Introduction
Historical perspective (prior to 1990)
Dental disease and the necessity of pre-cancer therapy dental clearance
Diagnosis | Management |
---|---|
Reversible pulpitis | Caries control |
Irreversible pulpitis | Initial biomechanical preparation of canal(s); temporary double closure |
Necrotic pulp with chronic periapical pathosis | No endodontic treatment unless patient has 7 days from completion of endodontic therapy to onset of myelosuppression (<1,000 granulocytes/mm3) |
Necrotic pulp with acute periapical infection | Endodontic therapy or extraction depending on systemic status of patient and scheduling of chemotherapy |
Primary wound closure with multiple interrupted sutures |
Ten days between extraction date and granulocyte count <500/mm3
|
Avoidance of intra-alveolar hemostatic packing agents |
Platelet transfusion if platelet count <40,000/mm3
|
Prophylactic antibiotics if granulocyte count <2,000/mm3
|
Long-term effect of cancer therapies on teeth and periodontium
Aims
Systematic review methodology
Search strategy and criteria for selecting studies
Review methodology
Results
Cancer diagnosis | Number of studies (references) | Number of patientsa
|
---|---|---|
Cancers in the head and neck region | ||
Squamous cell carcinoma | 385 | |
Head and neck cancer | 550 | |
Head and neck cancer (assumptions made by reviewers) | 77 | |
Nasopharyngeal cancer | 272 | |
Cancer requiring radiation to the ENT/H&N region | 2,507 | |
Tumors in the salivary gland areas | 17 | |
Hematologic malignancies | ||
Hematologic malignancies/diseases (exclude lymphoma if possible) | 2,008 | |
Lymphoma (Hodgkin's, non-Hodgkin's disease, NOS) | 325 | |
Other diagnosis | ||
Rhabdomyosarcoma | 264 | |
Osteosarcoma/Ewing sarcoma | 15 | |
Wilms tumor/nephroblastoma | 64 | |
Neuroblastoma | 59 | |
Small cell cancer | 1 [11] | 21 |
Breast cancer | 1 [41] | 1 |
Childhood cancer | 1 [34] | 52 |
Thyroid cancer | 1 [31] | 121 |
Diagnosis not specified | 25 |
Treatment modality | Number of studies (references) | Number of patientsa
|
---|---|---|
Chemotherapy only ± surgery | 710 | |
Radiation only ± surgery | 3,477 | |
Radiation and chemotherapy ± surgery | 696 | |
No breakdown or vague description of cancer therapy or other type of therapy | 1,812 |
Observational studies
Treatment modality | Number of studies | Mean prevalence (%) | STD error | 95% confidence interval |
---|---|---|---|---|
Chemotherapy only | 5 | 37.3 | 0.17 | 0–85.7 |
Radiotherapy only | 4 | 24.1 | 0.13 | 0–66.2 |
Chemoradiotherapy | 9 | 21.4 | 0.06 | 6.9–35.8 |
Interventional studies
Fluoride therapy
Author | Dx | Tx | Study type | Time of assessment | Final N/intervention 1 | Final N/intervention 2 | Final N/intervention 3 |
---|---|---|---|---|---|---|---|
Al Joburi et al. 1995 [43] | H&Na
| RTb
| RCTc
| Post-RTb
| N = 69 | N = 56 | N = 18 |
Patients recalled at intervals ranging 4 to 6 months, all patients reexamined after one year during recall appointments | Sodium fluoride gel in custom trays daily for 5 min for 3 months | Brush with stannous fluoride gel instead of dentifrice | Noncompliant with fluoride therapy | ||||
Single blind (operator) | Reminineralizing mouth rinse twice a day for next 3 months | ||||||
Continued use of regular dentifrice | |||||||
Chambers et al. 2007 [46] | H&Na
| RTb
| RCTc
| 3 months post-RTb
| Placement of IRFS retainers on bilateral maxillary molars for all patients and all used 1,100 ppm toothpaste twice daily, oral hygiene instructions | ||
N = 9 | N = 11 | ||||||
Single blind (operator) | At placement of intraoral fluoride releasing system (IRFS) retainers, at 4, 8, 12, 24, 36, and 48 weeks | Sustained release fluoride tablet replaced every 3 months | 0.4% Stannous fluoride gel in custom trays daily for 10 min | ||||
Sodium fluoride/hydroxy ethyl methacrylate/methyly methacrylate (50:50 ratio of HEMA/MMA) | |||||||
