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Oral HealthTransplantsLymphomaLeukemiaMultiple Myeloma

Bone Marrow Transplants and Oral Health for Patients with Blood Cancers

Two oral health experts offer a thorough exploration of bone marrow transplants and how they relate to the mouth, with many tips for maintaining proper oral care during and after a transplant.
February 2021 Vol 7 No 1
Jill Meyer-Lippert, RDH
Registered Dental Hygienist and Founder, Side Effect Support LLC
Manitowoc, Wisconsin
Amanda Swiecichowski, RN, BSN, CHPN
Bone Marrow Transplant After Care Coordinator, University of Wisconsin
Madison, Wisconsin

A bone marrow transplant is a treatment used for several types of blood cancers that affect blood cells and bone marrow, such as leukemias, lymphomas, or multiple myeloma. If a bone marrow transplant is part of your treatment plan, paying special attention to your mouth can make the process more comfortable and reduce your risks for serious complications during and after the transplant.

What Is a Bone Marrow Transplant?

The treatment of giving healthy stem cells (which are in the bone marrow) to a person with unhealthy bone marrow or stem cells is referred to by many names, including hematopoietic stem-cell transplant, related-donor transplant, and matched-unrelated donor transplant. In this article, we use the word “transplant” as an umbrella term to refer to a “bone marrow transplant,” in which healthy stem cells are placed (or transplanted) in a person who has a certain type of blood cancer.

Bone marrow is the tissue inside our bones that makes stem cells. These stem cells grow into blood cells, such as red cells (which carry oxygen), platelets (which control bleeding), and white cells (which fight infection).

Before the transplant, the recipient often receives intense chemotherapy, and sometimes also radiation therapy. This eliminates malignant cells within the bone marrow and prepares the body for the transplanted healthy cells. The healthy cells, which can be taken from the person undergoing the transplant or from a donor, are then used to replace the unhealthy stem cells.

What Does It Have to Do with My Mouth?

Certain cancer treatments and medications can have side effects that affect your mouth. This is especially true when having a bone marrow transplant. These side effects may range from mild irritations in the mouth to very serious complications that affect the ability to eat or drink and increase the risks for infections. Some of these problems can be temporary, and others can last a lifetime.

Our mouths are full of healthy, as well as harmful, strains of bacteria. The bad bacteria contribute to oral diseases, such as cavities, gum disease, and infections. Researchers are even making connections between these harmful bacteria and other health issues, including stroke and heart disease.

When mouth sores occur during cancer treatment, it increases the risk that the bad bacteria will enter the bloodstream in our body, causing a serious infection in our blood, called “sepsis.” A healthy mouth is important in so many ways!

Take Action Before Transplant

If you are scheduled for a transplant, you should have a dental checkup and any necessary treatment completed before the transplant. In fact, many programs that perform a transplant require this. It is important to make sure that your mouth does not have any infection, because the immune system is weakened during the transplant process. Oral complications can be minimized and, in some cases, prevented with this type of early intervention.

Dental care before a transplant includes a thorough examination, including x-rays and having your teeth cleaned by a registered dental hygienist. If cavities or infection are present, these teeth should be restored or removed before the transplant.

Your dental examination will also provide a baseline if oral health changes occur during your treatment process. Procedure codes used for billing are always changing, so having accurate records may also help to ensure that your insurance covers dental treatments that are needed as a result of medical conditions and therapies related to a cancer diagnosis.

Tips on Keeping a Clean Mouth During Transplant

Your dental and transplant teams can provide you with the information needed to care for your mouth during the treatment process. Always follow your transplant team’s specific recommendations, because these may differ between transplant centers.

Diligent oral care throughout treatment will reduce any short-term discomfort and prevent long-term damage to your teeth, gum tissue, and bone. Below are tips on keeping your mouth healthy during a transplant.

