Antibiotic strategy in orofacial/head and neck infections in severe neutropenia

Dental extraction in the neutropenic patient

PURPOSE

To identify risks of dental extraction in patients with mild, moderate, and severe neutropenia.

MATERIALS AND METHODS

The authors undertook an observational study of 116 patients diagnosed with neutropenia and undergoing dental extractions in the Mayo Clinic Division of Oral and Maxillofacial Surgery. Absolute neutrophil count (ANC) was no higher than 1,500/μL. Predictors were ANC, age, diagnosis, number of teeth removed, type and location of extraction, length of antibiotic use, presence and type of bacteremia at the time of consultation or extraction, reason for consultation, indication for extraction, and use of any granulocyte colony-stimulating factor (GCSF). Primary outcomes were total complications, surgical site infections, delayed healing, and prolonged postoperative pain. Descriptive and bivariate analyses were undertaken, with statistical significance set at a P value less than or equal to .05.

RESULTS

One hundred sixteen patients underwent extraction while neutropenic. The overall complication rate was 8.6% (n=10). All were minor complications requiring simple interventions, if any. Complications were delayed healing, surgical site infection, and prolonged postoperative pain. Delayed healing was not associated with ANC. GCSF and related medications did not appear to affect outcomes in these patients.

CONCLUSION

The results of this preliminary study suggest that extraction of teeth in patients at all stages of neutropenia can be conducted safely. Complications of extraction were few and should be easily controlled. Further studies are required to clarify and stratify risk for future patients.

Oral complications and management strategies for patients undergoing cancer therapy

With cancer survival rate climbing up over the past three decades, quality of life for cancer patients has become an issue of major concern. Oral health plays an important part in one's overall quality of life. However, oral health status can be severely hampered by side effects of cancer therapies including surgery, chemotherapy, radiotherapy, and hematopoietic stem cell transplantation. Moreover, prevention and treatment of these complications are often overlooked in clinical practice. The present paper aims at drawing health care professionals' attention to oral complications associated with cancer therapy by giving a comprehensive review. Brief comments on contemporary cancer therapies will be given first, followed by detailed description of oral complications associated with cancer therapy. Finally, a summary of preventive strategies and treatment options for common oral complications including oral mucositis, oral infections, xerostomia, and dysgeusia will be given.

Periodontal disease and periodontal management in patients with cancer

Periodontal infection may exacerbate during cancer therapy and may result in oral pain and infection, and systemic infection, which may cause morbidity and can lead to mortality in neutropenic cancer patients. Periodontal disease in head and neck cancer patients treated with radiation therapy may lead to acute and chronic complications. The literature was reviewed by a search of Medline of the National Library of Medicine. The search was conducted to identify publications assessing periodontal disease in cancer patients. In addition, a review of papers referenced in the retrieved papers was conducted to identify additional publications for review. Periodontal disease should be assessed and managed prior to medical treatment of cancer for those with oropharyngeal cancer, and for patients in whom neutropenia may develop during treatment. Pretreatment assessment and management, and maintenance of oral hygiene have been shown to be effective in preventing oral and systemic complications during treatment. A complete oral and periodontal examination is appropriate for all patients planned to receive head and neck radiation therapy and those to be treated with medical protocols that are anticipated to result in neutropenia. Oral and periodontal care must continue following cancer therapy, and requires that the health care provider have an understanding of the malignant disease, oral manifestations of the disease, medical management of the disease, and of the oral complications that may develop.

Oral complications associated with immunosuppression and cancer therapies

The oral manifestations of oropharyngeal infection in immunocompromised patients present a particular challenge for both medical and dental professionals because clinical signs and symptoms may be minimal and accurate diagnosis and appropriate treatment may be difficult. Effective control of infection and management of oral symptoms are important and may be achieved by the judicious use of topical and systemic agents and by maintaining good oral hygiene. Prevention of mucosal breakdown, suppression of microbial colonization, control of viral reactivation, and effective management of severe xerostomia are all critical steps to reduce the overall morbidity and mortality of oromucosal infections in the severely immunocompromised patient.

Periodontal implications: medically compromised patients

The presence of systemic disease in patients requiring periodontal therapy creates challenges for management. Alteration of treatment plans, with emphasis on physician consultation and preventive periodontal care, is frequently needed to minimize the impact of periodontal disease on the systemic condition. Conversely, detection and treatment of systemic disorders may impact upon the status of the periodontium and the success of periodontal therapy. The goal of holistic patient management is facilitated by a free flow of information between the patients and their medical and dental health care providers.