Dental Evaluation and Clearance Prior to Allogeneic Hematopoietic Cell Transplantation

Abstract

Introduction:

Dental examination and stabilization is performed prior to allogeneic hematopoietic cell transplantation to decrease infection risk during neutropenia. Burden of dental disease and treatment need is not well-characterized in this population.

Objectives:

This report describes the dental status of a cohort of patients within the Chronic Graft-versus-Host Disease Consortium, and treatment rendered prior to transplant.

Methods:

The cohort included 486 subjects (Fred Hutchinson: n = 245; Dana-Farber: n = 241). Both centers have institutional-based dental clearance programs. Data was retrospectively abstracted from medical records by calibrated oral health specialists.

Results:

Median age at transplant was 55.9 years, 62.1% were male, and 88% white. Thirteen patients were edentulous (2.7%). Mean teeth among dentate patients before clearance was 26.0 (SD, 4.6). Dental findings included untreated caries (31.2%), restorations (91.6%), endodontically treated teeth (48.1%), and dental implants (5.7%). Pretransplant procedures during clearance included endodontic therapy (3.6%; mean = 0.1 teeth), restorations (25.1%; mean = 0.7), dental prophylaxis (59.2%), scaling/root planing (5.1%), and extraction (13.2%; mean = 0.3). Mean teeth after clearance was 25.6 (SD, 5.0).

Conclusions:

Retrospective analysis of pre-AlloHCT dental data in subjects at two large transplant centers identified low levels of dental need. Findings suggest high access to care.

Introduction

Allogeneic hematopoietic cell transplantation (alloHCT) is a life-extending and potentially curative therapy for the treatment of malignant and non-malignant hematopoietic disorders (Appelbaum, 2007; Copelan, Chojecki, Lazarus, & Avalos, 2019). Conditioning chemoradiotherapy prior to alloHCT results in profound immunosuppression putting patients at risk for life-threatening infections (Almyroudis et al., 2005; Kruger et al., 1999; Mikulska et al., 2009; Mikulska et al., 2018; Young et al., 2016). Immunosuppression is further intensified by immunomodulating medications which help to prevent graft rejection and decrease risk for graft-versus-host disease (GVHD)-induced visceral organ damage (Martinez-Cibrian, Zeiser, & Perez-Simon, 2021).

The oral cavity is one of the most complex bacterial communities in the body and oral bacteria have been consistently implicated in blood stream infections in hematology-oncology patients (Allareddy et al., 2015; Bergmann, 1988; Bochud, Calandra, & Francioli, 1994; Greenberg, Cohen, McKitrick, & Cassileth, 1982; Heimdahl, Mattsson, Dahllof, Lonnquist, & Ringden, 1989; Kennedy et al., 2000), particularly in those with periodontal and/or periapical infections (Allareddy et al., 2015; Graber et al., 2001; Laine et al., 1992; Overholser, Peterson, Williams, & Schimpff, 1982; Peterson & Overholser, 1981; Raber-Durlacher et al., 2013). Studies have reported a decrease in oral mucositis (Gurgan et al., 2013; Kashiwazaki et al., 2012) and febrile neutropenia in cancer patients treated with interventions to address periodontal inflammation (Kashiwazaki et al., 2012). The potential impact of oral disease is underscored by the level of dental need identified in the hematopoietic cell transplantation (HCT) population at the time of transplant (Durey, Patterson, & Gordon, 2009; Elad et al., 2003; Fernandes et al., 2014; Gurgan et al., 2013; Hansen et al., 2021; Mawardi et al., 2014; Sultan et al., 2017). Oral considerations have prompted national and international consensus guidelines recommending dental evaluation and definitive disease stabilization prior to alloHCT (Cdc, the American Society of, & Marrow, 2001; “Consensus statement: oral complications of cancer therapies. National Institutes of Health Consensus Development Panel,” 1990; Elad et al., 2015). These recommendations are strengthened by the low incidence of oral source infection in cancer centers with dental stabilization protocols (Hansen et al., 2021; Yamagata et al., 2006; Yamagata et al., 2011) and a decision analysis model which estimated 1.8 fewer deaths following dental stabilization per every thousand hematology-oncology patients treated with high dose chemotherapy and/or HCT (Elad, Thierer, Bitan, Shapira, & Meyerowitz, 2008). The objective of this study was to characterize the oral health status at the time of pre-alloHCT dental clearance of a cohort in subjects at two large academic medical centers in the United States.

