In this article, Dr. Kate Matin evaluated the usefulness of an off-site dental evaluation program for bone marrow recipients. This evaluation packet enabled patients scheduled for bone marrow transplants to be evaluated by, and receive any treatment from, their own dentist rather than a dentist at the transplant center. The program generally was effective in achieving its goals and was well-accepted by patients and dentists alike.

1. U
OFF-SITE DENTAL EVALUATION PROGRAM
FOR PROSPECTIVE BONE MARROViITRANSPLANT RECIPIENTS
SOOK-BIN WOO, D.M.D., M.M.SC.; KATAYOUN MATIN, B.D.S.
Ohe mouth has been identi-
fied as a source offever and
septicemia in patients who have
undergone therapy for a variety
ofmalignancies.'-5 During can-
cer treatment, patients become
neutropenic, at which time
areas offocal chronic oral infec-
tion may undergo an acute ex-
acerbation. At best, these exac-
erbations may present as a local
infection; at worst, they may de-
velop into a potentially life-
threatening septicemia.
Therefore, identification and
treatment ofpre-existing and
potential sites oforal infection
are important components of
any pre-chemotherapy protocol.
Authors have recommended
that patients receive compre-
hensive oral and dental exami-
nations before the start of
chemotherapy and radiation,6
as such pretreatment strategies
have been shown to be cost-ef-
fective.7
Bone marrow transplanta-
tion, or BMT, is the treatment
often used for many leukemias,
lymphomas, bone marrow fail-
ure syndromes and immunode-
ficiency disorders. It is also the
primary and salvage therapy
used for solid malignancies such
as breast cancer. Since the con-
ditioning regimens for BMT
cause the white cell count to fall
to zero for several days and re-
main low for several weeks, pa-
The authors evaluated the use-
fulness of an off-site dental eval-
uation program for bone marrow
recipients. This evaluation pack-
et enabled patients scheduled
for bone marrow transplants to
be evaluated by, and receive any
treatment from, their own den-
tist rather than a dentist at the
transplant center. The program
generally was effective in
achieving its goals and was well-
accepted by patients and den-
tists alike.
tients who undergo this treat-
ment are at high risk for infec-
tions, especially those that are
of dental origin.
Fortunately, BMT candidates
are scheduled for this treatment
from several weeks to two
months in advance oftheir ad-
mission date and can plan to
have their dental treatment
completed before admission.
However, some patients may
undergo chemotherapy at re-
gional or out-of-state hospitals,
and it may be difficult for them
to receive their dental evalua-
tion and treatment at the BMT
center.
In 1991, Brigham and
Women's Hospital in Boston im-
plemented an off-site dental
evaluation program to allow pa-
tients the opportunity to be
evaluated by their own dentists.
There are several advantages to
the program. First, the patient
goes to his or her own dentist,
in whose office the patient's
dental records are kept. Second,
it reduces traveling time for the
patient. Third, the patient still
has the benefit ofreceiving a
consultation from our division
for the management of specific
dental conditions. Fourth, the
dentist is directly involved in
the management of an immuno-
compromised patient who is a
member ofhis or her practice.
The purpose ofthis study is to
-assess compliance ofdentists
with the request for evaluation;
- identify the dental needs of a
BMT patient population;
- draw attention to the special
needs ofpatients who are
scheduled for BMT.
METHODS AND
MATERIALS
Adult patients who were poten-
tial BMT recipients at the
Brigham and Women's Hospital
and the Dana Farber Cancer
Institute in Boston and who
lived more than 30 miles from
Boston or who wished to be seen
by their dentists were given a
JADA, Vol. 128, February 1997 189

2. AE [SE ARCH-
dental evaluation package. This
package was to be given to their
dentists and consisted of a two-
page letter explaining what
BMT entails and the role ofthe
mouth in sepsis and a three-
page clinical evaluation form,
which included a section for the
treatment plan proposed by the
dentist.
