Dental treatment prior to stem cell transplantation and its influence on the posttransplantation outcome

Influence of periodontal status on patients undergoing hematopoietic stem cell transplantation: A retrospective analysis

Objective

This retrospective analysis aimed to evaluate the prevalence of periodontitis in patients undergoing hematopoietic stem cell transplantation, and investigate the effects of various periodontal statuses and risk factors on oral infection incidence.

Study design

Medical records of patients pre- and post-hematopoietic stem cell transplantation from June 2019 to October 2021were reviewed. The study examined the effort of different periodontal statuses on oral complications and infections in patients during transplantation.

Results

Of 549 transplant patients studied, 363 had periodontitis. Patients with or without periodontitis showed significant differences in mean age, male proportion, and mucositis incidence during transplantation (P < 0.05). Bacteremia rates were slightly higher in patients with periodontitis, but not significant. Male proportion, age, and hospitalization duration significantly increased with advancing periodontitis stages. Only two patients experienced periodontal complications, that were effectively managed and did not interfere in the grafting process.

Conclusion

Periodontitis is prevalent in patients with hematopoietic diseases. Despite its association with oral mucositis, the occurrence of periodontal infection remains low and controllable.

Oral microbial changes and oral disease management before and after the treatment of hematological malignancies: a narrative review

OBJECTIVES

Patients with hematological malignancies have dynamic changes in oral microbial communities before and after treatment. This narrative review describes the changes in oral microbial composition and diversity, and discusses an oral microbe-oriented strategy for oral disease management.

MATERIALS AND METHODS

A literature search was performed in PubMed/Medline, Web of Science, and Embase for articles published between 1980 and 2022. Any articles on the changes in oral microbial communities in patients with hematological malignancies and their effects on disease progression and prognosis were included.

RESULTS

Oral sample detection and oral microbial sequencing analysis of patients with hematological malignancies showed a correlation between changes in oral microbial composition and diversity and disease progression and prognosis. The possible pathogenic mechanism of oral microbial disorders is the impairment of mucosal barrier function and microbial translocation. Probiotic strategies, antibiotic strategies, and professional oral care strategies targeting the oral microbiota can effectively reduce the risk of oral complications and the grade of severity in patients with hematological malignancies.

CLINICAL RELEVANCE

This review provides dentists and hematologists with a comprehensive understanding of the host-microbe associated with hematologic malignancies and oral disease management advice.

Pre-Chemotherapy Dental Screening: Is There Additional Diagnostic Value for a Panoramic Radiograph?

BACKGROUND

The oral cavity is a potential source of infectious complications in patients treated with myelosuppressive chemotherapy (CT). Pre-chemotherapy oral examination to identify foci of infection is recommended, but it is unclear whether this should include panoramic radiography. The present study aimed to evaluate the additional diagnostic merit of panoramic radiography as part of pre-CT oral screening.

METHODS

Patients with solid tumors scheduled to receive a myelosuppressive CT were eligible. The foci definition followed the guidelines of the Dutch Association of Maxillofacial Surgery. Oral foci assessed by clinical evaluation and panoramic radiography were compared.

RESULTS

In 33 out of 93 patients (35.5%), one or more foci were identified by clinical examination, whereas in 49.5% of patients, panoramic radiography showed pathology. In 19 patients, an oral focus was missed by clinical examination only, whereas in 11 patients, panoramic radiography indicated periodontal bone loss, but advanced periodontitis was not substantiated by clinical examination.

CONCLUSIONS

Panoramic radiographs complement clinical examinations and have additional diagnostic value. Nevertheless, the additional merit seems small, and the clinical relevance may vary depending on the anticipated risk of developing oral complications and the need for detailed diagnosis and rigorous elimination of oral foci prior to the start of cancer therapy.

Dental Evaluation Prior to Cancer Therapy

A comprehensive oral examination and dental care prior to the start of cancer therapy is the standard of care in many cancer centers. This is because good oral health will likely minimize the undesirable complications such as opportunistic infections during cancer therapy. As the considerations differ between anti-neoplastic regimens, this chapter discusses the indications and rationale when planning and executing a treatment plan for patients undergoing various cancer therapies.

Pre-medical dental evaluation and treatment of oral infection - a survey study among hospital-affiliated dentists in Sweden

OBJECTIVE

To examine how hospital-affiliated dentists assess risk and evaluate oral foci of infection in patients facing certain medical treatments, and whether the nature of upcoming medical treatment affects the choice of dental intervention.

