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Nguyen JT, Jessri M, Costa-da-Silva AC, Sharma R, Mays JW, Treister NS. Oral Chronic Graft-Versus-Host Disease: Pathogenesis, Diagnosis, Current Treatment, and Emerging Therapies. Int J Mol Sci 2024; 25:10411. [PMID: 39408739 PMCID: PMC11476840 DOI: 10.3390/ijms251910411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2024] [Revised: 09/16/2024] [Accepted: 09/23/2024] [Indexed: 10/20/2024] Open
Abstract
Chronic graft-versus-host disease (cGvHD) is a multisystem disorder that occurs in recipients of allogeneic hematopoietic (alloHCT) stem cell transplants and is characterized by both inflammatory and fibrotic manifestations. It begins with the recognition of host tissues by the non-self (allogeneic) graft and progresses to tissue inflammation, organ dysfunction and fibrosis throughout the body. Oral cavity manifestations of cGVHD include mucosal features, salivary gland dysfunction and fibrosis. This review synthesizes current knowledge on the pathogenesis, diagnosis and management of oral cGVHD, with a focus on emerging trends and novel therapeutics. Data from various clinical studies and expert consensus are integrated to provide a comprehensive overview.
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Affiliation(s)
- Joe T. Nguyen
- Nguyen Laboratory, Head and Neck Cancer Section, Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
- Oral Immunobiology Unit, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD 20892, USA; (A.C.C.-d.-S.); (R.S.); (J.W.M.)
| | - Maryam Jessri
- Metro North Hospital and Health Service, Queensland Health, Brisbane, QLD 4029, Australia;
- Department of Oral Medicine and Pathology, School of Dentistry, The University of Queensland, Herston, QLD 4072, Australia
| | - Ana C. Costa-da-Silva
- Oral Immunobiology Unit, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD 20892, USA; (A.C.C.-d.-S.); (R.S.); (J.W.M.)
| | - Rubina Sharma
- Oral Immunobiology Unit, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD 20892, USA; (A.C.C.-d.-S.); (R.S.); (J.W.M.)
| | - Jacqueline W. Mays
- Oral Immunobiology Unit, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD 20892, USA; (A.C.C.-d.-S.); (R.S.); (J.W.M.)
| | - Nathaniel S. Treister
- Division of Oral Medicine and Dentistry, Brigham and Women’s Hospital, Boston, MA 02115, USA
- Department of Oral Medicine, Infection and Immunity, Harvard School of Dental Medicine, Boston, MA 02114, USA
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Bulthuis MS, van Leeuwen SJM, Thomas RZ, van Gennip LLA, Whiteside HM, Isom S, Kline DM, Laheij AMGA, Raber-Durlacher JE, Hasséus B, Johansson JE, Hovan AJ, Brennan MT, von Bültzingslöwen I, Huysmans MCDNJM, Blijlevens NMA. Subjective Oral Dryness following Hematopoietic Cell Transplantation: A Report from the Orastem Study. Transplant Cell Ther 2024; 30:446.e1-446.e11. [PMID: 38242439 DOI: 10.1016/j.jtct.2024.01.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/12/2024] [Accepted: 01/14/2024] [Indexed: 01/21/2024]
Abstract
Xerostomia, or subjective oral dryness, is a serious complaint after hematopoietic cell transplantation (HCT). Xerostomia is rated as one of the most bothersome symptoms by HCT recipients, negatively affecting quality of life. This substudy of the Orastem study, a prospective longitudinal, international, observational, multicenter study, aimed to describe the prevalence and severity of xerostomia following HCT. Furthermore, the effect of the conditioning regimen, type of transplantation, and oral mucosal changes related to chronic graft-versus-host disease (cGVHD) in the development of xerostomia were studied. All HCT recipients rated xerostomia on a scale of 0 to 10 before the conditioning regimen, several times early post-HCT, and at 3 months post-HCT, and only allogeneic HCT recipients also rated xerostomia at 6 and 12 months post-HCT. In addition, stimulated whole mouth saliva was collected several times. Linear regression models and longitudinal mixed-effects models were created to investigate the influence of risk indicators on xerostomia. A total of 99 autologous and 163 allogeneic HCT recipients were included from 6 study sites in Sweden, Canada, the Netherlands, and the United States. The prevalence of xerostomia was 40% before the conditioning regimen, 87% early post-HCT, and 64% at 3 months post-HCT. Complaints after autologous HCT were transient in nature, while the severity of xerostomia in allogeneic HCT recipients remained elevated at 12 months post-HCT. Compared to autologous HCT recipients, allogeneic HCT recipients experienced 1.0 point more xerostomia (95% confidence interval [CI], .1 to 2.0) early post-HCT and 1.7 points more (95% CI, .4 to 3.0) at 3 months post-HCT. Allogeneic HCT recipients receiving a high-intensity conditioning regimen experienced more xerostomia compared to those receiving a nonmyeloablative or reduced-intensity conditioning regimen. The difference was 2.0 points (95% CI, 1.1 to 2.9) early post-HCT, 1.8 points (95% CI, .3 to 3.3) after 3 months, and 1.7 points (95% CI, .0 to 3.3) after 12 months. Total body irradiation as part of the conditioning regimen and oral mucosal changes related to cGVHD did not significantly influence the severity of xerostomia. Conditioning regimen intensity was a significant risk indicator in the development of xerostomia, whereas total body irradiation was not. Allogeneic HCT recipients experienced more xerostomia than autologous HCT recipients, a difference that cannot be explained by a reduction in stimulated salivary flow rate or the development of oral mucosal changes related to cGVHD.
