Graft-vs.-host disease

Oral graft-versus-host disease

Hematopoietic cell transplantation is used to treat malignancies, hematologic and immune deficiency states, marrow failure syndromes, and autoimmune diseases. Graft-versus-host disease (GVHD) is a clinical syndrome seen following allogeneic transplantation where donorderived immunocompetent T cells and inflammatory responses attack host tissues. GVHD can cause significant morbidity and even result in mortality. The oral cavity is a frequently involved site with clinical changes resembling autoimmune collagen vascular diseases. Recognition, diagnosis, and monitoring of oral GVHD can help with diagnosis and grading of GVHD and judging responses to therapy. Topical and local management of symptomatic oral GVHD can reduce oral symptoms that can interfere with oral function and quality of life, and can reduce the need for more intensive immunosuppressive systemic therapies.

Clinical evaluation of oral chronic graft-versus-host disease

Oral chronic graft-versus-host disease (cGVHD) is a significant and serious complication following allogeneic hematopoietic stem cell transplantation (HSCT). The purpose of this study was to characterize the distribution, type, and extent of lesions and their correlation with patient-reported symptoms such as pain and discomfort. The effect of time since transplantation on these measures was also assessed. Consecutive patients with oral cGVHD referred to the Center for Oral Disease at Brigham and Women's Hospital, Boston, MA, were evaluated over a 2-year period. Subjective data included the responses to 4 targeted symptom questions (yes/no) and a visual analog scale pain score (0-10). Objective data included the location and extent of reticulation, erythema, and ulcerations using a previously published scoring system as well as time since HSCT. Multiple linear regression analyses were performed using SAS. We evaluated 27 patients, for a total of 79 clinic visits (median 2, range: 1-8). The median time since HSCT was 18 months (range: 5-157 months). The buccal and labial mucosa and tongue were the sites of 93% of all ulcerations, 72% of all erythematous lesions, and 76% of all reticular lesions, and were the most frequently affected sites. The gingiva, floor of mouth, and hard and soft palate were infrequently affected. Although uncommon, ulceration of the soft palate was the objective finding most highly correlated with increased pain (P < .0001), and there was a generalized significant trend for increased pain scores with increased extent of ulceration. Overall, 95% of pain scores were <or=5 (scale from 0-10, range: 0-7), with 40% reporting a score of zero. However, 80% admitted to avoiding certain foods because of mouth pain. After controlling for the presence and extent of ulcerations, we found that time since HSCT was inversely related to the pain score (P < .04). There was a statistically significant inverse relationship between the overall presence of ulceration and time since HSCT. We found that oral cGVHD most frequently affects the buccal and labial mucosa and the tongue. The functional impact was significant, as most patients had to restrict oral intake because of discomfort. Both the signs and symptoms associated with oral cGVHD tend to decrease over time. The association between ulceration of the soft palate and patient-reported pain highlights the significance of the location of involvement and the need for targeted approaches to therapy. Our findings, in large part, support the recently introduced National Institutes of Health response criteria for oral cGVHD, which is critical for the conduct of effective and meaningful research in this field; however, prospective application in clinical and investigative settings is necessary for evaluating its utility and efficacy in practice.

Considerations in the pediatric population with cancer

This article is divided into three time periods according to the different phases of cancer treatment: pre, inter, and postcancer therapy. The purpose of dental protocols prior to cancer therapy and the incidence and management of acute and long term oral complications from cancer therapy in the pediatric population are discussed.

Mucositis in the cancer patient and immunosuppressed host

Oral mucositis is a serious complication of cancer therapy and in severely immunosuppressed patients. In immunosuppressed patients, the signs and symptoms of infection often are muted because of limited host response, and accurate diagnosis and appropriate treatment may be difficult. Prevention of mucosal breakdown, suppression of microbial colonization, control of viral reactivation, and effective management of severe xerostomia are all critical steps to reducing the overall morbidity and mortality of oromucosal infections.

