Oral disease burden in children and adolescents scheduled for allogeneic hematopoietic stem cell transplantation – a multicenter study

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The oral cavity, acting as a reservoir for infections, poses additional risks for patients undergoing HSCT. This study aimed to assess the burden of oral disease in children and adolescents preparing for allogeneic (a)HSCT and to evaluate the oral healthcare received before transplantation. Methods This prospective, longitudinal, multicentre cohort study included 91 children and adolescents under 18 years old scheduled for an aHSCT. Results The mean age of the cohort was 11.2 ± 4.6 years, with the most common diagnosis being acute leukaemia (47%), followed by non-malignant haematological disorders (15%). The prevalence of patient-reported oral symptoms was 49%, with sensitivity to hot and cold temperatures (10%) and loose teeth (7%) being the most common complaints. Dental caries was present in 37%, and 13% had visible dental plaque on more than half of their teeth. Dental extractions were performed in 24% of patients, and 22% received dental restorations. Conclusion Children and adolescents scheduled for aHSCT face a significant burden of oral disease, with notable dental issues that must be addressed before transplantation. This study highlights the importance of pre-transplant dental evaluations in addressing remaining dental concerns and minimizing post-transplant complications. Cancer Children Dental caries Patient-reported outcomes Prospective Introduction In hematopoietic stem cell transplantation (HSCT), the infusion of donor-derived stem cells acts as a curative treatment for both hematologic and non-hematologic disorders (Snowden et al. 2022 ). As treatment techniques and supportive care improve, long-term survival rates for paediatric HSCT continue to increase (Svenberg et al. 2016 ). However, survivors face the risk of developing various chronic health conditions (CHCs) that can result in late complications (Bhakta et al. 2017 ). More than 50% of children and adolescents experience oral mucositis during the neutropenic period after conditioning therapy and stem cell infusion. This condition is associated with prolonged nausea, dysphagia, and pain, even when using analgesics, including intravenous opioids (Kamsvåg et al. 2020 ; Barr Agholme et al. 2023 ). Due to compromised barrier function and the movement of oral microorganisms in an immunocompromised host, the oral cavity serves as a reservoir for both local and systemic infections during HSCT (Chaudhry et al. 2016 ). Patients scheduled for HSCT have either malignant or non-malignant diseases, which may increase their susceptibility to oral diseases (Hong et al. 2010 ; Doss et al. 2018 ). A study examining the oral health of 143 adult HSCT recipients before HSCT found a significantly lower stimulated salivary secretion rate and a higher prevalence of caries compared to controls (Uutela et al. 2019 ). A recent study found that the oral microbiome in children with malignant diseases showed lower diversity than that in children with non-malignant disorders prior to HSCT (Faraci et al. 2024). In adult HSCT recipients, conducting an oral exam and providing dental treatment before transplantation to achieve optimal oral health can help lower the risk of oral mucositis and other side effects during the neutropenic phase (Da Silva Santos et al. 2010; Yamagata et al. 2012; Hansen et al. 2021). Due to this risk, published pre-treatment assessments and dental care protocols before HSCT include essential steps (Elad et al., 2015 ; Bogusławska-Kapała et al., 2017; Hong et al., 2018 , 2019 ). These protocols aim to prevent infections, control pain, preserve oral function, and improve quality of life. There is ongoing debate about which oral conditions should be treated before HSCT (Hansen et al. 2021; Spijkervet et al. 2021 ). Given the limited studies on oral health in children undergoing HSCT, this research aimed to examine the burden of oral diseases in children and adolescents preparing for allogeneic hematopoietic stem cell transplantation (aHSCT) and the oral healthcare provided before HSCT. Patients and methods Patients In this prospective, longitudinal, multicentre cohort study (pediatric OraStem), children and adolescents under 18 years of age scheduled for an aHSCT were recruited from four centers: Atrium Health Carolinas Medical Center (Charlotte, North Carolina, USA), Karolinska University Hospital (Huddinge, Sweden), National University Hospital (Singapore), and Spedali Civili Hospital (Brescia, Italy). All children and adolescents (n = 122) referred for a dental evaluation before aHSCT between May 2015 and December 2019 were invited to participate in the study. We did not collect data on patients admitted to the HSCT centres but not referred for a dental evaluation. Eighteen patients were excluded due to language and communication barriers, six did not attend a dental examination because of administrative issues, five died, and two declined to participate. Patients who could answer questions, interpret the meaning of the pictures shown to them, and cooperate during an oral and dental examination were included (n = 91). No specific lower age limit was established; the youngest patient included was 4.5 years old. Before any assessments took place, the parents and adolescents signed an informed consent form regarding the research and publication of results. The local ethics committees at each site approved the study protocol: Stockholm, Sweden, daybook no. [DNR] 2016/757; Brescia, NP 1811 Studio AOBS; Charlotte, NC, USA, institutional review board [IRB] daybook no. 000884668; and Singapore, National University of Singapore [NUS] daybook no. 2012/00229. The study adheres to the ethical principles of the Declaration of Helsinki. All authors confirm the accuracy of the reported data. Methods The protocol used in this study was adapted for the paediatric population with minimal changes from the adult OraStem study protocol (Brennan et al. 2018 ). This study included data from Phase 1, which was the baseline oral assessment conducted one to eight weeks before HSCT, and from Phase 2 (2a and 2b), which involved eliciting patient symptoms and documenting dental treatments received before the stem cell infusion (Skallsjö et al., 2023 ). Phase 1 data included pre-HSCT baseline information: age, gender, overall health, medical diagnosis requiring HSCT, and current medications. Phase 2a information included dental care and oral hygiene practices. The baseline clinical oral evaluation involved assessing both hard and soft tissues in the mouth, performing a radiographic examination based on clinical indications, and noting current oral concerns reported by the patient. The total number of loose or exfoliating teeth was recorded, along with those affected by caries involving the dentin or pulp, or with pulpal exposure. This study classified oral hygiene as excellent if no teeth showed visible plaque, good if 1–20% of teeth had visible plaque, and intermediate or poor if 21–50% or more than 50% of teeth exhibited visible plaque, respectively. Patient-reported current oral symptoms include issues related to teeth, oral mucosa, and other oral conditions. Oral mucosal lesions were described by their location, clinical appearance, and diagnosis. Oral mucositis was assessed using the World Health Organization (WHO) toxicity scale (scores range from 0 to 4) (WHO, 1979). Phase 2b included a new oral assessment before the patient's admission to the HSCT ward. It focused on recent dental treatments after the baseline oral exam in phase 2a and any untreated oral and dental diseases. Three authors (CH, IvB, MTB) visited all centres to train and calibrate the participating researchers on the procedures and to ensure that the infrastructure met the study design requirements. To maintain consistency and facilitate data validation and audits across multiple sites, data were recorded using MedView computer software (Jontell et al. 2005 ). Statistical analyses The analyses to assess oral health and symptoms at baseline were descriptive, using frequency tables for categorical variables and summary statistics such as median and range for numerical variables. Fisher’s exact test was used to examine the effect of oral hygiene on the presence of oral mucosal lesions before HSCT. Statistical significance was set at p-value < 0.05. All analyses were conducted with R Version 4.4.2 (R Core Team, 2024). Results The baseline characteristics of the patients included in this study are shown in Table 1. Acute leukemia was the most common diagnosis, accounting for 47% of the patients, while 15% had non-malignant hematological disorders such as aplastic anemia, thalassemia, or sickle cell anemia. Forty-eight percent of the patients had no other medical diagnoses. In this cohort, 24% of the children were diagnosed less than six months before the planned HSCT. Among those included, 45% underwent a dental examination more than 14 days before transplantation, while 48% had one performed eight to 14 days prior. Most participants were on medications: 59% received antibiotics, 30% antifungals, 29% analgesics, 23% antivirals, and 20% immunosuppressants (data not shown). Oral health habits Sixty-five percent of patients reported visiting a dentist or dental hygienist regularly, while 35% said they never sought dental care or only did so for urgent issues (Table 2). Regarding oral health habits, 68% said they brushed their teeth twice daily, while 10% brushed less often than once a day. Patient-reported symptoms before aHSCT Table 3 presents the oral symptoms reported by patients during the pre-transplant exam, showing that 49% experienced issues related to the oral cavity. Among those with dental problems, the most common complaints were sensitivity to hot and cold (10%) and symptoms linked to loose teeth (7%). Additionally, 43% reported symptoms involving the oral mucosa and gingiva, with bleeding, ulceration, and