ISSN 2177-5273

Emdio, et al.
Artigo de REVISO

2010

Braz J Health, 2010; 1: 136-149

Oral manifestations of leukemia and antineoplastic treatment a literature review (part II)
Manifestaes orais da leucemia e do tratamento antineoplsico reviso da literatura (parte II)

Thais Christina Souza Emdio1, Yulli Cristina Maeda2, Angela Scarparo Caldo-Teixeira3,
2

Regina Maria Puppin-Rontani

Hematology Center,UNICAMP, Campinas, SP, Brasil. 2Faculdade de Odontologia de Piracicaba -FOP-UNICAMP, Piracicaba, SP, Brasil. 3Professor of Pediatric Dentistry Federal Fluminense University, Plo Universitrio de Nova Friburgo (FOUFF/NF), Brazil
1

Abstract
In the antineoplastic treatment the oral manifestations can be seen more intensely because radiotherapy and chemotherapy attack little differentiated cells or those with a high metabolism, affecting not only the blastic cells but also the normal ones. The main events are: mucositis, hyperplasia and gingival bleeding, opportunistic infections, radiation caries, xerostomia, trismus, osteorradionecrosis and taste alteration. Dentists must be aware of the oral manifestations in antineoplastic treatment to improve patients quality of life. When possible, patients should be examined before starting oral cavity treatment to remove infectious outbreaks. During treatment prophylactic measures can be taken such as strict control over oral hygiene, analgesic, antibiotic, and antiinflammatory administration when necessary, advising the patient to have a light alimentation. Key-Words: leukemia; oral manifestations; antineoplastic agents.

Resumo
so. No tratamento antineoplsico as manifestaes orais podem ser vistas mais intensamente, pois a radioterapia e a quimioterapia incidem nas clulas pouco diferenciadas, ou com alto metabolismo, atingindo no somente as clulas blsticas, mas tambm as normais. As principais manifestaes so: mucosite, hiperplasia e hemorragia gengival, infeces fngicas, virais e bacterianas, crie de radiao, xerostomia, dermatite, trismo, osteorradionecrose, hipertrofia dos ndulos linfticos, palidez da mucosa, petquias, eritema e alterao do paladar. O cirurgio-dentista deve ter conscincia das manifestaes bucais do tratamento antineoplsico para poder melhorar a sua qualidade de vida. Quando possvel, o paciente deve ser analisado antes do inicio do tratamento para que a adequao da cavidade bucal e remoo dos focos infecciosos. Durante o tratamento podem ser adotadas medidas profilticas como: controle rigoroso da

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higienizao bucal, uso de clorexidina, administrao de analgsico, antiinflamatrio e antibitico quando necessrio, orientando para que o paciente tenha uma alimentao branda. Palavras-chave: leucemia; manifestaes orais; agentes antineoplsicos.

Introduction
Neoplasia is the second leading cause of death by disease in the world, and about 70% of patients undergo the antineoplastic treatment1,2. between by chemotherapy neoplasia, during contribution is about the monitoring of antineoplastic treatment. An understanding of the pathogenesis of mouth acute infections in patients undergoing antineoplastic treatment is important to establish preventive strategies for these complications. Successful prevention, started prior to the treatment and maintained characterized during myelosuppression, may reduce the morbimortality of these patients10. Prevention and treatment of oral lesions resulting from antineoplastic treatment are essential since oral mucositis seriously interfere with the prognosis of patients, becoming them more susceptible to local and systemic infections, less tolerant to oral feeding. In addition, it interferes with the dosage and/or indication of drugs used in chemotherapy, prolonging the time of hospitalization and increasing costs. Many of the oral and systemic complications can be reduced with adequate oral hygiene guidance, adequacy of prior treatment, prevention and control of these children, which greatly improves these patients quality of life during treatment3,11-14. This second part of review of the literature is intended to clarify the features of help dentists by presenting not only the clinical and oral manifestations of the disease, Page136 leukemia, the main malignant disease, and the dentists great

