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