oral tenderness being the most frequently noted symptoms (9-11%). The tongue (15%), gingiva (12%), and buccal mucosa (15%) were the most reported sites for these complaints. We found no significant differences in self-reported oral symptoms based on cancer diagnosis, gender, or toothbrushing frequency (p-values >0.05). Dental and periodontal health prior to aHSCT Dental caries extending into the dentin were diagnosed in 37% of the evaluated patients, affecting between one and 15 teeth; in 13% of cases, four or more teeth had dentin caries. Nine patients (11%) were found to have one or more teeth with pulpal exposure. Additionally, 28% of patients had at least one exfoliating tooth or teeth. Regarding oral care, 13% of patients showed visible dental plaque on more than 50% of their teeth (Table 4). There were no significant differences in the occurrence of dentin caries or extensive plaque accumulation by gender (p=0.230), presence of malignancy (p=0.619), or frequency of tooth brushing (p=0.424). Treatment conducted after dental examination and before transplantation As shown in Table 4, 24% of the patients had dental extractions. The number of teeth removed ranged from one to eight per patient. Among the extracted teeth, 11 were primary first or second molars, five were primary canines, four were primary incisors, and five were permanent first molars. Dental restorations were performed in 22% of the patients, with a range of one to nine teeth restored. Periodontal therapy, including subgingival scaling, was provided to 7% of the patients. In 15% of patients, loose primary teeth were left untreated before transplantation. In 10% of patients with carious lesions in the dentin, these lesions remained untreated prior to transplantation, with a range of zero to 13. Overall, 40% of patients scheduled for an aHSCT had at least one dental issue addressed before the procedure. Discussion In this study, the most common diagnoses were acute lymphoblastic and acute myeloid leukemia, followed by lymphoma, other hematological malignancies, and non-malignant disorders such as hemoglobinopathies, which reflect the expanding use of aHSCT, particularly for non-malignant conditions (Svenberg et al. 2016; Snowden et al. 2022). Children scheduled for aHSCT often suffer from severe and potentially life-threatening conditions for months or even years, during which they face a higher risk of oral diseases. This is especially true for children with cancer, who have often undergone previous cycles of chemotherapy that may compromise their oral health (Vaughan et al. 2005). Here, we show that children and adolescents scheduled for an aHSCT face a significant burden of oral disease. In the initial assessment, 37% of patients had dental caries reaching the dentin, 11% had teeth with pulpal exposure, 28% had one or more loose or exfoliating teeth, and 13% exhibited visible dental plaque on more than half of their teeth. Additionally, nearly half of these patients had an acute dental issue requiring resolution before transplantation. This highlights the importance of a pre-transplant dental evaluation, especially considering the high prevalence of unresolved dental problems that can lead to post-transplant complications. Most patients reported regularly visiting a dentist or dental hygienist before their diagnosis, and 68% stated they brushed their teeth twice daily. Twenty-six percent of patients had intermediate oral hygiene, while 13% showed poor oral hygiene, with more than 50% of their teeth covered in visible plaque. In the adult OraStem study, 32% of patients had either intermediate or poor oral hygiene (Skallsjö et al. 2023). This underscores the importance of patient education on proper oral hygiene practices during transplantation, which is a vital part of the dental evaluation and treatment protocols available (Hong et al. 2019). Good oral hygiene is essential because it is linked to a lower risk of oral complications after HSCT (Yamagata et al. 2009; Kashiwazaki et al. 2012; Hong et al. 2019; van Gennip et al. 2024). Nearly half of the patients in this study reported experiencing oral symptoms during the pre-transplant examination. These symptoms mainly included swelling and discomfort around loose, shedding primary teeth, as well as sensitivity to hot and cold beverages. Although few studies have specifically focused on children, the adult OraStem study showed that 30% of adult HSCT recipients experienced oral symptoms before transplant, with dry mouth being the most common complaint, along with taste changes. Patients also reported tooth sensitivity and issues affecting the mucosa and gums, such as bleeding and tenderness (Skallsjö et al. 2023). In addition to the symptoms observed in adults, children and adolescents often have loose primary teeth and erupting permanent teeth, which are frequently linked to inflammation and discomfort (de Oliveira Lemes et al. 2024). The dental examination revealed that 37% of patients had dental caries extending into the dentin. In one patient with 15 affected teeth, we found teeth with pulpal exposure due to dental caries and loose, exfoliating primary teeth in 20% of cases. A Japanese study from 2006 reported that 63% of children exhibited one or more dental problems during the pre-transplant dental exam (Yamagata et al. 2006). Dental caries was present in 30% of cases, while pulpitis and periapical periodontitis were observed in 7%. Loose primary teeth were noted in 23% of children. Additionally, in a study of 259 pediatric bone marrow transplant recipients, 51% were diagnosed with dental caries during the pre-transplant exam (Vaughan et al. 2005). Research on adult HSCT recipients has shown a higher prevalence of oral diseases before transplantation. In the adult OraStem study (Skallsjö et al. 2023), data from the pre-transplant exam indicated that 46% of participants had more than one tooth with caries extending into the dentin or pulp, with counts ranging from one to 17 per patient. Furthermore, 7% had more than one tooth with pulpal exposure due to caries, fractures, or wear. A Swiss study (Uutela et al. 2019) involving 143 adult HSCT recipients found they had a significantly lower salivary secretion rate and a notably higher prevalence of caries compared to a matched control group during the pre-transplant exam. Pre-cancer therapy dental evaluation and treatment protocols are divided into three categories: complete protocols, which involve treating all dental issues before starting chemotherapy and HSCT (Melkos et al. 2003); partial protocols, where caries that do not reach the dentin are monitored, teeth with apical periodontitis are treated only if symptoms are present, and extraction of severely mobile deciduous teeth is performed only if they are likely to exfoliate within a few weeks (Yamagata et al. 2006); and minimal protocols, in which treatment is provided only when symptoms appear (Toljanic et al. 2009). In this study, we used a partial protocol, meaning teeth with caries reaching the dentin were not restored, and loose, exfoliating primary teeth were left untreated. Among the four centers in this study, 93% of patients had their pre-transplant dental examination at least eight days before the procedure. Of the 49% of patients with dental pathologies, all received some treatment before transplantation, although not all pathologies were treated in every patient, following a partial protocol. During this period, dental extractions were performed on 26% of the patients, dental restorations on 22%, and subgingival scaling on 8%. In the Japanese study, 15 of 19 patients with dental pathologies received treatment, while four were transplanted with pathologies that posed little or no risk of worsening during the neutropenic period (Yamagata et al. 2006). Conclusion Few studies have assessed the oral health of children preparing for HSCT. This study provides further evidence of the significant oral disease burden in these children and emphasizes the importance of pre-transplant dental assessments. It suggests that scheduling these evaluations approximately 14 days before myeloablative therapy begins allows enough time for planning dental treatments and for healing. Declarations Conflicts of Interest The authors declare no financial or non-financial interests to disclose. Author Contribution MB, IvB, and CH conceived and developed the multicenter study protocol, MBA, GD, AM, CH, HJT, SH and IvB study design, protocol, and data collection, JKT transplant consultant, YFS database and statistical analyses, MBA and GD original draft of the manuscript. All authors contributed to data analysis, commented on all manuscript versions, and read and approved the final manuscript. Acknowledgement The authors thank all participating children, adolescents, and their parents for agreeing to take part in this study. 