Leukemia is among the most prevalent which is represents 30%-51% of that total1-7. Leukemia uncontrolled production of immature white blood cells, causing a series of clinical and oral manifestations, which are important in disease diagnosis. Early detection of leukemia is very important because it provides a favorable prognosis3,5-8. Depending on the type, dosage and frequency of use of antineoplastic agents, severe oral complications can arise. In literature, about 40% of patients submitted to oncologic treatment have antineoplastic oral complications, such as mucositis, xerostomia, and fungal infections, viral or bacterial, among others1-9. As a health professional, the dentist should be able to handle not only dental alterations. He is responsible for the maintenance of health in the oral cavity and must also be attentive to the individual as a whole7,10,11. In addition to contributing to the disease diagnosis,

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but also the alterations of antineoplastic treatment (chemotherapy and radiotherapy) in the oral cavity, as well as to provide some subsidies for the professionals to control these alterations and thus improve patient quality of life. Literature review Mucosal which operates tissue as a has a protection through function and is composed by an epithelium, barrier differentiation or maturation to produce layers with appropriate functional properties and constant replenishment of desquamated cells on the surface through the differentiation in the layers below. These cells have high cellular metabolism and are more susceptible to antineoplastic agents. When this barrier breaks up in some way, it is exposed to infection, inflammation, followed by painful and debilitating mucositis. However, if therapies that allow repair and regeneration are discontinued, the ability of rapid spread allows oral epithelium healing in 2 or 3 weeks. A small quantity of cells (stem cells) will divide more slowly and are less affected by radiotherapy and chemotherapy, being important for the epithelium repopulation after treatment damages15. Oral complications can be classified as primary (resulting from the infiltration of malignant cells in the oral structures such as gum and bone with infiltration), secondary and (associated thrombocytopenia

anemia, tendency to bleeding, susceptibility to infections, and ulcers), and tertiary (associated with myelosuppression and immunosuppressive therapy of direct or indirect cytotoxicity)16,17. After the initiation of therapy there is an increase in prevalence of oral alterations, such as ulcerations, mucositis, taste decrease, skin desquamation, candidiasis, and late gingival effects: bleeding, xerostomia, dysphasia, opportunistic infections, trismus18-25, vascular lesions, tissue atrophy, taste loss or change, fibrosis, edema, soft tissue necrosis, loss of teeth, salivary flow decrease, carious lesions, osteorradionecrosis, and condrionecrosis23,24. Late effects of acute antineoplastic therapy which cause affects discomfort the quality to of patients, life of hampering or limiting their normal activities, individuals24. Mucositis Mucositis is one of the most common side effects in antineoplastic treatments and can be defined as an inflammatory condition of the mucosa, which manifests itself as erythema, ulceration, bleeding, swelling, and pain3,11,18,26-30. The pain may cause problems with feeding, hydration and speech. The continuing difficulty with feeding because of pain can lead to weight loss, anorexia, cachexia and dehydration, affecting the patients quality of life31,32. Page136

granulocytopenia as injuries associated with

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Thus, in many cases a treatment change or interruption can occur, which in turn leads to a decrease in the control of tumor growth and, consequently, to the the patient literature, survival34. According

saliva, compromised immune function, and local infection outbreaks35. It is believed that patients receiving radiotherapy with concurrent chemotherapy are more likely to develop serious oral mucositis15. Another factor aggravating oral mucositis is the susceptibility to infection by micro-organisms normally present in the oral cavity which are opportunistic and invade the damaged tissue. Candida yeast colonization increase during radiotherapy32. With regard to age, young patients develop more severe mucositis than elderly people. However, the episodes of mucositis in young people require less time for a complete healing when compared to elderly patients. Moreover, patients with better stomatological conditions develop mucositis with less

approximately 11% of cases of interruption and modification of the radiotherapy treatment occur due to the development of severe oral mucositis, requiring treatment replanning, and in some clinical situations, patient hospitalization32. Initial symptoms of mucositis include burning sensation, dry mouth and formication of lips. It occurs 5-7 days after initiation of therapy, due to a direct effect on the oral mucosa, and slowly disappears 2-4 weeks after the end of treatment34. The severity and duration of mucositis are directly related to the quality of preexistent oral health, treatment schedule, drugs used and occurrence of associated infections, such as patients with recurrent herpes simplex virus15,32. It is estimated that the incidence of mucositis varies between 40% and 76% for patients treated with conventional or highconcentration chemotherapy, respectively15, and it can be observed in almost 100% of patients undergoing head and neck cancer radiation therapy28,32. In the cases treated with radiotherapy, it is observed that the risk factors for the development of mucositis include location of the radiation field, preexistence of dental disease, poor oral hygiene, low production of