  • Brush your teeth and tongue at least daily
    • This will decrease the amount of harmful germs in your mouth
    • Use an extra-soft, compact-head toothbrush; the extra-soft bristles are gentle to tender gum tissue, and a small, compact head makes it easier to access hard-to-reach areas of the mouth, without causing toothbrush trauma. Continue gently brushing even if your gums become sore
    • Replace your toothbrush weekly to prevent germs from building up on the bristles
    • If you floss regularly, you may continue; if you are not a regular flosser, this is not a safe time to start. Talk with your dental hygienist to ensure your flossing technique is proper
    • Your transplant team may advise you to avoid flossing if certain blood cells drop to unsafe levels during the treatment
  • Rinse with a saline (saltwater) solution (provided by your nurse) at least 4 times daily
    • You can use this rinse as often as you like; make sure to spit out the solution after rinsing
    • Rinsing helps to wash away dangerous germs; do this more frequently if you have mouth sores
    • Rinsing also helps prevent the sores from getting infected, and from germs getting into your bloodstream
    • If your saliva gets thick or sticky, rinsing can help thin the saliva.

Use products without irritating detergents, harsh chemicals, and strong flavors; these can encourage sensitivity, mouth sores, and nausea.

After You Leave the Hospital

Oral health will continue to be important to your overall health after a transplant. Transplant recipients are at increased risk of dry mouth and bacterial, viral, and fungal infections. Diligent oral hygiene helps to reduce or avoid these issues. This involves the following practices:

  • Continue to brush your teeth and tongue at least twice daily
    • Continue to replace your toothbrush weekly for the first 2 months after transplant
    • Store your toothbrush away from family members’ brushes or flushing toilets
  • Continue using toothpaste and mouthwash free of irritating ingredients, as noted earlier
    • Avoid foaming agent, sodium lauryl sulfate, tartar control, and whitening ingredients; these are irritating
    • If products with sharp mint or cinnamon flavors irritate your tissue, try a bubblegum- or berry-flavored toothpaste
    • Mouthwash is not necessary, unless recommended by your transplant team; if your mouth remains sore, continue the saltwater rinses you used during transplant.
  • Treat dry mouth before it starts
    • Dry mouth is a common side effect that can contribute to discomfort, cavities, gum disease, and infections. Ask a trusted dental professional for recommendations; some remedies may provide temporary relief but may damage teeth.

Continued Dental Care Is Important

During the transplant treatments, you will be advised to avoid dental appointments, except for emergencies. Your transplant team will let you know when you can safely resume routine dental care, which is typically around 6 months to 1 year after transplant.

Ask your transplant team if you need to take antibiotics before dental care. Keep your dental providers informed of your medical status, medications, and any changes in your mouth. Don’t hesitate to ask your care teams to touch base with each other, or to bring appointment notes, lab results, or medication lists to your dental appointments.

Let your dentist know if you take bisphosphonates (such as Zometa, Reclast), which are often used for multiple myeloma or for osteoporosis. These medications can continue to work in your body years after they have been taken, and they carry a risk for jawbone problems. Therefore, it is important to avoid extracting teeth and other trauma to the jawbone after bisphosphonate therapy.

Your dental providers will determine how often you should have routine care. Each visit should include a thorough oral cancer screening; transplant recipients are at increased risks of other cancers, including oral cancers.

Transplant recipients whose cells came from a donor may later have an autoimmune-like disease called chronic graft-versus-host disease. This condition can affect many areas of the body, including the mouth. Oral chronic graft-versus-host disease may come and go and tends to be more severe with poor oral hygiene.

Symptoms of oral graft-versus-host disease include:

  • Dry mouth
  • Color changes in tissue: redness; white lacey lines or patches
  • Sensitivity with foods, flavors, toothpaste, carbonated liquids, or certain product ingredients
  • Chapped and/or blistered lips
  • Mouth sores
  • Other infections in the mouth, such as thrush (oral candidiasis).

Inform your dental and transplant teams if you have any of these symptoms. Your oral health remains important for your overall health. When your care providers work together, it ensures that you are receiving the safest and most effective treatment possible.

Key Points

  • Bone marrow is the tissue inside our bones that makes stem cells; bone marrow transplant replaces damaged stem cells with healthy cells
  • Side effects of a bone marrow transplant in the mouth range from mild irritations to more serious complications that affect the ability to eat or drink and increase infection risk
  • If you are scheduled for a transplant, have a dental checkup and any necessary treatment completed before
  • Use a diligent oral care regimen through treatment, including brushing your teeth and tongue at least once daily, and rinsing with a saline solution at least 4 times daily
  • After leaving the hospital, continue this oral care regimen

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Last modified: April 1, 2021

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