ABSTRACT Patients undergoing hematopoietic stem cell transplantation (HSCT) might present acute and late toxicities and the oral tissues are frequently affected. With the survival increasing, patients show late and long-term morbidities, and there is an important association between the general and the oral health. The first and second parts of this Consensus have showed the importance of the adequacy of oral health in the pre-HSCT, and the main alterations and oral care during the period of admission for HSCT. This third part aims to review specific themes of post-HSCT dental care, such as graft-versus-host disease (GVHD) and the pediatric patient. It also aims to review pertinent subjects, both during the HSCT period and post-HSCT, concerning quality of life, pain, cost-effectiveness, and remote care. Based on this review, it is evident the importance of the work of the dental surgeon (DS) in the follow-up and treatment of the HSCT patient, always collaborating with the whole multidisciplinary team.

ABSTRACT During the state of immune vulnerability in hematopoietic stem cell transplantation (HSCT), the patient has an increased risk of developing a vast number of complications, including severe problems in the oral cavity. These situations require professional oral care to act in the diagnosis and treatment of these conditions, as well as to develop prevention protocols to minimize patient's complications. Oral mucositis, opportunistic infections, bleeding, specific microbiota, taste, and salivary alterations are complications that can occur during HSCT and interfere with various aspects, such as pain control, oral intake, nutrition, bacteremia and sepsis, days of hospitalization and morbidity. Several guidelines have been published to address the role of professional oral care during the HSCT, we describe a consensus regarding these recommendations.

ABSTRACT The oral involvement in the Hematopoietic Stem Cell Transplantation is well described in the literature. The goal of the dental treatment and management of the oral lesions related to the HSCT is to reduce the harm caused by preexisting oral infection or even the worsening of oral acute/chronic GVHD and late effects. The aim of this guideline was to discuss the dental management of patients subjected to HSCT, considering three phases of the HSCT: pre-HSCT, acute phase, and late phase. The literature published from 2010 to 2020 was reviewed in order to identify dental interventions in this patient population. The selected papers were divided into three groups: pre-HSCT, acute and late, and were reviewed by the SBTMO Dental Committee's members. When necessary, an expertise opinion was considered for better translating the guideline recommendations to our population dental characteristics. This manuscript focused on the pre-HSCT dental management. The objective of the pre-HSCT dental management is to identify possible dental situations that On behalf of the Dental Committee of the Brazilian Society of Gene Therapy and Bone Marrow Transplantation (SBTMO) can worsening during the acute phase after the HSCT. Each guideline recommendations were made considering the Dentistry Specialties. The clinical consensus on dental management prior to HSCT provides professional health caregivers with clinical setting-specific information to help with the management of dental problems in patients to be subjected to HSCT.

ABSTRACT Cemiplimab is a novel programmed death-1 inhibitor recently approved for advanced cutaneous squamous cell carcinoma. Immune-related adverse events derived from cemiplimab are similar to other anti-PD-1 drugs, including gastrointestinal and cutaneous toxicities. Oral immune-related adverse events were not reported with cemiplimab in previous studies; thus this case report warns of the fact that the oral cavity may be a site of immune-related adverse events during programmed death-1 block therapy and that this can lead to significant limitations when not properly treated. The present report describes the case of a patient with locally advanced cutaneous squamous cell carcinoma metastatic to cervical lymph nodes who developed dysphagia due to large and painful oral ulcers after a single dose of cemiplimab. The patient also exhibited a sarcoid-like reaction in mediastinal lymph nodes. No immune-related adverse events were found in any other organs. The oral lesions showed significant improvement after topical and short-course systemic corticosteroids, and low-level laser therapy was also performed in the oral lesions. The patient achieved a near-complete response and treatment was discontinued. This article discusses in detail the clinical outcomes and oral toxicity management of cemiplimab therapy for cutaneous squamous cell carcinoma.