frequency and duration than those with poor oral hygiene and less frequent periods of odontological consultation15. It is important to note that when poor oral hygiene is observed, the action of viruses, fungi and opportunistic bacteria further deteriorates the situation. And as the patient is unable to adequately rinsing the oral cavity due to intense pain, a vicious circle is formed, which is very hard to break15. Thus, there is a wide variety of agents used in the prevention of mucositis, which seems to reflect research advancements in search for effective drugs, although further research still needs to be conducted15. Oral hygiene is the main prevention strategy because it reduces the growth of Page136

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ingredients phenol are

microorganisms and the development of severe mucositis, allowing the elimination of infection factors. Reports indicate the need for instructions about diet and oral hygiene one week prior to the beginning of antineoplastic treatment. The instructions should include the correct use of dental floss; brushing with fluoridated toothpaste after meals; replacement of failed restorations; assessment of the functionality of prostheses and its sanitation, and restoring treatment36,37. Mouthwash is the most frequently mentioned agent in the studies, such as: 0.12% antiseptic bicarbonate, multiplication negative chlorhexidine, which and creates the on an sodium alkaline of and

and 0.05% sodium fluoride (gel), daily38. However, containing all mouthwash or alcohol

counterindicated, since they cause mucosal desquamation and irritation16. With regard to the types of treatment available, it is important to emphasize that these are palliative and diverse, and involve prophylactic and therapeutic attempts to alleviate painful symptoms32. Prophylactic approaches include: awareness for the improvement of oral hygiene, avoid the use of spicy foods, use of growth factors, aluminum salts, cytokines, glutamine, cytoprotectors and antioxidants, and symptomatic approaches such as the use of camomile, betamethasone, benzidamide, acetylsalicylic acid, lidocaine, E polymyxine, lozenges, tobramycin, low-intensity laser, and criotherapy32. With regard to palliative treatments, the vast majority of studies indicate the use of mouthwash ingredients (these can be saline solution, bicarbonate, water, chlorhexidine and diluted hydrogen peroxide), epithelium protector medicines (aluminum hydroxide, magnesium hydroxide), topical anesthetics, systemic antibiotics and anti-inflammatory drugs29,30,32. It is noteworthy that oral rinse with 0.12% chlorhexidine gluconate is the most frequently indicated10,37,39-42, but its use has controversy because it contains alcohol, and thus can dehydrate oral tissues, exacerbate Page136

environment, interfering with the bacterial establishment the taste candidiasis; however, research indicates the impact uncomfortable feeling with its use; saline solution 0.9% is not irritating and does not alter saliva pH, and is economical and highly recommended; hydrogen peroxide, in spite of controversy, is still used, but causes irritation, damages granulation tissue, interrupts the normal flora of the oral cavity and can cause nausea due to its taste; magnesium and aluminum hydroxide suspensions are solutions that protect the mucosa, forming a layer with analgesic effect, minimizing acidity, however, they dry up oral mucosa, therefore, more research is needed; and mouthwash with nystatin for prevention of fungi are also recommended before starting treatment, three times a day for seven days;

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mucositis, besides being able to alter taste when used for a long period of time14. Studies suggest good results with the use of gel-based benzocaine and oral rinsing before meals; bicarbonate water (1 teaspoonful in 1 cup of water, three times a day for seven days)34,37,38. Other options that can be observed include: irrigation with saline solution to neutralize acidity, perform debridement, and dissolve secretions43; sucralfate mouthwash which creates a protective barrier through its mechanism of action, the ionic connection to proteins in the ulceration site. Studies have identified results for its effectiveness in reducing pain, mucositis severity and duration, with good patients experimenting interruption of treatment, nutritional support, analgesia, and infection, being 1-3g the recommended dose, three to six times a day during antineoplastic treatment44. Also recommended are lidocaine 2%, carbamide peroxide 10% and urea peroxide 10%, mouthwash with vitamin E and nystatin45. However, the use of hydrogen peroxide has been discouraged because of its mechanism of action previously described43. Similarly, topical lidocaine, despite being a commonly used agent, has anesthetic effect for only 15-30 minutes, not always solving the problem34,44. A new therapeutic approach has indicated the use of low-intensity laser, which has proven to be capable of significantly