MATERIALS AND METHODS

A survey comprising six clinical cases (50 teeth) was sent to hospital-affiliated dentists in Sweden. A treatment option for the affected tooth/teeth in each case was selected whether the patient was facing heart valve surgery, chemotherapy, radiation therapy, intravenous bisphosphonate treatment, solid organ transplantation or was diagnosed with endocarditis.

RESULTS

Consensus in choice of dental treatment was high in 62%, moderate in 32% and low in 6% of the assessments. High variability of choice of treatment was seen for eight teeth whereas the remaining 42 teeth often received the same therapy regardless of medical issue. Chemotherapy and radiotherapy were thought to entail the highest risk for oral infectious sequelae with a risk ranging from 1% to 100%.

CONCLUSION

Pre-medical dental evaluations and recommended treatments are often uniform with the exception of the management of asymptomatic root canal treated teeth with persisting apical radiolucency and heavily decayed molars. In many instances, dental diagnosis has a greater impact on choice of treatment than the underlying medical issue and associated implications thereof.

Oral Mucositis Association with Periodontal Status: A Retrospective Analysis of 496 Patients Undergoing Hematopoietic Stem Cell Transplantation

BACKGROUND

Hematopoietic stem cell transplantation (HSCT) can induce serious oral complications, including oral mucositis (OM). The presence of periodontal inflammation before HSCT is believed to be associated with OM. The aim of our study was to determine the prevalence and severity of OM in patients undergoing HSCT and its relation to periodontal status.

PATIENTS AND METHODS

This is a retrospective study of patients who underwent HSCT and a detailed dental examination between 2007 and 2015. The dental and periodontal status of all patients was evaluated by clinical and radiographic examination prior to HSCT. Oral health was assessed with the gingival index, the the community periodontal index, presence of plaque-related gingivitis, and marginal periodontitis. During the HSCT period, patients were examined daily for the presence of OM, which was graded according to World Health Organization (WHO) classification if present. The patients were assigned to the groups according to type of transplantation: autologous HSCT, myeloablative allogeneic HSCT, and non-myeloablative allogeneic HSCT.

RESULTS

A total of 496 patients were included in the study. OM was present in 314 of 496 patients (63.3%): 184/251 (73.3%) in the autologous group, 100/151 (66.2%) in the myeloablative allogeneic group, and 30/94 (31.9%) in the nonmyeloablative allogeneic group. Significantly more patients suffered from OM in the autologous and myeloablative groups versus the nonmyeloablative conditioning group (p < 0.001). The presence of periodontal inflammation did not significantly differ among the groups. There was only a borderline trend for the higher prevalence of OM in the non-myeloablative allogeneic nonmyeloablative group when periodontal inflammation was present (0.073939).

CONCLUSIONS

Oral mucositis prevalence and severity after stem cell transplantation is not widely affected by the oral hygiene and periodontal disease presence before HSCT. We confirmed the wide-known connection of the conditioning regimen intensity to the prevalence of OM.

Clinical utility of oral management in allogeneic hematopoietic stem cell transplantation recipients: microbiological evidence based on molecular analysis of oral bacteria

PURPOSE

This study aimed to clarify the clinical utility of oral management to prevent bloodstream infections by oral bacteria microbiologically in patients undergoing allogeneic hematopoietic stem cell transplantation (ASCT).

METHODS

Ten consecutive patients with hematological malignancies undergoing ASCT were enrolled in this study. We implemented dental treatments before transplantation, if required, and carried out oral hygiene instructions and oral management every other day after transplantation. Molecular analysis of bacterial DNA for seven oral species using a polymerase chain reaction (PCR) assay was performed for oral samples and peripheral blood once a week for 3 weeks after transplantation.

RESULTS

Periodontitis was found in all 10 patients (mild grade in 3 and middle grade in 7) for whom basic periodontal therapy was conducted. Necessary dental procedures, including tooth extraction were performed in 5 patients. After transplantation, oral mucositis occurred in 10 patients (grade 1 in 3, grade 2 in 2, and grade 3 in 5) for whom oral hygiene instruction and oral care were continued every other day. PCR-identified three to six bacterial species in oral samples from nine patients, but none in peripheral blood from any patient during the observation period.

CONCLUSIONS

Our study suggests that oral management could prevent bloodstream infections by oral bacteria in ASCT recipients despite the existence of periodontitis or oral mucositis. Its utility was confirmed by microbiological evidence based on molecular data.