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Tables TABLE 1 | Baseline demographics and clinical characteristics Characteristics All Sites (N=91) Charlotte (n=10) Stockholm (n=28) Singapore (n=30) Brescia (n=23) Age in years Mean (SD) 11.2 (4.6) 14.2 (3.5) 12.1 (3.1) 9.1 (5.0) 11.5 (5.2) Gender Male 57 (63%) 9 (90%) 18 (64%) 19 (63%) 11 (48%) Female 34 (37%) 1 (10%) 10 (36%) 11 (37%) 12 (52%) Medical Diagnosis Acute myelogenous leukemia 18 (20%) 1 (10%) 5 (18%) 8 (27%) 4 (17%) Acute lymphoblastic leukemia 25 (27%) 1 (10%) 7 (25%) 13 (43%) 4 (17%) Aplastic anemia 4 (4%) 0 (0%) 3 (11%) 1 (3%) 0 (0%) Hemoglobinopathy e.g., Thalassemia, sickle cell anemia 10 (11%) 4 (40%) 3 (11%) 1 (3%) 2 (8.7%) Hemophagocytic syndromes 1 (1%) 1 (10%) 0 (0%) 0 (0%) 0 (0%) High Risk solid tumor e.g., brain tumors, germ cell tumors, sarcomas 1 (1%) 0 (0%) 0 (0%) 1 (3%) 0 (0%) Lymphoma/Lymphoid neoplasms 10 (11%) 0 (0%) 1 (4%) 1 (3%) 8 (35%) Myelodysplastic syndromes (MDS) 4 (4%) 1 (10%) 1 (4%) 1 (3%) 1 (4%) MDS/Myeloproliferative Neoplasm overlap syndrome 3 (3%) 0 (0%) 3 (11%) 0 (0%) 0 (0%) Primary immunodeficiency conditions e.g., Wiskott Aldrich syndrome 6 (7%) 1 (10%) 1 (4%) 0 (0%) 4 (17%) Other e.g., autoimmune diseases 9 (10%) 1 (10%) 4 (14%) 4 (13%) 0 (0%) Dental examination before aHSCT >14 days 41 (45%) 9 (90%) 7 (25%) 15 (50%) 10 (43%) 8-14 days 44 (48%) 1 (10%) 20 (71%) 11 (37%) 12 (52%) 0-7 days 6 (7%) 0 (0%) 1 (4%) 4 (13%) 1 (4%) TABLE 2 | Oral health-related habits in patients scheduled for aHSCT Characteristic All Sites (N=91) Charlotte (n=10) Stockholm (n=28) Singapore (n=30) Brescia (n=23) How often do you see a dentist or a dental therapist 0 12 (13%) 0 (0%) 0 (0%) 8 (27%) 4 (17%) 1 20 (22%) 2 (20%) 1 (4%) 8 (27%) 9 (39%) 2 59 (65%) 8 (80%) 27 (96%) 14 (47%) 10 (43%) How often do you routinely brush your teeth Less than once a day 9 (10%) 0 (0%) 3 (11%) 4 (13%) 2 (9%) Once a day 20 (22%) 9 (90%) 4 (14%) 6 (20%) 1 (4%) Two times a day or more 62 (68%) 1 (10%) 21 (75%) 20 (67%) 20 (87%) TABLE 3 | Patient-reported oral symptoms at baseline assessment before aHSCT All Sites (N=91) Does the patient have oral symptoms right now? No 46 (51%) Yes 45 (49%) If symptoms involve the teeth, which symptoms are present? a None 61 (68%) Tooth sensitivity to hot and cold 9 (10%) Loose tooth but no discomfort 6 (7%) Tooth pain 6 (7%) Swelling / pain / discomfort around loose tooth 3 (3%) Grinding 3 (3%) Food impaction 3 (3%) Swelling / pain from infected tooth 2 (2%) Tooth or filling fracture 1 (1%) Swelling / pain / discomfort around erupting tooth 1 (1%) Others 2 (2%) If symptoms / conditions involve the oral mucosa, which are present? a None 52 (57%) Ulceration e.g., aphthae, infectious 10 (11%) Mucositis 10 (11%) Dry mouth 9 (10%) Bleeding / petechiae and related problem 8 (9%) Oral tenderness / pain: generalized / non-specific 8 (9%) Mucosal sensitivity 8 (9%) Sensation: burning 7 (8%) Mucosal tenderness / pain 6 (7%) Tongue: coated 6 (7%) Gingival edema / diffuse swelling 4 (4%) Tongue: tenderness / sensitivity / pain 4 (4%) Others 9 (10%) Location of this subjective mucosal symptom / disease? None 52 (58%) Gingiva 11 (12%) Tongue 14 (15%) Buccal mucosa 14 (15%) Alveolar mucosa 3 (3%) Lips 3 (3%) If the oral symptom does not involve the teeth or oral mucosa, which symptom is it? None 76 (84%) Halitosis 7 (8%) Taste changes 6 (7%) Throat sensitivity / pain 3 (3%) Others 2 (2%) How would you rate your overall feeling of dry mouth? Not dry 68 (77%) A little bit dry 14 (16%) A little more dry 5 (6%) Even more dry 1 (1%) A whole lot dry 0 (0%) Extremely dry 0 (0%) a One patient may have several symptoms TABLE 4 | Dental health status and treatment delivered All Sites (N=91) Dental health status at baseline oral assessment Number of teeth with caries into dentin None 53 (63%) 1 tooth 9 (11%) 2 teeth 7 (8%) 3 teeth 4 (5%) > 4 teeth 11 (13%) Patients not evaluated 7 Mean (SD) 1.32 (2.74) Number of teeth exhibiting pulpal exposure None 74 (89%) > 1 tooth 9 (11%) Patients not evaluated 8 Number of loose exfoliating teeth None 62 (72%) 1 tooth 7 (8%) 2 teeth 9 (10%) > 3 teeth 8 (9.3%) Patients not evaluated 5 Plaque visible to the naked eye No visible plaque 11 (13%) 1-20% of the teeth 40 (48%) 21-50% of the teeth 22 (26%) >50% of the teeth 11 (13%) Patients not evaluated 7 Treatment performed after dental examination Number of teeth extractions None 69 (76%) 1 tooth 8 (9%) 2 teeth 6 (7%) 3 teeth 1 (1%) > 4 teeth 7 (8%) Number of teeth that have been restored None 71 (78%) 1 tooth 5 (6%) 2 teeth 6 (7%) > 3 teeth 9 (10%) Has subgingival scaling been performed No 85 (93%) Yes 6 (7%) Number of children with loose exfoliating teeth remaining None 75 (85%) 1 tooth 2 (3%) 2 teeth 6 (7%) > 3 teeth 5 (6%) Patients not evaluated 3 Number of children with one or more carious lesions into dentin left untreated None 77 (90%) 1 tooth 2 (2%) 2 teeth 4 (5%) > 3 teeth 3 (3%) Patients not evaluated 5 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7601934","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":514770838,"identity":"db06bc3a-d8ac-4a66-a5e5-2ddd6346d86f","order_by":0,"name":"Monica Barr Agholme","email":"","orcid":"","institution":"Karolinska Institutet","correspondingAuthor":false,"prefix":"","firstName":"Monica","middleName":"Barr","lastName":"Agholme","suffix":""},{"id":514770839,"identity":"02845f96-55d2-44e1-bcfc-77c1b5e1ae5a","order_by":1,"name":"Göran Dahllöf","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3UlEQVRIiWNgGAWjYPACZgYDduYGhoqKBB4StDAzNjCcOUOylrNtCYTVyrv3PvxcwGAtb87M2Pjg4Lw0GQb+wwfwajE8c9xYegZDuuHOZsZmg4PbcngYJNLwW2U4I41BmofhMOOGw4xt0h+3VQC18BgQ0sL8G6jFHqRF4uAcoBb+8x/w+0UijQ1kSyJESwPQYQw5eHUwGPAcY7PmMUhPBmppNjhwLI2HTSINv8Pk29uYb/NUWNtuON588MGBmmR7fv7DD/DbcgBMIomw4XcW0JYGQipGwSgYBaNgFAAANdFAznuC3UgAAAAASUVORK5CYII=","orcid":"","institution":"Karolinska Institutet","correspondingAuthor":true,"prefix":"","firstName":"Göran","middleName":"","lastName":"Dahllöf","suffix":""},{"id":514770841,"identity":"ac4ab154-fb7a-4590-ac90-54fd478b310d","order_by":2,"name":"Johan Karlsson Törlén","email":"","orcid":"","institution":"Karolinska University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Johan","middleName":"Karlsson","lastName":"Törlén","suffix":""},{"id":514770842,"identity":"61bc6148-0827-4fc8-a92f-d993798ba313","order_by":3,"name":"Alessandra Majorana","email":"","orcid":"","institution":"University of Brescia","correspondingAuthor":false,"prefix":"","firstName":"Alessandra","middleName":"","lastName":"Majorana","suffix":""},{"id":514770843,"identity":"717ffc20-32ce-4d5e-a17d-eae0f22c039b","order_by":4,"name":"Michael T. Brennan","email":"","orcid":"","institution":"Atrium Health Carolinas Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Michael","middleName":"T.","lastName":"Brennan","suffix":""},{"id":514770844,"identity":"20273439-aae7-411d-855a-3ef59f935eec","order_by":5,"name":"Inger von Bültzingslöwen","email":"","orcid":"","institution":"University of Gothenburg","correspondingAuthor":false,"prefix":"","firstName":"Inger","middleName":"","lastName":"von Bültzingslöwen","suffix":""},{"id":514770845,"identity":"e403319a-9f99-41a5-ae20-ffdcdb2f87cf","order_by":6,"name":"Huei Jinn Tong","email":"","orcid":"","institution":"National University of Singapore","correspondingAuthor":false,"prefix":"","firstName":"Huei","middleName":"Jinn","lastName":"Tong","suffix":""},{"id":514770846,"identity":"150cc371-e4ac-4bf9-96bb-d5dabaf895cb","order_by":7,"name":"Shijia Hu","email":"","orcid":"","institution":"National University of Singapore","correspondingAuthor":false,"prefix":"","firstName":"Shijia","middleName":"","lastName":"Hu","suffix":""},{"id":514770847,"identity":"0c85e87d-4bfe-4711-9cc2-5cff5e4cc05b","order_by":8,"name":"Yu Fan Sim","email":"","orcid":"","institution":"National University of Singapore","correspondingAuthor":false,"prefix":"","firstName":"Yu","middleName":"Fan","lastName":"Sim","suffix":""},{"id":514770848,"identity":"a6a53043-0963-47dd-bae4-51438a709cc2","order_by":9,"name":"Catherine Hong","email":"","orcid":"","institution":"National University of Singapore","correspondingAuthor":false,"prefix":"","firstName":"Catherine","middleName":"","lastName":"Hong","suffix":""}],"badges":[],"createdAt":"2025-09-12 15:23:30","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7601934/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7601934/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":94362844,"identity":"105c1a5e-126f-47c6-bf98-8e382cb52674","added_by":"auto","created_at":"2025-10-27 13:05:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1166254,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7601934/v1/ad02e800-a45a-476c-b8ea-f4a8ade269c8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Oral disease burden in children and adolescents scheduled for allogeneic hematopoietic stem cell transplantation – a multicenter study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn hematopoietic stem cell transplantation (HSCT), the infusion of donor-derived stem cells acts as a curative treatment for both hematologic and non-hematologic disorders (Snowden et al. \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). As treatment techniques and supportive care improve, long-term survival rates for paediatric HSCT continue to increase (Svenberg et al. \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). However, survivors face the risk of developing various chronic health conditions (CHCs) that can result in late complications (Bhakta et al. \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMore than 50% of children and adolescents experience oral mucositis during the neutropenic period after conditioning therapy and stem cell infusion. This condition is associated with prolonged nausea, dysphagia, and pain, even when using analgesics, including intravenous opioids (Kamsv\u0026aring;g et al. \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Barr Agholme et al. \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Due to compromised barrier function and the movement of oral microorganisms in an immunocompromised host, the oral cavity serves as a reservoir for both local and systemic infections during HSCT (Chaudhry et al. \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePatients scheduled for HSCT have either malignant or non-malignant diseases, which may increase their susceptibility to oral diseases (Hong et al. \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Doss et al. \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). A study examining the oral health of 143 adult HSCT recipients before HSCT found a significantly lower stimulated salivary secretion rate and a higher prevalence of caries compared to controls (Uutela et al. \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). A recent study found that the oral microbiome in children with malignant diseases showed lower diversity than that in children with non-malignant disorders prior to HSCT (Faraci et al. 2024).