Managing Oral Health Issues Before, During and After a Bone Marrow/Stem Cell Transplant with a Focus on GVHD

Featuring Jacqueline W. Mays, DDS, MHSc, PhD, Chief, Oral Immunobiology Unit, National Institutes of Health and Cathy Spence, a patient.

Notes

Professional Speaker
Jacqueline W. Mays, DDS, MHSc, PhD
Lasker Clinical Research Scholar
Chief, Oral Immunobiology Unit
DIR/NIDCR/NIH/DHHS

I have had the great privilege of working with transplant patients in the NIH dental clinic for nearly the past decade, and through that time, you all have taught me so much not only about GVHD but about how resilient the human spirit is as you trek through the long – in some cases very long- journey before I see you – sometimes before transplant and more often, long after transplant through one of our cGVHD research programs.  I am also acutely aware that we don’t have great treatment options in many cases, and one of the privileges of being at the NIH is that I also run a research lab where we are focused on understanding how GVHD works in the mouth and on finding new treatments.

Today, we are going to walk through what to do before transplant, what you can expect early and later after transplant, things that you can do to take care of your mouth

Everyone’s experience is unique. Peggy was kind enough to share some of your pre-submitted questions, and I have tried to incorporate this information in the seminar. Of course, you are welcome to ask questions at the end – particularly if I am not clear or if you want more detail on a specific topic.

The Cliff Notes:

• See your dentist regularly after your transplant has stabilized.
• Call your dentist if you notice any problem or change in your mouth.
• Take care of your mouth by brushing and flossing every day. A healthy mouth is less likely to develop problems. GVHD cannot be prevented by brushing and flossing.

Oral “to dos” pre-transplant
See your dentist. Ideally, you would be able to see your community dentist. If your cancer center offers dental care, it might be a good time to establish a relationship with that clinic.

Before transplant, there is a lot going on, often within a very short timeframe.

Dental clearance is still an important part of keeping you healthy through your transplant and long after you have engrafted.

What are we looking for during a pre-transplant dental clearance?

• We take x-rays of your mouth to look for cavities, root infections, and other hidden dental problems – like cracked teeth, roots left behind after teeth came out, crowns about to come off, or wisdom teeth that could trigger infections while you are immunosupressed
• We check your gums
• We clean your teeth
• We talk about care for your mouth early after transplant. This can include cleaning teeth gently with soft swabs and using an antimicrobial rinse like chlorhexidine, or using an extra-soft toothbrush along with your normal toothpaste.
• In a research setting, we also measure your mouth opening and test how much saliva you can make in 5 minutes. This gives us a baseline for you, so that we know if your mouth opening or salivary gland function are changing after transplant.

Special care of the mouth needed as a cancer patient

• Use toothpaste with fluoride
• You may have a sensitive mouth: Fruit-flavored or children’s toothpaste
• You may have sensitive teeth:
  • Fluoride rinse/gel or desensitizing toothpaste (Sensodyne, ProNamel, Colgate Sensitive, etc)
  • Professional desensitizing treatment (several options in the dental office: Gluma, gum grafting, laser treatments)
• More about fluoride: Patients undergoing head and neck irradiation often have custom fluoride trays made that look like retainers. These are filled with a thin line of fluoride gel one or two times daily and are used to intensively re-mineralize tooth enamel.Your teeth are made of hydroxyapatite crystals, which are composed of calcium, phosphorous, and oxygen. An acidic environment in the mouth – either from bacteria metabolizing sugars, from foods you eat or from a lack of saliva that is no longer there to wash food particles away – causes the calcium from the tooth structure to leach away. This can be replaced by the slightly smaller fluoride molecule to re-form those tooth enamel crystals and to protect your teeth. It can also help to insulate your teeth by blocking spaces between the crystals – this helps to reduce tooth sensitivity to hot and cold, for example.  Fluoride can get a bad rap, and I think that it is important to explain exactly why it is so helpful to protect your teeth.
• Limited joint mobility? Electric toothbrush (any kind from the drugstore)

Finding Community Dental Care (a dentist!) 