The dentists were specifically
asked to
- obtain a full-mouth intraoral
radiograph series if a set had
not been obtained within the
last six months;
- obtain a panoramic radiograph
ifthird molars were present;
- reassess partially erupted
third molars, equivocally symp-
tomatic teeth, areas with peri-
odontal pockets deeper than 4
millimeters and deep restora-
tions with direct or indirect
pulp caps;
- test all teeth that had large
restorations or a history of a
pulp cap, preferably with an
electric pulp tester;
- perform a scaling, root plan-
ing and prophylaxis as soon as
possible.
Dentists were told that the
patient's hospitalization could
last from four weeks to several
months. The dentists were in-
formed that during the treat-
ment the patients would not be
allowed to brush or floss but
would use sponge-tipped appli-
cators for cleaning their teeth,
as well as a variety of antimi-
crobial oral rinses and topical
fluoride preparations. The den-
tists also were informed that
the patient probably would not
be able to see a dentist for six
months to one year after the
BMT, depending on how quickly
their white blood cell counts re-
covered and whether they de-
veloped other serious medical
problems. Additionally, infor-
TABLE I
Ill` x la El z 1,-;,
a-;'lu -l P !l'F!4_ l .l07 -
TIME (DAYS) NUMBER (%) OF PATIENTS*
7-14 84 (42.0)
15-28 ~~~~~~~43(21.5)
>29 24 (12.0)
UJrikronw 10 (5.0)
* N = 200 patients.
mation was provided regarding
the benefits of antibiotic pro-
phylaxis for patients who had
central venous catheters before
dental manipulation. This back-
ground information was provid-
ed so that the dentists would be
able to make informed decisions
regarding dental care for their
patients.
Patients who undergo BMT
also may receive ongoing
chemotherapy (with attendant
sequelae of oral mucositis and
Having the dental
evaluation performed
as soon as possible is
desirable so that
treatment can be
completed in time for
the patient's admis-
sion to the hospital
for cancer therapy.
myelosuppression), or
hematopoietic colony-stimulat-
ing factors such as granulocyte-
colony stimulating factor, or G-
CSF, that require periodic
leukopheresis (removal ofwhite
blood cells that are later rein-
fused) to collect circulating stem
cells. Therefore, we asked that
the radiographs, evaluations and
treatment plans be sent by
overnight or express mail to our
department for further evalua-
tion and to help us coordinate
the patient's treatment.
Coordination ofthe patients'
oncology and dental visits is an
important aspect ofcare. For
example, dental treatment
should not be performed on the
day ofleukopheresis because of
the possibility of contaminating
the pheresis specimen with bac-
teria. Since many expected and
unexpected occurrences may
delay the delivery of dental
care, having the dental evalua-
tion performed as soon as possi-
ble is desirable so that treat-
ment can be completed in time
for the patient's admission to
the hospital for cancer therapy.
The patient evaluations,
which were returned by the
dentists between January 1992
and December 1994, were re-
viewed and the following data
were recorded:
- time elapsed from the day
the patient was seen by the
dentist and the date on which
the evaluation was received;
- adequacy ofthe radiographs,
whether a full-mouth series was
performed and the diagnostic
quality ofthe films;
- comparison ofthe patient's
dental needs according to the
190 JADA, Vol. 128, February 1997

3. NUMBER ()
OF PATIENTS*
without bite wings
-1.,41".l .,.,s.,, '* N- tEk ;;T)
No radiographs 12 (6.0)
protocol set up by our division
vs. the needs as perceived by
the dentist.
RESULTS
We reviewed the evaluations of
214 consecutive patients for this
study. Ofthese, six were sent
with no radiographs, three had
no written clinical evaluation
and five ofthe clinical evalua-
tions were filled out incomplete-
ly. Because there was insuffi-
cient time for these patients to
be contacted and re-evaluated
before admission, data from
these 14 cases (7 percent) were
not used in this study.
Patient characteristics.
There were 80 male and 120 fe-
male patients ranging in age
from 18 to 65 years with a medi-
an age of44.3 years. Thirty-
seven percent ofthese patients
had metastatic solid tumors
(mainly breast carcinoma) and
63.0 percent had leukemia, lym-
phoma or another hematologic
malignancy.