Meurman et al. 1991 [47] | Hodgkin's and non-Hodgkin's disease | CTd
| RCTc
| During combination CTd
| All patients went through a rinse period with 0.05% sodium fluoride solution from weeks 2 to 4 | ||
Double-blind cross-over study | Assessed prior to anticancer treatment, and before and after each period of rinsing with different type of mouthwash | In addition, patients in the amine-stannous fluoride group also had 0.05% sodium fluoride solution from weeks 6 to 8 | |||||
N = 51 (self control) | N = 51 (self control) | ||||||
0.12% Chlorhexidine (CHLX) rinse | 0.025% Amine-stannous fluoride mouth rinse | ||||||
Meyerowitz et al. 1998 [45] | Not specified (assumed H&Na) | H&Na RT | RCTc
| Post-RTb (completed >3 months before study) | N = 13 | N = 10 | |
Single blind (operator) | Assessments at baseline (before placement of IFRS), 1, 2, 3, 4, 5, and 6 (end of study) months | Intraoral fluoride releasing system (IFRS), fluoride pellet: sodium fluoride/hydroxy ethyl methacrylate/methyly methacrylate (50:50 ratio of HEMA/MMA) | 1.1% Neutral sodium fluoride in custom trays, 5 min daily | ||||
Spak et al. 1994 [44] | H&Na
| RTb
| RCT c
| Assessed immediate prior to RTb, 6 and at 12 months after RTb
| N = 19 | N = 18 | |
Double blind | 0.42% Fluoride gel daily from start of radiation until 2 weeks after end of radiation, then daily use of 1.23% fluoride gel for 4 weeks. Thereafter, switched to 0.42% fluoride gel and use until 1 year after baseline exam | 0.42% Fluoride gel daily from start of radiation until 1 year after baseline exam |
Toothpaste
Author | Cancer Dx | Cancer Tx | Study type | Time of assessment | Final N/intervention 1 | Final N/intervention 2 |
---|---|---|---|---|---|---|
Papas et al. 2008 [50] | Not specified (assumed H&Na) | H&Na RTb
| RCTc
| Some post-RTb (0–15 years), some still actively treated with RTb
| N = 23 | N = 19 |
Double blind | Assessed at baseline, then 1,2, 4, 6, 8, 10, and 12 months | Enamelon (dual phase remineralizing toothpaste) | Conventional toothpaste | |||
Toljanic et al. 1996 [49] | H&Na
| RTb
| RCTc
| Post-RTb
| All were given a toothbrush and 1.1% neutral sodium fluoride gel every night for 5 min, cross-over at 3 months | |
Double blind | Assessments done at start of study, 1, 2, 3, 4, 5, and 6 months | N = 19 (self control) | N = 19 (self control) | |||
Group 1 (10), group 2 (9) | Group 1 (10), group 2 (9) | |||||
Group 1: toothpaste with lactoperoxidase and glucose oxidase then placebo toothpaste | Group 2: placebo toothpaste then toothpaste with lactoperoxidase and glucose oxidase | |||||
van Steenberghe et al. 1994 [48] | Tumors in the major salivary gland area | RTb
| RCTc
| Minimum 3 months post-RTb
| Prior to study, all patients received 2 sessions of oral hygiene instructions (OHI) which included supervised toothbrushing and interproximal plaque control. At baseline, all patients received a professional cleaning. Cross-over on day 42 | |
Single blind (patient) | Assessments done at days 0, 10, 42, and 52 | N = 12 (self control) | N = 12 (self control) | |||
6 On each group | 6 On each group | |||||
Biotene toothpaste then Sensodyne toothpaste on day 42 | Sensodyne toothpaste then Biotene toothpaste on day 42 |
Chlorhexidine
Author | Cancer Dx | Cancer Tx | Study type | Time of assessment | Final N/intervention 1 | Final N/intervention 2 |
---|---|---|---|---|---|---|
Bergmann et al. 1992 [39] | Acute myelogenous leukemia | CTd
| RCTc
| During antineoplastic treatment | N = 10 | N = 10 |
Blinding unknown | Assessed on days 1, 14, and 28 of CTd
| 0.1% Chlorhexidine rinse with mechanical removal of plaque and calculus on day 1 | 0.1% Chlorhexidine rinse | |||
Joyston-Bechal et al. 1992 [51] | H&Na
| RTb