Methods

Study Design

The Chronic Graft-versus-Host disease (cGVHD) Consortium includes 13 centers that enrolled, and prospectively followed, 911 allogeneic transplant recipients over a 3-year period (March 2011 to May 2014) (Arora et al., 2016). This nested sub-study was a retrospective analysis of dental/oral health parameters nested within the Consortium’s leading enrollment sites: Fred Hutchinson Cancer Research Center (FHCRC) in Seattle, WA, and Dana-Farber Cancer Institute (DFCI) in Boston, MA. The study was approved by Institutional Review Boards at both sites and subjects provided written informed consent in accordance with the Declaration of Helsinki.

Eligibility

The study population consisted of alloHCT recipients enrolled in the cGVHD Consortium at FHCRC and DFCI between March 2011 and May 2014. Subjects were eligible for enrollment up to day +121 posttransplant in the absence of late acute GVHD (aGVHD) or cGVHD (defined by NIH consensus criteria)(Filipovich et al., 2005). Patients under 18 years of age were excluded.

Data Collection

Pretransplant evaluation/dental clearance was performed by oral medicine (OM) faculty at FHCRC or DFCI prior to alloHCT. Dental examinations were completed according to institutional protocols and included dental radiography (full mouth series or panoramic with supplemental intraoral radiographs), caries assessment, periodontal evaluation, and oral mucosal exam. DFCI examinations were completed by community dentists based on written protocols and reviewed by OM faculty. All dental data were abstracted from radiographs, electronic health records, and external dental records by calibrated oral health specialists. Data included baseline oral health status (total tooth count, number of endodontically treated teeth, dental implants, removable prostheses, oral mucosal lesions), dental treatment completed as part of pretransplant stabilization (restorations, endodontic therapy, extractions, periodontal therapy), and number of untreated dental caries at time of alloHCT. Demographic data and alloHCT details (e.g., conditioning regimen, GVHD prophylaxis) were obtained from Consortium databases.

Indications for pretransplant dental treatment were based on institutional protocols which are summarized in Table 1. Endodontic infections, including periapical granulomas, were treated with either root canal therapy or extraction prior to pretransplant conditioning.

Table 1 –

Clinical Indications for Pretransplant Dental Treatment

Endodontic Pathology

Irreversible pulpitis *

Pulpal necrosis *

Periapical infection *

Periodontal Pathology

Tooth mobility, grade II ** or III †

PPD ≥6 mm Pericoronitis †

Dental Caries

Caries with imminent risk for infection

Tooth Fracture

Pulpal exposure *

Retained root tips **

Root fracture **

PPD = Periodontal probing depth; RCT = Root canal therapy.

^*Indication for EXT or RCT.

^**indication for periodontal therapy.

^†Indication for EXT or periodontal therapy.

Statistical Methods

Descriptive statistics (means, medians, frequencies, standard deviations, and ranges) were computed for demographic variables.

Results

Study Population

A total of 486 subjects met inclusion criteria for the retrospective dental analysis FHCRC: n = 245; DFCI: n = 241). Median age at time of alloHCT was 55.9 years (range: 19.4 to 78.1). Most patients were male (62.1%). Acute myeloid leukemia (45.3%) was the most common indication for alloHCT followed by lymphoma (14.8%) and myelodysplastic syndrome (14.2%). Most subjects self-identified as white (87.4%) with lower proportions of the cohort identifying as Asian (3.7%), Black (1.9%), or Native Hawaiian or Pacific Islander (1.9%). Greater than 1/3 (183/486, 37.7%) were college graduates or held advanced degrees. Demographic characteristics are summarized in Table 2.

