aminocaproic acid).5,8,10 petrolatum-based products.8,11

Dental sensitivity/pain: Tooth sensitivity could be related to Education: The importance of optimal oral and dental care
decreased secretion of saliva during radiation therapy and the for life must be reinforced. It is also important to emphasize
lowered salivary pH.5,8,10 Patients who are using plant alkaloid the need for regular follow-ups with a dental professional,
chemotherapeutic agents (eg, vincristine, vinblastine) may pre- especially for patients who are at risk for or have developed
sent with deep, constant pain affecting the mandibular molars GVHD and/or xerostomia and those who were younger than
with greater frequency, in the absence of odontogenic pathol- six years of age during treatment due to potential dental de-
ogy. The pain usually is transient and generally subsides shortly velopmental problems caused by cancer therapies.
after dose reduction and/or cessation of chemotherapy.5,8,10
Dental care
Xerostomia: Sugar-free chewing gum or candy, sucking tablets, Periodic evaluation: The patient should be seen at least every
special dentifrices for oral dryness, saliva substitutes, frequent six months (or in shorter intervals if issues such as chronic
sipping of water, alcohol-free oral rinses, and/or oral moistur- oral GVHD, xerostomia, or trismus are present). Patients who
izers are recommended.8,35 Placing a humidifier by bedside at have experienced moderate or severe mucositis and/or chronic
night may be useful.10 Saliva stimulating drugs are not ap- oral GVHD should be followed closely for malignant trans-
proved for use in children. Fluoride rinses and gels are formation of their oral mucosa (eg, oral squamous cell
recommended highly for caries prevention in these patients. carcinoma).6,36

Trismus: Daily oral stretching exercises/physical therapy must Orthodontic treatment: Orthodontic care may start or resume
continue during radiation treatment. Management of trismus after completion of all therapy and after at least a two year
may include prosthetic aids to reduce the severity of fibrosis, disease-free survival when the risk of relapse is decreased and
trigger-point injections, analgesics, muscle relaxants, and other the patient is no longer using immunosuppressive drugs.24 A
pain management strategies.3,5,10 thorough assessment of any dental developmental disturb-
ances caused by the cancer therapy must be performed before
Dental and oral care after the cancer therapy is completed initiating orthodontic treatment. The following strategies
(exclusive of HCT) should be considered when providing orthodontic care for pa-
Objectives tients with dental sequelae: (1) use appliances that minimize
The objectives of a dental/oral examination after cancer ther- the risk of root resorption, (2) use lighter forces, (3) terminate
apy ends are three-fold: treatment earlier than normal, (4) choose the simplest method
• To maintain optimal oral health. for the treatment needs, and (5) do not treat the lower jaw.37
• To reinforce to the patient/parents the importance However, specific guidelines for orthodontic management,
of optimal oral and dental care for life. including optimal force and pace, remain undefined. Patients
• To address and/or treat any dental issues that may arise who have used or will be given bisphosphonates in the future
as a result of the long-term effects of cancer therapy. present a challenge for orthodontic care. Although bisphos-
phonate inhibition of tooth movement has been reported in
Preventive strategies animals, it has not been quantified for any dose or duration of
Oral hygiene: Patients must brush their teeth two to three therapy in humans.38 Consultation with the patient’s parents
times daily with a soft nylon toothbrush. Brushes should be and physician regarding the risks and benefits of orthodontic
air-dried between uses.8 Patients should floss daily. care in this situation is recommended.

Diet: Dental practitioners should encourage a non-cariogenic Oral surgery: Consultation with an oral surgeon and/or
diet and advise patients/parents about the high cariogenic periodontist and the patient’s physician is recommended for
potential of dietary supplements rich in carbohydrate and oral non-elective oral surgical and invasive periodontal procedures
pediatric medications rich in sucrose. in patients who have used or are using bisphosphonates or
those who received radiation therapy to the jaws in order
Fluoride: Preventive measures include the use of fluoridated to devise strategies to decrease the risk of osteonecrosis and
toothpaste and gel, fluoride supplements if indicated, neutral osteoradionecrosis, respectively.25-27 Elective invasive procedures
fluoride gels/rinses, or applications of fluoride varnish for pa- should be avoided in these patients.37 Patients with a high risk
tients at risk for caries and/or xerostomia. A brush-on techni- of BRONJ are best managed by in coordination with the on-
cology team in the hospital setting.