Severe gingival recession and early loss of teeth in a child with chronic graft versus host disease: a case report

Graft versus host disease (GVHD) occurs after a hematopoietic stem cell transplantation (HSCT) when the donor's immune system rejects the recipient's body, leading to significant morbidity and mortality. Increased numbers of chronic GVHD (c-GVHD) patients are likely to be seen by dental professionals because of the advances made in transplantation. The oral cavity may be the primary or the only site of c-GVHD and may have persistent lesions after resolution has occurred in other areas. Approximately 80% of patients with extensive c-GVHD present some type of oral involvement, including xerostomia, oral pain and lesions. Dental and oral care can be challenging for these patients. This paper discusses the manifestations and treatment of oral c-GVHD and presents the case history of a 15-month-old girl who developed severe oral GVHD with an unusual periodontal presentation and early loss of primary teeth.

Orofacial pain in cancer: part II--clinical perspectives and management

Cancer-associated pain is extremely common and is associated with significant physical and psychological suffering. Unfortunately, pain associated with cancer or its treatment is frequently under-treated, probably due to several factors, including phobia of opioids, under-reporting by patients, and under-diagnosis by healthcare workers. The most common etiology of cancer pain is local tumor invasion (primary or metastatic), involving inflammatory and neuropathic mechanisms; these have been reviewed in Part I. As malignant disease advances, pain usually becomes more frequent and more intense. Additional expressions of orofacial cancer pain include distant tumor effects, involving paraneoplastic mechanisms. Pain secondary to cancer therapy varies with the treatment modalities used: Chemo-radiotherapy protocols are typically associated with painful mucositis and neurotoxicity. Surgical therapies often result in nerve and tissue damage, leading, in the long term, to myofascial and neuropathic pain syndromes. In the present article, we review the clinical presentation of cancer-associated orofacial pain at various stages: initial diagnosis, during therapy (chemo-, radiotherapy, surgery), and in the post-therapy period. As a presenting symptom of orofacial cancer, pain is often of low intensity and diagnostically unreliable. Diagnosis, treatment, and prevention of pain in cancer require knowledge of the presenting characteristics, factors, and mechanisms involved.

The effect of budesonide mouthwash on oral chronic graft versus host disease

Oral chronic graft versus host disease (cGVHD) is common and a major cause of morbidity and loss of quality of life in long term survivors. Cyclosporine with prednisone remains the first line therapy for oral manifestations of cGVHD. However, even with routine administration of systemic agents, many patients with oral manifestations of cGVHD do not have resolution of their disease and may benefit from incorporation of local therapy. Budesonide is a highly potent steroid which has minimal systemic side effects and being used for oral cGVHD. We designed a retrospective study to compare treatment results of patients with oral cGVHD who received topical budesonide in addition to systemic therapy that consists of combined prednisone and cyclosporine (Group A, n = 12), with the treatment results of patients who were administered the same systemic therapy alone (Group B, n = 11) to determine whether budesonide mouthwash had any advantage on response rates. Three mg topical budesonide/10 ml saline was used 3-4 times a day for up to 6 months in group A. Diagnosis, clinical staging, and treatment response scoring for cGVHD were performed according to National Institutes of Health (NIH) consensus criteria. At the baseline examination, there were no statistically significant differences in terms of median oral cGVHD examination scores between two groups. After treatment, there was statistically significant decrease in median oral cGVHD examination scores compared to baseline (P < 0.001 and 0.021), and significant differences were found between two groups (P < 0.032). Overall response rate was 83% and 36% for group A and B, respectively (P = 0.036). However, no statistically significant differences were found between median pain scores of two groups before and after treatment (P = 0.740 and P = 0.091). No major systemic side effects and oral candidiasis were observed in two groups of patients. We concluded that topical budesonide might be added to systemic therapy to obtain better response rates in patients with oral cGHVD.

