University of Toronto

Malignant Hematology - Bone Marrow/Stem cell Transplants

The Dentists Role

It is well documented that oral manifestations of systemic disease may be the presenting chief complaint. The dentist must be aware of these and act appropriately to aid in the diagnosis. For example, acute myelogenous leukemia (AML) may present with gingival involvement. In our experience of screening leukemia patients, this occurs in less than 2% of the newly diagnosed leukemics. However, it is a useful sign of underlying disease that may present to the dentist first. One of the distinguishing features from generalized hyperplastic gingivitis is the presence of gingival pain and hemorrhage when there are leukemic infiltrates in the gingiva. The following are examples of varying degrees of involvement of the gingiva in patients diagnosed with AML. With successful treatment of the leukemia, the gingival hyperplasia regresses. Until that time, empiric treatment with chlorhexidine mouthwashes is indicated.

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Another common finding may be petechia or ecchymosis with minor trauma secondary to thrombocytopenia as seen in the following example.

Malignant Hematology

Neutropenic ulcers may occur when a traumatic ulcer becomes secondarily infected because of the lack of immunoprotection of the neutrophils. These painful ulcers appear large and covered with a thick coating resembling bacterial cultures. Often the oncologist will refer the patient for biopsy of these lesions to rule out leukemic infiltrates. Caution must be exercised as the patient is often thrombocytopenic as well as neutropenic and excessive bleeding may result. The following 2 photographs are examples of neutropenic ulcerations.

Malignant Hematology
Malignant Hematology

This 66 yr-old male who was being treated with chemotherapy (Azacytadine) for myelodysplasia was referred for assessment and biopsy of this ulcer. He stated that he developed right facial swelling 4 days previously and felt that he had bitten his cheek during the night. His neutrophil count was 0.17 and his platelet count was 7. There was a 2 cm in diameter ulcer on a raised violaceous base. The ulcer had a black covering with a purulent exudate. Given the history of trauma and his blood counts, the impression of an infected neutropenic ulcer was entertained. He was placed on antibiotics and chlorhexidine mouth rinse and the following photograph was taken one week later.

Malignant Hematology

Although the blood counts remained low (neutrophil count 0.20), the ulcer and swelling have improved significantly in one week. The swelling was presumed to be a hematoma from the trauma and thrombocytopenia. Note the petechiae on the buccal mucosa indicative of thrombocytopenia.

Malignant Hematology

The following example is a 59 yr-old male who received an allogeneic bone marrow transplant for AML 2 months previously. He developed several large painful ulcers of which this was an example. His neutrophil count was 11 and the oncololgist referred him for biopsy of an ulcer to rule out graft vs. host disease. He had a previous episode prior to transplant of large oral ulcerations that resolved over a 6 week period. A biopsy was performed and the pathologic report was “non-specific ulcer”. This is consistent with aphthous major and given the previous history, the most likely diagnosis. He was being treated for GVH of the GI and his ulcers healed presumably with this treatment.

Malignant Hematology

The following example shows another ulcer in a patient with leukemia. The patient is an 85 yr-old male who was on chemotherapy for AML but not in remission. He developed this ulcer on the palate such that he had difficulty wearing his complete upper denture. The ulceration appears secondarily infected as well. The ulcer was biopsied and revealed a leukemic infiltrate.

Malignant Hematology

The previous examples illustrate that ulcerations in patients with leukemia or post-HCT may be difficult to diagnose. The differential diagnosis should include neutropenic ulcer, leukemic infiltrate, aphthous, chemotherapy related mucositis and infection. Careful review of the history and blood counts as well as documentation of the lesion are necessary to determine the best course of treatment for the patient. For example, topical steroids would be contraindicated for a viral ulcer. Oral pathology consultation if available is optimal.