Salivary BPIFA proteins are altered in patients undergoing hematopoietic cell transplantation

OBJECTIVE

The aim of this study was to evaluate the expression of BPIFA proteins in the saliva and salivary glands of hematopoietic cell transplant (HCT) patients.

MATERIAL AND METHODS

This longitudinal study included patients who had undergone autologous HCT (auto-HCT) and allogeneic HCT (allo-HCT), and unstimulated saliva was collected at three time points, with a fourth collection at oral chronic graft-versus-host disease (cGVHD) onset. BPIFA expression was analysed by Western blotting in saliva and immunostaining in the minor salivary glands of cGVHD patients.

RESULTS

Auto-HCT patients showed increased levels of BPIFA1 (p = .021) and BPIFA2 at D+7 (p = .040), whereas allo-HCT group demonstrated decreased expression of BPIFA2 at D+8 (p = .002) and at D+80 (p = .001) and a significant association between BPIFA2 low levels and hyposalivation was observed (p = .02). BPIFA2 was significantly lower in the cGVHD patients when compared to baseline (p = .04).

CONCLUSIONS

The results of this study show distinct pattern of expression of BPIF proteins in both auto-HCT and allo-HCT recipients with decreased levels of BPIFA2 during hyposalivation and cGVHD. Further studies are necessary to elucidate these proteins mechanisms and their clinical implications in these groups of patients.

Dental status and risk of odontogenic complication in patients undergoing hematopoietic stem cell transplant

PURPOSE

Dental evaluation and management prior to hematopoietic stem cell transplant (HSCT) plays a vital role in identifying and treating infections that may be life-threatening. The purpose of this study is to describe the dental management of patients undergoing pre-HSCT examination with the Dental Service at Memorial Sloan Kettering Cancer Center (MSKCC) and to report on odontogenic complications.

METHODS

Patients referred for evaluation as part of the standard preparation for HSCT were included. Following clinical and radiological examination, patients were assigned to one of three groups based on risk of odontogenic infection, and treatment was provided as indicated. Patients were followed, and their medical records were reviewed for odontogenic complications during the transplant admission.

RESULTS

Of the 375 patients evaluated, 350 patients underwent HSCT: allogeneic 143 (40.9%) and autologous 207 (59.1%). The distribution of primary cancer diagnosis was as follows: multiple myeloma 104 (29.7%), leukemias 95 (27.1%), Hodgkin's lymphoma 28 (8.0%), non-Hodgkin's Lymphoma 99 (28.3%), and other conditions 24 (6.9%). The median time from dental evaluation to transplant was 29 days. The median Decayed, Missing, Filled Teeth Index was 17. The median Community Periodontal Index was 1. Based on dental status, 145 patients (41.4%) were classified as low risk, 133 (38%) as moderate risk and 72 (20.6%) as high risk of odontogenic infection. One hundred fourteen patients (32.6%) required dental treatment prior to HSCT, and 100 of these (28.6%) completed treatment. Two (0.57%) patients had odontogenic complications.

CONCLUSIONS

With conservative pre-HSCT dental treatment based on an infection risk classification system, a low odontogenic complication rate was observed.

Dental management of a child with Wiskott Aldrich syndrome prior to bone marrow transplant: A case report

AIM

Orodental manifestations are commonly presented in Wiskott Aldrich Syndrome (WAS). The purpose of this paper is to report a case of dental management of a 5-year-old male child with WAS before Hematopoietic Stem Cell Transplantation (HSCT). Such patients are more prone to infection due to pretransplantation chemotherapy and posttransplantation immunosuppression; thus, it becomes imperative to eliminate all potential sources of infection before transplantation.

MATERIALS AND METHODS

Fluctuating blood parameters before the dental procedure was an important challenge in rendering dental treatment. Dental procedures were carried out under general anesthesia by maintaining the hematological parameters with blood and platelet transfusion. The conventional dental treatment may not be applicable in such patients as failure of dental treatment can cause the failure of HSCT, and it has to be modified based on the clinical acumen and recommendations.

CONCLUSIONS

This case report focuses on the measures to be taken before, during, and after the dental procedure to ensure the success of the dental therapy and prevent failure of HSCT due to residual dental foci of infection. A multidisciplinary approach involving a pedodontist, a pediatrician, and a hematologist can improve the quality of life of such patients.

Periodontal disease might be a risk factor for graft versus host disease. A systematic review

PURPOSE

The aim of this systematic review was to determine a potential association between periodontal disease and graft versus host disease (GVHD).