Oral lichen planus and oral lichenoid lesions: diagnostic and therapeutic considerations

Several therapeutic agents have been investigated for the treatment of oral lichen planus (OLP). Among these are corticosteroids, retinoids, cyclosporine, and phototherapy, in addition to other treatment modalities. A systematic review of clinical trials showed that particularly topical corticosteroids are often effective in the management of symptomatic OLP lichen planus. Systemic corticosteroids should be only considered for severe widespread OLP and for lichen planus involving other mucocutaneous sites. Because of the ongoing controversy in the literature about the possible premalignant character of OLP, periodic follow-up is recommended. There is a spectrum of oral lichen planus-like ("lichenoid") lesions that may confuse the differential diagnosis. These include lichenoid contact lesions, lichenoid drug reactions and lichenoid lesions of graft-versus-host disease. In regard to the approach to oral lichenoid contact lesions the value of patch testing remains controversial. Confirmation of the diagnosis of an oral lichenoid drug reaction may be difficult, since empiric withdrawal of the suspected drug and/or its substitution by an alternative agent may be complicated. Oral lichenoid lesions of graft-versus-host disease (OLL-GVHD) are recognized to have an association with malignancy. Local therapy for these lesions rests in topical agents, predominantly corticosteroids.

Ancillary therapy and supportive care of chronic graft-versus-host disease: national institutes of health consensus development project on criteria for clinical trials in chronic Graft-versus-host disease: V. Ancillary Therapy and Supportive Care Working Group Report

The Ancillary Therapy and Supportive Care Working Group had 3 goals: (1) to establish guidelines for ancillary therapy and supportive care in chronic graft-versus-host disease (GVHD), including treatment for symptoms and recommendations for patient education, preventive measures, and appropriate follow-up; (2) to provide guidelines for the prevention and management of infections and other common complications of treatment for chronic GVHD; and (3) to highlight the areas with the greatest need for clinical research. The definition of "ancillary therapy and supportive care" embraces the most frequent immunosuppressive or anti-inflammatory interventions used with topical intent and any other interventions directed at organ-specific control of symptoms or complications resulting from GVHD and its therapy. Also included in the definition are educational, preventive, and psychosocial interventions with this same objective. Recommendations are organized according to the strength and quality of evidence supporting them and cover the most commonly involved organs, including the skin, mouth, female genital tract, eyes, gastrointestinal tract, and lungs. Recommendations are provided for prevention of infections, osteoporosis, and steroid myopathy and management of neurocognitive and psychosocial adverse effects related to chronic GVHD. Optimal care of patients with chronic GVHD often requires a multidisciplinary approach.

Oral mucositis

Mucositis and xerostomia are the most common oral complications of the non-surgical therapy of cancer. Mucositis, a common sequel of radio- (DXR), chemo-(CXR) and radiochemo-therapy in patients with cancer, or patients requiring haemopoietic stem cell transplants (HSCT), has a direct and significant impact on the quality of life and cost of care, and also affects survival--because of the risk of infection. Apart from dose reduction, preventive and treatment options for mucositis are scarce, although multiple agents have been tested. Evidence suggests that cryotherapy, topical benzydamine and amifostine might provide some benefit in specific situations. The recombinant human keratinocyte growth factor Palifermin (Kepivance) was recently approved as a mucositis intervention in patients receiving conditioning regimens before HSCT for the treatment of haematological malignancies. A number of mechanistically based interventions are in various stages of development. Unfortunately, many other approaches have not been rigorously tested. This paper reviews the clinical features, prevalence, diagnosis, complications, pathogenesis, prophylaxis and management of mucositis.

Chronic graft versus host disease of oral mucosa: Review of available therapies

The use of hematopoetic stem cell transplantation (HSCT) has greatly expanded in the recent years for many neoplastic and hematological disorders. Chronic graft versus host disease (cGVHD) is a major complication of allogeneic HSCT and a major cause of morbidity and mortality. Oral mucosal involvement is frequent in cGVHD and contributes significantly to the overall burden of the condition. Oral medicine professionals should be familiar with various treatment options for oral cGVHD. This review discusses treatment modalities available for the management of oral mucosal manifestations of cGVHD. Available evidence for efficacy and safety of various systemic and topical agents, including corticosteroids, calcineurin antagonists, mycophenolate mofetil, and extracorporeal photopheresis, is reviewed.