Bone Marrow and Peripheral Stem Cell Transplants (Hematologic cell transplant HCT)

Patients require a HCT for certain hematologic malignancies such as leukemia, lymphoma, Hodgkin’s disease, and multiple myeloma; myelodysplasia, myelofibrosis and aplastic anemia. Rare conditions such as primary amyloidosis and POEMS syndrome have also benefitted from this therapy. In general there are 2 types of transplants: the autologous where the patient’s own stem cells are re-infused following high dose chemotherapy and allogeneic where another’s stem cells are used. The latter may involve a related donor such as a sibling, an identical twin donor (syngeneic) or an unrelated matched donor. In both cases, the stems cells that are infused will repopulate the bone marrow after high dose myelosuppressive chemotherapy is used to eradicate the malignant hematologic cells. Prior to engraftment, the patient is rendered pancytopenic and totally immunosuppressed making them a high risk for serious infections and hemorrhage. Because of these risks, dental treatment is contraindicated at this time. Patients should be seen prior to the transplant to eradicate dental infection and ensure optimal oral/dental health to prevent dental problems during the period of immunosuppression.

The procedure involves the insertion of a Hickman line (double lumen central venous catheter which is tunneled under the skin to enter the jugular vein), through which chemotherapy and stem cells are delivered. The line usually stays in place until engraftment takes place (approximately 2 weeks with autologous and 4 weeks with allogeneic). If emergency dental care is necessary, the presence of the indwelling catheter necessitates the use of prophylactic antibiotics. The same regimen as the AHA guidelines for cardiac patients is used.

Malignant Hematology

Autologous Peripheral Stem Cell Transplant

The autologous stem cell transplant is a procedure done for certain hematologic malignancies such as multiple myeloma, Hodgkin’s lymphoma, non-Hodgkin’s lymphoma and some types of leukemia. Certain solid tumors such as germ cell tumors may also benefit from this therapy. Higher doses of chemotherapy can be used to eradicate the cancer cells because of the support offered by the stem cells.

The stem cells are collected while the patient is in remission and frozen for later use. The collection process involves mobilization of stem cells. This usually entails infusion of a chemotherapeutic agent such as cyclophosphamide followed by granulocyte colony stimulating factor (G-CSF such as Neupogen® or Filagastrin®). It has been shown that a higher yield of stem cells can be retrieved when the chemotherapy is given initially. Also, the chemotherapy reduces possible tumor cell contamination in the stem cell collection. The cells are frozen and kept stored until the transplant procedure can be performed. After the harvesting but before the transplant, there may be a window of opportunity to perform safe dental care as the blood counts recover shortly after the harvest. It is essential that blood work be reviewed and the presence of a central line be known before any dental work is contemplated. Communication with the oncologist or the nurse coordinator is important.

The next step involves insertion of the Hickman line (if not already in place). Then infusion of the high dose chemotherapy agent is performed. Shortly after, the stem cells are retrieved from the freezer, warmed and infused through the Hickman line. Usually, a period of hospitalization of approximately 2-3 weeks in relative isolation for recovery during which time there will be pancytopenia. More and more, patients are being treated as outpatients and return to the hospital daily for blood work to determine engraftment. Patients may be on prophylactic antibiotics, antifungals and antivirals to prevent opportunistic infections.

Side Effects

The side effects of this therapy are similar to those of any myelosuppressive chemotherapy. As the doses are higher, more severe effects can be seen. Systemic effects such as nausea, vomiting, fatigue, dysgeusia and oral mucositis are not infrequent. Oral effects also include an increase in sensitivity of the teeth especially to cold and dry mouth. Generally, these effects are temporary and empiric treatment such as desensitizing agents and topical anaesthetics are sufficient. However, persistent dry mouth (greater than 3 months) may predispose to the development of root caries and patients should be followed with this in mind. Neutral pH topical sodium fluoride in custom trays may be necessary to prevent severe decay.