Table 2 –

Cohort Demographics

n = 486
Study Site	n	%
FHCRC	245	50.4
DFCI	241	49.6
			DFCI		FHCRC
Mean age (Range)	55.9	(19.4–77.9)	54.4	(19.4–73.9)	49.5	(19.9–77.9)
Sex			n	%	n	%
Female	184	37.9	89	36.9	95	38.8
Male	302	62.1	152	63.1	150	61.2
Race
White	425	87.4	219	90.9	206	84.1
Asian	18	3.7	7	2.9	11	4.5
Black/African American	9	1.9	7	2.9	2	0.8
Native Hawaiian/Pacific Islander	9	1.9	1	0.4	8	3.3
American Indian/Alaska Native	6	1.2	0	0	6	2.4
Multi-Race	3	0.6	1	0.4	2	0.8
Unknown	16	3.3	6	2.5	10	4.1
Level of Education
< High School	13	2.7	5	2.1	8	3.3
High School Graduate or GED	82	16.9	39	16.2	43	17.6
Vocational or Training School	24	4.9	13	5.4	11	4.5
Some College or Associate Degree	78	16.0	14	5.8	64	26.1
College Graduate	127	26.0	55	22.8	72	29.4
Advanced Degree (Masters, PhD, etc.)	56	11.5	15	6.2	41	16.7
Unknown	98	20.2	95	39.4	3	1.2
Employment
Disabled-Unable to Work	123	25.3	41	17.0	82	33.5
Retired	96	19.8	59	24.5	37	15.1
On Medical Leave from Work	91	18.7	24	10.0	67	27.3
Working-Full-Time or Part-Time	83	17.1	64	26.6	19	7.8
Unemployed	45	9.2	11	4.6	34	13.9
Other (e.g., Homemaker, Student)	10	2.1	7	2.9	3	1.2
Unknown	38	7.8	35	14.5	3	1.2
Hematologic Diagnosis
AML/ALL	214	44.0	102	42.3	118	48.2
NHL/HD	69	14.2	44	18.3	28	11.6
MDS	69	14.2	29	12.0	42	17.1
CML/CLL	43	8.8	26	10.8	17	6.9
Other	82	16.9	40	16.6	40	16.3

AML = Acute myeloid leukemia; ALL = Acute Lymphocytic Leukemia; NHL = Non-Hodgkin lymphoma; HD = Hodgkin disease; MDS = Myelodysplastic syndrome; CML = Chronic myeloid leukemia; ALL = Chronic Lymphocytic Leukemia.

Baseline Dental Findings

Over 95% of subjects had known tooth count at baseline (n = 466/486, 95.9%). Among subjects with known tooth count, dentate subjects (n = 453/466, 97.2%) had an average of 26.0 teeth at baseline. Edentulism was uncommon (2.7%). Twenty subjects had unknown tooth count due to lack of baseline radiographic examination. Dental restorations (91.6%), endodontically treated teeth (48.1%), and untreated dental caries (31.3%) were the most common dental findings during pretransplant examination. Baseline dental findings are summarized in Table 3. Soft tissue lesions were present in 11% (n = 52/477) of patients, with hyperkeratosis (2.5%), hematoma (2.3%), and ulceration (1.0%) being the most common.

