Published: May 2003
Bone marrow transplantation (BMT) for the treatment of leukemias, aplastic anemias, lymphomas and some solid tumours is becoming more common. Intensive chemotherapy with or without total body irradiation is administered to eliminate malignant cells and immunosuppress the patient. Following the intensive therapy, the bone marrow is restored by infusing bone marrow or peripheral blood stem cells (PBSC) into the patient through a central venous catheter. The dental team plays a significant role in the management of these patients because pre-existing dental disease may lead to significant infections during and after the transplant, thus compromising the success of the procedure and possibly resulting in sepsis and death.
Types of Transplants
Autologous - the patient's own bone marrow and/or PBSC are removed and preserved;
Allogeneic - bone marrow and/or PBSC are donated by a family member or individual identified through a computer data bank. Techniques are used to match the cell-surface markers to reduce the risk of complications and graft-versus-host disease;
Syngeneic - bone marrow and/or PBSC are taken from an identical twin.
Oral Complications
During initial phases of the transplant, the patient is at risk for developing significant oral sequelae, including oral mucositis and ulcerations, hemorrhage, infections (fungal, viral and bacterial) and xerostomia. The acute oral complications begin to resolve when engraftment is achieved and the hematologic status begins to improve. The initial intensive therapy may result in immunosuppression for up to one year post-BMT.
Graft-Versus-Host Disease (GVHD)
Allogeneic bone marrow transplant patients are at risk for developing acute and chronic GVHD. Associated GVHD oral complications may include mucositis, mucosal atrophy, ulcerations, and oral infections including candidiasis; immune-related complications, including lichenoid reactions, scleroderma and lupus-like changes (limited oral opening and tongue mobility); and xerostomia with secondary rampant dental breakdown. GVHD and its medical management may cause significant immunosuppression.
Oral/Dental Management Prior to BMT
Elimination of all oral sources of infection and irritation is the goal of pre-BMT dental evaluation and treatment.
Dental treatment should be scheduled in consultation with the oncologist. If the patient has a central venous catheter, prophylactic antibiotics should be prescribed in consultation with the physician prior to the dental appointment.
If oral surgery is required, at least 7-10 days of healing should be allowed before the anticipated date of bone marrow suppression (eg: ANC of <1000/mm3 and/or platelet count of
< 50,000/mm3).
Dental prophylaxis and oral hygiene instruction may have a significant positive impact on the severity of the oral complications. Patients scheduled for total body irradiation and/or allogeneic transplant should be taught an effective toothbrushing technique to apply fluoride gel on their teeth or, if necessary, study models should be made for fabrication of custom fluoride gel‑applicator trays.
It should be remembered that many of these patients will remain immunosuppressed for up to a year and will be at risk during selected post-transplant dental treatment.