Oral chronic graft-versus-host disease in pediatric patients after hematopoietic stem cell transplantation

Chronic graft-versus-host disease (cGVHD) is a serious and potentially life-threatening complication of hematopoietic stem cell transplantation. This study, which is the largest single-center series of oral disease in pediatric patients with cGVHD, describes the oral findings in 49 consecutive patients seen in a pediatric multidisciplinary cGVHD clinic. All consecutive patients seen at the multidisciplinary pediatric hematopoietic stem cell transplantation/cGVHD clinic at the Dana-Farber Cancer Institute (Boston, MA) from July 2001 through October 2003 were included in this study. Subjective and objective assessments of mucosal, salivary gland, and sclerotic pathology were performed for each patient, and specific therapy was initiated when indicated. Oral mucosal cGVHD was identified in 22 (45%) of 49 patients. Only 4 (8%) of 49 patients reported mouth pain, and all patients reported being able to eat well. All patients who required specific therapy for their oral mucosal cGVHD (45%) were already taking at least 1 immunomodulatory agent; however, efficacy of treatment was difficult to assess because of inconsistent follow-up periods. Subjective and objective salivary gland and sclerotic disease were observed far less often. Oral mucosal pathology is common in these patients, and appropriate diagnosis and management of oral lesions is critical to reduce patient morbidity and to improve quality of life. The apparent lack of salivary gland involvement was notable. Developing validated age-appropriate evaluation strategies and identifying effective treatment guidelines will be invaluable in the future management of these patients.

Chronic GVHD in minor salivary glands and oral mucosa: histopathological and immunohistochemical evaluation of 25 patients

BACKGROUND

Graft-vs.-host disease (GVHD) is the major cause of morbidity and mortality in patients undergoing allogeneic Bone Marrow Transplantation (BMT). The aim of our study was to identify the most relevant histological features for diagnosis of chronic Graft-vs.-Host Disease (cGVHD) in oral mucosa and minor salivary glands of 25 patients, as well as to evaluate the immunophenotype of the inflammatory cells.

METHODS

Sixteen patients that were submitted to allogeneic BMT but did not present cGVHD were selected as a control group. The sections were studied on H & E and CD68, CD45, CD4, CD8, CD20 staining.

RESULTS

The most frequent histologic findings in oral mucosa at the day of diagnosis of cGVHD were: hydropic degeneration of the basal layer of the epithelium, apoptotic bodies, lymphocytic infiltration, and focal or total cleavage between the epithelial and connective tissue. In the labial salivary glands (LSG), lymphocytic infiltration, acinar loss and fibrosis were the main alterations. Cytotoxic CD8-T cells and macrophages were predominant both in the epithelium and connective tissue, as well as in minor salivary glands.

CONCLUSIONS

Histological features were useful in the diagnosis of oral cGVHD. It is suggested that CD8-T cells and macrophages play important role in the pathogenesis of the disease.

Oral malignancies following HSCT: graft versus host disease and other risk factors

Allogenic hematopoietic stem cell transplantation (HSCT), a procedure that is widely used in the treatment of a large number of malignant and non-malignant hematological diseases, is still associated with a wide range of complications, one of the most important of which is graft versus host disease (GVHD). The patients undergoing allogenic HSCT are also at high risk of developing secondary neoplasms, particularly leukemias and lymphomas. Solid tumors are less frequent, and the incidence appears to increase over time; the most frequent solid tumors are squamous cell carcinomas. We found that almost all studies of solid cancers occurring after transplantation are based on relatively small numbers of cases which have been monitored for short periods, and little information is available on individual cancers. In particular, reports of oral cancers in HSCT are very few. Potential risk factors associated with the development of secondary solid cancers after HSCT have been well described. They include graft versus host disease (GVHD), preoperative regimens, with either radio-chemotherapy or chemotherapy alone, conditioning regimes, immunosuppressive GVHD prophylaxis, viral infection and chronic stimulation as a result of viral antigens, antigenic stimulation from histocompatibility differences between recipient and donor, primary diagnosis, interaction of any of these factors with genetic predisposition, and other factors such as sex and age. All patients treated with HSCT should therefore be closely followed over the long term with the aim of identifying the onset of secondary tumors as early as possible.

Oral mucositis

Oral mucositis refers to erythematous, erosive, and ulcerative lesions of the oral mucosa seen in two patient populations: (1) head and neck cancer patients undergoing radiation therapy to fields involving the oral cavity, and (2) patients receiving high-dose chemotherapy for cancer. Oral mucositis is a significant and dose-limiting toxicity of cancer therapy, with important clinical and economic implications. This article reviews the current knowledge on the pathogenesis, clinical presentation, diagnosis, and management of oral mucositis.