Table 3 –

Dental Status Prior to Allogeneic Hematopoietic Cell Transplantation

			Participants	%	DFCI		FHCRC
Dentate*			453/486	93.2	229	95.0	244	99.6
Edentulous			13/486	2.7	12	5.0	1	0.4
Untreated Dental Caries			145/464	31.3	92	40.7	53	22.3
Existing Dental Restorations			412/450	91.6	181	87.4	231	95.1
Endodontically Treated Teeth			225/468	48.1	104	46.4	121	49.6
Existing Dental Implants			25/441	5.7	16	8.0	9	3.75
Removable Partial Dentures			25/486	5.1	24	10.0	1	0.4
Complete Dentures (Maxillary/Mandibular)			10/486	2.1	8	3.3	2	0.8
Complete Denture (Single)			4/486	0.8	4	1.7	0	0.0
Tooth Count*†
	Mean	SD			DFCI		FHCRC
At Baseline	26.0	4.6			25.1	5.3	26.7	3.7
After Clearance	25.6	5.0			24.6	6.0	26.5	3.8
Dental Procedures Completed †ǂ
	Mean	SD	Participants	%	DFCI		FHCRC
Stabilization Required (EXT, RCT, restorations, SRP)	NA	NA	175/473	37.0	106	46.3	69	28.3
Teeth Extracted	0.3	1.2	62/470	13.2	38	16.8	24	9.8
Teeth Treated Endodontically	0.1	0.3	17/468	3.6	10	4.4	7	2.9
Dental Restorations	0.7	1.8	116/462	25.1	82	36.4	34	14.3
Scaling/Root Planing	NA	NA	24/473	5.1	1	0.4	23	9.4
Dental Prophylaxis	NA	NA	280/473	59.2	214	93.5	66	27.1

^*With known baseline tooth count.

^†Dentate patients only.

^ǂ20 patients were dentate but had unknown tooth count at baseline resulting in variable denominator.

EXT = Extraction; RCT = Root Canal Therapy (Endodontic Therapy); SRP = Scaling and Root Planing

Pretransplant Dental Treatment

Dental treatment was required in 175 patients prior to proceeding with transplant (37.0%). Dental restorations were the most common procedure (mean = 0.7 teeth ±1.8 in patients with known tooth count). Extractions were required in 13.1% of patients (mean teeth = 0.3±1.2) resulting in mean post-clearance tooth count of 25.6. Periodontally, dental prophylaxis was common (59.2%) while scaling and root planning was relatively infrequent (5.1%). Seventeen patients (3.6%) completed root canal therapy (mean = 0.1 teeth ±0.3). Pretransplant dental procedures are summarized in Table 3.

Discussion

Consensus guidelines recommend dental examination and stabilization prior to high-dose chemotherapy and/or HCT to minimize risk for oral source infection (Cdc et al., 2001; Elad et al., 2015). Though this standard is widely accepted, the burden of pretransplant dental disease is not well described in this population. Our study characterizes pretransplant oral health status in patients treated at two major transplant centers in the United States and to our knowledge represents the largest report of pre-alloHCT dental status to date. A summary of pre-transplant dental status in this cohort is compared to previously published works in Table 4.

Table 4 –

Literature Summary: Dental Status prior to Hematopoietic Cell Transplantation / High-Dose Chemotherapy

