Assessment of the need for treatment of postendodontic asymptomatic periapical radiolucencies in bone marrow transplant recipients

Edward Peters, DMD, MS, Michael Monopoli, DMD, MPH, MS, Sook B. Woo, DMD, MS, and Stephen Sonis, DMD, DMSc, Boston, Mass. DIVISION OF DENTISTRY BRIGHAM AND WOMEN’S HOSPITAL AND HARVARD SCHOOL OF

DENTAL MEDICINE

Oral screening and treatmient of existing oral disease before bone marrow transplantation have been reported to decrease the incidence of infectious complications during bone marrow transplantation. Information about the adverse sequelae of specific preexisting oral diseases duriing bone marrow transplantation is lacking. The presence of postendodontic periapical radiolucencies may suggest recurrent or latent infection. The purpose of this study was to compare the effect of endodontic treatment with nontreatment of asymptomatic postendodontic periapical radiolucencies on the frequency of infectious oral complications during bone marrow transplantation. The records of 276 patients undergoing bone marrow transplantation examined between July ‘1988 and June 1991 were reviewed retrospectively. Twenty-three postendodontic periapical radiolucencies were identified in 8 women and 15 men. The mean age of patients was 41 years (range, 25 to 58 years). Fourteen of the lesions were untreated, and nine were treated before bone marrow transplantation, When outcomes of transplant complications ‘were compared, neither increased systemic infection as measured by neutropenic days febrile nor local oral infectious complications were significantly different. These results suggest that nontreatment of asymptomatic postendodontic periapical radiolucencies does not increase the incidence of infectious complications during bone marrow transplantation. (ORAL Sunc ORAL MED ORAL PATHOL 1993;76345-8)

Patients who und.ergo cancer therapy are at increased risk of developing oral complications that may signif- icantly influence morbidity and mortality. Previous studies have demonstrated that 30% to 50% of patients treated with chemotherapy for cancers other than head and neck cancers develop oral complica- tions related to their disease.l, 2 Early dental inter- vention appears to significantly reduce the incidence of oral complications associated ,with myelosuppres- sive regimens from approximately 40% to about 1 2%.3 Thus, to reduce morbidity, pretreatment dental eval- uation has become the standard of care for patients who undergo bone marrow transplantation (BMT).

The objectives of a pre-BMT dental screening pro- gram should be the identification of foci of symptom- atic and asymptomatic oral infection or potential sources of oral infection. Screening should be effica- cious with a positive influence on patient morbidity and mortality without adversely affecting medical management. Previous reports have discussed the ra- tionale and effectiveness of screening.4 The challenge is to determine which conditions identified by screen- ing warrant trea.tment5 Furthermore, consideration should be given to the cost-effectiveness of treatment to positively influence outcome.

Much has belen discussed about the appropriate management of asymptomatic periapical disease,

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particularly in endodontically treated teeth.6 Periapi- cal lesions frequently appear as incidental findings on radiographic examination without clinical signs or symptoms7 When such findings are associated with a nonvital or symptomatic pulp, the management deci- sion is fairly straightforward, However, if the tooth has already been treated endodontically or if there is no clinical evidence to suggest an inflammatory origin for the periapical lesion, the treatment decision becomes complex. Although some advocate retreat- ment of teeth with an asymptomatic periapical radi- olucency (PE-PARL) noted 4 or more years after root canal treatment,’ several studies show support for a no-therapy alternative.9-1 1

Observations of our patients who could not be screened before BMT suggested that not treating as- ymptomatic PE-PARL did not increase risk for oral complications during BMT. This observation war- ranted further evaluation. We performed a retrospec- tive chart review to identify patients with asymptom- atic PE-PARLs found during pre-BMT oral evalua- tion. Differences in outcome for a set of measures were evaluated between patients who received treatment for the postendodontic radiolucencies and those who did not.

MATERIAL AND METHODS This study was conducted as a retrospective cohort

chart review of all patients seen at the Division of Dentistry, Brigham and Women’s Hospital, Boston,

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46 Peters et al. ORAL SURGERY ORAL MEDICINE ORAL PATHOLOCli

Table 8. Patient characteristics

Treated Untreated I Total

Wumber of patients 9 14 23 Male 6 9 15 Female 3 5 8 Autogenous 5 8 13 Allogeneic 4 6 IO

4s Mean = 40.8 yrs Mean = 44.4 yrs Range: 21-57 yrs Range: 25-58 yrs

number of days febrile (when the parients tempera- ture was greater than 100” F and the white blood cell count [ WBC] was less than 1 ,OOO/ml), (2) the num- ber of days when the absolute neutrophil count (ANC) was less than 500/m& and (3) local signs and symptoms associated with odontogenic infection, such as swelling, pain, and sensitivity. The number of days with a temperature greater than 100” F was the pri- mary outcome measure observed. Data were analyzed with Student’s t test to determine whether significant differences existed between the treated and untreated groups.

