Information for Bone Marrow Transplant Patients

How to Use Brush-on Fluoride

Daily fluoride (1.1% sodium fluoride or 0.4% stannous fluoride) helps teeth resist tooth decay caused by xerostomia (dry mouth). Radiation therapy to the head and neck area, total body irradiation, chronic graft vs. host disease and/or some medications can cause dry mouth that can lead to tooth sensitivity or decay. Compliance with the following fluoride regimen will greatly reduce the risk of tooth problems after cancer therapy.

  1. The best time to use fluoride is at bedtime.
  2. Remove partial or full dentures from the mouth.
  3. Brush teeth thoroughly with a soft toothbrush and regular toothpaste. Floss teeth by sliding the floss up and down each side of each tooth. Patients with low white blood cell and platelet counts may be instructed to avoid the use of floss while blood counts are low. A supersoft toothbrush, such as the one made by Biotene, can usually be used without causing the gums to bleed. Note: It is very important to remove all food and plaque from between teeth before using fluoride. Food and plaque can prevent the fluoride from reaching the surface of the tooth.
  4. Place a thin ribbon of the fluoride gel onto your toothbrush. Either 0.4% stannous fluoride (Gel Kam)or 1.1% sodium fluoride (Prevident) may be used. Thoroughly brush the fluoride into all surfaces of the teeth, especially where the tooth meets the gum tissue. A 1.1% sodium fluoride dentrifice, such as Prevident 5000, may be used instead of regular toothpaste in one step.
  5. Allow the fluoride to remain on the teeth for 5 minutes.
  6. 6After 5 minutes, thoroughly expectorate (spit out) the residual fluoride. 
    Very Important – do not rinse the mouth, drink or eat for at least 30 minutes after fluoride use.
  7. Bone marrow transplant patients should begin using fluoride soon after being admitted for the transplant. Repeat daily for as long as you have natural teeth remaining!!
  8. Custom fluoride trays may be fabricated before or after the bone marrow transplant. Patients with sensitive teeth, active decay or a history of radiation therapy to the head and neck areas should have fluoride trays before the bone marrow transplant.

Dental Examination Before Bone Marrow Transplant

WHY: The purpose of a dental examination before the bone marrow transplant is to identify potential sources of oral infection that can lead to bacteremia (bacteria in the blood). It is important to prevent or eliminate dental infection before chemotherapy or other medications that lower the ability of the body to fight infections. Severe gum disease, tooth decay, tooth abscesses and poor oral hygiene can lead to pain and/or bacteremia before, during and after chemotherapy.

WHEN: The dental evaluation should be performed as soon as possible after a diagnosis requiring chemotherapy that can potentially lower the blood counts. Xrays of the mouth and a clinical examination can usually be performed without causing any bleeding or trauma. If the dentist finds a dental problem that requires attention, he or she should call the medical oncologist and coordinate any dental care, including cleaning of teeth, at a time when the blood counts are at an acceptable level. Usually, dental care can be safely performed about three to four days before a round of chemotherapy. Leukemia patients should be in remission before elective dental procedures are performed. If a patient is aware of a dental problem or has not had routine dental examinations, the medical oncologist should schedule a dental evaluation as soon as possible to identify and/or treat potential dental problems (if the blood values are at acceptable levels.)

WHERE: The patient may go to his or her regular dentist to have a check-up before chemotherapy begins or even during chemotherapy, as long as the dentist is aware that the oncologist should be consulted before any dental procedures, that could cause bleeding, are performed. Bitewing Xrays, panoramic Xrays and clinical examinations are usually safe procedures when blood counts are low. A dental problem, if present, should be identified early in treatment so that it can be treated when the blood counts have recovered. If the patient does not have a family dentist, oral surgeons (associated with most hospitals) can often perform the prechemotherapy dental evaluation when requested by an oncologist.

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Oral Care During Bone Marrow Transplant

It is extremely important to keep the mouth clean and healthy during the bone marrow transplant procedure to help reduce the risk of infection and bleeding. Some research has shown that mouth sores are less severe in people with excellent oral hygiene. A professional dental cleaning 1-2 weeks prior to being admitted to the hospital for the bone marrow transplant, is highly recommended. Following are some suggestions for reducing oral complications during the transplant.

