Relationship of Pre-Transplant Periodontal Assessment and Post-Transplant Outcomes in Allogeneic Hematopoietic Cell Transplantation

Abstract

University of Washington <bold>Abstract</bold> Relationship of Pre-Transplant Periodontal Assessment and Post-Transplant Outcomes in Allogeneic Hematopoietic Cell Transplantation David Ryan Dean Chair of Supervisory Committee: Mark M. Schubert DDS, MSD Department of Oral Medicine <bold>Background:</bold> Global immunosuppression, particularly neutropenia, following allogeneic hematopoietic cell transplantation (HCT) increases the risk of post-transplant (post-TXP) bacteremia. Periodontal infection is highly prevalent in the general and HCT populations. Periodontal bacteria represent a potentially significant source of blood stream infection through compromised gingival epithelium and oral mucosal barriers. <bold>Aim:</bold> The primary aim of this study was to examine the relationship between pre-TXP periodontal assessment and post-TXP bacteremia of potential oral/periodontal origin in patients undergoing hematopoietic cell transplantation. Secondarily, maximum periodontal probing depths (PPD) measurements were compared against total inpatient hospitalization days and death within 100 days. Influence of completion of recommended pre-TXP periodontal therapy was also examined in relation to each outcome. <bold>Methods:</bold> Medical and dental records were reviewed for 609 consecutive patients treated with allogeneic HCT at Seattle Cancer Care Alliance (SCCA) between 1/27/2005-1/31/2013 who met eligibility requirements. Patients completed pre-TXP oral medicine examination, which included fixed 12-site partial mouth PPD assessment, as part of standard work-up. In accordance with standard of care protocols, every effort was made to stabilize dental/periodontal infections prior to TXP which included intensive oral hygiene instructions, periodontal scaling, curettage, sulcular antibiotic placement, and dental extractions (EXT). Blood cultures results obtained according to standard center protocol were reviewed for bacteria of potential oral/periodontal origin. All patients received antibacterial prophylaxis per center protocol in anticipation of neutropenia (standard = Levofloxacin 750mg/d). <bold>Results:</bold> 416 of 609 patients had maximum PPDs consistent with periodontal disease (≥≥4mm), including 104 patients with at least one site ≥≥6mm. 275 patients completed periodontal therapy (including EXT prior to TXP). Incidence of possible/likely oral bacteremia was 37% (Group 1, PPD 2-3mm), 43% (Group 2, and 34% (Group 3, PPD ≥≥6mm) respectively. No significant differences were noted between periodontal classification and outcomes of interest, though a trend approaching significance was seen in Group 2 [HR bacteremia of possible/likely oral origin: Any = 1.28 (1.0-1.7); Gram(+) = 1.22 (0.9-1.6); Gram(-−) 1.45 (0.8-2.6)]. Periodontal therapy was recommended more often in group 3 (p = 0.000) and patients in group 3 were significantly more likely to have completed intensive periodontal therapy (regular to heavy scaling, curettage, and local antibiotic therapy) prior to transplant (p = 0.0000 for each). <bold>Conclusions:</bold> Maximum pre-transplant PPD assessed during partial mouth fixed site periodontal assessment in this setting was not predictive of post-TXP bacteremia of oral/periodontal origin in the SCCA Oral Medicine Service's HCT population. Similarly, maximum PPD was not associated with increased hospitalization within the first 100 days post-transplant or survival at day 100. Though not statistically significant, our results suggest that patients with maximum PPD ≥≥6mm may be at decreased risk for post-transplant bacteremia compared to those with intermediate PPDs (4-5mm) due to more aggressive pre-transplant periodontal intervention in those with deeper pockets. HCT patients with pre-transplant PPDs consistent with periodontal disease may be at increased risk for coagulase-negative Staphylococci (CoNS) bacteremia though further study is necessary to confirm an oral source in these infections.