Time taken to return eval-
uation. Approximately 60 per-
cent ofthe evaluations were re-
ceived within two weeks ofthe
patient's examination by the
dentist. Twelve percent ofthe
dentists took more than four
weeks to return the evaluation
(Table 1).
Radiographs. Table 2 shows
the dentists' compliance with
sending radiographs. Dentists
of 12 patients (6 percent) did
not send radiographs; seven of
these patients returned to their
dentists for the radiographs so
that the treatment plan could
be completed, while five chose
to have their evaluation com-
pleted at our division.
Eighty-five percent ofthe ra-
diographs were ofgood or excel-
lent diagnostic quality (readily
interpreted) while the rest were
ofpoor or nondiagnostic quality.
In the latter category, more than
50 percent ofthe films were
severely cone-cut, severely over-
or underexposed, showed severe
overlap, did not include the
apexes or had severe artifacts.
Ninety-two patients had
third molars present and of
these, 38 patients (41.3 percent)
had panoramic radiographs
sent for evaluation. This per-
centage is probably related to
the availability ofpanoramic ra-
diograph machines in general
practice.
Dental needs of patients.
The figure shows that, as ex-
pected, periodontal disease and
caries were the two most preva-
lent conditions. Five cases of
mild and two cases of moderate
periodontal bone loss went un-
diagnosed by the dentists.
Eight patients (4.0 percent)
had periapical pathoses that re-
quired treatment, and three of
these were identified by the
dentists and treated. The five
cases (2.5 percent) ofperiapical
pathology that were not treated
consisted oftwo cases offailed
endodontics in which the root
canal filling was grossly inade-
quate (less than half ofthe
canal) and was associated with
clinical symptoms; one case of
root perforation by a post; and
two direct pulp caps with peri-
apical radiolucencies that sub-
sequently tested nonvital with
an electric pulp tester.
Ninety-two patients (46.0
percent) had third molars. There
was a moderate discrepancy in
the diagnosis and therefore in
the treatment plan between the
patients' dentists and our divi-
sion related to the need for ex-
tractions. According to our de-
partmental guidelines, 23 of92
patients who had third molars
required extractions, and 14 re-
quired extractions ofseverely pe-
riodontally involved or carious
teeth. Ofthese 37 teeth, 13 (35.0
percent) were not in the dentists'
treatment plans: nine were third
molars and four were considered
unsalvageable teeth. In five of
200 patients (2.5 percent), im-
pacted third molars were not
evaluated by the dentists.
Interestingly, 16.5 percent of
the dentists did not test the vi-
tality ofteeth that had large
restorations as requested. The
most common reason given was
the unreliability ofpulp tests.
When asked nevertheless to
test the teeth during a treat-
ment plan telephone interview,
13.0 percent complied. About 3
percent ofthe dentists did not
comply, and their patients had
the pulp testing performed at
our division during a routine
oncology visit at the hospital.
JADA, Vol. 128, February 1997 191
TABLE 2
RESEARCH
RADIOGRAPHS
J

4. DES[ARCH-
DISCUSSION
The off-site dental evaluation
program is a resource-efficient
way for candidates for BMT to
receive their dental treatment
in preparation for their condi-
tioning regimen. Dentists have
expressed enthusiasm for the
program because it provides
them with an opportunity to
learn more about the manage-
ment of cases involving patients
who are BMT candidates. Many
also expressed personal satis-
faction with the opportunity to
help patients and families who
had been treated at their prac-
tice for many years. Most pa-
tients, especially those who
lived out of state, preferred
being evaluated and treated by
a dentist with whom they were
familiar.