Multiple myeloma

Our clinic database reveals that over 2,500 patients with multiple myeloma have been seen. Multiple myeloma is a malignancy of plasma cells. Plasma cells are responsible for producing immunoglobulins and an increase in these proteins are responsible for proteinemia and proteinuria. Also as these cells originate in the bone marrow, symptoms often relate to bone pain, anemia and hypercalcemia. Ten to 15% of multiple myeloma patients have associated amyloidosis. This abnormal protein may be deposited in viscera such as the heart or kidney but does have a propensity to occur in the tongue. When this occurs, the tongue will be enlarged, very hard to palpation and there may be alterations in speech. It can be deposited in other sites in the oral soft tissues as well. Biopsy may be necessary to make a diagnosis. If suspected, it is important to state this as a provisional diagnosis to the pathologist so that special stains for amyloid will be used. (eg Congo Red)

This 67 yr-old male presented with a 6 month history of dysphonia, weight loss and fatigue. Oral examination revealed an enlarged tongue that was very firm to palpation. Note the crenations on the lateral borders with and the increased tissue mass on the right side covering the lingual portions of the crowns of the molars.

Malignant Hematology

Amyloid may significantly affect dental treatment in the following ways:

  • If there is cardiac involvement, consultation with the cardiologist may be necessary as prophylactic antibiotics may be recommended
  • Renal involvement may decrease renal function and some patients may be on dialysis
  • Amyloid in the oral soft tissues may be responsible for the development of hemorrhagic bullae with little trauma
  • The physical size and firmness of the tongue may limit the ability to perform routine dental procedures.

As a primary malignancy of bone, multiple myeloma lesions may be present in the jaws. In our experience, approximately 500 patients have lesions in the jaws accounting for 20%. No specific dental treatment is necessary for these but it is important for the dentist to recognize these lesions.

In the following case, the dentist was instrumental in making the diagnosis. This 60 yr-old female presented to her DDS with left TMJ pain with swelling. This pantomograph was exposed and shows a displaced pathologic fracture of the left condyle as well multiple lytic lesions throughout the mandible. The second pantomograph was taken 5 years after the peripheral autologous stem cell transplant with 3 years of intravenous bisphosphonate therapy.

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Malignant Hematology

Observations and discussion:

The first image shows a fractured and displaced left condylar head. The bone pattern of the mandible is generally osteoporotic with multiple lytic lesions of varying sizes of the rami bilaterally. The second image taken 5 years later shows the reduced left condylar head but the bone pattern of the mandible appears altered but the prior lytic lesions are barely discernable.

This next example shows a soft tissue mass in the posterior right maxilla of a 54F who had already had a peripheral autologous stem cell transplant for multiple one month previously. She developed this firm soft tissue mass in the right maxillary tuberosity region. It was biopsied and proven to be a myeloma lesion.

Malignant Hematology

The following examples show myeloma involvement of the mandible to varying degrees.

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Currently, patients with multiple myeloma are treated with 4 cycles of Cybor-D (Cyclophosphamide, Velcade® {Bortezomib} and Dexamethasone) often accompanied by an intravenous bisphosphonate such as Pamidronate (Aredia®) or Zoledronic acid (Zometa®). Occasionally, Denosumab (Prolia®) is used. This regimen is often followed by an autologous peripheral stem cell transplantation. Maintenance chemotherapy of Lenolidomide (Revlimid®) and intravenous bisphosphonate monthly often follow the transplant pending the response to initial therapy. Please refer to the section on bisphosphonate related osteonecrosis of the jaws (BRONJ or MRONJ) for further details.

Dental treatment plans must take into consideration the presence of the central venous line and blood count values. Prophylactic antibiotics are recommended for the central lines and in patients with absolute neutrophil counts less than 1. The platelet count may also be a mitigating factor. As patients recover, they may be treated as normal. Therefore, it is important to update their medical history keeping these parameters in mind.

Many myeloma patients have involvement of the spine and may have pain when reclined in the dental chair. Also, special head support for cervical spine involvement may be necessary. Consideration of patient comfort and knowledge of the medical condition will promote the patient’s confidence in your care.