Study	Population	EXT n (%)	RCT n (%)	SRP n (%)	Dental Restorations* n (%)	Time
Dean et al. (2023)	AlloHCT (n = 486)	62 (13.2)	17 (3.6)	24 (5.1)	116 (25.1)	3 to 4 weeks (estimated)
Akintoye et al. (2002) (Akintoye et al., 2002)	AlloHCT (n = 77)	32 (41.6)	Not reported	Not reported	27 (35.1)	1 to 3 weeks
Durey et al. (2009) (Durey, Patterson, & Gordon, 2009)	HCT (NOS) (n = 94)	36 (40.9)	1 (1.1)	39 (44.3)	19 (21.6)	31.5d ± 16.8d (mean)
Elad et al. (2003) (Elad et al., 2003)	AlloHCT (n = 31) AutoHCT (n = 15)	9 (19.5) 0.36 teeth/patient (mean)	4 (8.7) 0.15 teeth/patient (mean)	22 (47.8)	18 (39.1)	20.7 ± 16.8d (mean) 15d (median)
Graber et al. (2001) (Graber et al., 2001)	AlloHCT (n = 42)	20 (47.6)	Not reported	Not reported	Not reported	Not reported
Guenther et al. (2017) (Guenther et al., 2017)	AlloHCT (n = 80) AutoHCT (n = 83)	25(15.3)	Not reported	Not reported	Not reported	Not reported
Gurgan et al. (2013) (Gurgan et al., 2013)	AlloHCT (n = 202)	2.45 ± 1.25 teeth/patient (mean)	0 (0) †	Unknown ǂ	5.67 ± 3.56 teeth/patient (mean)	Not reported
Hansen et al. (2021) (Hansen et al., 2021)	AlloHCT (n = 143) AutoHCT (n = 207)	29 (42.6) of patients with apical pathology treated with EXT or RCT	24 (40.0)	46 (68.7)	29d (median)
Mawardi et al. (2014) (Mawardi et al., 2014)	HCT (NOS) (n = 405)	83 (20.5)	20 (4.9)	Not reported	196 (48.4)	Not reported
Schuurhuis et al. (2016) (Schuurhuis et al., 2016)	AutoHCT (n = 35) HD-Chemo (n = 28)	Not reported	Not reported	0 (0)	0 (0)	Not reported
Sultan et al. (2017) (Sultan et al., 2017)	AlloHCT (n = 91)	10 (11.0) of patients with apical pathology treated with EXT or RCT	Not reported	23 (25.3)	Not reported
Wilson-Dewhurst et al. (2021) (Wilson-Dewhurst, Kwasnicki, Macpherson, & Thompson, 2021)	AlloHCT (n = 34) AutoHCT (n = 40)	18 (24.3) 0.69 teeth/patient (mean)	Not reported	3 (4.1)	23 (31.1) 0.62 teeth/patient (mean)	15.8 ± 10.0d (mean)
Yamagata et al. (2006) (Yamagata et al., 2006)	HCT (NOS) (n = 41)	10 (24.4) 0.34 teeth/patient (mean)	4 (9.8) 0.12 teeth/patient (mean)	24 (58.5)	12 (29.3)	47d (median)
Zecha et al. (2022) (Zecha et al., 2022)	MA-Chemo (n = 88)	Not reported	Not reported	Not reported	Not reported	Not reported

^*Fillings and/or crowns;

^†All teeth with endodontic pathology were extracted;

^ǂPeriodontal therapy was a standard part of study protocol, but treatment only confirmed for the 29 patients who returned for post-HCT follow-up assessment.

AlloHCT = Allogeneic hematopoietic cell transplantation; AutoHCT = Autologous hematopoietic cell transplantation; HCT-NOS = hematopoietic cell transplantation (not otherwise specified); HD-Chemo = High-dose Chemotherapy; MA-Chemo = Myeloablative Chemotherapy

EXT = Extraction; RCT = Root Canal Therapy (Endodontic Therapy); SRP = Scaling and Root Planing

Early studies in HCT report a high prevalence of dental pathology prior to transplant with extensive stabilization therapy required prior to conditioning. A retrospective study of 46 HCT patients by Elad et al. found 19.5% of patients to require dental extractions (mean = 0.36 teeth), 8.7% endodontic therapy (mean = 0.15 teeth), 47.8% periodontal scaling, and 39.1% dental restorations (Elad et al., 2003). The study also highlighted the short timeframe for dental evaluation and stabilization prior to pretransplant conditioning (mean = 20.65 ± 16.82 days; median = 15). A prospective study of 41 HCT patients by Yamagata and colleagues reported very similar findings with extractions required in 24.4% of cases, endodontic therapy in 9.8%, periodontal scaling in 58.5%, and dental restorations in 29.3%, though, they also described substantially longer time for evaluation and management (median = 47 days, range 7 to 240 days)(Yamagata et al., 2006). The retrospective nature of this study limited the ability to quantify timeframe for pretransplant dental stabilization. General experience has been similar to that reported by Elad and colleagues with an estimated 3 to 4 weeks to complete treatment prior to conditioning therapy.