DESIGN

PubMed, Scopus and Web of Science databases were searched to identify all relevant articles. The eligibility criteria were prospective, retrospective, cross-sectional, cohort, case-control studies and interventional studies that assessed periodontal parameters in GVHD adults' patients.

RESULTS

Seven studies, published between 2000 and 2018, were eligible. The aggravation of periodontal tissues is due to inadequate oral hygiene, dental plaque, decays, gum recession, retained roots, tooth loss, periodontally infected teeth. Several studies have indicated that periodontitis treatment performed before transplantation showed the reduction of gingival inflammation and maintenance of periodontal health.

CONCLUSIONS

Periodontitis might be a risk factor for GVHD. However, due to the limited number of studies included in the review and their heterogeneity, more data are needed to sustain the correlation between periodontitis and GVHD.

Anesthetic Management of a Patient With Fanconi Anemia

Fanconi anemia (FA) is a type of bone marrow failure syndrome based on an autosomal recessive inherited trait with increased predisposition for other cancers. It is extremely rare and is characterized by short stature, polydactyly, and pancytopenia. At present, the only effective treatment for FA is allogeneic hematopoietic stem cell transplantation (SCT). Chemotherapy is necessary prior to allogeneic SCT. Dental treatment is usually performed before chemotherapy to reduce potential infections. We experienced the anesthetic management of a 4-year-old boy diagnosed with FA, who underwent extensive dental extractions before chemotherapy for SCT. In the preoperative examination, the platelet count was decreased to less than 3.0 × 10⁴ cells/μL because of chronic pancytopenia. The patient received 20 units of platelet transfusion over 3 days prior to anesthesia. Dental surgery and multiple dental extractions were successfully completed under general anesthesia with sevoflurane, fentanyl, and remifentanil, and chemotherapy started 3 days postoperatively.

Dissociations of oral foci of infections with infectious complications and survival after haematopoietic stem cell transplantation

Introduction

Haematopoietic stem cell transplantation (HSCT) recipients are at increased risk for severe infections. This study examined the associations of common oral infections with survival and infectious complications in HSCT recipients.

Materials and methods

All autologous and allogeneic HSCT recipients transplanted in the University Hospital of Basel, Switzerland, between 2008 and 2016 and referred to oral infection control pre-HSCT were included in this retrospective case-control study. All patients had a clinical and a panoramic radiological dental examination taken immediately prior to HSCT. Presence of acute or chronic oral foci of infections, decayed, missing or filled tooth index (DMFT) and radiological attachment loss (RAL) were examined. Survival and infections of the subjects were followed up for 6 months post-HSCT.

Results

Altogether 341 allogeneic and 125 autologous HSCT recipients were included in the study. Within 6 months post-HSCT, 47 (14%) of the allogeneic and 4 (3%) of the autologous recipients died. Oral foci of infections (acute or chronic), DMFT or periodontitis pre-HSCT were not associated with survival 6 months post-HSCT. Oral foci of infections were also not associated with hospital treated infectious diseases or blood culture positive bacteremia during the 6 month follow-up period. Untreated oral foci of infections were not associated with survival or severe infectious complications within 6 months post-HSCT.

Conclusion

The results of this study suggest that radical dental interventions to chronic oral infections could be postponed until post-HSCT.

Medication-Related Osteonecrosis of the Jaw: MASCC/ISOO/ASCO Clinical Practice Guideline

PURPOSE

To provide guidance regarding best practices in the prevention and management of medication-related osteonecrosis of the jaw (MRONJ) in patients with cancer.

METHODS

Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) and ASCO convened a multidisciplinary Expert Panel to evaluate the evidence and formulate recommendations. Guideline development involved a systematic review of the literature and a formal consensus process. PubMed and EMBASE were searched for studies of the prevention and management of MRONJ related to bone-modifying agents (BMAs) for oncologic indications published between January 2009 and December 2017. Results from an earlier systematic review (2003 to 2008) were also included.

RESULTS

The systematic review identified 132 publications, only 10 of which were randomized controlled trials. Recommendations underwent two rounds of consensus voting.