alleviate pain and may also reduce the severity and duration of mucositis14,16. Laser treatment stimulates cellular activity, leading to the release of macrophage growth factors, proliferation of keratinocytes, population increase and degranulation of mast cells, and angiogenesis. These effects can lead to acceleration of wound healing processes, due in part to the reduction of acute inflammation duration, resulting in a quick repair, with analgesic and antiinflammatory properties34,44. Laser use eliminates the pain in the first application. It is believed that this happens because of the release of -endorphin in the nerve endings of the ulcer, while it also promotes tissue biostimulation, facilitating a more rapid healing of ulceration46. According to literature, laser seems to be well tolerated by patients and has beneficial effects on mucositis, improving patient quality of life during oncologic treatment. But further controlled scientific studies with significant sampling are necessary for the development of protocols of this kind of treatment46. Xerostomia Xerostomia appears to be one of the most frequent effects of radiotherapy in the head and neck area11,12,18,25,39. It is characterized by a dysfunction of the salivary glands, when reduction or absence of salivary flow occurs. It occurs in around 53 percent of cases and could reach 100 percent11-13,25. Page136

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Xerostomia occurs due to changes in the salivary glands, causing qualitative and quantitative changes in salivary flow (saliva becomes more viscous, with a high proportion of organic material and changes in color, from transparent to yellow) due to fibrosis induction by radiotherapy, fat degeneration, acinar degeneration, and necrosis of the salivary glands. This change acidifies the pH, and there is a change in bacterial flora from gram-positive to gram-negative11,12,18,26,36,39. Xerostomia can be characterized as transitional during chemotherapy (being reverted in 48 hours) or severe, progressive or permanent in cases of radiotherapy (reversal may occur within 4 to 12 months after therapy)18,29,47. According to Lima et al. (2004)49, who evaluated the flow speed and salivary pH after radiotherapy in the head and neck area, at the end of treatment and up to six months later, no patient in that study showed salivary flow speed within the normal range of values, suggesting that there is a direct relationship between the dose of irradiation and the extent of glandular changes25,29. Xerostomia causes damage in oral physiology including difficulty with chewing, swallowing, speech, and a prevalence increase of infections such as candidiasis, periodontal disease and caries12,18,26,36,39. Moreover, there is also taste and appetite loss, as well as nausea, vomiting, and painful symptoms. These factors together predispose patients to adopt cariogenic food habits. Thus, the framework

of hypofunction or permanent loss of salivary flow may result in a rapid progression of dental caries, periodontal disease, candidiasis, dysgeusia and nutritional deficiency3,49. The proposed treatment for xerostomia has been the use of artificial salivas based on carboxymethylcellulose, stimulation of remaining saliva, meticulous oral hygiene and fluoride topical application14. More recently, the use of pilocarpine has been suggested, which is a cholinergic parasympathomimetic agent being used to stimulate salivary flow29. Given the significant changes in salivary pH values32, dental monitoring is of paramount importance to minimize the risk of caries and dental erosion18,26,36,39. Osteorradionecrosis Osteorradionecrosis (ORN) is one of the most severe and serious oral complications of radiotherapy for head and neck cancer18,23,36,49,50. Radiation reduces the potential for tissue vascularization, which creates hypoxic and hypovascular conditions, putting at risk cellular activity, collagen formation and the capacity for wound healing. Altered vessels induce blood flow decrease, thus reducing nutrients and defense cells. Without the necessary nutrients and defense the entire maxillary and mandibular bone structure suffers degeneration, characterized as a bone ischemic necrosis23,49,50. At the time of diagnosis, ORN may involve bone structure either superficially or Page136