Current practice and knowledge of oral care for cancer patients: a survey of supportive health care providers

BACKGROUND

The Oral Care Study Section of the Multinational Association of Supportive Care in Cancer (MASCC) and the International Society for Oral Oncology (ISOO) conducted a survey on clinical practices of oral/dental management of cancer patients among supportive health care providers. The main purpose was to evaluate the knowledge and current practice for preventing and managing oral side effects associated with intensive chemotherapy (ICT), hematopoietic cell transplant (HCT), and radiation therapy to the head and neck (H&N RT).

MATERIALS AND METHODS

A questionnaire designed and pretested was sent to 212 MASCC/ISOO members around the world with different dental and medical backgrounds.

MAIN RESULTS

Seventy-four individuals (35%) responded. The majority of respondents were aware of possible oral complications and provided patients with clinical strategies and recommendations although there was considerable variability among the respondents. Approximately 75% stated that patients were referred for oral/dental care prior to H&N RT and ICT including HCT. However, integrated dental and medical services were reported available in only about 25% of the institutions, and most patients were referred to community-based dental professionals.

MAIN CONCLUSIONS

The survey represents a first review of current, international oral care practices. It suggests a need to develop evidence-based clinical guidelines to support effective oral/dental interventions and management strategies for this population. Furthermore, strategies for implementation of oral care protocols and better integration of dental and medical services should be developed. Caution in interpreting these findings is urged due to the limited response rate.

CO2 laser in oral graft-versus-host disease: a pilot study

This paper is the first to report the benefits of CO2 laser treatment for pain control in severe oral chronic graft-versus-host disease (GVHD). A CO2 laser device was used during 17 treatment sessions in four patients. The CO2 laser was applied over the mucosal lesions using 1 W for 2-3 s/1 mm(2). This treatment resulted in a consistent and significant decrease in pain, measured using a standard visual analogue scale. These results suggest that the CO2 laser can be used for the alleviation of pain in oral chronic GVHD.

Oral graft-versus-host disease and programmed cell death: pathogenetic and clinical correlates

Graft-versus-host disease (GVHD) is an untoward complication of bone marrow transplantation. It is characterized by an immune-mediated attack by donor immune cells against various host cells and tissues, a process which may be associated with significant morbidity in affected patients. Oral lesions are a common sequelae and can serve as a highly predictive index to the presence of systemic GVHD. The oral lesions of GVHD are clinically and histologically lichenoid in nature and can be a challenge in terms of management. Ulcerated and painful mucosal lesions may represent a significant impediment to normal eating habits and nutritional intake, necessitating appropriate diagnosis and treatment. Importantly, recent evidence has indicated that programmed cell death, or apoptosis, is the major constituent in the pathogenesis of GVHD. Apoptosis not only plays a major role in normal growth and ontogeny, but has been shown to contribute to a wide spectrum of both inflammatory and neoplastic disorders. Since knowledge of apoptotic molecular pathways is requisite for understanding GVHD, the purpose of this paper is to provide a fundamental overview of the predominant apoptotic mechanisms implicated in the pathogenesis of GVHD and to relate these findings to the oral complications of the disease. Finally, we will discuss management strategies for diagnosing and treating the oral lesions of GVHD. By explicating the molecular events in the apoptotic pathway, unique therapeutic and pharmacologic strategies for regulating apoptosis may be developed in the future, reducing the morbidity associated with conditions like GVHD.

Successful treatment of oral lichen planus-like chronic graft-versus-host disease with topical tacrolimus: a case report

BACKGROUND

Bone marrow transplantation (BMT) is a common treatment used for deficiencies of host marrow or in the control of blood malignancies. Post-allogeneic BMT complications include graft-versus-host disease (GVHD). GVHD occurs when immunologically active T lymphocytes are transplanted into an immunosuppressed recipient who is genetically disparate from the donor. In this case report we describe the occurrence of oral lichen planus-like lesions as the first manifestation of chronic GVHD (c-GVHD) and the subsequent management of this disease with topical tacrolimus.