\u003c/p\u003e\u003cp\u003eIn adult HSCT recipients, conducting an oral exam and providing dental treatment before transplantation to achieve optimal oral health can help lower the risk of oral mucositis and other side effects during the neutropenic phase (Da Silva Santos et al. 2010; Yamagata et al. 2012; Hansen et al. 2021). Due to this risk, published pre-treatment assessments and dental care protocols before HSCT include essential steps (Elad et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Bogusławska-Kapała et al., 2017; Hong et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2018\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). These protocols aim to prevent infections, control pain, preserve oral function, and improve quality of life. There is ongoing debate about which oral conditions should be treated before HSCT (Hansen et al. 2021; Spijkervet et al. \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e Given the limited studies on oral health in children undergoing HSCT, this research aimed to examine the burden of oral diseases in children and adolescents preparing for allogeneic hematopoietic stem cell transplantation (aHSCT) and the oral healthcare provided before HSCT.\u003c/p\u003e"},{"header":"Patients and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003ePatients\u003c/h2\u003e\u003cp\u003eIn this prospective, longitudinal, multicentre cohort study (pediatric OraStem), children and adolescents under 18 years of age scheduled for an aHSCT were recruited from four centers: Atrium Health Carolinas Medical Center (Charlotte, North Carolina, USA), Karolinska University Hospital (Huddinge, Sweden), National University Hospital (Singapore), and Spedali Civili Hospital (Brescia, Italy). All children and adolescents (n\u0026thinsp;=\u0026thinsp;122) referred for a dental evaluation before aHSCT between May 2015 and December 2019 were invited to participate in the study. We did not collect data on patients admitted to the HSCT centres but not referred for a dental evaluation. Eighteen patients were excluded due to language and communication barriers, six did not attend a dental examination because of administrative issues, five died, and two declined to participate. Patients who could answer questions, interpret the meaning of the pictures shown to them, and cooperate during an oral and dental examination were included (n\u0026thinsp;=\u0026thinsp;91). No specific lower age limit was established; the youngest patient included was 4.5 years old.\u003c/p\u003e\u003cp\u003e Before any assessments took place, the parents and adolescents signed an informed consent form regarding the research and publication of results. The local ethics committees at each site approved the study protocol: Stockholm, Sweden, daybook no. [DNR] 2016/757; Brescia, NP 1811 Studio AOBS; Charlotte, NC, USA, institutional review board [IRB] daybook no. 000884668; and Singapore, National University of Singapore [NUS] daybook no. 2012/00229. The study adheres to the ethical principles of the Declaration of Helsinki. All authors confirm the accuracy of the reported data.\u003c/p\u003e\u003c/div\u003e"},{"header":"Methods","content":"\u003cp\u003eThe protocol used in this study was adapted for the paediatric population with minimal changes from the adult OraStem study protocol (Brennan et al. \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). This study included data from Phase 1, which was the baseline oral assessment conducted one to eight weeks before HSCT, and from Phase 2 (2a and 2b), which involved eliciting patient symptoms and documenting dental treatments received before the stem cell infusion (Skallsj\u0026ouml; et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePhase 1 data included pre-HSCT baseline information: age, gender, overall health, medical diagnosis requiring HSCT, and current medications.\u003c/p\u003e\u003cp\u003ePhase 2a information included dental care and oral hygiene practices. The baseline clinical oral evaluation involved assessing both hard and soft tissues in the mouth, performing a radiographic examination based on clinical indications, and noting current oral concerns reported by the patient. The total number of loose or exfoliating teeth was recorded, along with those affected by caries involving the dentin or pulp, or with pulpal exposure. This study classified oral hygiene as excellent if no teeth showed visible plaque, good if 1\u0026ndash;20% of teeth had visible plaque, and intermediate or poor if 21\u0026ndash;50% or more than 50% of teeth exhibited visible plaque, respectively.\u003c/p\u003e\u003cp\u003ePatient-reported current oral symptoms include issues related to teeth, oral mucosa, and other oral conditions. Oral mucosal lesions were described by their location, clinical appearance, and diagnosis. Oral mucositis was assessed using the World Health Organization (WHO) toxicity scale (scores range from 0 to 4) (WHO, 1979).\u003c/p\u003e\u003cp\u003ePhase 2b included a new oral assessment before the patient's admission to the HSCT ward. It focused on recent dental treatments after the baseline oral exam in phase 2a and any untreated oral and dental diseases.\u003c/p\u003e\u003cp\u003eThree authors (CH, IvB, MTB) visited all centres to train and calibrate the participating researchers on the procedures and to ensure that the infrastructure met the study design requirements. To maintain consistency and facilitate data validation and audits across multiple sites, data were recorded using MedView computer software (Jontell et al. \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2005\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eStatistical analyses\u003c/h3\u003e\n\u003cp\u003eThe analyses to assess oral health and symptoms at baseline were descriptive, using frequency tables for categorical variables and summary statistics such as median and range for numerical variables. Fisher\u0026rsquo;s exact test was used to examine the effect of oral hygiene on the presence of oral mucosal lesions before HSCT. Statistical significance was set at p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05. All analyses were conducted with R Version 4.4.2 (R Core Team, 2024).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe baseline characteristics of the patients included in this study are shown in Table 1. Acute leukemia was the most common diagnosis, accounting for 47% of the patients, while 15% had non-malignant hematological disorders such as aplastic anemia, thalassemia, or sickle cell anemia. Forty-eight percent of the patients had no other medical diagnoses. In this cohort, 24% of the children were diagnosed less than six months before the planned HSCT. Among those included, 45% underwent a dental examination more than 14 days before transplantation, while 48% had one performed eight to 14 days prior.\u003c/p\u003e\n\u003cp\u003eMost participants were on medications: 59% received antibiotics, 30% antifungals, 29% analgesics, 23% antivirals, and 20% immunosuppressants (data not shown).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eOral health habits\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSixty-five percent of patients reported visiting a dentist or dental hygienist regularly, while 35% said they never sought dental care or only did so for urgent issues (Table 2). Regarding oral health habits, 68% said they brushed their teeth twice daily, while 10% brushed less often than once a day.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePatient-reported symptoms before aHSCT\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTable 3 presents the oral symptoms reported by patients during the pre-transplant exam, showing that 49% experienced issues related to the oral cavity. Among those with dental problems, the most common complaints were sensitivity to hot and cold (10%) and symptoms linked to loose teeth (7%). Additionally, 43% reported symptoms involving the oral mucosa and gingiva, with bleeding, ulceration, and oral tenderness being the most frequently noted symptoms (9-11%). The tongue (15%), gingiva (12%), and buccal mucosa (15%) were the most reported sites for these complaints. We found no significant differences in self-reported oral symptoms based on cancer diagnosis, gender, or toothbrushing frequency (p-values \u0026gt;0.05).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDental and periodontal health prior to aHSCT\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDental caries extending into the dentin were diagnosed in 37% of the evaluated patients, affecting between one and 15 teeth; in 13% of cases, four or more teeth had dentin caries. Nine patients (11%) were found to have one or more teeth with pulpal exposure. Additionally, 28% of patients had at least one exfoliating tooth or teeth. Regarding oral care, 13% of patients showed visible dental plaque on more than 50% of their teeth (Table 4). There were no significant differences in the occurrence of dentin caries or extensive plaque accumulation by gender (p=0.230), presence of malignancy (p=0.619), or frequency of tooth brushing (p=0.424). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTreatment conducted after dental examination and before transplantation\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAs shown in Table 4, 24% of the patients had dental extractions. The number of teeth removed ranged from one to eight per patient. Among the extracted teeth, 11 were primary first or second molars, five were primary canines, four were primary incisors, and five were permanent first molars. Dental restorations were performed in 22% of the patients, with a range of one to nine teeth restored. Periodontal therapy, including subgingival scaling, was provided to 7% of the patients.\u003c/p\u003e\n\u003cp\u003eIn 15% of patients, loose primary teeth were left untreated before transplantation. In 10% of patients with carious lesions in the dentin, these lesions remained untreated prior to transplantation, with a range of zero to 13. Overall, 40% of patients scheduled for an aHSCT had at least one dental issue addressed before the procedure.