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deeply. Furthermore, it may be a gradual process with slow or rapid change, possibly leading to a pathological fracture31. This process is usually associated with signs and symptoms such as intra- or extraoral fistula, trismus, pain, difficulty chewing, pathological fracture, local infection, and drainage of purulent secretion23,49. Predisposing factors include poor oral hygiene, periodontal disease, alveolodental abscess, extensive caries, anatomical location of the tumor, radiotherapy dose increase, and alveolodental surgery during radiotherapy or in post-operative period. Alcohol and tobacco habits irritate the oral mucosa and may also increase the risk of ORN50. Regardless pathophysiology of the disease, it should be established that cruel procedures such as exodontias or periodontal surgery are counter-indicated, since they may be risk factors for tissue decomposition and ORN4. Oral conditions of individuals under cancer treatment always trend to aggravate. The initially inflamed mucosa is aggravated by hyposalivation. Xerostomia facilitates the proliferation Streptococcus of Lactobacillus to sp and saliva mutans prevent

As a consequence, besides taste loss, the patient is unable and unwilling to eat properly, becoming increasingly frail. These factors provide an ideal of environment carious for the and development lesions

periodontal disease, predisposing to ORN51. Some authors argue that despite the improvement in oral care prior radiotherapy, ORN incidence has not declined significantly in recent years, on the contrary, it has increased by 1-30 percent. Meanwhile, other authors report that the introduction assessment improvement before and after of preventive oral hygiene and thorough dental irradiation, of radiotherapy techniques,

establishment of a reliable diagnosing, and adoption of the best therapeutic practices resulted in a decreased ORN incidence51. Treatment is still a challenge and initially it occurs in a conservative way through wound debridement and cleaning with surgical of antimicrobial to solutions, through treatment, antibioticotherapy and minor surgery. In cases refractory conservative hyperbaric oxygen therapy (HBO) should be indicated, associated or not with surgery23,49. The oxygen administered in controlled doses and pressure provokes oxygen tension growth in the affected area, vascular neoformation, increase in the number of cells, cellular activity increase, and collagenase increase, besides being bacteriostatic and bactericidal. These measures provide Page136 appropriate means for healing the tissue damaged by radiation23,49.

buffering capacity. The difficulty of saliva production leads the individual to change eating habits. In general, food becomes viscous and rich in carbohydrates. Since the individual is not able to rinse oral cavity properly due to intense pain, a vicious circle is formed which is very difficult to be broken.

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Alternative techniques such as BMPs (morphogenetic proteins) that induce bone differentiation have been studied and show to be promising51. Recently, low intensity laser radiation has presented good results for bone fracture and bone neoformation. It also works as a biostimulator in osteoblasts and as bio-modulator of mesenchymal undifferentiated cells in osteoblasts and osteocytes, but it still needs further studies51. Candidiasis Candidiasis contributing is one of the most factors include common fungal opportunistic infections and myelosuppression, impairment of the salivary flow and trauma to the mucosa, inadequate oral hygiene,
3,8,11,39

left untreated, candidiasis can progress to a systemic infection51.

Gingival bleeding Spontaneous bleeding or from traumatic brushing occurs because of platelet reduction. It is most commonly associated with chemotherapy, with severity depending on the degree of thrombocytopenia and imunossupression18,27,39. Oral hygiene in these cases it is of fundamental importance, since when it is inadequate or absent, gingival bleeding is exacerbated, which enables the severity of the clinical status25,29. Dysgeusia It is characterized by taste changes and is resulting from direct radiation damage to gustatory buds as well as changes in salivary flow, with 50% reduction in the perception of bitter and sour tastes18,26. Taste loss is transitional and partial or total recovery may occur between 2-12 months after radiotherapy. It can be fixed with zinc supplementation11,30. Trismus It is the limitation of mouth opening as a result of edema, cellular destruction and fibrosis of muscle tissue induced by radiation, making it difficult to maintain patients proper oral hygiene. The degree of restriction and radiation distribution11,18. Page136 depends on the radiation dose, tumor location,

malnutrition, and

debilitating mucositis

physical injuries

condition,

. Clinically, it is characterized by

the presence of white plaques in the oral mucosa, tongue and palate, caused by Candida albicans fungi, eventually resulting from the aggressive effects of chemotherapy or radiotherapy51. It can be treated through topic and/or systemic medication. Topic medication most commonly used is nystatin and its action depends directly on the time of contact with the tissues. The systemic use of fluconazole also has proven effective in antifungal therapy. But when comparing the effectiveness between topical and systemic drugs, no significant difference is found4,16. If

