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Cancer therapies can have a significant impact on a patient's oral health, and the condition of the mouth can greatly affect a patient's experience and the success of his or her treatments. This is especially true with bone marrow transplants, which are used to treat cancers that affect blood cells and bone marrow, such as leukemias, lymphomas, or multiple myelomas. Dental professionals can play a critical role in making the transplant process more comfortable for patients while reducing their risks of serious complications both during and after the transplant.
Bone Marrow Transplants
Bone marrow is a tissue inside of the bones that produces stem cells. These stem cells grow into blood cells, including red blood cells that carry oxygen, platelets that control bleeding, and white blood cells that fight infection. In a bone marrow transplant, the unhealthy bone marrow is replaced with healthy stem cells. This article uses "bone marrow transplant" as an umbrella term to describe this type of treatment; however, it is referred to by many names, including bone marrow transplant, hematopoietic stem cell transplant, related donor transplant, and matched unrelated donor transplant.
Before undergoing a bone marrow transplant, the recipient often receives intense chemotherapy that is sometimes combined with radiation therapy to eliminate malignant cells within the bone marrow and prepare the body for the transplanted healthy cells. Healthy stem cells can be taken from the person undergoing the transplant, which are referred to as autologous, or from a donor, which are referred to as allogeneic.1 During the transplant process, the patient's immune system is severely suppressed. This can result in problems in the mouth that range from mild irritations to complications that affect the patient's ability to eat or drink and significant risks for potentially life-threatening infections.
What Can Dental Professionals Do?
Communication between the transplant team and the dental team is essential to ensure that clinicians and other dental healthcare professionals understand the patient's diagnosis and treatment plan in order to provide care safely. The dental team should ask if the patient's regime will include bone-modifying agents, such as bisphosphonates, which are often used for bone-related complications associated with multiple myeloma. Bone-modifying agents may also be used for treating the high prevalence of osteopenia and osteoporosis associated with bone marrow transplants.2 Patients who are taking bone-modifying agents are at risk of developing medication-related osteonecrosis of the jaw, so it is important to avoid extracting teeth and performing other invasive dental procedures involving the jawbone after bisphosphonate therapy.3 Coordination of care also helps to ensure that the information provided to the patient by the dental team is consistent with that provided by the medical team.
It is important to complete a thorough oral examination and any necessary dental treatment prior to pretransplant chemotherapy or radiation therapy, and many bone marrow transplant programs will require this. Oral complications can be minimized and, in some cases, prevented with this type of early intervention.4 The dental care provided before undergoing a bone marrow transplant should include the following:
• Evaluation and documentation of caries, infections, and periodontal disease
• Radiographic examination
• Visual and tactile oral cancer screening
• Restoration or removal of any decayed teeth and those at risk for infection
• Provision of fluoride varnish (the ability to tolerate fluoride trays will likely be limited during the transplant process)
• Performance of oral hygiene procedures as indicated
• Counseling about the potential oral adverse effects of transplantation
• Instruction regarding modified oral hygiene practices and product recommendations
A pretreatment dental examination also provides a baseline to document any oral health changes that may occur as a result of the cancer therapies or the cancer itself for future treatment planning and insurance coverage.
Time is of the essence for cancer patients, so beginning the bone marrow transplant process should not be delayed. Invasive dental procedures should be completed at least 7 days prior to starting chemotherapy and 14 days prior to radiation therapy involving the head and neck regions.5 To accomplish this, certain dental procedures may need to be prioritized and potentially adjusted as needed. The transplant doctor should be consulted to determine if antibiotic prophylaxis is necessary to reduce infection risks. If the patient's treatment needs are extensive, the use of silver diamine fluoride (SDF) and a glass ionomer should be considered to facilitate timely cancer therapy, and more permanent restorations can be placed when the patient is more medically stable.
Regular use of a sodium bicarbonate rinse is commonly recommended by the transplant team, and although the recipe may differ from one clinic to another, the International Society of Oral Oncology recommends mixing 1 level teaspoon of salt, 1 level teaspoon of baking soda, and 4 cups of water.6 This solution can be stored in a container with a lid at room temperature for the patient to use throughout the day. The patient should be instructed to shake the solution well before using it and to discard it at the end of each day.
Oral Hygiene Instructions
For transplant patients, oral hygiene instructions should focus on techniques to gently remove bacterial biofilm with minimal risk of tissue trauma. Patients should be instructed to adhere to certain guidelines, including the following:
• Brush the teeth and tongue two to three times each day. If oral mucositis becomes severe, using a sterilized, 2-in square gauze pad can provide an alternative to brushing. Patients can wrap the moistened gauze around a finger and use it to gently wipe plaque from the teeth and tissue.
• Use a toothbrush with extra-soft bristles and a compact head. The extra-soft bristles are gentler on tender gum tissue than standard ones, and a small, compact head makes it easier to access hard-to-reach areas of the mouth while avoiding toothbrush trauma. Patients should be instructed to continue gently brushing even if gums become sore.
• Avoid germs while infection risks are high. This can be accomplished by not sharing items such as lip balm, straws, and toothpaste. The patient's toothbrush should be replaced weekly and stored separately from family members' brushes and away from flushing toilets.
• Continue regular flossing with the approval of the oncologist. For cancer patients who are not regular flossers, this is not a safe time to start. Be sure to demonstrate and stress the use of a proper flossing technique to reduce the risks of tissue trauma. The transplant team may recommend avoiding flossing if blood counts drop to unsafe levels during treatment.