Mass., who had been referred from the Dana Farber Cancer Institute and Brigham and Women’s Hospi- tal for pre-BMT dental assessment between 1987 and I99 1. We reviewed the dental charts of 276 patients who underwent allogeneic or autologous BMT proto- cols in use at these institutions between 1987 and 1991. All patients were screened before BMT by a dental resident and an attending dentist. The screen- ing examination consisted of a complete intraoral ra- diographic survey, panoramic radiograph, and hard and soft tissue examination.

ESULTS Patient characteristics are described in Table I.

The subjects’ underlying diagnoses included: chronic myelogenous leukemia, non-Hodgkin’s lymphoma, acute myelogenous leukemia, chronic lymphocytic leukemia, myelodysplastic syndrome, and testicular and breast malignant conditions.

Patients with a PE-PARL were identified on the basis of the complete intraoral radiographic exami- nation obtained at the time of screening. All dental records and intraoral radiographs were again re- viewed by two dental residents and an attending den- tist. Patients were included in the study if there was (1) no clinical evidence of extensive caries in the in- volved tooth, (2) no clinical evidence suggestive of in- fection, (3) no complaints of pain or sensitivity, and (4) a history of endodontic treatment completed at least 1 year before the examination. On the basis of intraoral (periapical) radiographic exam, a PE-PARL was defined as a widening of the periodontal ligament space greater than 1.5 mm located at the apex of an endodontically treated tooth. Through review of med- ical and dental records, patients included were grouped into those whose PE-PARL was treated and those who did not receive treatment. Some PE-PARLs were not treated because of insufficient time for treatment between screening and BMT.

Asymptomatic PE-PARLs were treated on average at least 7 days before BMT in nine patients with re- treatment, apicoectomy, or extraction; PE-PARLs in 14 patients were not treated. Subsequent medical chart review revealed no reports of adverse sequelae in either group. There were no documented reports of oral complications or complaints such as swelling, pain, or sensitivity associated with teeth with PE- PARLs. No organisms suggestive of oral flora were isolated from the blood of patients in either group throughout the transplantation-associated hospital- ization. Follow-up of patients did not extend beyond this hospitalization.

A total of 23 patients, each with a single lesion, who met the eligibility criteria were identified. Of these, 14 did not receive treatment for the PE-PARL and nine lesions were treated with endodontic retreatment, apicoectomy, or extraction. The patients’ medical charts were reviewed, and documentation of oral complaints or complications was noted. The follow-up observation was conducted only during the BMT hospitalization, which on average was I month in du- ration. Patients were examined twice a week by the dental staff. The outcomes measured were (1) the

The number of days that the patients had a temperature greater than 100” F and the WBC of less than 1 ,OOO/ml was not statistically different between the treated and untreated groups (t test = 1.19, p = 0.25). The mean number of febrile days was 9.2 & 6.0 in the treated group and 6.7 I 4.1 in the untreated group. The number of days with an ANC less than 500/ml also did not differ statistically between the two groups (t test = 0.55, p = 0.59). No statistical difference existed between the two trans- plantation regimens (allogeneic and autologous) with respect to the number of days febrile (t test = -I .38, p = 0.18) or to the total number of days with an ANC less than 500 (t test = -1.39, p = 0.18) (Fig. I).

BlSCtiSSlON Dental screening of the patient about EO undergo

BMT has become the standard of care. The goal of screening is to reduce the morbidity and mortalit)! that may arise from oral complications associated with BMT. However, at the same time, the patient

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Peters et al. 47

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0-I ANC <5Oo/ml TEMP ~100°F ’

OUTCOME

Fig. 1. Bar graph shows mean number (of days when temperature was greater than 100” F and WBC was less than 1 ,OOO/ml and mean number of days when ANC was less than 50O/ml and standard deviations for treated and untreated PARLs.

should not incur additional morbidity or mortality from needless dental intervention. It is therefore im- portant to recognize the findings revealed by screen- ing that do not need treatment. To do so, there must be information about how the findings revealed by screening affect ou.tcome. In addition, screening must be cost-effective, that is, the costs of screening and treatment of potential sources of dental infection must be less than the costs associated with the devel- opment and treatment of a complication during BMT. One way to increase cost-effectiveness is to limit the number of unnecessary dental procedures.

