MANAGEMENT OF A PATIENT UNDERGOING CHEMOTHERAPY AND ANTI-RESORPTION TREATMENT
I-CHEMOTHERAPY
DEFINITION
Chemotherapy is part of the therapeutic arsenal against cancers. It consists of using cytotoxic or cytostatic drugs aimed at destroying cancer cells.
INDICATION
- Neoadjuvant
When started before surgery or radiation therapy.
- Adjuvant
After surgery.
SUBSTANCES USED
- Alkylants,
- Antimetabolites,
- Inhibitors of tubulin formation,
- Others: asparginase, bleomycin.
SIDE EFFECTS OF CHEMOTHERAPY
- Direct side effects
1 – MUCOSITIS:
– Decreased rate of renewal of the basal epithelium
– Thinning, denudation and ulceration of the oral mucosa
– Symptoms: from erosion to ulceration.
– Severe forms: hospitalization.
2-XEROSTOMIA:
– Less important than that after radiotherapy.
– Thick, sticky saliva.
– Dry, atrophic mucosa.
– Candidiasis, periodontitis
– Decalcification of the enamel.
3-NUTRITION:
– Anticancer drugs have variable emetic potential.
– Nutrition is compromised by chemotherapy.
– Dysgeusia.
Indirect side effects
1-INFECTION:
– The infection can be bacterial, viral or fungal.
– Alteration of the patient’s immune system.
– Immunological alteration of saliva.
– Clinic: periodontal diseases, candidiasis, cellulitis, osteitis, etc.
– General infection: bacteremia, septicemia.
2-HEMOSTASIS DISORDERS:
– Qualitative and quantitative alteration of platelets.
– Thrombocytopenia → petechiae, ecchymoses, hemorrhage.
– Spontaneous or induced bleeding.
PRECAUTIONS TO TAKE WHEN TAKING CHEMOTHERAPY
Before chemotherapy
- Motivation for oral hygiene.
- Oral health restoration.
During chemotherapy
- Emphasize hygiene.
- Treatment of mucositis.
- Relieve pain.
- Extractions: platelets > 80000/mm3.
- Starts 10 days after induction.
After chemotherapy
- After the remission phase, no dental treatment is contraindicated.
- Monitoring oral hygiene.
- Complete oral health restoration.
- Prosthetic realization.
II-ANTI-RESORPTIVES
- BISPHOSPHONATES (BP)
Definition
BPs are small molecules analogous to inorganic pyrophosphate with a very short blood half-life (30-120 min), but which accumulate very rapidly in the calcified bone matrix exposed to the blood flow, which explains their very long tissue lifespan.
The mode of action of (BP)
Bisphosphonates inhibit bone resorption by selectively binding to the hydroxyapatite crystal structure of the mineral phase of bone tissue. They are taken up by osteoclasts, disrupt their function and induce their apoptosis.
BP indications
- Intravenous BPs are used:
-In malignant tumor pathology in patients with multiple myeloma, bone metastases from cancer (breast, lung, liver).
- Oral BPs are indicated in:
-Postmenopausal or corticosteroid-induced osteoporosis.
-Paget’s disease.
-Osteogenesis imperfecta.
-Primary mandibular osteitis.
-Periodontal resorption.
General side effects of (BP):
– Flu syndrome with fever.
-Fatigue; Chills; Arthralgia; Myalgia.
-Gastrointestinal disorders with nausea and vomiting.
-Alterations of renal function.
-Blood disorders such as anemia and leukopenia.
– Ulcerations of the oral, esophageal and gastric mucosa when taking oral BPs.
Local side effects of (BP):
OSTEONECROSIS OF THE MAXILLA (ONJ)
The clinic
Bisphosphonate-induced maxillomandibular osteochemonecrosis is clinically defined by the presence of an area of maxillary and/or mandibular bone exposure that does not respond to treatment for at least six weeks.
Progression stages of osteochemonecrosis
The AAOMS classifies lesions into 4 stages:
- Stage 0 : Patient without apparent necrosis but presenting non-specific clinical or radiographic symptoms;
- Stage 1: Asymptomatic patient with exposed or necrotic bone without signs of infection;
- Stage 2: patient with exposed or necrotic bone, pain, and clinical signs of infection;
- Stage 3: Patient with exposed or necrotic bone, pain, signs of infection, or at least one of the following: pathologic fracture, oronasal, oronosinusal, or extraoral fistula, or osteolysis extending well beyond the alveolar region.
Diagnosis
Positive diagnosis:
- Patients treated or having been treated by (BP)
- Exposure of the maxillary and/or mandibular bone for at least 8 weeks.
- The absence of prior irradiation of the maxillary legion.
- The absence of localized metastasis in the area of osteonecrosis.
Differential diagnosis:
- Malignant bone tumors
- Osteomyelitis
- Alveolitis
- Prosthetic or other trauma (also a trigger for osteochemonecrosis)
- Ulcerative-necrotic gingivitis.
Management of a patient on BP
Prescribing physicians and dental surgeons have an important role in informing and educating the patient before, during and after the initiation of oral or parenteral bisphosphonate treatment.
- Before starting treatment with bisphosphonates :
-A clinical and radiological oral health assessment must be carried out
-Rehabilitation of the oral cavity
– Elimination of all infectious sources
NB: Bisphosphonate treatment should begin after oral health has been restored and the surgical site has completely healed. Ideally 120 days after surgery, a period that is difficult to observe, especially in cases of malignant disease.
- During treatment with bisphosphonates :
– Consent of the patient,
-The treating physician must be contacted,
– Descaling before the procedure is recommended,
-Prescription of antiseptic mouthwash,
-Antibiotic prescription: the day before until mucosal healing (Amoxicillin 2g per day for 2 to 3 weeks) in case of allergy to penicillin: Prescription of a macrolide.
-Anesthesia with or without vasoconstrictor (preferably without vasoconstrictor),
-The least traumatic technique possible,
– Hermetically sealed banks,
-Prolonged monitoring of healing.
- After bisphosphonate treatment :
-A clinical and radiological oral check-up should be carried out every four months in the case of intravenous treatment or annually in the case of oral treatment.
- DENOSUMAB
Since its approval in 2010, denosumab, a human monoclonal antibody, has proven its worth in the treatment of osteoporosis but also in the treatment of bone metastases from certain malignant pathologies.
Cases of ONJ have also been reported in patients treated with denosumab, which is thought to have fewer side effects than bisphosphonates.
In the absence of recommendations regarding the management of patients taking denosumab, the same protocol as that used for the management of patients taking bisphosphonates should be applied until specific recommendations for treatment with denosumab are put in place.
CONCLUSION
The role of the dentist is important from the therapeutic decision-making stage and throughout the TRT.
Restoring the oral cavity before treatment allows for a reduction in complications, greater patient comfort and improved therapeutic results.
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Good oral hygiene Regular scaling at the dentist Dental implant placement Dental x-rays Teeth whitening A visit to the dentist The dentist uses local anesthesia to minimize pain