RECOMMENDATIONS

Currently, MRONJ is defined by (1) current or previous treatment with a BMA or angiogenic inhibitor, (2) exposed bone or bone that can be probed through an intraoral or extraoral fistula in the maxillofacial region and that has persisted for longer than 8 weeks, and (3) no history of radiation therapy to the jaws or metastatic disease to the jaws. In patients who initiate a BMA, preventive care includes comprehensive dental assessments, discussion of modifiable risk factors, and avoidance of elective dentoalveolar surgery (ie, surgery that involves the teeth or contiguous alveolar bone) during BMA treatment. It remains uncertain whether BMAs should be discontinued before dentoalveolar surgery. Staging of MRONJ should be performed by a clinician with experience in the management of MRONJ. Conservative measures comprise the initial approach to MRONJ treatment. Ongoing collaboration among the dentist, dental specialist, and oncologist is essential to optimal patient care.

Patient eligibility for hematopoietic stem cell transplantation: a review of patient-associated variables

Assessing patient eligibility for hematopoietic stem cell transplantation (HSCT) remains a complex, multifaceted challenge. Among these challenges, the paucity of comprehensive clinical data to guide decision making remains problematic coupled with unclear trade-offs between patient, disease and local HSCT center factors. Moreover, it is unclear that the modification of poor patient characteristics will improve post-HSCT outcomes. However, the use of Comorbidity Indices and Comprehensive Geriatric Assessments helps meet this challenge, but may be limited by overlapping patient characteristics. The increasing consideration for pre-HSCT psychosocial assessments and interventions remains to be studied. Ultimately, the decision to proceed with a HSCT remains interdisciplinary while considering the available evidence discussed in this review.

Oral shedding of human herpesviruses in patients undergoing radiotherapy/chemotherapy for head and neck squamous cell carcinoma is not affected by xerostomia

Background: Xerostomia is a very relevant and frequent complication of radiotherapy, causing the irradiated oral mucosa to be affected by bacterial, fungal and viral infections.

Objective: The objective of this study was to evaluate a possible relationship between oral shedding of human herpesviruses and xerostomia in patients with squamous cell carcinoma of head and neck submitted to radio/chemotherapy.

Methods: In this study, oral rinse samples were collected weekly from 20 patients during radiotherapy. The samples were submitted to PCR and enzymatic digestion for detection of human herpesviruses. Xerostomia was evaluated according to the Seminars in Radiation Oncology criteria.

Results: There was a higher frequency of grade 1 xerostomia (51.4%), observed first in the 1st week of radiotherapy. In the 4th week of radiotherapy, all patients presented some degree of xerostomia. Analysis of herpesviruses showed oral shedding of EBV, HHV-6 and HHV-7 in all weeks. Considering all the periods, the highest frequency was in patients with EBV excretion (55.0%), which was significantly higher than that of other viruses.

Conclusion: We observed that oral shedding of herpesviruses was not affected by xerostomia as there was a progression in their excretion, even with the evolution of xerostomia. This suggested that there is a local replication in the oral cavity that is not completely dependent of salivary excretion.

Oral health of adult patients undergoing hematopoietic cell transplantation. Pre-transplant assessment and care

Hematopoietic cell transplantation (HCT) is now one of the frequent procedures used for treatment of malignant and non-malignant blood diseases, autoimmune disorders, and certain solid tumors. Despite improvements of therapeutic protocols, HCT still carries a high risk of non-relapse mortality due to early and late complications. Side effects of the therapy regimen frequently occur in the oral cavity and often significantly decrease the patients' quality of life. The complications may result from or may be exacerbated by improper oral preparation of the patient before transplantation. Therefore, it is mandatory that all patients referred to HCT undergo thorough dental examination and receive appropriate treatment before the procedure. It is also very important to develop an individual post-transplantation oral care protocol with special concerns to oral hygiene before implementation of the conditioning. This paper presents a review of dental management methods intended for patients before HCT proposed in literature as well as recommendations based on the experience of the Department of Comprehensive Dental Care and the Department of Conservative Dentistry of Warsaw Medical University and the Warsaw Institute of Hematology and Blood Transfusion. The article pays special attention to the problem of potential foci of infection and bleeding. It also presents protocol of oral hygiene in post-transplantation period, used by patients of Warsaw Medical University and Institute of Hematology and Blood Transfusion.

Effect of leaving chronic oral foci untreated on infectious complications during intensive chemotherapy

BACKGROUND

Leukaemic patients receiving intensive chemotherapy and patients undergoing autologous stem-cell transplantation (ASCT) are routinely screened for oral foci of infection to reduce infectious complications that could occur during therapy. In this prospective study we assessed the effect of leaving chronic oral foci of infection untreated on the development of infectious complications in intensively treated haematological patients.

