This Medicines Q&A provides advice on what to consider when providing dental treatment, and information about the main adverse effects of cancer therapies that could cause problems when dental health professionals provide treatment.

 Dental infections

• Dentists should be alert for the possibility of neutropenic sepsis in any patient with a dental infection who is currently receiving chemotherapy, or received chemotherapy in the previous six months, or had a stem cell/bone marrow transplant in the last six months – if suspected, call 999 and urgently contact the patient’s oncology or haematology team and secondary dental care.
• For a patient who is currently receiving chemotherapy, or received chemotherapy in the previous six months, or had a stem cell/bone marrow transplant in the last six months, who does not have neutropenic sepsis, dental infections may be treated in primary care but dentists must get advice from the patient’s oncology or haematology team. Infections should be managed aggressively with close monitoring. Treatment choice often depends on whether the patient is immunosuppressed or at risk of bleeding. Obtain the patient’s blood test results taken within the last 48 hours and check with the patient’s oncology or haematology team whether treatment in primary care is suitable or if special precautions are needed.
• In all other patients with cancer, treat infections the same as those in patients who do not have cancer, but be extremely vigilant about follow-up and monitoring for deterioration.
• Before prescribing or using medicines, the dentist should consider the possibility of interactions with the patient’s current cancer treatments.

Dental procedures

Ideally, the patient’s oncology or haematology team is responsible for arranging or carrying out all active dental treatment while the patient is currently receiving cancer treatment, so always liaise with them before starting a dental procedure during this time.

• Provide emergency dental treatment to a patient currently receiving chemotherapy or radiotherapy to head or neck, or who received chemotherapy or radiotherapy to head or neck in the previous six months, or had a stem cell/bone marrow transplant in the previous six months, ONLY after contacting the patient’s oncology or haematology team to find out whether treatment can be carried out safely. If this is not possible, refer the patient urgently to secondary dental care.
• Do not provide elective invasive dental treatment to a patient currently receiving chemotherapy or radiotherapy to head or neck, or to those who received chemotherapy or radiotherapy to head or neck in the previous six months, or had a stem cell/bone marrow transplant in the last six months, without taking advice from the patient’s oncology or haematology team.
• Non-invasive dental treatment may be provided in primary care to all patients with cancer, except non-essential work should be avoided during the six months after a stem cell/bone marrow transplant. If the patient is currently receiving chemotherapy or radiotherapy to head or neck (or received it in the last six months) or had a stem cell/bone marrow transplant in the last six months, contact the patient’s oncology or haematology team before proceeding.
• Invasive dental treatment may be provided in primary care without taking advice from a specialist to patients who:
  • are currently receiving radiotherapy to areas other than head or neck, or
  • received chemotherapy more than six months ago, or
  • are receiving biological or hormonal therapies for their cancer.

Confirm with patients who have received chemotherapy that their blood tests are normal prior to providing invasive dental treatment. If patients are not sure, consult their oncology or haematology team. Also confirm patients with blood cancer are in remission/blood tests are normal. The dentist should be aware of the possibility of oral adverse effects from cancer treatment, including risk of non-healing.

Osteoradionecrosis risk

• High doses of radiation to the head or neck carry a lifelong risk of osteoradionecrosis. In a patient who has received radiotherapy to head or neck, refer to secondary dental care if oral or periodontal surgery is needed or dental infections do not respond to treatment. Do not extract teeth involving irradiated bone due to risk of osteonecrosis.

Medication-related osteonecrosis of the jaw risk

• Patients who are receiving or have received bisphosphonates will be at higher risk of medication-related osteonecrosis of the jaw (in some cases lifelong). Patients who have received denosumab in the last nine months will be at higher risk of medication-related osteonecrosis of the jaw. Patients currently receiving anti-angiogenic biological therapies (e.g. bevacizumab, sorafenib or sunitinib) will also be at higher risk.
• Assess whether the patient is at low or higher risk of osteonecrosis of the jaw – see SDCEP Risk Assessment Flowchart:
  • Patients being treated with a bisphosphonate, denosumab or an anti-angiogenic drug (e.g. bevacizumab, sorafenib or sunitinib) as part of the management of cancer are always considered to be at higher risk.
  • Patients taking bisphosphonates for osteoporosis or other non-malignant bone diseases for less than five years and not also concurrently being treated with systemic glucocorticoids are at low risk of osteonecrosis. If they are also on a systemic glucocorticoid or have taken a bisphosphonate for more than five years, they are at higher risk of osteonecrosis.
  • Patients who have taken a bisphosphonate at any time in the past and those who have taken denosumab in the last nine months should be allocated to a risk group as if they are still taking the drugs.
• For patients at higher risk of osteonecrosis of the jaw in whom an extraction is indicated, explore all possible alternatives where teeth could potentially be retained, e.g. retaining roots in the absence of infection. Consider seeking advice from secondary dental care.
• If an extraction or any procedure that impacts on bone is required, discuss the risks and benefits of treatment with the patient to ensure valid consent before proceeding.
• Do not prescribe antibiotics or antiseptic prophylaxis unless required for other clinical reasons.
• Refer to secondary dental care if the socket has not healed at eight weeks.

Attachments

• UKMi_QA_Cancer-in-dental-patients_update-Nov-2019 · PDF · 434 KB