Frequency of Pathologic Changes in the Oral Cavity in Patients Subjected to Long-term Pharmacologic Immunosuppressive Therapy After Kidney, Liver, and Hematopoietic Cell Transplantation

Caries, periodontitis and tooth loss after haematopoietic stem cell transplantation: A systematic review

OBJECTIVE

A systematic review was conducted to assess scientific knowledge concerning the effect of haematopoietic stem cell transplantation (HSCT) on the occurrence of caries, periodontal conditions and tooth loss, and to evaluate the prevalence of these diseases in adult HSCT survivors (PROSPERO 152906).

METHODS

PubMed and Embase were searched for papers, published from January 2000 until November 2020 without language restriction, assessing prevalence, incidence or parameters of caries, periodontal conditions and tooth loss in HSCT recipients (≥80% transplanted in adulthood). Bias risk was assessed with checklists from Joanna Briggs Institute, and data synthesis was performed by narrative summary.

RESULTS

Eighteen papers were included (1618 subjects). Half were considered at high risk of bias. Longitudinal studies did not show caries progression, decline in periodontal health or tooth loss after HSCT. The prevalence in HSCT survivors ranged from 19% to 43% for caries, 11% to 67% for periodontitis, and 2% to 5% for edentulism. Certainty in the body of evidence was very low.

CONCLUSIONS

Haematopoietic stem cell transplantation, on the short term, may have little to no effect on caries, periodontal conditions and tooth loss. Caries and periodontitis may be more common in HSCT survivors compared with the general population, whereas edentulism may be comparable. However, the evidence for all conclusions is very uncertain.

Etiological diagnosis of macroglossia: Systematic review and diagnostic algorithm

BACKGROUND

The objective of this literature review was to list the different etiologies of macroglossia reported in the literature, to identify characteristics that might guide diagnosis, and to create a diagnostic algorithm.

METHODS

The bibliographic search was carried out between October 2019 and July 2020 in the PubMed research base using the keywords "macroglossia" (MESH) and/or "tongue enlargement".

RESULTS

Of the 1711 references identified, 615 articles were excluded, and 1096 abstracts were reviewed. We classified the different etiologies identified according to their mechanism and whether they were congenital or acquired. The etiologies are divided into the following categories: genetic malformation syndromes, non-syndromic congenital malformations, endocrinopathies, neuromuscular diseases, storage disorders, infectious, inflammatory, traumatic, and iatrogenic diseases.

CONCLUSION

Based on this review, we propose a diagnostic algorithm for macroglossia according to the characteristics described. The most common diagnoses among acquired causes were amyloidosis (13.7%), endocrinopathies (8.8%), myopathies (4%) and tongue tumors (6.7%). The most common congenital causes were aneuploidy, lymphatic malformations, and Beckwith-Wiedemann syndrome, which is the main cause of congenital macroglossia, even if it appears isolated.

Atypical oral viral coinfection after allogeneic hematopoietic stem cell transplantation: Diagnosis and treatment challenge

BACKGROUND

Viral reactivation in patients undergoing immunosuppressive therapy after hematopoietic stem cell transplantation (HSCT) is a serious complication associated with significant morbidity and mortality. Infections caused by human herpes viruses such as herpes simplex virus (HSV), cytomegalovirus (CMV), and Epstein-Barr virus (EBV) can result in oral lesions.

CASE PRESENTATION

A 40-year-old male patient who had undergone HSCT presented with ulcerated lesions in different areas of the mouth, for 7 months. The lesions had evolved to painful exophytic nodules with an erythematous, ulcerated surface. They were present on the tongue margins and soft and hard palate. Histological, immunohistochemical (IHC), and polymerase chain reaction analyses were performed, and the results were compatible with HSV-1 and -2 and CMV infections. Treatment comprised five sessions of antimicrobial photodynamic therapy (aPDT) and oral valganciclovir. Thirty days after combined antiviral therapy and aPDT, the lesions were completely resolved. Patient was followed up for 12 months without recurrence.

CONCLUSION

Diagnosis and treatment of atypical oral infections in immunosuppressed patients is challenging. Assessment of both clinical and laboratory findings is mandatory for a conclusive diagnosis. The use of local antimicrobial and systemic therapies contributes to positive clinical response in such cases.