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, the most common diagnoses were acute lymphoblastic and acute myeloid leukemia, followed by lymphoma, other hematological malignancies, and non-malignant disorders such as hemoglobinopathies, which reflect the expanding use of aHSCT, particularly for non-malignant conditions (Svenberg et al. 2016; Snowden et al. 2022). Children scheduled for aHSCT often suffer from severe and potentially life-threatening conditions for months or even years, during which they face a higher risk of oral diseases. This is especially true for children with cancer, who have often undergone previous cycles of chemotherapy that may compromise their oral health (Vaughan et al. 2005).\u003c/p\u003e\n\u003cp\u003eHere, we show that children and adolescents scheduled for an aHSCT face a significant burden of oral disease. In the initial assessment, 37% of patients had dental caries reaching the dentin, 11% had teeth with pulpal exposure, 28% had one or more loose or exfoliating teeth, and 13% exhibited visible dental plaque on more than half of their teeth. Additionally, nearly half of these patients had an acute dental issue requiring resolution before transplantation. This highlights the importance of a pre-transplant dental evaluation, especially considering the high prevalence of unresolved dental problems that can lead to post-transplant complications.\u003c/p\u003e\n\u003cp\u003eMost patients reported regularly visiting a dentist or dental hygienist before their diagnosis, and 68% stated they brushed their teeth twice daily. Twenty-six percent of patients had intermediate oral hygiene, while 13% showed poor oral hygiene, with more than 50% of their teeth covered in visible plaque. In the adult OraStem study, 32% of patients had either intermediate or poor oral hygiene (Skallsjö et al. 2023). This underscores the importance of patient education on proper oral hygiene practices during transplantation, which is a vital part of the dental evaluation and treatment protocols available (Hong et al. 2019). Good oral hygiene is essential because it is linked to a lower risk of oral complications after HSCT (Yamagata et al. 2009;\u0026nbsp;Kashiwazaki et al. 2012;\u0026nbsp;Hong et al. 2019; van\u0026nbsp;Gennip et al. 2024).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNearly half of the patients in this study reported experiencing oral symptoms during the pre-transplant examination. These symptoms mainly included swelling and discomfort around loose, shedding primary teeth, as well as sensitivity to hot and cold beverages. Although few studies have specifically focused on children, the adult OraStem study showed that 30% of adult HSCT recipients experienced oral symptoms before transplant, with dry mouth being the most common complaint, along with taste changes. Patients also reported tooth sensitivity and issues affecting the mucosa and gums, such as bleeding and tenderness (Skallsjö et al. 2023). In addition to the symptoms observed in adults, children and adolescents often have loose primary teeth and erupting permanent teeth, which are frequently linked to inflammation and discomfort (de Oliveira Lemes et al. 2024).\u003c/p\u003e\n\u003cp\u003eThe dental examination revealed that 37% of patients had dental caries extending into the dentin. In one patient with 15 affected teeth, we found teeth with pulpal exposure due to dental caries and loose, exfoliating primary teeth in 20% of cases. A Japanese study from 2006 reported that 63% of children exhibited one or more dental problems during the pre-transplant dental exam (Yamagata et al. 2006). Dental caries was present in 30% of cases, while pulpitis and periapical periodontitis were observed in 7%. Loose primary teeth were noted in 23% of children. Additionally, in a study of 259 pediatric bone marrow transplant recipients, 51% were diagnosed with dental caries during the pre-transplant exam (Vaughan et al. 2005). Research on adult HSCT recipients has shown a higher prevalence of oral diseases before transplantation. In the adult OraStem study (Skallsjö et al. 2023), data from the pre-transplant exam indicated that 46% of participants had more than one tooth with caries extending into the dentin or pulp, with counts ranging from one to 17 per patient. Furthermore, 7% had more than one tooth with pulpal exposure due to caries, fractures, or wear. A Swiss study (Uutela et al. 2019) involving 143 adult HSCT recipients found they had a significantly lower salivary secretion rate and a notably higher prevalence of caries compared to a matched control group during the pre-transplant exam.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePre-cancer therapy dental evaluation and treatment protocols are divided into three categories: complete protocols, which involve treating all dental issues before starting chemotherapy and HSCT (Melkos et al. 2003); partial protocols, where caries that do not reach the dentin are monitored, teeth with apical periodontitis are treated only if symptoms are present, and extraction of severely mobile deciduous teeth is performed only if they are likely to exfoliate within a few weeks (Yamagata et al. 2006); and minimal protocols, in which treatment is provided only when symptoms appear (Toljanic et al. 2009). In this study, we used a partial protocol, meaning teeth with caries reaching the dentin were not restored, and loose, exfoliating primary teeth were left untreated.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAmong the four centers in this study, 93% of patients had their pre-transplant dental examination at least eight days before the procedure. Of the 49% of patients with dental pathologies, all received some treatment before transplantation, although not all pathologies were treated in every patient, following a partial protocol. During this period, dental extractions were performed on 26% of the patients, dental restorations on 22%, and subgingival scaling on 8%. In the Japanese study, 15 of 19 patients with dental pathologies received treatment, while four were transplanted with pathologies that posed little or no risk of worsening during the neutropenic period (Yamagata et al. 2006).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eFew studies have assessed the oral health of children preparing for HSCT. This study provides further evidence of the significant oral disease burden in these children and emphasizes the importance of pre-transplant dental assessments. It suggests that scheduling these evaluations approximately 14 days before myeloablative therapy begins allows enough time for planning dental treatments and for healing. \u0026nbsp;\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflicts of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no financial or non-financial interests to disclose.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eMB, IvB, and CH conceived and developed the multicenter study protocol, MBA, GD, AM, CH, HJT, SH and IvB study design, protocol, and data collection, JKT transplant consultant, YFS database and statistical analyses, MBA and GD original draft of the manuscript. All authors contributed to data analysis, commented on all manuscript versions, and read and approved the final manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgement\u003c/h2\u003e\n\u003cp\u003eThe authors thank all participating children, adolescents, and their parents for agreeing to take part in this study. We also appreciate the nursing staff at the pediatric departments.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eThe datasets analyzed in this study can be obtained from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBarr Agholme M, Dahll\u0026ouml;f G, Karlsson T\u0026ouml;rl\u0026eacute;n J, Majorana A, Brennan M, von B\u0026uuml;ltzingsl\u0026ouml;wen I, Tan P et al. Incidence, severity, and temporal development of oral complications in pediatric allogeneic hematopoietic stem cell transplant patients \u0026ndash; a multicenter study. Support Care Cancer. 2023;31(12):702\u003c/li\u003e\n \u003cli\u003eBhakta N, Liu Q, Ness K, Baassiri M, Eissa H, Yeo F, Chemaitilly W et al. The cumulative burden of surviving childhood cancer: an initial report from the St Jude Lifetime Cohort Study (SJLIFE). Lancet\u003cem\u003e.\u003c/em\u003e 2017;390:2569-82.\u003c/li\u003e\n \u003cli\u003eBogusławska-Kapała A, Hałaburda K, Rusyan E, Gołąbek H, Strużycka I. Oral health of adult patients undergoing hematopoietic cell transplantation. Pre-transplant assessment and care. Ann Hematol. 2017;96:1135\u0026ndash;45.\u003c/li\u003e\n \u003cli\u003eBrennan MT, Hass\u0026eacute;us B, Hovan AJ, Raber-Durlacher JE, Blijlevens NM, Huysmans MC, et al. Hematopoietic stem cell transplantation: Protocol for a multicenter study. MIR Res Protoc. 2018;7(4):e103.\u003c/li\u003e\n \u003cli\u003eChaudhry HM, Bruce AJ, Wolf RC, Litzow MR, Hogan WJ, Patnaik MS, et al. The incidence and severity of oral mucositis among allogeneic hematopoietic stem cell transplantation patients: A systematic review. Biol Blood Marrow Transplant\u003cem\u003e.\u003c/em\u003e 2016;22:605-16.\u003c/li\u003e\n \u003cli\u003eda Silva Santos PS, Coracin FL, Barros JC, Dulley FL, Nunes FD, Magalhaes MG. Impact of oral care prior to HSCT on the severity and clinical outcomes of oral mucositis. Clin Transplant. 2010;25:325\u0026ndash;8\u003c/li\u003e\n \u003cli\u003eDoss LM, Dandoy CE, Kramer K, Pate A, Flesch L, El-Bietar J, et al. Oral health and hematopoietic stem cell transplantation: A longitudinal evaluation of the first 28 days. Pediatr Blood Cancer. 2018;65(1).\u003c/li\u003e\n \u003cli\u003eElad S, Raber-Durlacher JE, Brennan MT, Saunders DP, Mank AP, Zadik Y, et al. Basic oral care for hematology\u0026ndash;oncology patients and hematopoietic stem cell transplantation recipients: a position paper from the joint task force of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) and the European Society for Blood and Marrow Transplantation (EBMT). Support Care Cancer. 2015;23:223\u0026ndash;36.