METHODS

We included and prospectively evaluated all intensively treated leukaemic patients and patients undergoing ASCT who were referred to our medical centre between September 2012 and May 2014, and who matched the inclusion/exclusion criteria. Acute oral foci of infection were removed before chemotherapy or ASCT, whereas chronic oral foci were left untreated.

RESULTS

In total 28 leukaemic and 35 ASCT patients were included. Acute oral foci of infection were found in 2 leukaemic (7%) and 2 ASCT patients (6%), and chronic oral foci of infection in 24 leukaemic (86%) and 22 ASCT patients (63%). Positive blood cultures with microorganisms potentially originating from the oral cavity occurred in 7 patients during treatment, but were uneventful on development of infectious complications.

CONCLUSIONS

Our prospective study supports the hypothesis that chronic oral foci of infection can be left untreated as this does not increase infectious complications during intensive chemotherapy.

Dental treatment in patients with leukemia

Dental treatment of patients with leukemia should be planned on the basis of antineoplastic therapy which can be chemotherapy with or without radiotherapy and bone marrow transplantation. Many are the oral manifestations presented by these patients, arising from leukemia and/or treatment. In addition, performing dental procedures at different stages of treatment (before, during, or after) must follow certain protocols in relation to the haematological indices of patients, aimed at maintaining health and contributing to the effectiveness of the results of antineoplastic therapy. Through a literature review, the purpose of this study was to report the hematological abnormalities present in patients with leukemia, trying to correlate them with the feasibility of dental treatment at different stages of the disease. It is concluded in this paper that dental treatment in relation to haematological indices presented by patients with leukemia must follow certain protocols, mainly related to neutrophil and platelet counts, and the presence of the dentist in a multidisciplinary team is required for the health care of this patient.

Prospective study of dental intervention for hematopoietic malignancy

Various chemotherapeutic agents used in patients with hematopoietic malignancy cause serious side effects, including myelosuppression and immunosuppression. Immunosuppression makes patients more susceptible to infection, resulting in an increased risk of infectious complications, including the development of severe septicemia that may be life-threatening. It is necessary for dental staff to be familiar with an appropriate protocol in such cases and to share information about the chemotherapy with a hematologist. To verify the effectiveness of our dental intervention protocol, we conducted a prospective study on the incidence of complications for each myelosuppressive grade of chemotherapy in patients with hematopoietic malignancy. We compared the incidence of complications between treatment P (patients who finished all the dental treatments according to the protocol) and treatment Q (patients who did not) per grade (A, B, C, D) and incidence of systemic or oral findings. We also compared the incidence of oral complication related to the residual teeth between first chemo (patients who were undergoing chemotherapy for the first time) and prior chemo (not the first time). There were significant differences in inflammatory complications between treatment P and treatment Q. We found that both systemic and oral inflammatory complications increased with higher-grade myelosuppressive chemotherapy. Additionally, there was a significant difference between the incidence of oral complications related to the residual teeth between first chemo and prior chemo. Complete implementation of the dental intervention protocol was associated with fewer oral and systemic infectious and inflammatory complications in patients with hematopoietic malignancies undergoing chemotherapy. The incidence of oral and systemic complications also increased with grade of chemotherapy. These results support the validity of our dental intervention protocol. We should pay close attention to the oral state of de novo hematopoietic malignancy patients.

Evaluation of the pretransplantation workup before allogeneic transplantation

An extensive workup is generally performed before allogeneic transplantation. The extent of this workup varies substantially between centers because of a lack of guidelines. We analyzed 157 consecutive allogeneic transplant candidates to understand the significance of components of the pretransplant evaluation. Workup consisted of chest computed tomography (CT); magnetic resonance imaging of the head; dental, ears-nose-throat (ENT), ophthalmology, and gynecology evaluations; pulmonary function tests; echocardiography; cytomegalovirus PCR; urine culture; clinical evaluation; and disease staging. Results were categorized as "normal or minor finding" or "major finding" (having significant consequences such as further testing or therapy). Major findings were classified as incidental or related to history and symptoms. Components of the pretransplant workup with the highest rate of major findings were CT (22%), dental evaluation (13%), and ENT (12%, mostly symptomatic). All other components had a low rate of major findings. Although 126 transplants were performed as scheduled, 24 were delayed and 7 canceled at short notice. The main reasons for delaying or canceling transplantation were active infection and unexpected disease progression. A prospective evaluation of a more restricted, symptom-guided pretransplant evaluation appears to be warranted.