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The treatment should include exercises to stimulate mouth opening and closing, concomitantly with moist heat before and after the exercises, as well as administration of antiinflammatory medication, and muscle relaxers11. Carious lesions Taste changes combined with mouth dryness provoke dietary changes, leading patients to consume soft food with cariogenic potential. In addition, mouth rinsing difficulty because of the oral cavity sensitivity favors the growth of cariogenic bacterial flora and the consequent emergence of new carious lesions18,25. Thus, carious lesion is not a direct result of a healthy tooth structure affected by radiotherapy or chemotherapy, but a direct and secondary result of salivary gland hypofunction, dietary and oral microflora changes, and a precarious oral hygiene18,25,26,36,39. It appears that both

Infections In patients with myelosuppression arising from chemotherapy, fungal, viral, and bacterial infections can occur18,27,39. A complex interaction of factors contribute to the etiology of infections, including pre-existing oral diseases, loss of the oral mucosa integrity, impairment of the immune system, xerostomy and uncontrolled proliferation of oral and/or opportunistic microbiota. These factors are capable of causing serious infections quality that, of besides life and compromising the

interfering in the protocols of antineoplastic treatment, can pose risk to the patients life15,27. A common oral infection which may occur is caused by herpes simplex virus, associated with chemotherapy and bone marrow transplant. There may be a primary infection or, most commonly, the activation of infection latent form during periods of immunosuppression chemotherapy14. Intra herpetic injuries are often seen on the palate, grouped as lesions that may ulcer up quickly. Depending on the degree of bone marrow suppression, erythema can occur. Other oral viral infections that pose risk to cancer patient include varicella-zoster and cytomegalovirus14. Bacterial infections are derived from a secondary involvement of the ulcerated mucosa due to the therapy, and may become a source of cellulite and/or septicemia14. Page136 and intensive

chemotherapy and radiotherapy cause sequels during the oral antineoplastic treatment; however, they are related to dietary habits and inadequate oral hygiene25. Dentists should encourage patients commitment to topical fluoride use, dietary restrictions and regular appointments. The use of antibiotics can help eliminate the infection and the patient should be reassessed periodically every 3 months4,14.

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The role of dentists and oral surgeons Dentists and oral surgeons play an important role in related diagnosing to oral manifestations antineoplastic

radiographic evaluation11. There are different approaches described in the literature14,35,36,39,51, but generally the following should be prioritized: removal of infected areas through exodontias, endodontic treatment and oral care; dental prophylaxis; topical applications of fluoride 0.5 or 1.23%; antiseptic mouthwash, and periodic control. Any dental program should be focused mainly on education and awareness regarding the patient's oral health51. It should be emphasized that dentists should orient their patients about oral care and hygiene (use of fluoridated toothpaste, dental floss, and dental soft brush) throughout cancer treatment and post-treatment maintenance15, since some oral complications such as osteorradionecrosis and trismus present risk of relapse4. With regard to diet, dentists should inform the patient which foods should be avoided, such as rough, thick, hot and spicy food, as well as those that irritate or burn the oral mucosa, such as citrus juices and alcoholic beverages11,14,35. On the other hand, cold foods and liquids should be suggested, since they are well tolerated and, frequently, bring a sense of relief14. When it comes to child patients, studies indicate that a large number of parents and guardians received little or no explanation about oral changes that occur during Page136 antineoplastic treatment. Thus, it is believed that the presence of a dentist as a member of the oncology team can reduce the morbidity

treatment and should monitor the processing of applications, providing a better quality of life, since lesions resulting from cancer treatment considerably aggravate the patient clinical condition and the risk of infection4,11,14,26. Ideally, dental treatment should start before antineoplastic treatment to minimize morbidity and improve the general health of patients during therapy. In such cases, prevention becomes critical, since oral lesions resulting from the oral treatment considerably aggravate the clinical condition and the risk of infection, and even hamper the dental treatment when necessary11,29. However, there is some difficulty in prior dental treatment, due to the short interval of time between disease diagnosis and initiation of antineoplastic treatment. Often the disease is in advanced stages or with clinical manifestations, which hampers dental treatment. It would be interesting that dentists and cancer multidisciplinary team attending the patient work together, so that the initial dental assessment can be carried out adequately15. The development of a treatment plan, besides being appropriate for each individuals condition, aims to eliminate possible sources of infection15,46. Thus, dental treatment should start after a clinical and

