DHYG336 - Ch20 Case Study

Louisa S. is a 51-year-old patient being treated for breast cancer that has metastasized to her spine. She is on a combination of chemotherapies, including intravenous bisphosphonates and tamoxifen. Her oncologist has referred her to your office because of oral lesions so severe that she is having trouble eating, swallowing, and talking, as well as spontaneous bleeding of her gums. The oncologist is concerned that the chemotherapy will have to be discontinued if her oral condition does not improve, which could severely compromise her cancer treatment. She is also running a low-grade fever and is exhausted most of the time.

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What is the probable cause of Louisa's fever and exhaustion?

a. Direct adverse effect of tamoxifen

b. Indirect adverse effect of tamoxifen

c. Direct adverse effect of bisphosphonates

d. Indirect adverse effect of bisphosphonates

e. Indirect effect of chemotherapy caused by suppression of bone marrow cells

e. Indirect effect of chemotherapy caused by suppression of bone marrow cells.

Bone marrow cells are rapidly dividing, and these cells are adversely affected by chemotherapeutic agents. Bone marrow suppression results in leukopenia or agranulocytosis, thrombocytopenia, and anemia, with the severity depending on the drugs being used, the condition of the bone marrow at the time of administration, and other contributing factors. Symptoms of this adverse reaction may include susceptibility to infection, bleeding, and fatigue.

Which additional adverse effects would you expect to see in Louisa during her chemotherapy?

a. Muscle spasms, constipation, and agitation

b. Headaches, seizures, and muscle spasticity

c. Increased dental caries, bone loss, and periodontal disease

d. Gastrointestinal upset, hair loss, and immunosuppression

d. Gastrointestinal upset, hair loss, and immunosuppression

Chemotherapy has many adverse effects, especially affecting the rapidly dividing cells of the gastrointestinal tract, bone marrow, and hair follicles. Other effects include hepatotoxicity with the antimetabolites, nephrotoxicity, and impairment of the germ cells.

When is the most appropriate time for Louisa to receive oral hygiene care?

a. At the end of her chemotherapy cycle

b. In the middle of her chemotherapy cycle

c. A day or two before the start of her chemotherapy cycle

d. One month after her last chemotherapy cycle

c. A day or two before the start of her chemotherapy cycle

Patients taking antineoplastic agents need optimal oral hygiene to prevent the spread of infection from the oral cavity, but immunosuppression and bleeding problems during chemotherapy can put the patient at risk. Dental procedures should take place just before chemotherapy begins or on the first few days of treatment before too much bone marrow suppression has occurred.

Louisa needs to have a tooth extracted. Which special considerations should the oral surgeon take?

a. Use general anesthesia, and stop the bisphosphonate therapy before the extraction.

b. Perform the extraction with minimal manipulation, and add local and systemic antibiotic prophylaxis.

c. Wait to do the extraction until her chemotherapy is finished.

d. Stress immaculate oral hygiene, and institute alcohol-free chlorhexidine rinses.

e. b and d only

f. b and c only

e. b and d only

Osteonecrosis can occur in patients with cancer who are taking intravenous bisphosphonates and in much lower incidence in those taking oral bisphosphonates for osteoporosis. Ideally, dental treatment should be performed before or at the beginning of bisphosphonate therapy. Experts do not recommended that bisphosphonate therapy be discontinued before dental procedures because it stays in the bones for years. The oral surgery should take place with minimal bone manipulation and supported with local and systemic antibiotic prophylaxis.

Why is Louisa having such severe mouth sores?

a. Louisa's oral hygiene is poor.

b. The cancer has spread to the oral cavity.

c. Louisa has poor nutrition and dehydration.

d. The rapidly dividing cells of the oral mucosa are adversely affected.

d. The rapidly dividing cells of the oral mucosa are adversely affected.

Rapidly growing cells, such as neoplastic cells, are more susceptible to inhibition or destruction by antineoplastic agents. Unfortunately, other rapidly dividing cells such as those of the oral mucosa and gastrointestinal tract are also damaged.

Which is the probable cause of Louisa's gingival bleeding?

a. Poor oral hygiene

b. Platelet suppression

c. Red blood cell suppression

d. White blood cell suppression

e. Aggressive oral hygiene techniques

b. Platelet suppression

Chemotherapy has suppressed bone marrow production of blood cells, including platelets. Low platelet count (thrombocytopenia) can cause bleeding.

All considerations should be taken by the dental hygienist treating a patient such as Louisa who is undergoing chemotherapy except:

a. Avoid oral hygiene procedures during chemotherapy.

b. Match hygiene instructions to the patient’s symptoms.

c. Monitor the patient for symptoms of infections.

d. Treat only if the neutrophil count is greater than 1000/mm3.

e. Check thrombocytes for adequate blood clotting.

f. Recommend oral rinses with baking soda.

a. Avoid oral hygiene procedures during chemotherapy.

Maximizing oral hygiene before, during, and after chemotherapy is important to prevent infections caused by bacteria and fungal infections. All of the other considerations are important in the dental care of the patient undergoing chemotherapy.