Presence of Trichomonas spp. in oral ulcerations of a patient with kidney transplant. A case report

Mucosal ulcerations are an oral complication that can often affect kidney transplant patients, mostly due to the effect of immunosuppression. It has been frequently reported drug-induced ulceration or lymphoproliferative disorders with buccal manifestations however, some unusual disorders should also be considered, such as fungal infections, viruses, as well as opportunistic infection by other microorganisms. Determining the etiology and differential diagnose from other causes of mouth ulcers is very important for the adequate treatment of said lesion. Dental health of patients should also be taken into the account prior to the transplant surgery, since periodontal pockets are the main niche of microbial reservoir. Moreover, mixed with oral microbiota, parasites such as Trichomonas spp. can be found in the dental plaque of patients with periodontal disease. Particularly, Trichomonas spp. are anaerobic motile-flagellated protozoa that can both induce tissue damage and exacerbate preexistent injuries in vaginal and oral mucosa. Parasitic infection in the oral cavity has not been well studied and it is thought to be underreported. In the present study we report the first case in literature of presence of Trichomonas spp. as a potential etiological factor of the oral ulcerations of a kidney transplanted patient that remitted after antibiotic treatment.

Key words:Immunosuppression, protozoan, buccal lesion, oral mucosa, kidney transplant.

Preliminary Clinical Data and the Comparison of the Safety and Efficacy of Autogenous Bone Grafts Versus Xenograft Implantations in Vertical Bone Deficiencies Before Dental Implant Installation

Two different techniques of vertical bone augmentation were compared to apply them to immunocompromised patients. One of them used autogenous bone graft; the other used xenograft. Thirty patients were involved in the study. Fifteen received autogenous ring shape grafts harvested from the mental region, and 15 received xenograft vertical tunnel augmentation. They have a total of 60 implants placed in the posterior region of the mandible (2 for each patient). Fixed full ceramic crowns were delivered. Two-year follow-up appointments after implant placement were made. Both autogenous bone grafts and xenografts showed similar long-term clinical regeneration outcome of vertical bone defects. Using autogenous bone rings simultaneously fixed by dental implants, the total treatment time and cost were shortened, but the traumatic reactions and complication rates were higher when compared to xenograft vertical tunnel augmentation. Due to the less traumatic character of the procedure, smaller complication rates and higher safety for the patients receiving chronic immunosuppression should avoid bone block augmentation and reap the benefits from vertical tunnel bone augmentation using xenograft materials.

New Surgical Technique Using Xenograft as a Microinvasive Method to Avoid Extensive Bone Reconstruction in Patients With Compromised General Health: Promising Surgical Methodology and First Clinical Results

The innovative microinvasive immediate implantation technique of dental implants insertion was described. The technique uses bovine xenograft material to restore the bone defect resulting from teeth pathologies and subsequent extraction. Ten patients had extractions of their premolar upper teeth and immediate implantations with xenograft socket augmentation. This unique procedure allowed primary stability of implant above 70 implant stability quotient in all cases. All of the implants healed without complications and were restored with screwed ceramic crowns. Two-year uneventful follow-ups confirmed alveolar xenograft condensation technique as a microinvasive and safe technique, especially for patients with compromised general health who may not undergo complicated restorative operations.

Differences in the Incidence of Pathologic Lesions on the Oral Mucosa in Patients Undergoing Hemodialysis vs Renal Organ Transplant Recipients Subjected to Long-term Pharmacologic Immunosuppressive Therapy

Disorders of homeostasis and an increased incidence of infection in patients undergoing hemodialysis causes frequent appearance of pathologic changes in the oral mucosa. The organ transplant and subsequent pharmacologic immunosuppression may result in systemic disorders manifesting by pathologic oral lesions.

METHODS

The study was conducted on 18 patients undergoing hemodialysis and 18 patients after renal transplant. The study comprised case taking and physical examination, including detailed intraoral and extraoral examination.

RESULTS

The intraoral examination revealed gingivitis in 61.1% of patients in both groups. In the renal transplant group compared with the hemodialysis group 55.6% vs 38.9% of patients had gingival recession, 55.6% vs 44.4% had periodontitis, 27.8% vs 22.2% had macroglossia, and 11.1% vs 5.6% had geographic tongue, respectively. In the patients on hemodialysis leukoplakia and pallor or pathologic pigmentation of oral mucosa were more frequently observed lesions. Other significant findings in the renal transplant group were lingual papillary atrophy, aphthae, and erythroplakia. Patients of both group reported xerostomia, halitosis, gum bleeding, dysgeusia in their history.

DISCUSSION

Both groups of patients after renal transplant and patients undergoing hemodialysis presented pathologic lesions in the oral cavity. The study revealed the differences between type and frequency of these pathologic changes, which shows different effect of the above methods of treatment of end-stage renal failure on the oral cavity.

Unusual oral presentation of HSV-1 lesions in an adult liver transplant recipient

Herpes Simplex Virus (HSV) hepatitis in liver transplant patients is a rarely reported infective complication of HSV with severe consequences, often leading to fulminant hepatitis if left untreated. The clinical signs are often atypical, leading to under-reporting in the literature and potential delays in treatment. Our case report describes such atypical mucocutaneous lesions in a liver transplant recipient. We highlight the need for further reports, especially those with images, in order to aid the diagnosis of HSV infection, and to allow prompt treatment to prevent complications such as HSV hepatitis.