Pediatric Bone Marrow transplantation: oral complications and recommendations for care

Department of Pediatric Dentistry
Lutheran Medical Center

Name: Craig Elice Date: January 22, 2010
Article title: Pediatric Bone Marrow transplantation: oral complications and recommendations for care.
Author(s): da Fonseca MA.
Journal: Pediatric Dentistry 20 (7)
Volume (number): 20(7) 386-94
Month, Year: 1998
Major topic: Bone Marrow transplant, oral complications
Type of Article: Review of Literature
Main Purpose: The article provided an overview of Bone Marrow Transplant and the importance of a detailed oral examination prior to transplant and then to review oral complications and recommendations for treatment
Findings: Pretreatment goals are to identify, eliminate, and prevent problems that will cause the transplant to be less successful. The medical history should yield information on the disease, time of onset, modalities of the treatment received so far and complications. Surgeries, hospitalizations, ER visits, past episodes of infection, current hematologic status, allergies, meds and review of systems. Information about the transplant should include the type of transplant, donor preparation regimen, graft vs. host disease prophylaxis. The patient and family should be informed of the high sucrose level of some of the meds like nystatin, and clotrimazole troches . the patients central venous line needs antibiotic coverage due to the increased risk of infection.

Hematologic status focuses on platelet status and absolute neutrophil count. Thrombocytopenia occurs with platelets at <100000 cells/mm3. Moderate risk of bleeding occurs when platelets are <50000 cells/mm3. Neutropenia is when ANC <1500 cells/mm3 and elective dental treatment is contra indicated when ANC <100 cells/mm3.

Dental history and examination is necessary. Radiographs should be exposed as part of the screening. OHI and oral rehabilitation should be accomplished pre BMT as the patient will not be able to receive any dental procedures for up to one year post BMT. A cleaning , scaling as well as restoration of caries should occur ASAP with procedures that have moderate success like pulpotomies, and pulpectomies being contraindicated. Loose primary teeth should be allowed to exfoliate naturally, Wisdom teeth should be extracted if patient is at an appropriate age, Orthodontic appliances should be removed OH consists of toothbrushing with fluoridated toothpaste, and flossing should be done as tolerated. Oral rinses are effective (Na Bicarbonate, saline, and sterile water) are effective at cleaning and keeping tissues moist. Hydrogen peroxide can irritate and cause super infection. Chlorhexidine rinse is indicated, but long-term use is discouraged due to altered taste, high alcohol content, and possibility of super infection.

Education is critical. The importance of OH and preventing infection is discussed as it improves the transplant outcome. Disuss dietary habits, potential effects of some of the meds, and the effects of chemotherapy and radiation on the craniofacial growth and development and dental structures with the patient.

Oral complications can occur from conditioning regimen (7-10 days prior to transplant) to early ingraftment period (up to 30 days post BMT). It includes the following:
Mucositis: neutropenia seems to have the greatest relationship to mucositis. Great variability in mucositis amongst patients but there seems to be a minimal relationship to drug doses, schedules, duration of treatment, and impairment of renal and hepatic function. It can occur as early as 4-7 days after initiation of conditioning phase and last 10-14 days o. it generally starts with the nonkeratinized surfaces of buccal and lingual mucosa

Pain management: Young infants frequently need narcotic analgesics. Older children are given paitent controlled analgesics of sedative meds. Local analgesics include viscous lidocaine 2% and dyclonine HCl are effective topical agents. Ice packs and ice pops increase comfort level of patients,

OH as noted.

Oral bleeding: oral manifestations of thrombocytopenia include bruising , petechiae, purpura and oozing of mucosal tissues which can be potentiated by local irritating factors like calculus, plaque, etc. Ulcerations, infections, spontaneous bleeding occurs when platelets are <20000cells/mm3 or less. Platelet transfusion may be necessary. Topical therapies like moist gauze pressure packs, ice packs, and topical hemostatic agents shold be tried first.

Infections: Candida is the most common oral infection in BMT patients. Nystatin solutions and clotrimazole troches are effective. Ketoconazole, miconozole and flucononazole are ingested and amphotericin B IV is for aggressive treatment. HSV is the main viral pathogen. Patients with a + serotype receive low dose acyclovir up to 28 days post BMT. CMV seropositive patients receive genocidovir for at least 100 days post BMT. Lastly bacterial infections are less common.

Xerostomia and taste disturbances usually last for a few weeks with the exception of radiation patients. Salivary flow can be stimulated with sugar free gum or hydration. Avoid coarse foods and spicy foods and consult with a nutritionist.

Acute GVHD occurs when transplanted T Lymphocytes treat host tissues as foreign causing injury to several parts of the body. Acute GV-HD occurs within the first 100 days post BMT with the median onset at 19 days. Most common oral changes include erythema (dorsal and ventral surface of tongue, floor of mouth) and lichenoid changes. Prevention includes good oral hygiene, steroid rinses, treatment of concurrent infections and topical analgesics.

Neurotoxicity: Vinblistine and vincristine in the conditioning phase can cause peripheral neuropathy including jaw pain and lower molar toothaches. Treatment is palliative as it disappears after the drugs are discontinued.
Key points/Summary: The pediatric dentist is an important part of the transplant team. We are best consulted during the pretherapy phase when oral disease is eliminated and the patient can attain an optimal state of dental health. Dental health is important to improve the chances of a successful outcome to the transplant
Assessment of article: Good article which I believe provides up to date information regarding the role of the pediatric dentist in providing care to this patient. .