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and mortality related to these complications. In addition, the dentist can provide guidance and establish a more frequent and intense hygiene control which will contribute to reducing mucositis rate, carious lesions, etc4. Thus, preventive measures should be taken to alleviate the side effects of antineoplastic therapy, through the provision of information on cancer treatment. Also, guiding measures to alleviate discomfort and support to reduce anxiety and depression should be provided15,24. It is important to be aware that patients and their families are in a very delicate moment of their lives, requiring great dedication and support from all those involved in their treatment, and everything possible must be done for the patients to feel protected and confident16.

lymph-node hypertrophy, mucosal pallor, petechiae, erythema, and taste dysfunction. Dentists should improve patients mouth conditions, thus increasing their quality of life through an appropriate protocol which should possibly include oral cavity evaluation and adequacy before starting antineoplastic treatment, strict control of oral hygiene, antiseptic mouthwash, analgesic, antibiotic, and antiinflammatory administration when necessary.

References
1. Hespanhol FL, Tinoco EMB, Teixeira HGC, Falabella MEV, Assis NMSP. Buccal manifestations in patients submitted to chemotherapy. [in portuguese] Rev. Cincia e Sade Coletiva [serial on the Internet]. 2008 Jun [cited 2008 Jun 30]. about 12p. Available from: http://www.abrasco.org.br/cienciaesaudecoletiva/artigos/artig o_int.php?id_artigo=1688. 2. Brasil. Ministrio da Sade. Secretaria de Ateno Sade. Instituto Nacional de Cncer. Coordenao de Preveno e Vigilncia de Cncer. Estimativas 2008: Incidncia de Cncer no Brasil. Rio de Janeiro: INCA, 2007, 94p. 3. Childers NK, Stinnett EA, Wheeler P, Wright JT, Castleberry RP, Dasanayake AP. Oral complication in children with cancer. Oral Surg Oral Med Oral Pathol. 1993; 75 (1): 41-7. 4. Goursand D, Borges CM, Alves KM, Nascimento AM, Winter RR, Martins LHPM, Zarzar PMPA, Paiva SM. Oral sequelae in children submitted to the antineoplastic therapy: causes and definition of the dental surgeons role. [in portuguese], Arquivos em Odontologia 2006; 42 (3): 180-9. 5. Lopes MA, Coletta RD, Alves FA, Abbade N, Rossi AJ. Reconhecendo e controlando os efeitos colaterais da radioterapia. Rev Assoc Paul Cir Dent. 1998; 52 (3): 241-4. 6. Silva DB, Pires MMS, Nassar SM. Pediatric cancer: analysis of hospital records [in portuguese]. J Pediatr. 2002; 78 (5): 409-14. and practices of oral health on hospitalized children with cancer. [in portuguese]. Rev. Cincia e Sade Coletiva [serial

Conclusion
Through this literature review it can be concluded that dentists should be concerned about patients general health, being attentive to fatigue, low and constant fever, malaise, anorexia and diffuse infection, and mainly to oral manifestations such as gingival bleeding and hyperplasia, as well as viral, fungal or bacterial infection. Patients already diagnosed and under treatment can present oral manifestations such as mucositis, gingival hyperplasia, infections (viral, bacterial or fungal), spontaneous bleeding, dermatitis, radiation trismus, caries, xerostomia, osteorradionecrosis,

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Recebido em: 24/03/2009 Aceito em: 02/09/2010

Faculdade de Odontologia de Piracicaba (FOP-UNICAMP) Departamento de Odontopediatria - Av. Limeira, 901 Piracicaba, So Paulo, Brasil. CEP: 13414-903. Phone 55-019-21065286 /Fax 55-019-34210144 E-mail: rmpuppin@fop.unicamp.br

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