METHODS

Diagnostic aids included routine histology and direct immunofluorescence studies to rule out immunobullous diseases and to confirm the c-GVHD. Treatment consisted of topical application of 0.1% tacrolimus ointment three times a day.

RESULTS

Routine histology confirmed the clinical diagnosis of oral lichen planus-like c-GVHD. Treatment with tacrolimus ointment completely resolved the oral lesions after 2 months of therapy.

CONCLUSIONS

Topical tacrolimus at low concentrations (0.1%) shows promise in the management of oral lichen planus-like c-GVHD. Controlled studies are necessary to assess the efficacy, the duration of therapy required for effective results, and the safety of this treatment over the long-term.

Oral mucositis: A challenging complication of radiotherapy, chemotherapy, and radiochemotherapy. Part 2: Diagnosis and management of mucositis

BACKGROUND

Oral mucositis is a common sequel of radiotherapy, chemotherapy, and radiochemotherapy in patients with cancer or patients requiring hemopoietic stem cell transplants. Mucositis has a direct and significant impact on the duration of disease remission and cure rates, because it is a treatment-limiting toxicity. Mucositis also affects survival because of the risk of infection and has a significant impact on quality of life and cost of care.

METHODS

This article reviews publications on the diagnosis and management of oral mucositis accessible from a MEDLINE search using as key words mucositis, radiotherapy, chemotherapy, hemopoietic stem cell transplant, and oral.

CONCLUSIONS

Conventional care of patients with mucositis is currently essentially palliative, with good oral hygiene, narcotic analgesics, and topical palliative mouth rinses.

Gingival lesions in a patient with chronic oral graft-versus-host disease: a case report

BACKGROUND

The patient reported in this study was diagnosed with acute nonlymphocytic leukemia and underwent an allogenic bone marrow transplantation. She was referred for persisting oral ulceration and pain associated with the transplant procedure.

AIM

To present an unusual involvement of gingival tissues during a case of oral chronic graft-versus-host-disease.

CONCLUSION

This is one of the very few reports in the dental literature of a case of oral chronic graft-versus-host disease that includes the unusual manifestation of prominent gingival lesions.

Budesonide: a novel treatment for oral chronic graft versus host disease

OBJECTIVE

This clinical trial aims to evaluate the efficacy of budesonide, a newly registered steroid with high potency and low bioavailability, for the treatment of chronic oral graft versus host disease (GVHD).

STUDY DESIGN

Twelve patients with chronic resistant oral GVHD were treated with 3 mg budesonide/5 ml saline 2 to 3 times a day for up to 3 months. Oral manifestations were monitored, and mucosal response scored.

RESULTS

All patients responded positively to the mouthwash, and 7 of the 12 patients were scored as having "good" or "complete" recovery by both examiner and subject. An early response noted within the first 2 to 3 weeks of treatment was complemented by a probable cumulative effect seen during the first months of treatment.

CONCLUSION

Budesonide is suggested as an alternative treatment for chronic oral GVHD.

Severe oral manifestations of chronic graft-vs.-host disease

BACKGROUND

Graft-vs.-host-disease, or GVHD, is the main cause of morbidity in patients who have received bone marrow transplants. Chronic GVHD, or cGVHD, occurs 100 days or more after the transplant procedure and may take the form of various oral manifestations.

CASE DESCRIPTION

A 23-year-old woman received an allogeneic bone marrow transplant. Although prophylactic therapy was provided, the patient developed cGVHD. Appropriate therapy was initiated, and it received a good clinical response at all sites affected by cGVHD, except in the oral cavity. The patient received complete symptomatic relief through revised systemic therapy, improved oral hygiene, use of topical medications and a monitored diet.

CLINICAL IMPLICATIONS

Effective intervention by dentists is an important part of increasing treatment effectiveness and improving quality of life in patients who received bone marrow transplants.

