[MUSIC] The next category of patients that I would like to discuss regarding the dental health is those that are going to be treated with chemotherapy. As you already probably know, different chemotherapuetic regimens really have different impact. There are some patients undergoing chemotherapy that have very little significance in the oral cavity, whereas there are others, the majority of them, whereby chemotherapy will have a profound effect on the oral cavity. And the oral cavity may have a profound effect on the patient's overall health. One thing that I think is important is that we differentiate the chemotherapeutic regimens to those that are myeloablative. Those that will actually have a significant effect on the patients bone marrow because if the chemotherapy affects the bone marrow, patients will be at a much greater risk of infection and bleeding. So the dentist might get consulted prior to chemotherapy. Once again, to eliminate any risk during the chemotherapeutic period. And that risk, again, could be associated with infection, or it could be associated with bleeding. Once again, the dentist must consult with the patient's oncologist regarding the patient's blood counts, and their ability to withstand dental treatment. If in fact their white blood count, specifically their neutrophil count is low, antibiotics prior to dental procedures are often recommended. Also it's important to understand that the oral cavity once again is susceptible to varied infections when the blood counts are diminished and, the patients may be at risk of bleeding if in fact the chemotherapy will affect the patient's platelet count. So taking care of patients that are undergoing chemotherapy, or contemplating chemotherapy, it is important to maximize the oral health of that individual, once again, as their medical stability permits. The next group of patients that I'd like to discuss are those undergoing radiation therapy. And patients undergo radiation therapy for various cancers. And in this case, I'll focus on those patients that are undergoing head and neck cancers. Often, once again, the dentist will be asked to evaluate the dentition and eliminate any potential infections prior to radiation therapy to the head and neck region. It is important, in fact, that the dentist recognizes infection and potential infection. As the teeth and dental, as well as, periodontal infection can lead to a serious condition known as osteoradionecrosis. Since the bone has a limited capacity after radiation to repair. Since the blood flow is not as good to that area as it was before the radiation, patients are susceptible to this necrosis of bone that occurs post-radiation. There are other significant changes that occur post radiation in which the dentists will play a significant role in helping the patient's quality of life. Those conditions include, dryness in the mouth, which can lead to both dental decay or caries, as well as periodontal disease. Further, yeast infections, mucositis and even trismus, which is the difficulty of opening the mouth, are all potential sequelae to radiation therapy. As I mentioned earlier, perhaps the most significant sequelae of radiation therapy is when a patient develops osteoradionecrosis, which is described as a significant necrosis of bone. Due to the bones inability to repair itself post-radiation and often associated with dental infection. Once again, the dentist plays a vital role in protecting the patient from some or all of these sequelae. Additionally, the dentist will play a vital role in improving the patient's quality of life. The dentist may want to prescribe salivary substitutes so that the patient is much more comfortable with the dryness that is associated with radiation therapy. Additionally, the dentist may also want to initiate fluoride therapy to prevent carries post radiation. Lastly, let's talk about patients that are to receive antiresorptive therapy. This is therapy that strengthens the bone. In patients that are under going antiresorptive therapy. They are at risk of medication related osteonecrosis of the jaw. In this group of patients, we have to understand exactly why they are taking antiresorptive therapy. Antiresorptive therapy is used for two main reasons. One is as part of cancer therapy for various types of cancer including things like multiple myeloma or metastatic cancers that affect the bone. And these medications are also used osteopenia and osteoporosis. So it's very, very important to understand the reasoning why patients are using the medication. In addition to that it's important to understand if the patient is being administered intravenously this medications or if in fact they're taking them orally. One, would also want to know the type of medication used. And how long it has been used, understanding the parameters of these antiresorptive medications helps you understand the risk of developing osteonecrosis of the jaw. For instance, the risk of osteonecrosis of the jaw in patients with cancer trials do not receive any antiresorptive therapy is about 0.019%, or 1.9 cases per 10,000 patients with cancer. Medication-related osteonecrosis of the jaw is range from just under 1% to 6.7%. If in fact, however, a patient is taking medication to prevent osteporosis and their using long term oral antiresorptive therapy. This equates to approximately a 0.1% or 10 cases per 10,000, which increases to approximately 21 cases per 10,000 if the patients are using that medication longer than four years. What else puts a patient at risks who were taking these medicines, clearly, it is associate with pre-existing oral inflammatory disease, and that is why the dentist often gets quarried prior to starting this medications. If, in fact, there is any pre-existing oral inflammatory disease, with the understanding that that should be eliminated prior to starting these medications. With antiresorptive therapy used for osteopenia, osteoporosis, there's often time available to do it. However, cancer patients who are at greater risk because they are taking IV antiresorptive therapy and usually more potent agents, often do not have the time to undergo significant dental treatment or pretreatment, dental screening. So other things that put patients at risk are the length of time that they are actually using the medications. If in fact there is a denture that is supported by the soft tissue, but perhaps the highest risk for a patient developing a medication related osteonecrosis of the jaw is a dental extraction. So as we can see, the health of the oral cavity prior to major medical or surgical procedures is very important in improving the overall outcome for the patient.
