and neck cancer are independently and signifi - cantly associated with risk of oral fungal infection
Lalla et al. 2010
. Oropharyngeal candidiasis i.e., thrush is the
most common oral mucosal infection in the immu- nocompromised patient and most often secondary
to C. albicans Allen et al. 2010
; Lalla et al. 2010
. Oral candidiasis can have multiple clinical presen-
tations including: 1 pseudomembranous candi- diasis thrush with whitish plaques with raised,
indurated borders; 2 chronic hyperplastic candi- diasis with a hyperkeratotic white patch; 3 ery-
thematous candidiasis; and 4 angular chelitis Lalla et al.
2010 . Topical oral antifungal agents
such as nystatin rinse and clotrimazole troches are often used to treat oral candidiasis although there
is no evidence to support their use in neutropenic patients. Clarkson et al.
2007 ; Lalla et al.
2010 ;
Worthington et al. 2010
. In a Cochrane review Clarkson et al.
2007 reported that there is strong
evidence supporting the use of antifungals which are absorbed in the gastrointestinal GI tract
i.e., fl uconazole, ketoconazole, itraconazole in
the prevention of oral candidiasis. In their review, Lalla et al.
2010 similarly reported that systemic
antifungals are effective in preventing oral fungal infection. Data on treatment of fungal infection are
less clear; in another Cochrane meta-analysis Worthington et al.
2010 reported there is insuffi -
cient evidence to support any particular antifungal agent although again drugs absorbed in the GI
tract appear more effi cacious. Both Cochrane reviews included studies which contained pediat-
ric patients.
Table 11.3 Summary of recommendations for oral care and hygiene for pediatric oncology patients
a
Clinical scenario Recommendations
Orodental care at time of cancer
diagnosis All children with an oncology diagnosis undergo a dental assessment at the time of cancer
diagnosis and if possible before cancer therapy commences The people most suitable to undertake the initial assessment be a pediatric dentist or dental
hygienist The possible long-term dentalorofacial effects of cancer and treatment should be discussed
Communication and collaboration between community and cancer center dentistry should occur Oral hygiene advice and education should be given to patients and parents prior to starting
therapy and should be provided verbally and in writing and delivered by a member of the dental team or a member of the medical team who has received appropriate training
Oral hygiene at diagnosis and
during cancer treatment
Brush teeth with a fl uoride toothpaste at least twice daily Toothbrush should be for the sole use of the patient and changed on a 3-month basis or when
bristles splay. Toothbrush should be changed following an oral or respiratory infection For patients up to the age of 6, parentscaregivers should be educated on how to brush the child’s teeth
Oral sponges should be utilized in infants and in those unable to brush their teeth Use of a non-cariogenic diet should be encouraged. Education should be provided about the
high cariogenic potential of dietary supplements rich in carbohydrates and oral medications rich in sucrose
Orodental care during cancer
treatment Elective dental care should not occur during periods of immunosuppression
Close monitoring for oral mucositis and oral mucosal infection Orodental care
after cancer treatment
Review of potential long-term dentalorofacial effects of childhood cancer and treatment Oral health to be monitored during growth and development
Collaboration for transfer back to routine dental provider Treatment and
prevention of xerostomia
b
There is insuffi cient evidence to support the use of pharmacologic agents for the prevention of salivary gland damage and xerostomia in pediatrics
Use of saliva stimulants when approved for use in children, artifi cial saliva, sugar-free chewing gum or frequent sipping of water may aid in relief of dry mouth
Adapted from Glenny et al. 2010
, American Academy of Pediatric Dentistry 2013
a
All recommendations are level of evidence 1C per Guyatt et al. 2006
; see Preface
b
See Chap. 13
for a detailed discussion of radiation- induced xerostomia 11 Oral Mouth Care and Mucositis
Viral infections differ clinically from mucosi- tis as they are typically localized to and involve
keratinized mucosa of the hard palate, gingiva, and dorsal tongue, present in crops, and may
present with fever Scully et al. 2006
. Herpes simplex virus HSV type 1 is the most common
viral pathogen isolated from mucosal lesions in immunocompromised patients and in a Cochrane
review acyclovir has been found effective for both the prevention and treatment of HSV infec-
tions in adult and pediatric cancer patients Glenny et al.
2009 .
11.7 Summary
Oral mucositis is one of the most common and distressing side effects of cancer therapy occurring
in 50 of children undergoing cancer therapy. Appropriate oral care, as well as complementary
patient and family education from diagnosis on the importance of oral care, is the cornerstone of pre-
vention of mucositis and prevention of infection during periods of neutropenia. Assessment of
mucositis is ideally done through the utilization of a scale validated specifi cally in pediatric patients.
Multiple interventions have been trialled, espe- cially in adult oncology patients, for the preven-
tion and treatment of OM and the majority of these interventions have reported potential weak benefi t
or mixed results to date. Pediatric data are limited and confl icting; further studies are required to
make fi rm recommendations on these agents in the pediatric oncology cohort.
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