Allogenic stem cell transplants

Allogeneic stem cell transplants are indicated for aplastic anemia, leukemias, myelodysplasia, myelofibrosis and lymphoma. Myelofibrosis is a disorder where neoplastic cells stimulate fibrosis and scarring of the bone marrow resulting in pancytopenia. Myelodysplasia (MDS) is a disorder where there is ineffective production of hematopoietic cell lines. Approximately 30% of MDS will progress to acute myeloid leukemia (AML). MDS can be seen after previous chemotherapy for another malignancy. It has also been associated with environmental exposure to certain chemicals such as benzene.

The allogeneic HCT is a procedure that carries significant morbidity and mortality. This type of transplant requires a donor source of stem cells. Related donors especially siblings are preferred; however, only approximately 30% of patients will have a family member match. Therefore, matched unrelated donor (MUD) are done if there is no appropriate family donor. The matching is based on HLA markers. An identical twin donor is referred to as a syngeneic graft. The better the match the better the engraftment with less risk of graft versus host disease (GVHD). For HCT, the patient must be in remission. This is achieved with myelosuppressive chemotherapy regimens based on the disease type. It usually involves induction chemotherapy followed by 2 consolidation or intensification cycles. There may be a window of opportunity to perform dental care safely after consolidation and prior to transplant.

The procedure involves conditioning of high dose chemotherapy and total body irradiation prior to the infusion of the donor cells. This is aimed at removing all of the malignant cells and will render the patient immunosuppressed until engraftment occurs. This requires the insertion of a central venous line (usually a Hickman line) and a period of hospitalization of approximately 4 weeks in isolation for recovery during which time there will be pancytopenia. The chemotherapy places the patient at risk of infection and with the low blood counts, dental care may not safe. Therefore, the patient requires a thorough oral and dental radiographic examination to remove potential sources of odontogenic infection prior to transplantation. Consultation with the hematologist is important to ascertain the patient’s stability for dental treatment. There are no hard and fast rules for this and each patient must be considered on a case-by-case basis. Also, different centres may have differing guidelines as to the use of prophylactic antibiotics. Obvious active dental disease requires treatment and optimal oral health should be attained before hospitalization. The duration of the immunosuppressed period is variable and can be up to one year or more after the transplant. These patients may have the central venous line in situ for this time period and may require frequent transfusions or intravenous drug therapy. For these reasons, safe dental care in the private office setting is variable and thorough review of the medical history is necessary at each visit. A period of isolation, usually averaging at 4 weeks for engraftment follows. Close monitoring for graft versus host disease and other complications will occur for several months to years after the transplant. The patient may be on many medications during this period. These include systemic immunosuppressants (on a tapering dose if no flare of GVHD), antivirals, antifungals, antibiotics, oral bisphosphonates (especially if on long term steroid therapy). Long term steroid therapy will also predispose to diabetes, cataract formation and osteoporosis. The dose of steroid does not require supplemention for dental care.

Factors to consider in the delivery of safe dental treatment include:

  1. blood counts, particularly platelets and neutrophils
  2. presence of a Hickman line (requiring prophylactic antibiotics)
  3. immunosuppressant medications
  4. presence of graft versus host disease

Oral complications related to bone marrow transplantation include chronic graft versus host disease (GVHD), gingival atrophy, and oral lesions secondary to opportunistic infections. Other lesions described below have been documented in literature and seen in our clinic. The pathogenesis or etiology is unclear.