\u003c/li\u003e\n \u003cli\u003eFaraci M, Bonaretti C, Dell\u0026acute;Orso G, Pierri F, Giardino S, Angiero F, Blasi S et al. Association between oral and fecal microbiome dysbiosis and treatment complications in pediatric patients undergoing allogenic hematopoetic stem cell transplantation. Sci Rep. 2024;1:6708\u003c/li\u003e\n \u003cli\u003evan Gennip L, Thomas R, Bulthuis M, Hannink G, Bronkhorst E, Blijlevens N. Oral foci of infection and their relationship with hospital stay after haematopoietic cell transplantation. Support Care Cancer. 2024,32:816.\u003c/li\u003e\n \u003cli\u003eHansen H, Estilob C, Owoshoc A, Solanod A, Randazzod J, Hurynd J, Yome S. Dental status and risk of odontogenic complication in patients undergoing hematopoietic stem cell transplant. Support Care Cancer. 2021;29(4):2231\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eHong CH, Nape\u0026ntilde;as JJ, Hodgson BD, Stokman MA, Mathers-Stauffer V, Elting LS, Spijkervet FK, Brennan MT. A systematic review of dental disease in patients undergoing cancer therapy. Support Care Cancer. 2010;18(8):1007-21.\u003c/li\u003e\n \u003cli\u003eHong CHL, Hu S, Haverman T, Stokman M, Napenas JJ, Braber JB, et al. A systematic review of dental disease management in cancer patients. Support Care Cancer. 2018;26:155\u0026ndash;74.\u003c/li\u003e\n \u003cli\u003eHong C, Gueiros L, Fulton J, Cheng K, Kandwal A, Galiti D, Fall-Dickson J et al. Systematic review of basic oral care for the management of oral mucositis in cancer patients and clinical practice guideline. Support Care Cancer\u003cem\u003e.\u003c/em\u003e 2019;27:3949\u0026ndash;67.\u003c/li\u003e\n \u003cli\u003eJontell M, Mattsson U, Torgersson O. MedView: An instrument for clinical research and education in oral medicine. Oral Surg Oral Med Oral Pathol Oral Radiol Endod\u003cem\u003e.\u003c/em\u003e 2005;99:55-63.\u003c/li\u003e\n \u003cli\u003eKamsv\u0026aring;g T, Svanberg A, Garming Legert K, Arvidson J, von Essen L, Mellgren K, Toporski J et al. Prevention of oral mucositis with cryotherapy in children undergoing hematopoietic stem cell transplantations\u0026mdash;a feasibility study and randomized controlled trial. Support Care Cancer. 2020;28(10): 4869\u0026ndash;79.\u003c/li\u003e\n \u003cli\u003eKashiwazaki H, Matsushita T, Sugita J, Shigematsu A, Kasashi K, Yamazaki Y, et al. Professional oral health care reduces oral mucositis and febrile neutropenia in patients treated with allogeneic bone marrow transplantation. Support Care Cancer\u003cem\u003e.\u003c/em\u003e 2012;20:367-73.\u003c/li\u003e\n \u003cli\u003eMelkos AB, Massenkeil G, Arnold R, Reichart PA. Dental treatment prior to stem cell transplantation and its influence on the posttransplantation outcome. Clin Oral Investig 2003;7:113\u0026ndash;5.\u003c/li\u003e\n \u003cli\u003ede Oliveira Lemes LT, Troian-Michel CH, Weissheimer T, Reis S\u0026oacute; MV. The prevalence of apical periodontitis in patients prior to hematopoetic cell transplantation: a systematic review. Restor Dent Endod. 2024;49:1-12\u003c/li\u003e\n \u003cli\u003eSkallsj\u0026ouml; K, von Bultzingslowen I, Hasseus B, Johansson J-E, Ohman J, Raber-Durlacher JE, et al. (2023) Oral health in patients scheduled for hematopoietic stem cell transplantation in the Orastem study. PLoS One. 2023;18(5):e0285615.\u003c/li\u003e\n \u003cli\u003eSnowden JA, S\u0026aacute;nchez-Ortega I, Corbacioglu S, Basak GW, Chabannon C, de la Camara R, et al. Indications for haematopoietic cell transplantation for haematological diseases, solid tumors and immune disorders: current practice in Europe, 2022. Bone Marrow Transplant\u003cem\u003e.\u003c/em\u003e 2022;57:1217\u0026ndash;39.\u003c/li\u003e\n \u003cli\u003eSpijkervet F, Schuurhuis J, Stokman M, Witjes M, Vissink A. Should oral foci of infection be removed before the onset of radiotherapy or chemotherapy? Oral Dis. 2021;27:7\u0026ndash;13.\u003c/li\u003e\n \u003cli\u003eSvenberg P, Remberger M, Uzunel M, Mattsson J, Gustafsson B, Fjaertoft G, et al. Improved overall survival for pediatric patients undergoing allogeneic hematopoietic stem cell transplantation \u0026ndash; A comparison of the last two decades. Pediatr Transplant\u003cem\u003e.\u003c/em\u003e 2016;20:667\u0026ndash;74.\u003c/li\u003e\n \u003cli\u003eToljanic JA, Bedard J-F, Larson RA, Fox JP. A prospective pilot study to evaluate a new dental assessment and treatment paradigm for patients scheduled to undergo intensive chemotherapy for cancer. Cancer 1999;85(8):1843\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eUutela P, Passweg J, Halter J, Weiger R, Waltimo T, Mauramo M. Common oral diseases in allogeneic haematopoietic stem cell transplantation (HSCT) recipients pre-HSCT. Eur J Haematol. 2019;102:351\u0026ndash;6.\u003c/li\u003e\n \u003cli\u003eVaughan MD, Rowland CC, Tong X, Srivastava DK, Hale GA, Rochester R, Kaste SC. Dental abnormalities in children preparing for pediatric bone marrow transplantation. Bone Marrow Transplant\u003cem\u003e.\u003c/em\u003e 2005;36:863\u0026ndash;6.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. Handbook for reporting results of cancer treatment. Geneva: World Health Organization,1979:15\u0026ndash;22.\u003c/li\u003e\n \u003cli\u003eYamagata K, Onizawa K, Yanagawa T, Takeuchi Y, Hasegawa Y, Chiba S, Bukawa HA. Prospective study to evaluate a new dental management protocol before hematopoietic stem cell transplantation. Bone Marrow Transplant. 2006;18:237\u0026ndash;42.\u003c/li\u003e\n \u003cli\u003eYamagata K, Onizawa K, Yoshida H, Yamagata K, KojimaY, Koike K et al. Dental management of pediatric patients undergoing hematopoetic stem cell transplant. Pediatr Hematol Oncol. 2009;23(7):541-8.\u003c/li\u003e\n \u003cli\u003eYamagata K, Arai C, Sasaki H, Takeuchi Y, Onizawa K, Yanagawa T, et al. The effect of oral management on the severity of oral mucositis during hematopoietic SCT. Bone Marrow Transplant\u003cem\u003e.\u003c/em\u003e 2012;47:725\u0026ndash;30.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTABLE 1 | Baseline demographics and clinical characteristics\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"643\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAll Sites\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(N=91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharlotte\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(n=10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStockholm\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(n=28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSingapore\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(n=30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBrescia\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(n=23)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge in years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e11.2 (4.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e14.2 (3.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 85px;\"\u003e\n \u003cp\u003e12.1 (3.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e9.1 (5.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e11.5 (5.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e57 (63%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e9 (90%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 85px;\"\u003e\n \u003cp\u003e18 (64%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e19 (63%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e11 (48%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e34 (37%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 85px;\"\u003e\n \u003cp\u003e10 (36%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e11 (37%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e12 (52%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedical Diagnosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003eAcute myelogenous leukemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e18 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 85px;\"\u003e\n \u003cp\u003e5 (18%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e8 (27%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e4 (17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003eAcute lymphoblastic leukemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e25 (27%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 85px;\"\u003e\n \u003cp\u003e7 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e13 (43%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e4 (17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003eAplastic anemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e4 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 85px;\"\u003e\n \u003cp\u003e3 (11%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e1 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003eHemoglobinopathy e.g., Thalassemia, sickle cell anemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e10 (11%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e4 (40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 85px;\"\u003e\n \u003cp\u003e3 (11%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e1 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e2 (8.