Durey et al. similarly reported high levels of dental need in a retrospective study of 94 HCT patients in which 74.5% of patients were found to have untreated dental need at baseline. Nearly half (46.6%) required extraction as part of their treatment plan. Time to complete therapy was limited to 1–2 weeks (mean = 7.88± 6.78 days) (Durey et al., 2009). These statistics are nearly identical to those reported by Graber and colleagues in which 73.8% of alloHCT patients (n = 31/42) receiving pre-HCT were found to have dental pathology on pretransplant exam with nearly half requiring extraction (Graber et al., 2001). Timeframe for stabilization was not reported in the study. The prevalence of pretransplant dental treatment in these studies, particularly dental extractions, was higher than that seen in this cohort. This observation is certainly multifactorial, but likely reflects differences in baseline systemic and/or oral health status between study populations, access to dental resources prior to arrival at transplant centers, and variation in dental treatment parameters, including threshold for dental extraction, between groups. Time available to complete dental treatment may also influence clinical decision making, though in our experience, conservative therapies are likely to be prioritized over extraction when timeframe is limited to maintain transplant timelines.

Review of pretransplant dental data suggests healthier dental status in the present cohort compared to previous reports. Less than 40% of subjects in the cohort required stabilization therapy prior to transplant. More invasive dental procedures were uncommon, with endodontic therapy completed in 13 subjects (mean = 0.1 teeth) and dental extraction in 62 (mean = 0.3 teeth). Low prevalence of edentulism (2.7%) and high baseline prevalence of dental implants (5.7%) and endodontically treated teeth (48.1%) suggest high access to dental care which may have been influenced by the demographic makeup of the cohort and the location of both transplant centers in affluent American cities. Prior studies in oncology in the United States have identified systemic, logistical, and financial barriers to participation in clinical studies and access to HCT (Majhail, Omondi, Denzen, Murphy, & Rizzo, 2010; Penberthy et al., 2012; Saphner, Marek, Homa, Robinson, & Glandt, 2021). These factors influence the composition of research cohorts with overrepresentation of individuals with greater access to healthcare resources. It is expected that greater access to healthcare is a primary factor associated with stable oral health status in this study population. Anecdotally, dental infection risk rarely leads to transplant delay in our centers; in the rare circumstances in which this occurs patients most commonly present with profound dental need resulting from lack of dental care over many years prior to arrival to the transplant service.

The hypothesis that relative dental health in this population is related to access to care is supported by similarities in pre-HCT dental health reported at other major transplant centers in the United States. Hansen et al. reported baseline periapical pathology in 19.4% of 350 HCT patients treated at Memorial Sloan Kettering Cancer Center. One hundred forty-five patients (41.4%) did not require dental stabilization prior to transplant. Extraction or endodontic therapy was required in 29 cases (8.3%) (Hansen et al., 2021). Similar pretransplant dental treatment needs were reported in 405 HCT patients treated at Dana Farber Cancer Institute (DFCI) between 2005 and 2007 with 11.9% completing extractions, 4.9% endodontic therapy, and 45.6% dental restorations (Mawardi et al., 2014). Stable oral health was also described by Sultan and colleagues in a cohort of AML patients treated with alloHCT at DFCI between 2007 and 2011, with only 13 of the 91 individuals deemed to have compromised dentition at baseline and all successfully completing stabilization therapy prior to transplant (Sultan et al., 2017).