Beyond being provided with modified oral hygiene instructions, transplant patients should be advised to avoid oral healthcare products that contain certain ingredients that could result in negative effects and to consider the use of others with ingredients that could potentially be beneficial. For example, transplant patients should avoid products with potentially irritating and drying ingredients such as sodium lauryl sulfate, tartar control agents, alcohol, and whitening agents. In addition, products with mint or cinnamon flavors should be avoided because they can aggravate tender tissue and encourage nausea. Those that are completely unflavored or that have milder flavors, such as bubblegum or berry, may be the easiest to tolerate. Transplant patients should also avoid acidic oral care products that may contribute to enamel erosion and the development of caries.
The dental team should assume that dry mouth will occur and take steps to treat it before it starts. There is no one-size-fits-all solution, so patients should be encouraged to try different products to see what works best for them. Products sweetened with xylitol can stimulate saliva production and help to support a healthy oral microbiome and pH level. Xylitol products come in many forms, including sprays, gels, gums, and mints. In addition to dry mouth, the lips of patients undergoing cancer treatment can become excessively dry and cracked, so the use of a petroleum-free lip balm is recommended to hydrate and protect.
Regarding the prevention and treatment of oral mucositis in transplant patients, clinicians should consider the use of a calcium phosphate rinse.7 Chlorhexidine should not be used for the prevention or treatment of oral mucositis in transplant patients.8
Post-transplant Dental Care
After leaving the hospital, transplant recipients will continue to be medically fragile and should make oral hygiene a priority to reduce the risks of bacterial, viral, and fungal infections. They will be advised to avoid dental appointments, except for emergencies. The transplant team will let the patient know when he or she can safely resume routine dental visits, which is typically around 6 to 12 months after the transplant. Once the patient is medically cleared, dental providers can resume care but should take certain actions, including the following:
• Inquire if antibiotic prophylaxis is needed prior to dental care.
• Request medical status updates from the transplant team, including appointment notes, laboratory test results, and medication lists.
• Start with a more frequent 3-month recall schedule and then adjust accordingly to the patient's individual needs.
• Include a thorough oral cancer screening in each visit because transplant recipients are at an increased risk of developing other cancers, including oral cancers.9
• Use caution for invasive procedures involving the jawbone, particularly if the patient received bisphosphonates.
Transplant recipients are at risk of developing an autoimmune-like disease called chronic graft versus host disease (GVHD). Although it is still possible to develop chronic GVHD with autologous transplants, it is much more common with allogeneic transplants. Chronic GVHD can affect many areas of the body and have a significant impact on the mouth. Oral presentations of chronic GVHD may come and go and tend to be more severe for patients who demonstrate poor oral hygiene. The symptoms of oral chronic GVHD include:
• dry mouth;
• color changes in the soft tissue, including redness and white lacy lines or patches;
• sensitivity to foods, flavors, toothpaste, carbonated liquids, or certain product ingredients;
• chapped or blistered lips;
• oral mucositis; and
• infections in the mouth, such as oral candidiasis.10
The recommendations for managing oral presentations of chronic GVHD are similar to the basic oral hygiene instructions that patients are asked to follow during their cancer treatments, which emphasize meticulous yet gentle oral hygiene. In addition, many chronic GVHD patients continue to be sensitive to flavors and other ingredients in oral hygiene products.10 Prior to pursuing any prescription options, the patient's medical team should be consulted to address symptoms and ensure coordination of care and no contraindications.
Dental professionals should embrace their role as an important part of the journey of care for bone marrow transplant patients. Proactive oral care can improve outcomes and quality of life throughout treatment and survivorship. When medical and dental healthcare providers work together, they ensure that patients are receiving the safest and most effective care possible.
1. What is a bone marrow transplant (stem cell transplant)? Cancer.Net website. https://www.cancer.net/navigating-cancer-care/how-cancer-treated/bone-marrowstem-cell-transplantation/what-bone-marrow-transplant-stem-cell-transplant. Updated July 2020. Accessed October 25, 2022.
2. Kendler DL, Body JJ, Brandi ML, et al. Osteoporosis management in hematologic stem cell transplant recipients: executive summary. J Bone Oncol. 2021;28:100361.
3. Ruggiero SL, Dodson TB, Aghaloo T, et al. American Association of Oral and Maxillofacial Surgeons' position paper on medication-related osteonecrosis of the jaws-2022 update. J Oral Maxillofac Surg. 2022;80(5):920-943.
4. National Institute of Dental and Craniofacial Research. Dental Management of the Organ or Stem Cell Transplant Patient.U.S. Department of Health and Human Services, National Institutes of Health; 2016.
5. National Institute of Dental and Craniofacial Research. Dental Provider's Oncology Pocket Guide.U.S. Department of Health and Human Services, National Institutes of Health; Reprinted 2009.
6. International Society of Oral Oncology website. http://www.isoo.world/.
7. Markiewicz M, Dzierzak-Mietla M, Frankiewicz A, et al. Treating oral mucositis with a supersaturated calcium phosphate rinse: comparison with control in patients undergoing allogeneic hematopoietic stem cell transplantation. Support Care Cancer. 2012;20(9):2223-2229.
8. Elad S, Cheng KKF, Lalla RV, et al. MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy. Cancer. 2020;126(19):4423-4431.
9. Kruse ALD, Grätz KW. Oral carcinoma after hematopoietic stem cell transplantation--a new classification based on a literature review over 30 years. Head Neck Oncol.2009;1:29.
10. Mouth and chronic GVHD (Oral GVHD): graft-versus-host disease can cause mouth dryness and sores, sensitivity to food and eating difficulties. BMT InfoNet website. https://www.bmtinfonet.org/transplant-article/mouth-and-gvhd-oral-gvhd. Updated August 2022. Accessed October 25, 2022.