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Affiliation(s)
- Marjolein S Bulthuis
- Radboud University Medical Center, Department of Dentistry, Nijmegen, The Netherlands.
| | | | - Renske Z Thomas
- Radboud University Medical Center, Department of Dentistry, Nijmegen, The Netherlands
| | - Lucky L A van Gennip
- Radboud University Medical Center, Department of Dentistry, Nijmegen, The Netherlands
| | - Heidi M Whiteside
- Wake Forest University School of Medicine, Division of Public Health Sciences, Department of Biostatistics and Data Science, Winston-Salem, North Carolina
| | - Scott Isom
- Wake Forest University School of Medicine, Division of Public Health Sciences, Department of Biostatistics and Data Science, Winston-Salem, North Carolina
| | - David M Kline
- Wake Forest University School of Medicine, Division of Public Health Sciences, Department of Biostatistics and Data Science, Winston-Salem, North Carolina
| | - Alexa M G A Laheij
- Department of Oral Medicine, Academic Centre for Dentistry Amsterdam, University of Amsterdam and VU University, Amsterdam, The Netherlands; Department of Oral, Maxillofacial Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Judith E Raber-Durlacher
- Department of Oral Medicine, Academic Centre for Dentistry Amsterdam, University of Amsterdam and VU University, Amsterdam, The Netherlands; Department of Oral, Maxillofacial Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bengt Hasséus
- Department of Oral medicine and Pathology, Institute of Odontology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jan-Erik Johansson
- Department of Hematology and Coagulation, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Allan J Hovan
- Oral Oncology and Dentistry, British Columbia Cancer, Vancouver, British Columbia, Canada
| | - Michael T Brennan
- Department of Oral Medicine/Oral & Maxillofacial Surgery, Atrium Health Carolinas Medical Center, Charlotte, North Carolina; Department of Otolaryngology/Head & Neck Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Inger von Bültzingslöwen
- Department of Oral Microbiology and Immunology, Institute of Odontology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Nicole M A Blijlevens
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
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Tollemar V, Garming Legert K, Sugars RV. Perspectives on oral chronic graft-versus-host disease from immunobiology to morbid diagnoses. Front Immunol 2023; 14:1151493. [PMID: 37449200 PMCID: PMC10338056 DOI: 10.3389/fimmu.2023.1151493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023] Open
Abstract
Chronic Graft-versus-Host Disease (cGVHD) is a major long-term complication, associated with morbidity and mortality in patients following allogenic hematopoietic cell transplantation (HCT) for immune hematopoietic disorders. The mouth is one of the most frequently affected organs after HCT (45-83%) and oral cGVHD, which may appear as the first visible sign. Manifestations present with mucosal lichenoid lesions, salivary gland dysfunction and limited oral aperture. Diagnosis of oral cGVHD severity is based on mucosal lesions with symptoms of sensitivity and pain and reduced oral intake. However, diagnostic difficulties arise due to subjective definitions and low specificity to cover the spectrum of oral cGVHD. In recent years there have been significant improvements in our understanding of the underlying oral cGVHD disease mechanisms. Drawing upon the current knowledge on the pathophysiology and biological phases of oral cGVHD, we address oral mucosa lichenoid and Sjogren's Syndrome-like sicca syndromes. We consider the response of alloreactive T-cells and macrophages to recipient tissues to drive the pathophysiological reactions and biological phases of acute inflammation (phase 1), chronic inflammation and dysregulated immunity (phase 2), and subsequent aberrant fibrotic healing (phase 3), which in time may be associated with an increased malignant transformation rate. When formulating treatment strategies, the pathophysiological spectrum of cGVHD is patient dependent and not every patient may progress chronologically through the biological stages. As such there remains a need to address and clarify personalized diagnostics and management to improve treatment descriptions. Within this review, we highlight the current state of the art knowledge on oral cGVHD pathophysiology and biological phases. We address knowledge gaps of oral cGVHD, with a view to facilitate clinical management and improve research quality on lichenoid biology and morbid forms of oral cGVHD.
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Affiliation(s)
| | | | - Rachael V. Sugars
- Division of Oral Diagnostics and Rehabilitation, Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden
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