Differences in pretransplant dental therapy may also be related to differences in treatment philosophy between cancer centers. Gurgan and colleagues reported a mean of 2.45 (± 1.25) extracted teeth in alloHCT patients prior to transplant, 87% of which were third molars (Gurgan et al., 2013). Other groups have reported low risk for systemic infection related to third molars in the HCT population, particularly when teeth are asymptomatic (Hansen et al., 2021) (Ohman et al., 2010). Third molars were regularly managed with conservative interventions in this study cohort. Differences in periodontal therapy also appear to exist between groups. Wilson-Dewhurst and colleagues reported high levels of pretransplant dental pathology in 74 HCT patients with 34% requiring dental extraction. Notably, only 4% were treated with periodontal therapy (Wilson-Dewhurst, Kwasnicki, Macpherson, & Thompson, 2021). Other studies suggest much greater periodontal need in the HCT population. Gurgan et al. reported periodontal probing depths of ≥4 mm at 21.2% of sites in their study cohort with bleeding on probing identified at 60.9% of sites. Akintoye and colleagues reported ≥20% periodontal bone loss in 18.2% of HCT patients in baseline panoramic radiographs (n = 14 of 77) (Akintoye et al., 2002). Greater than 40% of their study population required pretransplant extraction (n = 32). In the present study, scaling and root planing to treat active periodontal disease was relatively low (5.1%) while prophylactic dental cleaning was very common (59.2%); however, a detailed periodontal analysis was beyond the scope of this study.

A prospective study by Schuurhuis and colleagues examined a mixed cohort of autologous HCT (autoHCT) recipients (n = 35) and patients with leukemia treated with high-dose chemotherapy (n = 28)(Schuurhuis et al., 2016). All patients completed dental screening with elimination of acute dental pathology. Chronic oral foci including periodontal pockets ≥6 mm, periapical radiolucencies, and retained root tips were monitored rather than treated. Chronic oral foci were identified in 86% of leukemic patients and 73% of autoHCT patients prior to therapy. Bacteremia of potentially oral source was seen in 11.1% of patients (n = 7). Four patients developed acute oral bacterial infections, 2 of which were exacerbations of previously identified chronic foci. All were managed conservatively. Zecha et al. identified untreated chronic oral infection in 44.3% of cancer patients (n = 39/88) prior to myeloablative chemotherapy(Zecha et al., 2022). Only 3 patients with chronic oral infection developed febrile neutropenia of potentially oral source; no association was found between oral foci and febrile neutropenia post-chemotherapy. Finally, Guenther and colleagues described high levels of perceived dental need in 163 patients pre-HCT including partially impacted wisdom teeth (17.4%) and insufficient root canal filling (52.3%)(Guenther et al., 2017). Neither factor was statistically associated with incidence of bacteremia or neutropenic fever which is consistent with prior studies(Ohman et al., 2010; Peters, Monopoli, Woo, & Sonis, 1993). Lack of clarity regarding optimal dental intervention has led to the recommendation for dental risk stratification which has been associated with low rates of odontogenic complication when used to inform pretransplant treatment planning(Hansen et al., 2021).

Limitations of this study include the retrospective nature of its design and relative lack of diversity in the study population. Data was limited to willing research participants (in a parent cohort) at two transplant centers which limits the generalizability of study findings to other groups. The dental health within this study population may not be representative of that seen in other transplant centers nationally or internationally and may also differ between cohort participants and those electing not to enroll in the parent study. Direct comparison to the general US population was limited by the data variables recorded during baseline examination, though mean number of teeth was consistent with reports for adults ages 20 to 64 (Centers for Disease Control and Prevention. Oral Health Surveillance Report: Trends in Dental Caries and Sealants, Tooth Retention, and Edentulism, United States, 1999–2004 to 2011–2016. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services 2019). Strengths include the presence of fully integrated Oral Medicine services at DFCI and FHCRC. Both centers have consistent pretransplant dental examination and stabilization protocols which facilitated data collection. Outcome measures in this study were chosen to ensure accuracy in interpretation and reporting.

Conclusions

Retrospective analysis of pretransplant dental data in a cohort of subjects at two large transplant centers identified low levels of dental need prior to alloHCT. Findings suggest high access to care in this population. Prospective data is currently being collected to help characterize long-term dental status within the cohort and the potential predictive value of pretransplant oral health status in relation to posttransplant health outcomes.