There is a lack of data on the efficacy and outcomes of screening Ion which practitioners can balse treat- ment decisions during pre-BMT dental evaluation. National Cancer Institute Consensus Panel recom- mendations12 for dental screening before BMT are without clear guidelines as to which specific screening outcomes should be pursued with pre-BMT interven- tion. Some evidence suggests that pre-BMT oral as- sessment and treatment can have a significant effect on outcome during myelosuppression in cases of severe periodontal disease or partially impacted third molars.r3 However, most recommendations for the approach to abnormal findings on routine screening examinations are based on case reports, personal preference and on limited anecdotal experience. There is a need to identify which strategies are optimal to prevent or to minimize oral complications during pe- riods of profound immunosuppresion. In addition, if patients who undergo profound myelosuppression as- sociated with! BMT do not experience adverse se-

quelae from untreated asymptomatic PE-PARLs, then it can be assumed that healthy persons would have a similar outcome.

Retrospective chart reviews have their limitations but are frequently the only way to study some clinical problems. Because of ethical constraints, randomized and clinical trials are not always possible. The ques- tion of whether treatment of asymptomatic PE- PARLs affects outcome in patients who undergo pro- found myelosuppression associated with BMT was best studied retrospectively because conducting a randomized clinical trial was considered inappropri- ate. Although all patients in this study were subjected to an identical screening protocol, time limitations imposed by treatment schedules or by the severity of their medical illness often dictated which lesions could be treated. As a result it was possible to iden- tify patients through retrospective chart review and measure their outcome.

The finding that nontreatment of PE-PARLs did not influence outcome in BMT recipients should not imply that the mouth is not a potential source of in- fection in this population. Further study is warranted to assess the contributions of specific dental conditions that are likely sources of morbidity and mortality in myelosuppressed patients. These studies should eval- uate the efficacy and cost-effectiveness of dental intervention in cancer patients to distinguish those findings that mandate treatment from those that will not adversely affect outcome if left untreated.

Studies have shown that there is a lack of consen- sus among general dentists and endodontists on the

48 Peters et al. ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY

management of periapicai lesions in endodonticahy treated teeth.(js *, 9 There is disagreement on both the diagnosis and the recommended treatment strategies for PE-PARL, so individual clinicians rely on per- sonal experience and intuition to guide their decision making. On the basis of a sample of 23 patients this study shows that there is no need to treat asymptom- atic postendodontic periapical radiolucencies. These periapical radiolucencies may represent periapical scars or areas of incomplete bone fill.

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2. Dreizen S, McCrededie KB, Bodey GP, et al. Quantitative analysis of the oral complications of antileukemic chemother- apy. ORAL SURG ORAL MED ORAL PATHOL 1986;62:650-3.

3. Sonis ST, Kunz A. Impact of improved dental services on the frequency of oral complications of cancer therapy. ORAL SbRCi QRALMEDORAL PATHOL 1988;65:19-22.

4. Sonis ST, Woods PD, White BA. Pretreatment oral assess- ment, NC1 Monograph 1990;9:29-32.

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tions of cancer therapies: diagnosis, prevention, and treatment. J Am Dent Assoc 1989;119:179-83. Reit C, Grondahl HG. Management of periapical lesions in endodontically treated teeth. Swed Dent J I984;8: 1-7. Marmary Y, Kutiner G. A radiographic survey of periapical jawbone lesions. ORAL SURG ORAL MED ORAL PATHOL 1986;61:405-8. Reit C, Grondahl HG. Endodontic retreatment decision mak- ing among a group of general practitioners. Stand J Dent Res 1988;96:112-7. Reit C. On decision making in endodontics a study of diagno- sis and management of periapical lesions in endodontically treated teeth. Sw-ed Dent J Suppl 1986;41:2-30. Stevenson-Moore P. Essential aspects of a pretreatment oral examination. NC1 Monograph 1990;9:33-6. Peterson DE, Overholser CD, Williams LT. Endodontic ther- apy in patients receiving myelosuppressive therapy. J Dent Res 1982;61:276. Consensus development conference on oral complications of cancer therapies: diagnosis, prevention, and treatment. NCI Monograph 1990;9:1-184. Peterson DE. Pretreatment strategies for infection prevention in chemotherapy patients. NC1 Monograph 1990;9:61-71.

Reprint requests: Edward Peters, DMD Brigham Dental Group Brigham and Women’s Hospital 75 Francis Street Boston, MA 02115