Overall, approximately 80
percent ofthe diagnoses and
treatment plans were appropri-
ate and adequate. The dentists
diagnosed caries and periodon-
tal disease in 76.9 percent and
91.0 percent of cases, respec-
tively, and appropriately identi-
fied patients who needed ex-
IThe conditions most
likely to give rse to
local symptoms of
pain and swelling in
the immediate post-
BMT penod are im-
pacted third molars,
failed endodontics
and periapical
pathoses associated
with nonvital nonen-
dodontically treated
teeth.
tractions in 64.9 percent of
cases. The appropriate diagno-
sis and treatment plan for third
molars was rendered in 60.9
percent (14 of 23) of cases. The
appropriate diagnosis for non-
salvageable teeth requiring ex-
F'igure. Dental needs of patients scheduled for bone marrow transplants.
traction was 71.4 percent (10 of
14). Although the number of pa-
tients with endodontic lesions
requiring treatment was small,
the appropriate diagnosis was
made in only 37.5 percent of
cases (three ofeight cases).
Two significant findings
emerged from this study. The
first relates to the delay of sev-
eral weeks before the evalua-
tions were returned to us.
Fourteen percent of dentists
took more than four weeks to
return the evaluation. Although
we did not specifically record
the number of patients this af-
fected, there were a few pa-
tients who did not have the nec-
essary treatment completed
before admission (such as ex-
traction ofthird molars) and
who subsequently developed
dental infections during hospi-
talization. An oral infection
translates into increased use of
antibiotics, pain medications,
increased need for blood prod-
uct support, increase in total
hospitalization days and the
risk of septicemia.
Timely return of the evalua-
tion is crucial to the success of
an off-site dental evaluation
program, indeed to the success
of any screening program. Ifthe
evaluation is so delayed as to
preclude necessary treatment,
then the value ofthe screening
is greatly diminished.
The second significant find-
ing relates to missed pathology.
In our experience, the condi-
tions most likely to give rise to
local symptoms of pain and
swelling in the immediate post-
BMT period are impacted third
molars, failed endodontics and
periapical pathoses associated
with nonvital nonendodontically
treated teeth.
Our criteria for third-molar
extractions are strict. Anecdotal
192 JADA, Vol. 128, February 1997

5. ESEA RCH1
evidence suggests that when
third molars have erupted in
young patients and there is no
operculum over the tooth, the
closer the distal gingival margin
ofnos. 17 and 32 is to the oc-
clusal surface, the greater the
chances ofan infection during
neutropenia. Therefore, third
molars with the distal gingiva
in the occlusal one-third ofthe
crown are usually very careful-
ly assessed for erythema, histo-
ry of pain and pericoronitis. In
most cases, such teeth are ex-
tracted. These criteria are ap-
plied less stringently to pa-
tients who have solid tumors
because their period of neu-
tropenia is shorter and they
tend to be less immunocompro-
mised. As these criteria were
not clearly stated in the evalu-
ation form and accompanying
letter, this probably resulted in
an increased number ofthird
molars that we considered as
being "misdiagnosed" by the
dentist.
Since this study was conduct-
ed, the evaluation form has been
modified to include assessment
ofthe height ofthe distal gingiva
surrounding teeth nos. 17 and
32 that have erupted. Immediate
return ofthe evaluation forms
has been re-emphasized.
CONCLUSION
This study evaluated the useful-
ness ofan off-site dental evalua-
tion program for BMT recipi-
ents. The program has been
found to be widely accepted by
dentists and patients. Only 7
percent ofpatients' evaluations
were grossly deficient. More
than 80 percent of dentists
identified carious lesions and
periodontal disease correctly;
only about 60 percent diagnosed
endodontic pathoses correctly,
although endodontic pathoses
constituted a small percentage
oflesions. Only about 60 per-
cent ofdentists correctly diag-
nosed the necessity ofthird-
molar extractions and 70
percent the need for other ex-
tractions in this population.
From this study, we realize
that more comprehensive mate-
rial needs to be made available
to dentists to improve diagnosis
and treatment planning ofden-
tal conditions in a BMT popula-
tion and that stronger language
needs to be used in the evalua-
tion form to encourage dentists
to return their evaluations in
an expeditious manner. .
Dr. Woo is attending dentist, Division of
Oral Medicine and Dentistry, Brigham and
Women's Hospital, 45 Francis St., Boston,
Mass. 02115. Address reprint requests to Dr.
Woo.
Dr. Matin is attending dentist, Guy's
Hospital, London.
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JADA, Vol. 128, February 1997 193