Oral Care Supportive Care in Pediatric Oncology irantextbook.ir 93df

examining the dental health of children with cancer found that 43 of patients had untreated decay and only 35 had been seen by a dentist since diagnosis. Their study exemplifi ed the lack of dental preventive care for pediatric oncology patients and stressed the need to continue to pro- vide primary oral hygiene during pediatric cancer therapy Clarkson and Eden 1998 . A European multidisciplinary group, in collaboration with the United Kingdom Childhood Cancer Study Group UKCCSG and the Paediatric Oncology Nurses Forum PONF, was established in 2001 princi- pally to produce comprehensive, evidence-based guidelines on mouth care for children and adoles- cents being treated for cancer. The potential ben- efi ts of such guidelines include improved patient care, consistency of care, the promotion of inter- ventions of proven benefi t and a reduction in use of ineffective or potentially harmful practices Glenny et al. 2010 . The UKCCSG-PONF Mouth Care for Children and Young People with Cancer guidelines used the agreed-upon methodology of SIGN Scottish Intercollegiate Guidelines Network to aid them in their development of evidence-based guidelines Glenny et al. 2010 . A consensus approach was utilized to establish the scope and basic structure of the guidelines. Three key areas were identifi ed and covered by the guidelines: 1 dental care and basic oral hygiene, 2 methods of oral assess- ment, and 3 drugs and therapies Glenny et al. 2010 . The group conducted a systematic review of the literature to examine these three key areas and, where no evidence existed, a consensus opin- ion on best practice was determined Glenny et al. 2010 . Additionally, the American Academy of Pediatric Dentistry AAPD has published guide- lines on the dental management of pediatric patients receiving chemotherapy, HSCT or radia- tion AAPD 2013 . The overarching purpose of these guidelines is to recognize that the pediatric dental professional plays an important role in the care of pediatric oncology patients. The AAPD guidelines focus on basic oral hygiene and dental care for pediatric oncology patients before, during and after cancer therapy. The AAPD and UKCCSG-PONF guidelines make recommendations in fi ve areas, as summarized in Table 11.3 : 1 orodental care at the time of can- cer diagnosis, 2 oral hygiene at diagnosis and dur- ing cancer treatment, 3 orodental care during cancer treatment, 4 orodental care after cancer therapy, and 5 prevention and treatment of xero- stomia Glenny et al. 2010 . The UKCCSG-PONF guidelines emphasize the importance of oral assessment throughout cancer treatment utilizing the discussed oral assessment tools. Frequency of oral assessment should be determined on an individual basis and should be increased if oral complications arise Glenny et al. 2010 . The AAPD describes the importance of identifying and stabilizing, or elim- inating, existing and potential sources of infection or local irritants in the oral cavity. Emphasis on the education of patients and parents on the importance of oral care should occur throughout therapy as well as in regard to the potential short- and long-term effects of therapy. The AAPD fur- ther elaborates on care when the use of radiation will affect the orofacial region with the goal of reduction of radiation to healthy oral tissue through consultation with the radiation oncologist and utilization of lead-lined stents, prostheses and shields to spare structures such as the salivary glands. Patients who receive radiation therapy involving the masticatory muscles should be edu- cated on daily oral stretching exercises to decrease the potential of trismus AAPD 2013 . Finally, for patients that experience xerosto- mia, the AAPD recommends fl uoride rinses and gels for the prevention of caries as well as the use of humidifi cation for symptomatic relief.

11.6 Oral Infections

Patients experiencing OM are predisposed to infections of the oral cavity. Viral, fungal and bac- terial infections may arise with incidence depen- dent on the use of prophylactic anti- infective regimens, oral status prior to chemotherapy, and secondary to the duration and severity of neutro- penia. The most frequent documented source of sepsis in the immunocompromised cancer patient is the mouth Allen et al. 2010 . In adults, chemo- therapy and radiotherapy in patients with head 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