Chronic graft-versus-host disease: clinical manifestation and therapy

Chronic graft-versus-host disease (GVHD) is a major cause of morbidity and mortality in long-term survivors of allogeneic stem cell transplantation. The immunopathogenesis of chronic GVHD is, in part, TH-2 mediated, resulting in a syndrome of immunodeficiency and an autoimmune disorder. The most important risk factor for chronic GVHD is prior history of acute GVHD and strategies that prevent acute GVHD also decrease the risk of chronic GVHD. Other important risk factors are the use of a non-T cell-depleted graft, and older age of donor and recipient. Whether recipients of peripheral blood stem cells are at increased risk of chronic GVHD remains unsettled. There are no known pharmacologic agents which can specifically prevent development of chronic GVHD. Agents which have efficacy in the treatment of autoimmune disorders have been utilized as therapy for established chronic GVHD and are associated with response rates of 20% to 80%. Most responses are confined to skin, soft tissue, oral mucosa and occasionally liver. Bronchiolitis obliterans responds infrequently to therapy and is associated with a dismal prognosis. Newer, promising therapeutic strategies under investigation include thalidomide, photopheresis therapy, anti-tumor necrosis factor and B cell depletion with anti-CD20 monoclonal antibody.

Topical azathioprine in the treatment of immune-mediated chronic oral inflammatory conditions: a series of cases

OBJECTIVES

After hematopoietic cell transplantation, a variety of complications can occur, including chronic graft-versus-host disease (GVHD), with 25% to 70% of these involving the oral cavity. Those lesions, as well as oral involvement of autoimmune mucocutaneous diseases, might present as painful, erythematous, and ulcerative oral lesions. Management includes topical and systemic immunosuppressive agents, including systemic azathioprine (AZA). The purpose of this study was to evaluate the efficacy of topical AZA in chronic oral GVHD and in oral autoimmune diseases in a series of patients.

METHODS

Four men and 2 women with GVHD and 2 men with autoimmune vesiculo-ulcerative oral lesions were treated with topical AZA. A rinse of 5 mL of 5 mg/mL AZA in methylcellulose were rinsed 3 to 4 times daily for over 1 minute and expectorated, or a gel in the same concentration in 3% methylcellulose was topically applied. The outcome was evaluated separately for total ulcer size, assessment of the erythema, and severity of pain by using a visual analogue scale. Global estimated improvements represented a proportional combined improvement of ulcers, erythema, and pain.

RESULTS AND CONCLUSIONS

The mean estimated global improvement for 6 patients with GVHD who used AZA rinse was 60% in a mean of 16.67 weeks. Ulcers improved by 58%, erythema by 55%, and pain was reduced by 63%. Two patients with oral lesions of vesiculo-ulcerative diseases (1 AZA rinse and 1 topical gel) improved by 95% and 96%, respectively, in 3 months. One patient with GVHD applied topical AZA gel in addition to mouthrinses, and a 29% estimated global improvement was achieved in addition to 50% of improvement achieved with AZA mouthrinses. The observed effect of topical AZA suggests that it can be used for management of oral immune-mediated inflammatory conditions, and for patients who are provided with systemic immunosuppressives it can allow control of oral findings with lower systemic dosing. The therapeutic potential of topical AZA as mouthrinse versus topical applications and the most effective concentration should be further investigated.

Topical azathioprine in the combined treatment of chronic oral graft-versus-host disease

This paper presents the first report of the use of topical azathioprine in the management of persistent symptomatic chronic oral graft-versus-host disease (GVHD). Topical azathioprine suspension was used as an oral rinse and was swallowed, maintaining the previously prescribed systemic dose of azathioprine, and resulted in improvement in a case of oral GVHD that was resistant to other approaches to management. Topical azathioprine may provide additional therapy in the management of immune-mediated oral mucosal disease. Clinical trials appear warranted based upon the results of topical azathioprine use as presented in this case report.

Changes in the periodontal status of patients undergoing bone marrow transplantation

BACKGROUND

Patients receiving an HLA-matched bone marrow transplant (BMT) from a relative or unrelated donor undergo a permanent alteration of their immune system, followed by a prolonged period of immunodeficiency. This study aimed to examine alterations in the periodontal status of patients over 6 months post-bone marrow transplantation.

METHODS

Thirty-seven patients scheduled for bone marrow transplantation participated in this study. One calibrated examiner carried out periodontal examinations (clinical and radiographic) immediately prior to and at 3 and 6 months after transplantation. All patients followed an intense oral care program. Subgingival plaque samples were analyzed by enzyme-linked immunosorbent assay (ELISA) for the presence of Porphyromonas gingivalis, Actinobacillus actinomycetemcomitans, and Prevotella intermedia. Data were subjected to statistical analyses to determine the relationships between the frequency distribution of the radiographic and clinical variables over time.

