Title: Pediatric bone marrow transplantation: oral complications and recommendations for care
The paper discusses the important and unique role that pediatric dentistry has in the multiprofessional BMT team to help bring about a successful outcome through the prevention and tx of acute or al complications often seen in these patients. BMT results in immunosuppression and problems in the oral cavity, which can become life threatening and increase hospital stay, pt discomfort, and tx costs.
· BMT has become the tx of choice for patients with disease affecting BM directly or indirectly. Donor stem cells provide recipient with new hemopoietic and immune system response. The BMT replaces marrow in patients with: 1. Hematological malignancies (leukemia) 2. Hematatologic disorders (aplastic and sickle cells anemia) 3. Congenital immunodeficiencies (severe combined immuno def. disorders such as Wiskott-Aldrich syndrome). 4. Lipidoses 5. Metabolism errors (Hurlers Syndrome).
· BMT is also used as marrow to support patients needing chemo/radiation therapy for solid tumors and receive autologous transplants using BM.
· Allogenic BM is used in patients with hematologic malignancies which come from three main sources: 1. Iliac crest aspirations 2. Peripheral circulating blood (PBSC) 3. Umbilical cord blood (UCB)
Pre-transplant oral/dental evaluation:
· Goal: to eliminate and prevent potential problems to insure successful BMT. According to PIzzo and Schimpf, bolster host defense mechanisms, preserve body’s natural defense, reduce environmental organisms and endogenous microflora
· Review of Md Hx: underlying disease, time of diagnosis, types of tx patient has received, complications, surgeries, hospitalizations, ER visits, past episodes of infections, current hematological status, allergies, meds, review of systems.
o Transplant details: type, donor, preoperative regiment, GVHD, pediatric BMT meds
o Was a central line placed: If so establish if any AHA prophylaxis is necessary.
· Hematological Status
o Know patients blood counts
o Before Dental Tx you should know patients # of platelets and ANC
§ Thrombocytopenia: platelets <100kmm3, moderate bleeding risk <50kmm3
§ Neutropenia: ANC <1500 cells/mm3 when ANC <1000 cells/mm3 NO ELECTIVE DENTAL TX
o Oral hygiene dental rehab should be aggressive as possible before transplant because patients may not experience dental tx for one year after BMT
o Dental consult should be one of first in work-up schedule to allow enough time to coordinate services
o Dental rehab should be scheduled with other medical procedures
o Eliminate active infection potential sources of problems when low # of granulocytes
o Fever in immunosuppressed pts requires prompt assessment and antibiotics
o Dental scaling, cleaning, and carious lesions should be taken care of promptly
o Pulpotomies/pulpectomies in primary teeth are not advocated –ext
o Endo tx in one visit
o Smooth enamel fractures, leave loose primary teeth and remove all fixed ortho appliances.
o Problems most likely when pt noncompliant with good OH
o Many BMT teams believe toothbrushing increases risk of bacteremia/bleeding and advocate discontinuation of OH with a regular TB when pt is neutropenic
o Sponges of foam brushes “toothettes’ are not effective to remove plaque and debris and should be discouraged
o BID TB with atramatic flossing
o Rinses: Saline, Sodiumbicarbs for four to six times daily
o Do not use hydrogen peroxide – delays healing
o Chlorhexidine rinses BID if poor OH
§ Oral mucosa affected bc of rapid cell turnover
§ Severity based on drug doses schedules, duration of tx and impairment of renal and hepatic fxn
§ Tissue changes noted between 4-7 days and lasts from 10-14 days
§ Nonkeratinized surfaces of buccal/labial mucosa, lateral/ventral tongue and soft palate
§ Morbidity includes dysphagia, poor nutrition, increased discomfort, difficult speech, oral bleeding and secondary infections
§ Pain Management of Mucositis
· Patient controlled analgesia
· Viscous lidocaine hydrochloride (2%) and dyclonine hydrochloride (0.5 or 1%) are common topical anethesthics to be used for at least three minutes
o Gargling not advised as loss of gag reflex can cause aspiration of saliva and mucous tissues
· Ice packs on cheeks and throat, popsicles and ice chips/drinks
o Oral Bleeding
§ Thrombocytopenia – bruising petechiae, purpura and oozing are complicated by the presence of irritants such as plaque, calculus, ortho bands.
§ Spontaneous bleeding: platelets <20kmm3 (avoid elective surgical procedures and IA blocks)
§ Most common: Candida albicans and treated with nystatin and clotrimazole troches
§ Most frequent viral: Herpes (HSV) and if pts test positive then prophylactic acyclovir
§ Cytomegalovirus infection can happen
o Xerostomia and Taste Disturbances
§ Salivary dysfunction can be increased by: use of oxygen support, anticholinergic meds, GVHD, mouth breathing
§ Saliva is thick and viscous
§ Saliva stimulated by sugar free gum, candy and drinks
§ Avoid high sugar and cab drinks
o Acute GVHD
§ Transplanted T-lymphocytes recognize histocompatiblity antigens of host tissue as foreign, causing injury
§ Occurs within 100d post-BMT w/median onset 19d
§ Most common oral changes in GVHD: erythema (dorsal/ventral tongue, FOM, gingival, labial mucosa)
§ Acute GVHD suspected when mucosal changes appear, worsen, or persist beyond day 21 post BMT