- Email: [email protected]
Assessment of the need for treatment of postendodontic asymptomatic periapical radiolucencies in bone marrow transplant recipients
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 DENTAL
OF DENTISTRY
BRIGHAM
AND
WOMEN’S
HOSPITAL
AND
HARVARD
SCHOOL
OF
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 significantly 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 complications related to their disease.l, 2 Early dental intervention appears to significantly reduce the incidence of oral complications associated ,with myelosuppressive regimens from approximately 40% to about 12%.3 Thus, to reduce morbidity, pretreatment dental evaluation has become the standard of care for patients who undergo bone marrow transplantation (BMT). The objectives of a pre-BMT dental screening program should be the identification of foci of symptomatic and asymptomatic oral infection or potential sources of oral infection. Screening should be efficacious with a positive influence on patient morbidity and mortality without adversely affecting medical management. Previous reports have discussed the rationale and effectiveness of screening.4 The challenge is to determine which conditions identified by screening 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, Copyright @ 1993 by Mosby-Year Book, 0030-4220/93/$1.00 + .lO 7/13/47304
Inc.
particularly in endodontically treated teeth.6 Periapical 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 decision 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 retreatment of teeth with an asymptomatic periapical radiolucency (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 asymptomatic PE-PARL did not increase risk for oral complications during BMT. This observation warranted further evaluation. We performed a retrospective chart review to identify patients with asymptomatic PE-PARLs found during pre-BMT oral evaluation. 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, 45
46
Peters et al.
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOCli
Table 8.Patient characteristics Treated Wumber of patients Male Female Autogenous Allogeneic 4s
Untreated
9 14 9 6 3 5 5 8 4 6 Mean = 40.8 yrs Mean = 44.4 yrs Range: 21-57 yrs Range: 25-58 yrs
I
Total 23 15 8 13 IO
Mass., who had been referred from the Dana Farber Cancer Institute and Brigham and Women’s Hospital for pre-BMT dental assessment between 1987 and I99 1. We reviewed the dental charts of 276 patients who underwent allogeneic or autologous BMT protocols in use at these institutions between 1987 and 1991. All patients were screened before BMT by a dental resident and an attending dentist. The screening examination consisted of a complete intraoral radiographic survey, panoramic radiograph, and hard and soft tissue examination. Patients with a PE-PARL were identified on the basis of the complete intraoral radiographic examination obtained at the time of screening. All dental records and intraoral radiographs were again reviewed by two dental residents and an attending dentist. Patients were included in the study if there was (1) no clinical evidence of extensive caries in the involved tooth, (2) no clinical evidence suggestive of infection, (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 medical 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. 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 duration. Patients were examined twice a week by the dental staff. The outcomes measured were (1) the
number of days febrile (when the parients temperature was greater than 100” F and the white blood cell count [ WBC] was less than 1,OOO/ml), (2) the number 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 primary outcome measure observed. Data were analyzed with Student’s t test to determine whether significant differences existed between the treated and untreated groups. 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. Asymptomatic PE-PARLs were treated on average at least 7 days before BMT in nine patients with retreatment, 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 PEPARLs. No organisms suggestive of oral flora were isolated from the blood of patients in either group throughout the transplantation-associated hospitalization. Follow-up of patients did not extend beyond this hospitalization. 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 transplantation 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 EOundergo 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
?%%i
SURGERY ORAL MEDICINE
Peters et al.
ORAL PATHOLOGY
47
Volume 76, Number 1
DAY9 15
0-I
ANC <5Oo/ml
TEMP ~100°F
’
OUTCOME
Fig. 1. Bar graph shows mean number (ofdays when temperature was greater than 100” F and WBC was less than 1,OOO/mland 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 important to recognize the findings revealed by screening 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 development 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 treatment decisions during pre-BMT dental evaluation. National Cancer Institute Consensus Panel recommendations12 for dental screening before BMT are without clear guidelines as to which specific screening outcomes should be pursued with pre-BMT intervention. Some evidence suggests that pre-BMT oral assessment 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 periods of profound immunosuppresion. In addition, if patients who undergo profound myelosuppression associated 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 question of whether treatment of asymptomatic PEPARLs affects outcome in patients who undergo profound myelosuppression associated with BMT was best studied retrospectively because conducting a randomized clinical trial was considered inappropriate. 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 identify 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 infection in this population. Further study is warranted to assessthe contributions of specific dental conditions that are likely sources of morbidity and mortality in myelosuppressed patients. These studies should evaluate 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 consensus among general dentists and endodontists on the
48 Peters et al.
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
July 1993 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 personal 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 asymptomatic postendodontic periapical radiolucencies. These periapical radiolucencies may represent periapical scars or areas of incomplete bone fill.
6. I.
8.
9.
10. REFERENCES 1, Sonis ST, Sonis AL, Lieberman A. Oral complications in patients receiving treatment for malignancies other than of the head and neck. J Am Dent Assoc 1978;97:468-71. 2. Dreizen S, McCrededie KB, Bodey GP, et al. Quantitative analysis of the oral complications of antileukemic chemotherapy. 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 assessment, NC1 Monograph 1990;9:29-32. 5. National Institutes of Health. National Institutes of Health consensus development conference statement: oral complica-
11. 12.
13.