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003eHemophagocytic syndromes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003eHigh Risk solid tumor e.g., brain tumors, germ cell tumors, sarcomas\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e1 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003eLymphoma/Lymphoid neoplasms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e10 (11%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e1 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e8 (35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003eMyelodysplastic syndromes (MDS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e4 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e1 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e1 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003eMDS/Myeloproliferative Neoplasm overlap syndrome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e3 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 85px;\"\u003e\n \u003cp\u003e3 (11%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003ePrimary immunodeficiency conditions e.g., Wiskott Aldrich syndrome\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e6 (7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e4 (17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003eOther e.g., autoimmune diseases\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e9 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4 (14%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e4 (13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDental examination before aHSCT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e\u0026gt;14 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e41 (45%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e9 (90%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 85px;\"\u003e\n \u003cp\u003e7 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e15 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e10 (43%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e8-14 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e44 (48%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 85px;\"\u003e\n \u003cp\u003e20 (71%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e11 (37%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e12 (52%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e0-7 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e6 (7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e4 (13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e1 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTABLE 2 | Oral health-related habits in patients scheduled for aHSCT\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"643\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAll Sites\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(N=91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharlotte\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(n=10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStockholm\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(n=28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSingapore\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(n=30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBrescia\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(n=23)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHow often do you see a dentist or a dental therapist\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e12 (13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e8 (27%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e4 (17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e20 (22%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e2 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e1 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e8 (27%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e9 (39%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e59 (65%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e8 (80%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e27 (96%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e14 (47%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e10 (43%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHow often do you routinely brush your teeth\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003eLess than once a day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e9 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e3 (11%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e4 (13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e2 (9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003eOnce a day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e20 (22%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e9 (90%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e4 (14%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e6 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e1 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003eTwo times a day or more\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e62 (68%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e1 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e21 (75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e20 (67%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e20 (87%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;TABLE 3 | Patient-reported oral symptoms at baseline assessment before aHSCT\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAll Sites\u0026nbsp;\u003c/strong\u003e(N=91)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDoes the patient have oral symptoms right now?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e46 (51%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e45 (49%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIf symptoms involve the teeth, which symptoms are present?\u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e61 (68%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eTooth sensitivity to hot and cold\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e9 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eLoose tooth but no discomfort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e6 (7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eTooth pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e6 (7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eSwelling / pain / discomfort around loose tooth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e3 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eGrinding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e3 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eFood impaction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e3 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eSwelling / pain from infected tooth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e2 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eTooth or filling fracture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e1 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eSwelling / pain / discomfort around erupting tooth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e1 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e2 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIf symptoms / conditions involve the oral mucosa, which are present?\u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e52 (57%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eUlceration e.g., aphthae, infectious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e10 (11%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eMucositis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e10 (11%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eDry mouth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e9 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eBleeding / petechiae and related problem\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e8 (9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eOral tenderness / pain: generalized / non-specific\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e8 (9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eMucosal sensitivity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e8 (9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eSensation: burning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e7 (8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eMucosal tenderness / pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e6 (7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eTongue: coated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e6 (7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eGingival edema / diffuse swelling\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e4 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eTongue: tenderness / sensitivity / pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e4 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e9 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLocation of this subjective mucosal symptom / disease?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e52 (58%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eGingiva\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e11 (12%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eTongue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e14 (15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eBuccal mucosa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e14 (15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eAlveolar mucosa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e3 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eLips\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e3 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIf the oral symptom does not involve the teeth or oral mucosa, which symptom is it?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e76 (84%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eHalitosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e7 (8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eTaste changes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e6 (7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eThroat sensitivity / pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e3 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e2 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHow would you rate your overall feeling of dry mouth?