• Tell your dentist that you are a transplant survivor
• Show your dentist anything unusual or new that you see or feel in your mouth
  • Mouth ulcers, lumps and bumps should heal within 3 weeks***
  • Teeth, gums, lips, tongue and cheeks
• Do ask for an oral cancer screening
  • Highest risk in patients with oral cGVHD history
  • 5-10+ years post-transplant
  • Tongue is the most common site
• Signs you need to see a dentist or oral medicine specialist or cancer center dentist:
  • New taste changes that were not present right after your transplant. Chemotherapies, irradiation and transplant medications can affect your sense of taste, but the normal course for this is that it improves after transplant. If you suddenly lose your sense of taste and it is not because you have a cold, it might signal changes in the soft tissues of your mouth
  • New sensitivity to spicy foods
  • New dry mouth, especially if you have not started any new medications. Sometimes this happens at the same time as new dry eyes, but not always
  • Whiteness on your lips, tongue or the lining of your cheeks. This can look like a white coating that does not wipe away, or it may look like lacy white tracings on the inside of your mouth.
• Not every dentist appreciates your complex medical history and needs.
• If your dentist is not a good fit, interview other dental offices
• Ask: Do you have experience treating medically complex patients?
• University (dental school faculty or resident practice) or Medical Center Clinics are a good option
• Dental care has changed a lot with COVID19, and good dental offices are taking exceptional measures to protect patients from aerosol transmission of SARS COV2 virus and other pathogens. Ask about how they will protect you, also, as an immunosuppressed person, if you need treatment – especially in the next few months.

Your Mouth After Transplant 

Early: (first 100 days) mucositis, dry mouth – this may be from pre-transplant radiation, oral thrush – this is overgrowth of yeast in your mouth that is common with immunosupression

Overlap: drug-induced complications (oral side effects from methotrexate, sirolimus), viruses (like herpes simplex virus or CMV)

After 60 days:

Graft-versus-Host disease

Symptoms of GVHD – many of you listening on this call can describe these better than can I.

• Dry mouth – your salivary glands are a target of GVHD
• Red or white patches in your mouth that you cannot scrape away
• Mouth ulcers
• White lines on the cheek lining or other mucosa
• Oral sensitivity to spicy/citrus/acidic foods
• Mucoceles – blisters on the roof of your mouth

Oral GVHD is really 3 distinct conditions: oral mucosal disease, salivary dysfunction and limited mouth opening. These can occur together in the same individual (less than 1% of patients!) or separately. The important thing to remember is that different clinical situations may need different treatment.

If we see white lacy changes on the inside of your mouth and there is no suspicion that it could be caused by something else (infection or medications), then we can diagnose oral GVHD in the clinic. We may need to biopsy the inside of your cheek to confidently diagnose oral GVHD, and a small biopsy is the only way we can diagnose GVHD in the salivary gland.

Important questions to ask in the clinic include:

• Is your mouth suddenly drier?
• Is your mouth progressively drier?
• Can you chew and swallow food without drinking water?
• Are you taking medications that can cause dry mouth?
• Did you have irradiation (total body irradiation or targeted to the head and neck) as part of your cancer therapy or transplant preparation?

Like all cGVHD, there is a difference in scale. The mouth might be the only site affected, and it could be quite mild. If you have bothersome symptoms or if your mouth is dry, you need medication and supportive care.

So, you have oral GVHD – what next? 

If the soft tissues of your mouth or the oral mucosa are affected, it can be difficult to eat and possibly to talk. Try to find something nutritious that you can eat. Soft foods like yogurt, mashed potatoes, overcooked carrots, smoothies, anything blended, TV dinner meats, popsicles or frozen smoothies or yogurt; protein drinks like ensure, peanut butter or other nut butters, soft breads (think wonder bread). Drink room-temperature water while eating and try to stay hydrated otherwise. Ask a nutritionist at your cancer center for help.

Numbing your mouth before eating can help you get some calories in if eating is very painful. You can use viscous lidocaine or magic mouth wash (lidobenalox) – both are prescriptions – for 30 seconds before eating. Swish then spit them out and eat. This is a short-acting anesthetic. This can be used before using other oral rinses that may be painful (burn or hurt) while your mouth is very raw.

We start treating oral GVHD with dexamethasone rinse. This can be compounded at higher strengths. This is held in the mouth for at least 2 minutes, then spit out. Longer contact time lets more drug soak into your soft tissues. Progressively stronger steroid rinses can be compounded (clobetasol).

With isolated lesions, we recommend applying a gel – either a steroid gel or – if it is on the external lips – a non-steroid gel like tacrolimus.

If topical treatments are not effective and oral GVHD is severe, then systemic therapy may need to be increased, changed or added. Steroid pulses, ECP and some other drugs have shown major positive impact on oral cGCHD.

Mouth opening problems are usually related to severe skin GVHD and get worse as the fibrosis around the mouth progress. You can counteract this to some degree by doing daily stretching exercises for the mouth and applying topical steroids or other creams around the mouth. If the mouth opening is very affected, it may require surgery to open up the tissues.

Salivary gland GVHD is silent – it is not always clear what causes dry mouth after transplant – drugs, GVHD, dehydration etc. – and sometimes it is not recognized until the salivary glands are almost completely fibrotic and have irreversibly lost their structure.