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 making among a group of general practitioners. Stand J Dent Res 1988;96:112-7. Reit C. On decision making in endodontics a study of diagnosis 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 therapy 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
OF DENTISTRY
BRIGHAM
AND
WOMEN’S
HOSPITAL
AND
HARVARD
SCHOOL
OF
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 significantly 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 complications related to their disease.l, 2 Early dental intervention appears to significantly reduce the incidence of oral complications associated ,with myelosuppressive regimens from approximately 40% to about 12%.3 Thus, to reduce morbidity, pretreatment dental evaluation has become the standard of care for patients who undergo bone marrow transplantation (BMT). The objectives of a pre-BMT dental screening program should be the identification of foci of symptomatic and asymptomatic oral infection or potential sources of oral infection. Screening should be efficacious with a positive influence on patient morbidity and mortality without adversely affecting medical management. Previous reports have discussed the rationale and effectiveness of screening.4 The challenge is to determine which conditions identified by screening 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, Copyright @ 1993 by Mosby-Year Book, 0030-4220/93/$1.00 + .lO 7/13/47304
Inc.
particularly in endodontically treated teeth.6 Periapical 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 decision 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 retreatment of teeth with an asymptomatic periapical radiolucency (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 asymptomatic PE-PARL did not increase risk for oral complications during BMT. This observation warranted further evaluation. We performed a retrospective chart review to identify patients with asymptomatic PE-PARLs found during pre-BMT oral evaluation. 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, 45
46
Peters et al.
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOCli
Table 8.Patient characteristics Treated Wumber of patients Male Female Autogenous Allogeneic 4s
Untreated
9 14 9 6 3 5 5 8 4 6 Mean = 40.8 yrs Mean = 44.4 yrs Range: 21-57 yrs Range: 25-58 yrs
I
Total 23 15 8 13 IO
Mass., who had been referred from the Dana Farber Cancer Institute and Brigham and Women’s Hospital for pre-BMT dental assessment between 1987 and I99 1. We reviewed the dental charts of 276 patients who underwent allogeneic or autologous BMT protocols in use at these institutions between 1987 and 1991. All patients were screened before BMT by a dental resident and an attending dentist. The screening examination consisted of a complete intraoral radiographic survey, panoramic radiograph, and hard and soft tissue examination. Patients with a PE-PARL were identified on the basis of the complete intraoral radiographic examination obtained at the time of screening. All dental records and intraoral radiographs were again reviewed by two dental residents and an attending dentist. Patients were included in the study if there was (1) no clinical evidence of extensive caries in the involved tooth, (2) no clinical evidence suggestive of infection, (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 medical 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. 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 duration. Patients were examined twice a week by the dental staff. The outcomes measured were (1) the
number of days febrile (when the parients temperature was greater than 100” F and the white blood cell count [ WBC] was less than 1,OOO/ml), (2) the number 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 primary outcome measure observed. Data were analyzed with Student’s t test to determine whether significant differences existed between the treated and untreated groups. 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. Asymptomatic PE-PARLs were treated on average at least 7 days before BMT in nine patients with retreatment, 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 PEPARLs. No organisms suggestive of oral flora were isolated from the blood of patients in either group throughout the transplantation-associated hospitalization. Follow-up of patients did not extend beyond this hospitalization. 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 transplantation 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 EOundergo 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
?%%i
SURGERY ORAL MEDICINE
Peters et al.
ORAL PATHOLOGY
47
Volume 76, Number 1
DAY9 15
0-I
ANC <5Oo/ml
TEMP ~100°F
’
OUTCOME
Fig. 1. Bar graph shows mean number (ofdays when temperature was greater than 100” F and WBC was less than 1,OOO/mland 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 important to recognize the findings revealed by screening 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 development 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 treatment decisions during pre-BMT dental evaluation. National Cancer Institute Consensus Panel recommendations12 for dental screening before BMT are without clear guidelines as to which specific screening outcomes should be pursued with pre-BMT intervention. Some evidence suggests that pre-BMT oral assessment 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 periods of profound immunosuppresion. In addition, if patients who undergo profound myelosuppression associated 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 question of whether treatment of asymptomatic PEPARLs affects outcome in patients who undergo profound myelosuppression associated with BMT was best studied retrospectively because conducting a randomized clinical trial was considered inappropriate. 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 identify 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 infection in this population. Further study is warranted to assessthe contributions of specific dental conditions that are likely sources of morbidity and mortality in myelosuppressed patients. These studies should evaluate 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 consensus among general dentists and endodontists on the
48 Peters et al.
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
July 1993 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 personal 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 asymptomatic postendodontic periapical radiolucencies. These periapical radiolucencies may represent periapical scars or areas of incomplete bone fill.
6. I.
8.
9.
10. REFERENCES 1, Sonis ST, Sonis AL, Lieberman A. Oral complications in patients receiving treatment for malignancies other than of the head and neck. J Am Dent Assoc 1978;97:468-71. 2. Dreizen S, McCrededie KB, Bodey GP, et al. Quantitative analysis of the oral complications of antileukemic chemotherapy. 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 assessment, NC1 Monograph 1990;9:29-32. 5. National Institutes of Health. National Institutes of Health consensus development conference statement: oral complica-
11. 12.
13.
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 making among a group of general practitioners. Stand J Dent Res 1988;96:112-7. Reit C. On decision making in endodontics a study of diagnosis 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 therapy 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