Graft versus Host Disease

Graft vs host disease (GVHD) occurs when the donor immunocompetent cells recognize the host as foreign. Generally, it involves the skin, gut, liver and lungs but any system may be involved. Acute GVHD usually occurs within the first 3 months post HCT. Oral GVHD usually presents as a lichenoid mucositis with or without ulceration. The ulcerations as seen in the following examples can cause significant pain and inability to eat, perform oral hygiene procedures and generally function. It is a serious complication that requires systemic therapy with steroids and immunosuppressants. If asymptomatic, no treatment is recommended as the presence of some GVHD is desirable because of graft versus leukemia effect. Chronic GVHD occurs later (over 100 days) post HCT. In the oral cavity, GVHD may also involve the salivary glands and hyposalivation results with the attendant dental problems of root caries. Fibrosis of the oral soft tissues may result in trismus and atrophy and recession of the gingiva may lead to dental sensitivity.

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In these examples, lichen planus like changes are seen. These consist of fine white lines or white plaques. Secondary ulcerations may be a source of pain and dysfunction. The histologic features of these lesions would be identical to lichen planus; therefore the pathologist must be made aware of the history of an allogeneic HCT to make the diagnosis of GVHD.

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These photos show a more acute case of GVHD where ulceration predominate.

This 56 male received an allogeneic stem cell transplant one year previous for AML. He presents with severe oral GVH of the buccal mucosa bilaterally as large ulcerations with erythematous rim. The tongue shows a lichenoid mucositis. He is also being treated for GVH of eyes, liver and gut.

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The oral GVH was treated with topical steroids and although not totally resolved, he is now able to eat more comfortably. The elapsed time was 3 months.

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Malignant Hematology

Gingival Atrophy/Telangiectasia

Gingival atrophy and recession have been thought to be a result of oral GVHD. However, this is rarely documented as biopsy of the thinned gingiva would result in more loss of attached gingiva. It may be totally asymptomatic but most patients will complain of tooth sensitivity to cold stimuli and to brushing. With loss of the interdental papilla, “black” spaces between the teeth may be the only chief complaint. Although the gingiva do not recover, this is usually self-limiting. Periodontal surgical procedures may be contemplated when the GVH has resolved. The following are examples which show a very thinned gingiva with virtually no stippled attached gingiva. Recession to expose cervical roots appears to be accelerated and the underlying vasculature appears quite prominent.

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Gingival erythema

In the following examples, irregular but generalized gingival erythema is seen. The first two cases are asymptomatic but have remained unchanged in appearance for several years post transplant.

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The next two examples show irregular red patches as well but in these cases, there is pain with brushing and eating acidic or spicy foods. Toothpastes without sodium lauroyl sulfate are recommended for this type. Oral hygiene is extremely important to reduce the added inflammation of bacterial plaque. These are examples of chronic GVH of the gingiva.

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These 2 clinical photographs are examples of acute GVH of the gingiva. Topical steroids would be indicated if symptomatic.

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The oral lesions of GVHD may have significant impact on his oral/dental health and include xerostomia, (which would predispose to caries), atrophy of the gingiva and oral mucosal lichenoid lesions with or without ulceration.

Opportunistic infections

An increase in the incidence of opportunistic infections such as oral herpetic infections, human papilloma virus infections (e.g. condyloma acuminatum) and candidiasis may also occur. Also, should GVHD develop, medical therapy (systemic) would include immunosuppressant agents. If this occurs, prophylactic antibiotics (as per the current AHA regimen) are advised for dental procedures which will result in gingival bleeding.

The following two clinical photographs are patients who have had allogeneic bone marrow transplants. They presented with painful oral ulcerations which proved to be positive for Herpes Simplex I and were treated successfully with antiviral agents.

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This patient was also post HCT and has numerous white plaques that wiped off revealing erythematous mucosa. Candidiasis was diagnosed and treated with antifungals.

Malignant Hematology

This patient presented post HCT with painful oral ulcers which were CMV positive

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This 57M had a HCT for AML 5 years previous and presented with several recurrent white papules. He had numerous warts on the fingers of both hands as well. Biopsy of the oral lesions were consistent with verucca vulgaris. They recurred for a few years until the lesions on his hands were treated successfully.

Other oral lesions not related to infection or GVH have also been well-documented.