| Before and after | Assessed 1 week before RTb, once weekly during 4 weeks of treatment, and at approximately 6, 8, 10, 12, 26, 40, and 52 weeks after start of RTb
| N = 25 | NA |
0.2% Chlorhexidine, diluted 1:1 with water twice a day for 1 week before RT, during RT, and 4 weeks after radiation | ||||||
Meurman et al. 1991 [47] | Hodgkin's and non-Hodgkin's disease | CTd
| RCTc
| During combination CTd
| All patients went through a rinse period with 0.05% sodium fluoride solution from weeks 2 to 4 | |
Double-blind cross-over study | Assessed before anticancer treatment began and before and after each period of rinsing with different type of mouthwash | In addition, patients in the amine-stannous fluoride group also had 0.05% sodium fluoride solution from weeks 6 to 8 | ||||
N = 51 (self control) | N = 51 (self control) | |||||
0.12% Chlorhexidine rinse | 0.025% Amine-stannous fluoride mouth rinse |
Dental restorations
Author | Cancer Dx | Cancer Tx | Study type | Time of assessment | Final N/intervention 1 | Final N/intervention 2 | Final N/intervention 3 |
---|---|---|---|---|---|---|---|
Hu et al. 2002 [54] | Malignant tumors (assumed H&Na) | Cervicofacial RTb
| Cohort | Post-RTb
| N = 73 restorations | N = 73 restorations | |
Assessment at placement 6, 12, and 24 months | 15 patients | 15 patients | |||||
Ketac molar restorations | Fuji IX GP restorations | ||||||
McComb et al. 2002 [52] | Not specified (assumed H&Na) | H&Na RTb
| Cohort/N-RCS | Post-RTb
| N = 39 patients/44 class V restorations (initial) | N = 39 patients/44 class V restorations | N = 39 patients/44 class V restorations |
Split mouth design | Recall at 6,12, 18, and 24 months | Conventional glass ionomer (GI) restorations | Resin-modified glass ionomer restorations (RMGI) | Composite restorations | |||
Wood et al. 1993 [53] | H&Na
| RTb
| Before and after | Post-RTb
| N = 54 (36 patients/self control) | N = 54 (36 patients/self control) | |
Split mouth design | Placement before RT then 6 month assessment | Glass ionomer cement restorations | Amalgam restorations |
Others
Author | Cancer Dx | Cancer Tx | Study type | Time of assessment | Final N/intervention 1 | Final N/intervention 2 |
---|---|---|---|---|---|---|
Rojas de Morales et al. 2001 [55] | Hematologic malignancies (defined) | Not provided | RCTc
| All were seen pre-treatment then assessed twice a week during hospitalization, once a week if outpatient; seen until CTd completed and hematological parameters reestablished | N = 5 | N = 7 |
Blinding unknown | 154 evaluations | Preventive protocol | Oral physiotherapy | |||
Average evaluations per patient: 13 (2–30) | Reinforce oral physiotherapy, removal of plaque, non-alcoholic 0.05% fluoride mouth rinse, topical application of 20% miconazole during chemotherapy, use of toothpaste 4 times a day before and after chemotherapy, toothpaste substituted with sodium bicarbonate during chemotherapy | |||||
Rudat et al. 2000 [56] | Squamous cell carcinoma | RTb
| Cohort | Before and 1 year post-RTb
| N = 17 | N = 18 |
Intravenous Amifostine (200 mg/m2) | Nothing | |||||
Sela et al. 2000 [58] | H&Na
| Not provided (RTb assumed) | N-RCS | Post-RTb
| Honey from wildflowers, swish 5 ml for 5 min and swallow | |
Assessment before and after rinse (same visit) | N = 12 radiated patients | N = 12 healthy controls | ||||
Sela et al. 1994 [57] | H&Na
| RTb
| N-RCS | Post-RTb
| Appliance with etched (in vitro exposure to cola for 60 min) enamel slabs (extracted human molars), for radiated and non-radiated patients | |
N = 14 (8 RT, 6 non-RT) | N = 14 (8 RT, 6 non-RT) | |||||
Chew on a piece 20 g hard cheese for 5 min | Chewing parafilm | |||||
Toljanic et al. 1999 [41] | Hematologic malignancies (defined) and breast cancer | CTd: 46 | Cohort | Pre-cancer treatment then daily exam during treatment | N = 48 | |
CTd and RTb: 2 | Minimal intervention pretherapy dental treatment |