Objetivo: Verificar a redução da frequência e da gravidade de mucosite oral nos pacientes submetidos a cuidados odontológicos e à laserterapia durante transplante alogênico de células hematopoiéticas. Métodos: Foram analisados retrospectivamente prontuários de pacientes transplantados, com e sem atendimento odontológico acompanhado de laserterapia, coletando-se as seguintes informações: sexo, idade, doença de base, regime mieloablativo e profilático para doença do enxerto contra o hospedeiro, extensão e gravidade de mucosite oral, sintomatologia dolorosa na cavidade oral e para deglutir, diarreia, necessidade de nutrição parenteral periférica e presença de doença do enxerto contra o hospedeiro aguda. Resultados: Houve redução significativa da extensão e da gravidade de mucosite oral, bem como de dor na cavidade oral, nos pacientes com atendimento odontológico/laserterapia (p < 0,01). Não se observaram diferenças estatisticamente significantes entre as frequências de diarreia, dor para deglutir e necessidade de nutrição parenteral entre os grupos de pacientes. Houve associação significativa entre doença do enxerto contra o hospedeiro aguda e dor para deglutir (p < 0,01); para gravidade de mucosite oral, dor na cavidade oral e diarreia, essa associação não foi observada. Conclusão: O atendimento odontológico acompanhado de laserterapia reduziu a extensão e a gravidade de mucosite oral nos pacientes com transplante alogênico de células hematopoiéticas. Mais estudos são necessários para elucidar a eficácia isolada da laserterapia nessas condições clínicas, principalmente com relação à influência dessa redução de mucosite oral sobre a doença do enxerto contra o hospedeiro.

Objective: To verify decrease in frequency and severity of oral mucositis in patients submitted to dental care and laser therapy during allogeneic hematopoietic cell transplant. Methods: Medical records of patients submitted or not to dental care associated with laser therapy during allogeneic transplant were reviewed. The following data were collected: sex, age, underlying disease, myeloablative conditioning regimens, prophylaxis for graft versus host disease, extension and severity of oral mucositis, pain in the oral cavity and when swallowing, diarrhea, need of peripheral parenteral nutrition and presence of acute graft versus host disease. Results: Significant reduction in extension and severity of oral mucositis, as well as in frequency of oral cavity pain, was observed in patients with dental care/laser therapy (p < 0.01). There were no statistically significant differences regarding frequency of diarrhea, pain when swallowing, and need of parenteral nutrition among the groups. Significant association was found between acute graft versus host disease and pain when swallowing (p < 0.01). Acute graft versus host disease was not associated with oral mucositis severity, oral cavity pain, and diarrhea. Conclusion: Dental care associated with laser therapy reduces the extension and severity of oral mucositis in patients with allogeneic hematopoietic transplant. Further studies are necessary to clarify the isolate efficacy of laser therapy in these conditions, mainly regarding the influence of reduced oral mucositis on the graft versus host disease.

BACKGROUND: Oral care is a fundamental procedure for the success of the hematopoietic stem cell transplantation, particularly regarding the control of oral infectious diseases. Information about oral care protocols and the inclusion of dental professionals in transplantation medical staff is poorly known. OBJECTIVE: The aim of this study was to carry out a survey about the protocols of Brazilian dental professionals with regard to oral care of HSCT patients. METHODS: A questionnaire was mailed to 36 Brazilian transplant centers with questions about basic oral care protocols, the indication of specific mouthwashes, antibiotic therapy regimens, laser therapy, and treatment of oral mucositis and graft-versus-host disease. All the respondent centers (n = 12) have dentists as members of the HSCT medical staff. RESULTS: The majority indicate non-alcoholic chlorhexidine (n = 9; 75.0%) and sodium bicarbonate (n = 5; 41.7%) as routine mouthwashes. Laser therapy was frequently indicated (n= 9; 75.0%), mainly in the prevention of oral mucositis and in oral pain control. In the post-transplant period, antibiotic therapy was only indicated for invasive dental treatments (n= 8; 66.7%). Several treatments for graft-versus-host disease were mentioned without a trend towards establishing a standard protocol. CONCLUSION: Basic oral care constitutes regular assessment in the routine treatment of hematopoietic stem cell transplantation patients in Brazilian centers.