Indubitably, solid organ transplants and hematopoietic stem cell transplants (HSCT) are lifesaving and have transformed the field of medicine. Hematopoietic stem cell transplants (HSCT) may involve either the transfer of stem cells from one individual to another, known as an allogeneic HSCT, or the return of the harvested cells to the same person known as an autologous HSCT. Nonetheless, these treatments are invariably linked to a variety of orofacial conditions mainly due to the immunosuppressive nature of the pre-transplant therapies. So what are some of these conditions?
Lip and Oral Cancer Risk
Believe it or not, the risk of lip and oral cancer is higher amongst patients with a history of organ and stem cell transplants. Specifically, heart and kidney transplant recipients have an increased risk of lip cancer, whilst liver transplant recipients have an increased risk of oral cancer.
So what does that mean?
That means regular dental visits are essential as early detection is extremely important in treating lip and oral cancer. Additionally, it is important to inform your dental professional of your complete medical history so that he/she may be aware of your potential risk for cancer. It is also crucial to always apply sunscreen to your entire body including your lips all year round and to avoid tobacco usage and alcohol usage, which in combination, are linked to an increased risk of oral cancer.
Graft Versus Host Disease (GVHD)
Graft versus Host Disease (GVHD) is a condition that occurs when the transplanted cells (also known as the graft cells) attack the host (the patient who has received the transplant). It was first reported in the 1960s. It was originally classified as acute v. chronic based on the time at which it was observed, but the NIH has now changed the classification system to differentiate acute GVHD v. chronic GVHD based on its manifestations. Acute GVHD may include involvement of the skin, liver, and the gastrointestinal tract excluding the mouth. By contrast, chronic GVHD may involve the skin, nails, mouth, eyes, muscles, joints, genitalia, liver, gastrointestinal tract, lungs, kidneys, heart, bone marrow, and fascia. The oral cavity is actually one of the most frequently affected sites of GVHD, and may also be the first site of GVHD. The symptoms of oral GVHD include sensitivity to spicy, acidic, and hot foods and beverages, dry mouth (xerostomia), ulcers/sores, white patches that resemble a picket fence, restricted mouth opening, gingival recession and the sensation of mouth tightness. The most common intraoral sites are the tongue and the cheeks (buccal mucosa).
So what does this mean?
Oral GVHD can be diagnosed with a biopsy to rule out other conditions including oral cancer, a viral infection, a fungal infection, a bacterial infection, or another noninfectious condition. In terms of treatment, there are a variety of topical medications that a dental oncologist can prescribe to treat the burning sensation and ulcers associated with oral GVHD. Because hyposalivation and dry mouth are often associated with oral GVHD, patients with oral GVHD are at an increased risk for dental decay, fungal infections, and bacterial infections. Thus, regular dental visits are recommended to help reduce the risk of developing these conditions and to diagnose and treat them if they arise. Additionally, given the increased cancer risk as listed above, it is essential to visit a dentist for regular oral cancer screenings.
Mucositis, or inflammation of the oral mucosa, is a common condition associated with cancer therapy including stem cell transplant patients who undergo total body irradiation (TBI). It presents as mouth sores, intraoral mucosal redness, tissue sloughing, and a burning sensation. It can affect any tissues in the oral cavity but is more commonly seen on the cheeks and tongue. Not all patients experience mucositis, and the severity of mucositis is highly variable. Among other risk factors, poor oral hygiene is associated with mucositis along with tobacco and alcohol usage. Mucositis is an acute condition meaning that it will resolve after completing treatment.
So what does this mean?
There are several palliative medicaments that a healthcare professional may prescribe to patients with mucositis. It is important to note that literature indicates that visiting a dentist prior to conditioning may reduce the duration time of mucositis.
Given the decreased salivary flow from the conditioning therapies as well as the decreased salivary flow associated with oral salivary GVHD (when GVHD affects the salivary glands), patients with a history of transplants are at an increased risk for dental decay (aka cavities). Saliva acts as a natural buffer in the mouth, lubricating and washing the teeth and oral tissues. Thus, reduced salivary flow to wash away the food leaves patients prone to an increased risk for dental decay.
So what does this mean?
This means that visiting a dentist regularly is important to help prevent and diagnose dental decay. It also means practicing good oral hygiene including brushing twice daily and flossing daily is crucial.
Mawardi, H., S. Elad, M. E. Correa, K. Stevenson, S-B Woo, S. Almazrooa, R. Haddad, J. H. Antin, R. Soiffer, and N. Treister. “Oral Epithelial Dysplasia and Squamous Cell Carcinoma following Allogeneic Hematopoietic Stem Cell Transplantation: Clinical Presentation and Treatment Outcomes.” Bone Marrow Transplantation 46.6 (2011): 884-91. Web.
Petti, Stefano, A. Polimeni, P. B. Berloco, and C. Scully. “Orofacial Diseases in Solid Organ and Hematopoietic Stem Cell Transplant Recipients.” Oral Diseases 19 (2012): 18-36. Wiley.com. John Wiley & Sons A/S, 1 Feb. 2012. Web. 20 Oct. 2014.
Schubert, Mark M., and Maria Elvira Pizzigatti Correa. “Oral Graft-Versus-Host Disease.” Dental Clinics of North America 52.1 (2008): 79-109. Web.
Treister, N., C. Duncan, C. Cutler, and L. Lehmann. “How We Treat Oral Chronic Graft-versus-host Disease.” Blood 120.17 (2012): 3407-418. Web.
About Dr. Levi
As a general dentist with advanced training in dental oncology, Dr. Lauren Levi delivers comprehensive oral care to cancer patients in a warm, supportive, and gentle environment. After receiving her D.M.D. at the University of Florida College of Dentistry, Dr. Levi completed a general practice residency at New York Presbyterian-Weill Cornell Medical Center. During her residency, Dr. Levi rotated through Memorial Sloan Kettering Cancer Center, where she discovered her interest in dental oncology. She then pursued a fellowship in dental oncology at Memorial Sloan Kettering Cancer Center. This training equipped her with extensive experience performing dental treatment on patients who are receiving chemotherapy, radiation therapy, and stem cell transplants, and those who may face individual dental needs because of these treatment programs. For more information on dental oncology, visit http://laurenlevidmd.com.