Neutropenia Precautions for Children Receiving Chemotherapy or Stem Cell Transplantation for Cancer

Infections in children and adolescents with cancer are a significant cause of morbidity and mortality, especially in those receiving chemotherapy who are neutropenic and/or immunocompromised. The aim of this article is to review existing evidence in order to provide a practice recommendation to prevent or minimize infections in neutropenic and/or immunocompromised patients receiving chemotherapy and/or stem cell transplant. Systematic reviews were undertaken and research was graded according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. A variety of interventions are implemented to reduce infections in the neutropenic and/or immunocompromised population; however, few are supported by research evidence. Existing literature should continue to be reviewed to further identify interventions that can influence positive patient outcomes and provide opportunities for individuals in the medical field to work together to improve clinical care.

Oral health as a predictive factor for oral mucositis

OBJECTIVES

Oral mucositis is a complication frequently associated with hematopoietic stem cell transplantation, decreasing a patient's quality of life and increasing the occurrence of opportunistic infections. The purpose of this study was to determine the incidence and severity of oral mucositis and to assess the correlation of this disease with the oral health of an individual at the time of hematopoietic stem cell transplantation.

METHODS

Before transplantation, patients' oral health and inflammatory conditions were determined using the gingival index and the plaque index, which are based on gingival bleeding and the presence of dental plaque, respectively. Additionally, the dental health status was determined using the decayed, missing, and filled teeth index. The monitoring of oral mucositis was based on the World Health Organization grading system and was performed for five periods: from Day 0 to D+5, from D+6 to D+10, from D+11 to D+15, from D+16 to D+20, and from D+21 to D+30.

RESULTS

A total of 97 patients (56% male and 44% female) who underwent hematopoietic stem cell transplantation at the Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo between January 2008 and July 2009 were prospectively examined. The incidence of ulcerative mucositis was highest from days +6 to +10 and from days +11 to +15 in the patients who underwent autologous and allogeneic hematopoietic stem cell transplantation, respectively.

CONCLUSION

The data, including the dental plaque and periodontal status data, showed that these oral health factors were predictive of the incidence and severity of oral mucositis in a cohort of patients with similar conditioning regimens before hematopoietic stem cell transplantation.

Dental assessment prior to stem cell transplant: treatment need and barriers to care

OBJECTIVE

To assess the treatment needs of patients undergoing pre-haematopoietic stem cell transplant (HSCT) dental assessment, to collate the examination findings and treatment provided and to define the management issues impacting on care.

DESIGN

Single centre retrospective analysis.

SETTING

Salaried Primary Care Dental Service, Western General Hospital, Edinburgh, UK.

SUBJECTS AND METHODS

One hundred and sixteen available charts of patients who attended for pre-transplant dental assessment during April 2004-June 2007 were examined.

RESULTS

Ninety-four patients, 52 men (55.3%) and 42 women (43.6%), were included. Patients were referred a mean of 31.5 (SD 18.82) days before admission for transplant. Dental assessment occurred, on average, 7.88 days (SD 6.78) following referral. Eighty-eight (93.6%) patients were dentate, while six (6.3%) were edentulous. Eighty-eight (93.6%) patients presented with oral disease; 89 (94.7%) patients received dental care. Issues impacting on care were medical (n = 88, 93.6%), time constraints (n = 73, 77.7%), no GDP (n = 25, 26.7%), dental complexity (n = 5, 5.3%) and anxiety management (n = 1, 1.1%).

CONCLUSION

The majority of patients required dental care, most of which, for healthy adults, would normally be completed within a primary care setting. However, the issues surrounding the care of patients destined for HSCT indicate that there is a place for a dedicated dental service as part of the multidisciplinary team.

Oral infections and systemic disease--an emerging problem in medicine

The relationship between oral and general health has been increasingly recognised during the past two decades. Several epidemiological studies have linked poor oral health with cardiovascular disease, poor glycaemic control in diabetics, low birth-weight pre-term babies, and a number of other conditions, including rheumatoid arthritis and osteoporosis. Oral infections are also recognised as a problem for individuals suffering from a range of chronic conditions, including cancer and infection with human immunodeficiency virus, as well as patients with ventilator-associated pneumonia. This review considers the systemic consequences of odontogenic infections and the possible mechanisms by which oral infection and inflammation can contribute to cardiovascular disease, as well as the oral conditions associated with medically compromised patients. A large number of clinical studies have established the clinical efficacy of topical antimicrobial agents, e.g., chlorhexidine and triclosan, in the prevention and control of oral disease, especially gingivitis and dental plaque. The possible risks of antimicrobial resistance are a concern, and the benefits of long-term use of triclosan require further evaluation. Oral infections have become an increasingly common risk-factor for systemic disease, which clinicians should take into account. Clinicians should increase their knowledge of oral diseases, and dentists must strengthen their understanding of general medicine, in order to avoid unnecessary risks for infection that originate in the mouth.