Pyogenic granulomas or hyperplastic granulation tissue have been described post HCT. They are self-limiting and resolve with surgical excision.

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Verrucous hyperplasia

Isolated well-demarcated white patches and plaques are also encountered post HCT. Histologically, they are described as hyperkeratosis with a veruccous surface morphology. Usually they are asymptomatic and require no treatment other than close follow-up.

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This last example also shows extensive root caries secondary to dry mouth.

Drug-induced gingival hyperplasia is well-documented with phenytoin, cyclosporine, diltiazem, amlodopine and others. As cyclosporine is an immunosuppressant that is often used in the treatment of GVH, it is important to distinguish it from leukemic gingivitis. The first example below is a patient post HCT with cyclosporine induced gingival hyperplasia. Biopsy was necessary to rule out relapsed AML. The second example is a more classic picture of the fibrotic gingival overgrowth seen with cyclosporine. Once the diagnosis is confirmed, communication with the oncologist may prompt the use of an alternative immunosuppressant.

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Malignant Hematology

Post HCT caries

Rampant caries that occurs post transplant are not unlike caries seen after therapeutic radiation to the head and neck. It is usually secondary to dry mouth from GVH of the salivary glands. This combined with poor oral hygiene because of gingival pain and soft diet exacerbates and accelerates root caries. They are very difficult to restore and preventive home fluoride in custom trays are often necessary to prevent further deterioration of the dentition.

Here are 2 examples of rampant decay seen after allo HCT.

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May, 2011

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Feb, 2015

Oral Squamous cell carcinoma

Chronic GVH predisposes to the development of other cancers. It is necessary to perform thorough oral examinations to diagnose early oral changes. Documentation (best with photographs) for follow-up or biopsy

This 45 yr old male patient had an allo HCT 16 years previous for CML. He had chronic GVH of the gingiva but complained of this non-healing ulcer on his tongue for several months. Biopsy proved that it was an early squamous cell carcinoma.

Malignant Hematology

This 42 yr-old male patient had an allo-HCT 3 years previously for AML. He had severe oral GVH and this red pebbly lesion was noted on the left buccal mucosa. It was biopsied and prove to be a squamous cell carcinoma. He developed another squamous cell carcinoma of the lower lip.

Malignant Hematology

This 70yr-old female had an allo HCT for myelodysplasia in 2001. She had very severe oral, skin and eye GVH resulting in blindness. She presented in 2015 stating that the upper left teeth had spontaneously "fallen out". Oral examination reveals hyperkeratosis/ veruccous hyperplasia of the hard palate and gingiva of the second quadrant. There is an obvious red and white mass of the left maxillary alveolar ridge extending on to the hard palate. It was biopsied and showed squamous cell carcinoma.

Malignant Hematology

This 73 yr-old male had an allo HCT in 1997 for AML. He had chronic oral GVH and was unaware of this lesion that was noted during a routine dental visit in 2006. An irregular red and white mass emanating from the right tonsil is seen. Biopsy revealed squamous cell carcinoma. He later developed an oral tongue squamous cell carcinoma.

Malignant Hematology

This pantomograph is from a 30yr-old male who had an allo HCT 15 years previously for Fanconi’s anemia. He developed a sore on the posterior right gingiva which was biopsied and proven to be a squamous cell carcinoma. He underwent a partial mandibulectomy but lost the graft and was left with this poor result.

Malignant Hematology

These examples illustrate the potentially long latent period from HCT to the development of the second malignancy. This underscores the importance of a thorough oral examination in all of these patients to detect early oral changes that may require biopsy.

Summary

Patients who have a malignant hematological condition require special considerations for safe dental care. These parameters vary depending on the stability of the disease, whether the patient is pre-treatment, during treatment or post treatment. There is no set protocol in seeing these patients as each require individual consideration.