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Xerostomia: Sugar-free chewing gum or candy, special den- immunosuppression. If emergency treatment is necessary, the
tifrices for oral dryness, saliva substitutes, frequent sipping of dentist should consult and coordinate with the attending
water, alcohol-free oral rinses, and/or oral moisturizers are hematology/oncology team.
recommended.8,36,39 Placing a humidifier by bedside at night
may be useful10. Saliva stimulating drugs are not approved Phase III: Engraftment to hematopoietic recovery
for use in children. Fluoride rinses and gels are recommended The intensity and severity of complications begin to decrease
highly for caries prevention in these patients. normally three to four weeks after transplantation. Oral
fungal infections and herpes simplex virus infection are most
Trismus: Daily oral stretching exercises/physical therapy notable.1 Acute GVHD can become a concern for allogeneic
should continue after radiation therapy is finished in order to graft recipients. Xerostomia, hemorrhage, neurotoxicity, tem-
prevent or ameliorate trismus. Management of trismus may poromandibular dysfunction, and granulomas/papillomas
include prosthetic aids to reduce the severity of fibrosis, sometimes are observed.1 A dental/oral examination should be
trigger-point injections, analgesics, muscle-relaxants, and other performed and invasive dental procedures, including dental
pain management strategies.3,5,10 cleanings and soft tissue curettage, should be done only if
authorized by the HCT team because of the patient’s con-
Hematopoietic cell transplantation tinued immunosuppression.8 Patients should be encouraged to
Specific oral complications can be correlated with phases of optimize oral hygiene and avoid a cariogenic diet. Attention
HCT.1,8,14,15 to xerostomia and oral GVHD manifestations is crucial. HCT
Phase I: Preconditioning patients are particularly sensitive to intraoral thermal stimuli
The oral complications are related to the current systemic and between two and four months post-transplant.8 The mecha-
oral health, oral manifestations of the underlying condition, nism is not well understood, but the symptoms usually
and oral complications of recent medical therapy. Oral com- resolve spontaneously within a few months. Topical application
plications observed include oral infections, gingival leukemic of neutral fluoride or desensitizing toothpastes helps reduce
infiltrates, bleeding, ulceration, temporomandibular dysfunc- the symptoms.8
tion.1 Most of the principles of dental and oral care before the
transplant are similar to those discussed for pediatric cancer.17 Phase IV: Immune reconstitution/recovery from systemic toxicity
The two major differences are: 1) in HCT, the patient receives After day 100 post-HCT, the oral complications predominant-
all the chemotherapy and/or total body irradiation in just a ly are related to the chronic toxicity associated with the condi-
few days before the transplant, and 2) there will be prolonged tioning regimen, including salivary dysfunction, craniofacial
immunosuppression following the transplant. Elective dentis- growth abnormalities, late viral infections, oral chronic GVHD,
try will need to be postponed until immunological recovery has and oral squamous cell carcinoma.1,8 Xerostomia and relapse-
occurred, at least 100 days following HCT, or longer if chronic related oral lesions may also be observed.1 Unless the patient is
GVHD or other complications are present.5,8 Therefore, all neutropenic or with severe chronic GVHD, mucosal bacterial
dental treatment should be completed before the patient infections are less frequently seen. Periodic dental examinations
becomes immunosuppressed. with radiographs can be performed, but invasive dental treat-
ment should be avoided in patients with profound impairment
Phase II: Conditioning neutropenic phase of immune function.8 Consultation with the patient’s physician
In this phase, which encompasses the day the patient is admit- and parents regarding the risks and benefits of orthodontic
ted to the hospital to begin the transplant conditioning to 30 care is recommended.
days post-HCT, the oral complications are related to the con-
ditioning regimen and supportive medical therapies.8 Mucositis, Phase V: Long-term survival
xerostomia, oral pain, hemorrhage, opportunistic infections, Craniofacial, skeletal, and dental developmental issues are some
taste dysfunction, neurotoxicity (including dental pain, muscle of the complications faced by cancer survivors1,8,14 and usual-
tremors), and temporomandibular dysfunction (including jaw ly develop among children who were less than six years of age
pain, headache, joint pain) may be seen, typically with a high at the time of their cancer therapy.8,14 Long term effects of
prevalence and severity of oral complications.1 Oral mucositis cancer therapy may include tooth agenesis, microdontia, crown
usually begins seven to 10 days after initiation of conditioning, disturbances (size, shape, enamel hypoplasia, pulp chamber
and symptoms continue approximately two weeks after the end anomalies), root disturbances (early apical closure, blunting,
of conditioning.1 Among allogeneic transplant patients, hyper- changes in shape or length), reduced mandibular length, and
acute GVHD can occur, causing more severe inflammation and reduced alveolar process height.14 The severity of the dental
severe mucositis symptoms, although its clinical presentation developmental anomaly will depend on the age and stage of
is difficult to diagnose.1 The patient should be followed closely development during exposure to cytotoxic agents or ionizing
to monitor and manage the oral changes and to reinforce the radiation. Patients may experience permanent salivary gland
importance of optimal oral care. Dental procedures usually hypofunction/dysfunction or xerostomia.37,39 Relapse or sec-
are not allowed in this phase due to the patient’s severe ondary malignancies can develop at this stage.1 Routine periodic

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 AMERICAN ACADEMY OF PEDIATRIC DENTISTRY

examinations are necessary to provide comprehensive oral 11. Semba SE, Mealy BL, Hallmon WW. Dentistry and the
healthcare. Careful examination of extraoral and intraoral cancer patient: Part 2: Oral health management of the
tissues (including clinical, radiographic, and/or additional chemotherapy patient. Compend 1994;15(11):1378, 1380-
diagnostic examinations) are integral to diagnosing any 7; quiz 1388.
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Oncol 2011;22(Suppl 6):vi78-84. Erratum in Ann Oncol
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