What can you do?

• Take frequent sips of water or a non-sugar drink
• Cavities can progress really fast in a dry mouth, and it is important to wash away any food that might be left in the mouth
• Use a prescription fluoride toothpaste nightly.
• Try stimulating your salivary glands. Use sugar-free gum that contains xylitol (an alcohol-based sugar). Prescription medicines can stimulate your saliva flow. These take up to a month to work at all and may have side effects

There are a lot of dry-mouth products on the market. You may need to try a few before you find one that helps – they are just lubricating agents for your mouth that keep you more comfortable. Ask your dentist for samples of different kinds!

Specific Questions

Paying for dental care is a major challenge. I work at a free clinic and working the social safety net is not my strong suit. These resources vary a lot by region. A local social worker at your cancer center could hopefully help you find local resources. Often, a local dental school (there are one or two in most states) will have a resident clinic that has reduced fees, with fully licensed dentists performing the treatment. 

My GVHD of my cheeks has cleared up but I am facing dental issues

How common is progressive periodontal disease and eventual tooth loss post-transplant?  Is it from GvHD or from the extreme Chemotherapy (or both)?

• Bone loss can come from long-tern steroid use, but we are not sure if it is directly related to GVHD. It is a common problem in GVHD patients and seems to be more prevalent than in the general population (people of a similar age). It can be related to TBI or focused radiation as well.

Right now, just curious I am 10 years out…have extreme sensitivity to both hot and cold.

• This is most likely a dental/tooth problem. Start with a desensitizing toothpaste and possibly some fluoride varnish treatments at your dentist office. A dental exam may find some small cavities or exposed tooth roots that are making you more susceptible to tooth sensitivity.

How best to care for mouth and gums when doctor says you cannot go to dentist yet.

• Brush and use mouth rinse. If you are 6-months from transplant and are doing well, you should revisit the topic of going to the dentist with your medical team.

What if you have a tooth ache what do you do 

• It is more dangerous to have a dental infection than to have dental work done early after transplant. That said, if you have a hospital-based dental clinic, this would be the best place to get treatment.

Revlimid (lenalidomide), pomalidomide and other thalidomide-derived drugs are not related to bone loss or dental issues. We have seen some modest improvement in oral GVHD with patients on pomalidomide

How to get rid of ongoing tongue ulcers?

• Tongue ulcers can persist for a long time. If I see these in my clinic, I treat them by using a tiny needle to inject a steroid called triamcinolone around the ulcer base. This is the same steroid injected into joint for arthritis patients. It is like throwing a hammer at the ulcer to convince it to close. We repeat every 2 weeks if possible until the ulcers close. Because the sides of the tongue are often a site for oral cancers to develop, we try to reduce inflammation and close ulcers at those sites.

I have GVHD of my lower lip. It is raw & bleeds I tried several creams prescribed by my dermatologist & oncologist to no avail.

• This may need to be biopsied if it has been raw and bleeding for a long time to check for dysplasia.
• Protecting the area as much as possible – coating with petroleum jelly, reducing sun exposure and abrasion from food and toothbrush may help with healing.
• Steroid creams/gels or tacrolimus gel would be our go-tos for treatment.
• Low level laser therapy/cold laser/photobiomodulation has been used successfully for similar isolated GVHD lesions. There are centers like UPMC that offer this treatment.

Cathy Spence- Survivor

Cathy discussed the challenges of getting her transplant in Canada and how a fellow transplant patient helped advocate for her to come to the states for her care. Dental care is apparently not part of the universal health coverage in Canada.

She shared how she received a dental check up before her transplant and they took out her wisdom teeth as they were more likely to cause issues.

Her platelets were quite low during her transplant, so she used a special sponge-like lollipop brush to prevent bleeding when she “brushed”.

She did a great deal of swishing and spitting of a special mouth wash to avoid infection.

She did end up getting Mucositis which was painful and had her off food for about 10days.

She followed all the post-transplant care Dr. Mays suggested.

About 6 months after transplant, she developed cGVHD of the mouth.  She had low saliva, an unusual coating, and taste changes. and it helped to take frequent sips of water and to take sips of water with food.  She avoided citrus and spicy foods.  She brushed after each meal and used tooth sticks to clean in between.  She ended up needing a gum graft as her gums had receded.  She also found some help with gum stretch exercises.   Dexamethasone swishes were also helpful.

She tried two meds to try to increase saliva, but she did not like the side effects.  Ultimately, she went on Jakafi which helped her other cGvHD symptoms more.

Cathy encouraged others to be aware of the choices they have in their care, to network and educate yourself, and to get support.