  1. The medical oncologist will prescribe antiviral and antifungal medications, when appropriate. These medications are usually very effective in lowering the risk of viral and fungal (thrush) infections in the mouth as well as in other areas of the body. Fewer infections in the mouth results in less pain and better nutrition.
  2. Toothbrushing should be performed at least twice daily. Supersoft toothbrushes* are available that will not cause bleeding if used appropriately. Brushing should be done in agentle, circular motion. To be thorough, brush teeth in a systematic fashion to include all surfaces of every tooth. Flossing and the use of a normal toothbrush are not recommended when the platelet count is lower than 50,000. The use of a water-irrigating device, on a low setting, is a good way to eliminate food between teeth without causing bleeding.

    Important: Always disinfect the toothbrush before each use. Soak toothbrush in a fresh solution of Clorox and water (1 tbs. Clorox per 1/2 cup water) or wash with an antimicrobial soap containing chlorhexidine. Thoroughly rinse the toothbrush after disinfection and before placing it in the mouth. Change toothbrush weekly.

    Hint: The bristles of the supersoft toothbrush will become even softer if held under warm water before use.

    Hint: It is a good idea to gently brush the tongue, palate and gums with a supersoft toothbrush on a daily basis in order to remove harmful germs.

    Hint: If a particular brand of toothpaste burns or irritates the mouth, try a toothpaste that is specially made for children or people with dry mouth.*

  3. 3. Some people with gum disease may be asked to rinse with a mouthrinse containing 0.12% chlorhexidine. It is best to use the mouthrinse 2-3 times daily after meals and at bedtime.
  4. Saline or saltwater and baking soda rinses (1 tsp. salt and 1 tsp. baking soda in one quart of water) may be used throughout the day to sooth the sore and dry mouth. When using mouthrinses, be sure to stagger their use throughout the day, allowing at least one hour before another mouthrinse. Using several different mouthrinses at one time will reduce their effectiveness.
  5. To ease the pain of mouth ulcers, rinse with viscous lidocaine about 15 minutes before eating. Some pharmacies can also make flavored lollipops with medications that have a numbing effect to use before eating. Eat small bites and chew thoroughly when using these numbing medicines to reduce the risk of choking.
  6. Keep mouth and lips well lubricated with a water-based lubricant*. Petroleum jelly repels water and is not recommended for use.
  7. When the mouth is sore, remove dentures and leave them out until the mouth heals. All full dentures and partial dentures should be disinfected before each use with a soap or rinse containing chlorhexidine. Dentures without metal may be soaked daily in a fresh solution of Clorox and water (1 tbs. Clorox to 1/2 cup of water). Rinse the dentures well before placing them back in the mouth.

*Biotene supersoft toothbrush, mouthrinse without alcohol, water-based lubricant (Oral Balance) and toothpaste are specially made for people with dry and sore mouths. They can be obtained through most pharmacies and are over-the-counter. The manufacturer of these products is Laclede, 15011 Staff Court, Gardena, CA 90248, 1-800-922-5856.

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Oral Care After Bone Marrow Transplant

  1. The use of daily fluoride is strongly recommended (see fluoride instructions) for patients experiencing the following:
    • radiation to the head and neck areas
    • total body irradiation
    • allogeneic (sibling or unrelated donor) transplants
    • long-term chemotherapy
    • dry mouth
    • active tooth decay
    • tooth sensitivity to cold
  2. If the platelet count is greater than 50,000, brushing can be accomplished with a soft-bristled toothbrush (never medium or hard). Daily flossing is also advised if the platelet count is adequate.
  3. If the platelet count is greater than 50,000, dental cleanings, fillings, root canals and extractions can usually be safely performed as long as these procedures are coordinated and approved by the medical oncologist. If emergency dental care is needed when the platelet count is below 50,000, a platelet transfusion may be necessary prior to the dental procedure.
  4. If an indwelling catheter is present, it may be necessary to take a dose of antibiotics one hour prior to any dental procedure that may cause bleeding. The dentist providing the care should provide the prescription for the antibiotic.
    (Note to health care professionals: The American Heart Association’s regimen for SBE prophylaxis may be used in these situations.)