In general there are 3 broad categories to take into account:

  1. Malignant hematologic conditions where myelosuppressive chemotherapy is the single modality treatment. This group would include patients whose disease can be successfully treated in this manner and those who may be deemed unfit for transplant due to age or other co-morbidities.
  2. Malignant hematologic conditions where autologous HCT is the best option. This group includes multiple myeloma, relapsed Hodgkin’s disease, non Hodgkin’s lymphoma and other rare conditions such as germ cell tumors, POEMS syndrome and primary amyloidosis. In most of these cases, a chemotherapy regimen is employed first to achieve remission. For example, with multiple myeloma, 4 cycles of Cybor-D (Velcade, Dexamethasone and Cyclophosphamide) is usually completed prior to HCT.
  3. Malignant hematologic conditions where allogeneic HCT is the best option. This group would include the acute leukemias (ALL, AML), some chronic leukemias (CML, CLL) , myelodysplasia, myelofibrosis and the non-malignant condition aplastic anemia. Again, these patients will undergo 2 phases of treatment beginning with induction chemotherapy, followed by consolidation/intensification to achieve remission. If there is a sibling matched donor or if an unrelated HLA matched donor is identified,

Phase 1 – Myelosuppressive Chemotherapy

Pre-treatment

  • These patients usually are not stable and are at risk of hemorrhage and infection
  • Dentists can aid in the diagnosis if there is unusual gingival hyperplasia or oral petechial/ecchymosis with minor trauma
  • Empiric treatment with chlorhexidine and antibiotics may be the only option
  • Consultation with the oncologist for emergency care is necessary

During Treatment

  • Patients in groups 1 and 3 above usually are not stable and are at risk of hemorrhage and infection. They may also have a Hickman line.
  • Emergency care to be done only with consultation with oncologist as platelet transfusions and antibiotics may be necessary
  • Patients in group 2, eg. Multiple myeloma patients may be stable for dental care if the complete blood count is adequate. Bear in mind that many of these patients will be on intravenous bisphosphonates as well.
  • Consultation with the oncologist for invasive dental care may necessary

After Treatment

  • Blood work necessary; Current medications
  • If stable counts, without Hickman line, may treat as normal

Phase II – Autologous HCT

Pre-HCT

  • If CBC adequate, this is an optimum time to perform any necessary dental treatment.
  • Remove potential sources of infection – extraction, root canal therapy (time permitting)
  • Timing of dental care may have to be coordinated with chemotherapy for harvesting and insertion of Hickman line. Dental prior to insertion of central line and after harvesting is optimal.
  • If patient on intravenous bisphosphonates or denosumab, patient education regarding ONJ will be necessary.

During

  • Emergency care only when referred by oncologist as counts will be low and risk of hemorrhage and infection will be high.

Post HCT

  • Review and update medical history – complications during transplant and current medications and blood counts
  • If counts acceptable, routine dental care can be done 6 months after HCT.
  • If emergency care necessary before then, consultation with oncologist is advisable.
  • For patients on long term bisphosphonates, annual pantomographic imaging to assess changes such as thickened lamina dura may be prudent

Phase II – Allogeneic HCT

Pre-HCT

  • This may be the best window of opportunity to perform all necessary dental care to treat potential sources of infection .
  • Consultation with the oncologist regarding timing of procedures may be necessary
  • Blood counts and presence of Hickman line may alter the treatment plan;

During

  • This period could be while in isolation (usually 1 month) or for up to 6 months after HCT
  • Emergency care only when referred by the oncologist;
  • Blood counts, current medications and complications of GVHD or other from the transplant and presence of Hickman line are mitigating factors in emergency dental care

Post HCT

  • Ascertain stability of blood counts and presence or absence of Hickman Line
  • Update medical history for current medications and treatment of GVHD or other complications; if treatment of GVHD with steroids, supplementation of steroids is NOT necessary
  • Thorough examination for any of the lesions shown above and presence of dry mouth
  • Radiographic examination for caries
  • If stable, on no medications and no GVHD, may be treated as normal