A decision analysis: the dental management of patients prior to hematology cytotoxic therapy or hematopoietic stem cell transplantation

There is a controversy regarding whether dental treatment before chemotherapy protocols, including hematopoietic stem cell transplantation (HSCT), is helpful to prevent infections during the consequent immunosuppression. The aim of this study was to develop a decision analysis framework that would test the effect of dental treatment prior to chemotherapy on the survival of the patient. A decision tree was created to compare the clinical outcomes of two treatment alternatives for a base-case patient receiving cytotoxics or undergoing HSCT. The variables used to build the model were "systemic infection", "unmet dental needs", "dental needs". The outcomes evaluate to compare the two strategies was "survival". We performed MEDLINE and PubMed searches of English-language literature according to a list of related terms. The decision analysis model selected dental treatment prior to chemotherapy as the preferred strategy for the base case analysis. The results of this study suggest that dental treatment prior to chemotherapy is the preferred treatment strategy. Using our base case data, 1.8 of every 1000 hemato-oncologic patients or HSCT patients will die compared to the non-treatment prior to chemotherapy strategy.

A prospective study to evaluate a new dental management protocol before hematopoietic stem cell transplantation

Pre-hematopoietic stem cell transplantation (HSCT) dental treatment is essential to prevent serious infections from oral sources during immunosuppression, in patients who undergo HSCT therapy. This study was planned to establish a dental management protocol for such patients. Forty-one patients scheduled for HSCT to treat hematological malignancies were consecutively enrolled in the prospective trial. The dental status of all patients was evaluated by clinical and radiographic examination at a median of 47 days before the commencement of HSCT therapy. Thirty-six patients had one or more dental diseases; the remaining five had none. Caries was found in 26 patients, apical periodontitis in 19, marginal periodontitis in 24 and a partially erupted third molar in 11. Our policy is to preserve patients' teeth whenever possible, and therefore minimal dental intervention was planned. Treatment was completed for all 36 patients with dental pathologies, before the conditioning regimen began. All patients received the scheduled HSCT therapy without alteration, interruption or delay, and did not show any signs or symptoms associated with odontogenic infection while they were immunosuppressed. This protocol, therefore, appears to be appropriate for the pre-HSCT dental treatment of patients with hematological diseases.

The role of basic oral care and good clinical practice principles in the management of oral mucositis

BACKGROUND

The Basic Oral Care Group is one of eight subcommittees functioning within the Mucositis Study Group Guidelines Panel of the Multinational Association of Supportive Care in Cancer and International Society for Oral Oncology (MASCC/ISOO). The Basic Oral Care Group, comprised of the four authors of this paper, represented the disciplines of nursing (DBM, JJ), dentistry (MEPC), and pediatric dentistry (PW). This group reviewed research and clinical literature to update the original 2004 Mucositis Management Guidelines in the areas of basic oral care, bland rinses, protocols and education, and good clinical practices such as pain management, oral assessment, oral care, and dental care.

MATERIALS AND METHODS

Over 100 articles published between 2000 and 2005 were identified, and 32 of these were useful for the analysis. Each article was rated by at least two authors using a structured rating form and systematic determination of levels of evidence, based on the American Society of Clinical Oncology criteria. Discussion at the 2005 MASCC/ISOO Geneva pre-conference meeting of the Guidelines Panel resulted in the development of consensus on the interpretation of the literature.

RESULTS

Based on the literature and on Panel discussions, a revision of the original guidelines for protocols and education was produced by the group, and they developed a set of recommendations related to good clinical practices.

CONCLUSIONS

Although research remains scanty for components of basic oral care, bland rinses, protocols, and education, the original 2004 guidelines with the help of newer literature from 2000 to 2005 and expert consensus among the Guidelines Panel enabled the development of useful clinical practice guidelines for managing oral mucositis in patients receiving cancer treatment with radiation and/or chemotherapy.