Bone Marrow Transplantation

Bone Marrow Transplantation

Section I: Clinical Scenario and Dental Considerations

A 63‐year‐old male presents to the dental clinic complaining of intermittent mouth ulcers which presented after he had his bone marrow transplantation.

Medical History

  • Multiple myeloma diagnosed 3 years ago
  • Bone marrow transplant 6 months ago (unrelated, allogeneic)
  • Wears a back brace for support and uses a walking cane (Figure 11.7.1)
  • Oesophageal spasm
  • Chronic obstructive pulmonary disease


  • One year of oral bisphosphonates – ibandronate
  • Followed by 2 years of intravenous bisphosphonates 3 monthly – zoledronic acid (ongoing)
  • Cyclosporine
  • Methotrexate
  • Calcium supplementation
    Photos depict back brace for support (S).

    Figure 11.7.1 Back brace for support.

  • Aciclovir
  • Glyceryl trinitrate
  • Budesonide and formoterol
  • Carbocisteine
  • Fentanyl
  • Multivitamins
  • Omega‐3

Dental History

  • Regular dental attender
  • Last dental visit was before the bone marrow transplantation
  • Brushes twice daily; uses floss occasionally
  • Not using fluoride toothpaste
  • Requires frequent sips of water for dry mouth

Social History

  • Retired accountant, originally from Jordan
  • Lives with wife
  • Two adult children who live overseas
  • Care‐giver support daily
  • Private transport
  • Twenty‐year history of smoking 20 cigarettes a day – stopped prior to transplantation
  • Nil alcohol

Oral Examination

  • Dry lips
  • Healing ulcer in the vestibule close to #26 (Figure 11.7.2)
  • Pale palate; small asymptomatic ulcer adjacent to #11 and #12
  • Minimal saliva pooling in the floor of mouth (Figure 11.7.3)
  • Smooth and atrophic tongue
  • Calculus and plaque present in all quadrants
  • Pale gingivae, generalised recession, clinical attachment loss consistent with generalised chronic periodontitis
  • Class III furcation involvement #46
  • Caries in #44, #45 and #46
    Photo depicts mucosa – healing ulcer in the vestibule close to number 26 (S).

    Figure 11.7.2 Mucosa – healing ulcer in the vestibule close to #26.

    Photo depicts floor of mouth – minimal saliva pooling.

    Figure 11.7.3 Floor of mouth – minimal saliva pooling; caries #44, #45 and #46; generalised tooth surface loss.

  • Generalised tooth surface loss, predominantly on occlusal surface and buccal surfaces

Radiological Examination

  • Orthopantomogram
    • Generalised moderate bone loss
    • Large radiolucent area of poorly defined ‘punched‐out’ lesions in the maxilla and mandible
    • ‘Soap‐bubble’ pattern localised in the left side of the mandibular body
    • Well‐defined margins of the extraction socket of #36
    Photo depicts periapical radiograph demonstrating caries in number 44, number 45 and number 46.

    Figure 11.7.4 Periapical radiograph demonstrating caries in #44, #45 and #46.

  • Periapical
    • Caries in #44, #45 and #46 (Figure 11.7.4)
    • Intraradicular bone loss in the furcation of #46
    • Horizontal bone loss
    • Large radiolucent area of poorly defined ‘punched‐out’ lesion near the apex of lower right first molar
  • Cone beam computed tomography (Figure 11.7.5)
    • Changes in bone density posteriorly but not directly connected to the dentition

Structured Learning

  1. What is multiple myeloma (MM)?
    • MM is a plasma cell malignancy
    • Monoclonal plasma cells proliferate in bone marrow, resulting in an overabundance of monoclonal paraprotein (M protein), destruction of bone and displacement of other haematopoietic cell lines
    • It accounts for 15% of blood cancers, mainly affects those over 65 years of age and is more common in men than women
    • Variable presentation from early asymptomatic types to severely symptomatic; signs and symptoms of MM include the following:
      • Bone pain, pathological fractures, spinal cord compression (from pathological fracture)
      • Weakness, malaise
      • Bleeding, anaemia, infection (often pneumococcal)
      • Hypercalcaemia, renal failure
      • Neuropathies
      Photo depicts cone beam computed tomography images showing a changed bone density in the molar region and a ‘punched-out’ lesion with a sclerotic margin located near the lower right first molar (M/L).

      Figure 11.7.5 Cone beam computed tomography images showing a changed bone density in the molar region and a ‘punched‐out’ lesion with a sclerotic margin located near the lower right first molar.

    • Although there is no cure, advances in therapy, such as bone marrow transplantation, may help to limit disease progression
  2. Given the patient’s medical history, what is the most likely reason that the patient is wearing a back brace?
    • Osteolytic disease affecting the spine is common in MM
    • This results in vertebral body compression fractures and is potentially exacerbated by high‐dose steroids used in the treatment of MM, further weakening the bone
    • Thoracic kyphosis may also occur, significantly reducing lung function and increasing pulmonary complications
    • In view of this, a back brace is worn to provide support, reduce movement‐associated pain and improve posture
  3. What are oesophageal spasms and what causes them and how is this relevant to you?
    • These are powerful, irregular and unco‐ordinated contractions of the oesophagus that are of unknown cause
    • They are important to keep in mind as symptoms include chest pain that can mimic angina pectoris, difficulty swallowing, the feeling of something stuck in the throat and regurgitation
    • The condition is usually managed by treating any underlying contributing condition such as depression or gastrointestinal reflux disease
    • Muscle relaxants/vasodilators such as glyceryl trinitrate may be used to relieve the symptoms
    • Botulinum toxin injections and surgery (myotomy/peroral endoscopic myotomy [POEM]) may also be considered.
  4. What could be the cause of the oral ulceration?
    • Secondary to medication, i.e. methotrexate and cyclosporine (drugs commonly used as graft‐versus‐host disease [GVHD] prophylaxis)
    • Related to anaemia secondary to MM/immunosuppression
    • GVHD, an immune condition that occurs after transplantation when immune cells present in donor tissue (the graft) attack the host’s own tissues – the risk in this patient is higher as he had an unrelated allogeneic bone marrow transplant
  5. When you show the patient the dental radiographs and cone beam CT, he asks what is causing the radiographic appearance of the jawbone. What explanation would you provide?
    • The classic MM bone lesion visualised in radiographs is a sharply defined and small lytic lesion with the so‐called ‘punched‐out’ appearance
    • Single or multiple well‐defined punched‐out radiolucencies often present as the first signal of MM with the jawbones affected in 20–30% of cases; it is more common in the mandible than in the maxilla and especially affects the molar region, ramus, angle and condylar process, probably because of the lower amount of haemopoietic marrow in the mandible
    • The cone beam CT scans confirm that the area adjacent to the lower right first molar is not dental in origin
    • Differential diagnoses should be considered (e.g. brown tumours, metastatic lesions, chronic osteomyelitis, arteriovenous malformations and Langerhans cell disease)
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Nov 6, 2022 | Posted by in Implantology | Comments Off on Bone Marrow Transplantation

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