RESULTS

Gains in clinical attachment level (CAL) of > or =2 mm at 4 or more sites from baseline to 6 months post-BMT were noted in 9/16 patients (56%), while 6/16 (38%) patients experienced a loss of CAL > or =2 mm at 4 or more sites in the same period. At a site level, 4.8% of sites exhibited a gain in CAL > or =2 mm between baseline and 3 months post-BMT while 2.3% of sites showed a loss of CAL > or =2 mm in the same period. From baseline to 6 months, a gain in CAL of > or =2 mm was recorded at 3.1% of sites, and 2.4% of sites experienced a loss of > or =2 mm. A significant improvement in the gingival index occurred between all sequential time periods when assessed at a site level. At a patient level, 11/18 (61%) patients showed a significant change in gingival index between baseline and 3 months and 10/16 (63%) between baseline and 6 months. There was no significant relationship between clinical changes and the prevalence of the periodontal pathogens at the various time periods.

CONCLUSIONS

An improvement in periodontal health was recorded between baseline and 6 months post-transplantation. Most of the improvement in periodontal status was noted in the first 3 months after BMT, with a slight decline in periodontal health between 3 and 6 months post-transplant. No significant alteration was noted in the prevalence of periodontal pathogens during the study period.

Oral complications associated with immunosuppression and cancer therapies

The oral manifestations of oropharyngeal infection in immunocompromised patients present a particular challenge for both medical and dental professionals because clinical signs and symptoms may be minimal and accurate diagnosis and appropriate treatment may be difficult. Effective control of infection and management of oral symptoms are important and may be achieved by the judicious use of topical and systemic agents and by maintaining good oral hygiene. Prevention of mucosal breakdown, suppression of microbial colonization, control of viral reactivation, and effective management of severe xerostomia are all critical steps to reduce the overall morbidity and mortality of oromucosal infections in the severely immunocompromised patient.

Ultraviolet B irradiation: a new therapeutic concept for the management of oral manifestations of graft-versus-host disease

Ultraviolet irradiation inhibits the proliferative responses of lymphoid cells to mitogens and alloantigens by inactivation of T lymphocytes and antigen-presenting cells. Its immunosuppressive capacity led to the introduction of UV irradiation into clinical practice for the treatment of dermatologic manifestations of chronic graft-versus-host disease. The cumulative experience with psoralen-UV-A rays in the treatment of cutaneous and oral graft-versus-host disease was the incentive for the application of oral UV-B rays in 2 patients with oral graft-versus-host disease signs and symptoms after allogeneic marrow transplantation. Intraoral UV-B irradiation (0.02 mJ/cm(2)) was administered 2 or 3 times per week on an ambulatory basis; the dose was increased by 0. 02 mJ/cm(2) every fourth session. Both patients responded early and satisfactorily, displaying only minimal side effects at a relatively low cumulative dose. Intraoral UV-B proved a valuable modality in the treatment of resistant chronic oral graft-versus-host disease.

Management and long-term complications of pediatric cancer

The impact of recently intensified and novel therapies for the treatment of childhood cancer has been an increased number of survivors and an increase in the number of treatment complications among survivors. Thus, it is important for the primary care practitioner to be aware of not only acute but chronic complications of therapy, including the possibility of second malignancies. Long-term follow-up is essential, and continuous education of patients and health care personnel is an important aspect for the complete success of treatment. Primary care practitioners also need to incorporate other subspecialties in the management of these patients to ensure that they receive complete evaluation and treatment.

Treatment of oral chronic graft-versus-host disease with PUVA therapy: case report and literature review

Chronic graft-versus-host disease commonly appears with oral manifestations subsequent to allogeneic bone marrow transplantation. These manifestations include leukoplakia, mucosal atrophy, erythema, ulcers, and xerostomia. Some lesions are resistant to treatment with immunosuppressive medications. Ultraviolet A irradiation therapy with oral psoralen has been shown to be effective in treating these resistant lesions. This article presents a review of the literature and a case report.