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eNot dry\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e68 (77%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eA little bit dry\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e14 (16%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eA little more dry\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e5 (6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eEven more dry\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e1 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eA whole lot dry\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eExtremely dry\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003ea\u003c/sup\u003e One patient may have several symptoms\u003c/p\u003e\n\u003cp\u003eTABLE 4 | Dental health status and treatment delivered\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 70px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAll Sites\u003c/strong\u003e (N=91)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDental health status at baseline oral assessment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of teeth with caries into dentin\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 70px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e53 (63%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 70px;\"\u003e\n \u003cp\u003e1 tooth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e9 (11%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 70px;\"\u003e\n \u003cp\u003e2 teeth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e7 (8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 70px;\"\u003e\n \u003cp\u003e3 teeth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e4 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cu\u003e\u0026gt;\u003c/u\u003e4 teeth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e11 (13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 70px;\"\u003e\n \u003cp\u003ePatients not evaluated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 70px;\"\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e1.32 (2.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of teeth exhibiting pulpal exposure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 70px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e74 (89%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cu\u003e\u0026gt;\u003c/u\u003e1 tooth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e9 (11%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 70px;\"\u003e\n \u003cp\u003ePatients not evaluated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of loose exfoliating teeth\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 70px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e62 (72%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 70px;\"\u003e\n \u003cp\u003e1 tooth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e7 (8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 70px;\"\u003e\n \u003cp\u003e2 teeth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e9 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cu\u003e\u0026gt;\u003c/u\u003e3 teeth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e8 (9.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 70px;\"\u003e\n \u003cp\u003ePatients not evaluated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlaque visible to the naked eye\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003eNo visible plaque\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e11 (13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e1-20% of the teeth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e40 (48%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e21-50% of the teeth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e22 (26%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026gt;50% of the teeth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e11 (13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 70px;\"\u003e\n \u003cp\u003ePatients not evaluated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTreatment performed after dental examination\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of teeth extractions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e69 (76%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e1 tooth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e8 (9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e2 teeth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e6 (7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e3 teeth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e1 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cu\u003e\u0026gt;\u003c/u\u003e4 teeth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e7 (8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of teeth that have been restored\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e71 (78%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e1 tooth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e5 (6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e2 teeth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e6 (7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cu\u003e\u0026gt;\u003c/u\u003e3 teeth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e9 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHas subgingival scaling been performed\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e85 (93%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e6 (7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of children with loose exfoliating teeth remaining\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e75 (85%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e1 tooth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e2 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e2 teeth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e6 (7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cu\u003e\u0026gt;\u003c/u\u003e3 teeth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e5 (6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003ePatients not evaluated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of children with one or more carious lesions into dentin left untreated\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e77 (90%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e1 tooth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e2 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e2 teeth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e4 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cu\u003e\u0026gt;\u003c/u\u003e3 teeth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e3 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003ePatients not evaluated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-archives-of-paediatric-dentistry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"EAPD","sideBox":"Learn more about [European Archives of Paediatric Dentistry](https://link.springer.com/journal/40368)","snPcode":"40368","submissionUrl":"https://submission.springernature.com/new-submission/40368/3","title":"European Archives of Paediatric Dentistry","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Cancer, Children, Dental caries, Patient-reported outcomes, Prospective","lastPublishedDoi":"10.21203/rs.3.rs-7601934/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7601934/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003eHematopoietic stem cell transplantation (HSCT) is a curative treatment for various hematologic and non-hematologic disorders. The oral cavity, acting as a reservoir for infections, poses additional risks for patients undergoing HSCT. This study aimed to assess the burden of oral disease in children and adolescents preparing for allogeneic (a)HSCT and to evaluate the oral healthcare received before transplantation.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis prospective, longitudinal, multicentre cohort study included 91 children and adolescents under 18 years old scheduled for an aHSCT.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe mean age of the cohort was 11.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6 years, with the most common diagnosis being acute leukaemia (47%), followed by non-malignant haematological disorders (15%). The prevalence of patient-reported oral symptoms was 49%, with sensitivity to hot and cold temperatures (10%) and loose teeth (7%) being the most common complaints. Dental caries was present in 37%, and 13% had visible dental plaque on more than half of their teeth. Dental extractions were performed in 24% of patients, and 22% received dental restorations.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eChildren and adolescents scheduled for aHSCT face a significant burden of oral disease, with notable dental issues that must be addressed before transplantation. This study highlights the importance of pre-transplant dental evaluations in addressing remaining dental concerns and minimizing post-transplant complications.\u003c/p\u003e","manuscriptTitle":"Oral disease burden in children and adolescents scheduled for allogeneic hematopoietic stem cell transplantation – a multicenter study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-24 18:08:59","doi":"10.21203/rs.3.rs-7601934/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-14T08:42:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-13T04:49:08+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-13T04:48:44+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Archives of Paediatric Dentistry","date":"2025-09-12T15:12:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-archives-of-paediatric-dentistry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"EAPD","sideBox":"Learn more about [European Archives of Paediatric Dentistry](https://link.springer.com/journal/40368)","snPcode":"40368","submissionUrl":"https://submission.springernature.com/new-submission/40368/3","title":"European Archives of Paediatric Dentistry","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"835ac452-7bbd-402f-bf86-27446e45a39a","owner":[],"postedDate":"October 24th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-07T17:38:17+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-24 18:08:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7601934","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7601934","identity":"rs-7601934","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}