Long-term oral complications of allogeneic haematopoietic SCT

Oral complications in a paediatric graft versus host disease (GVHD) clinic: A retrospective study

OBJECTIVE

The aim of this study was to investigate the oral health status among allogeneic transplant recipients who were seen in a multidisciplinary graft-versus-host disease paediatric clinic at the University of California, San Francisco (UCSF).

METHODS

This was a retrospective cohort study of patients who underwent allogeneic transplants and were seen in the graft-versus-host disease paediatric clinic between January 2010 and September 2021. Demographic, medical and oral health data were recorded and analysed using descriptive statistics.

RESULTS

A total of 25 patients were seen in the paediatric graft-versus-host disease clinic (68% males) with a median age of 12 years at the time of transplant were included. Among them, 12 patients (48%) were diagnosed with oral chronic GVHD, 11 (44%) with dry mouth, four (16%) with oral pseudomembranous candidiasis, one (4%) with recrudescent Herpes Simplex Virus (HSV) infection and one (4%) with mammalian target of rapamycin-inhibitor stomatitis and were managed by the oral medicine team, accordingly with medications, such as topical steroids (44%) and anti-fungal (20%).

CONCLUSIONS

HSCT recipients may present with a variety of oral complications. Patients may benefit by a multi-disciplinary approach including a dental specialist as part of the cancer care team.

Subjective Oral Dryness following Hematopoietic Cell Transplantation: A Report from the Orastem Study

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.

The effect of conditioning regimen and prescribed medications on hyposalivation in haematopoietic cell transplantation (HCT) patients: an 18-month prospective longitudinal study

OBJECTIVES

Haematopoietic cell transplantation (HCT) preceded by a conditioning regimen is an established treatment option for (non)malignant haematologic disorders. We aim to describe the development of hyposalivation over time in HCT recipients, and determine risk indicators.

MATERIALS AND METHODS

A multi-centre prospective longitudinal observational study was conducted. Unstimulated (UWS) and stimulated (SWS) whole saliva was collected before HCT, early post-HCT, and after 3, 6, 12, and 18 months. The effect of type of transplantation (allogeneic vs autologous) and intensity (full vs reduced) of the conditioning regimen on hyposalivation (UWS < 0.2 mL/min; SWS < 0.7 mL/min) was explored.

RESULTS

A total of 125 HCT recipients were included. More than half of the patients had hyposalivation early post-HCT; a quarter still had hyposalivation after 12 months. The conditioning intensity was a risk indicator in the development of hyposalivation of both UWS (OR: 3.9, 95% CI: 1.6-10.6) and SWS (OR: 8.2, 95% CI: 2.9-24.6). After 3 and 12 months, this effect was not statistically significant anymore.

CONCLUSIONS

Hyposalivation affects the majority of patients early post-HCT. The conditioning intensity and the type of transplantation were significant risk indicators in the development of hyposalivation. The number of prescribed medications, total body irradiation as part of the conditioning regimen and oral mucosal graft-versus-host disease did not influence hyposalivation significantly.

CLINICAL RELEVANCE

Because of the high prevalence of hyposalivation, HCT recipients will have an increased risk of oral complications. It might be reasonable to plan additional check-ups in the dental practice and consider additional preventive strategies.

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.

The effect of hematopoietic stem cell transplantation on patient-reported subjective oral dryness: a systematic review focusing on prevalence, severity and distress

OBJECTIVE

The aim of the present systematic review is to assess the prevalence and severity of and distress caused by xerostomia over time in adult hematopoietic stem cell transplantation (HSCT) recipients.

METHODS

PubMed, Embase, and the Cochrane Library were searched for papers published between January 2000 and May 2022. Clinical studies were included if patient-reported subjective oral dryness was reported in adult autologous or allogeneic HSCT recipients. Risk of bias was assessed according to a quality grading strategy published by the oral care study group of the MASCC/ISOO, resulting in a score between 0 (highest risk of bias) and 10 (lowest risk of bias). Separate analysis focused on autologous HSCT recipients, allogeneic HSCT recipients receiving a myeloablative conditioning (MAC), and those receiving a reduced intensity conditioning (RIC).

RESULTS

Searches yielded 1792 unique records; 22 studies met the inclusion criteria. The quality scores ranged between 1 and 7, with a median score of 4. The prevalence, severity, and distress of xerostomia increased shortly after HSCT. Severity of xerostomia in allogeneic MAC recipients was higher compared to allogeneic RIC recipients 2-5 months post-HSCT (mean difference: 18 points on 0-100 scale, 95% CI: 9-27); after 1-2 years, there was no significant difference anymore.

CONCLUSION

The prevalence of xerostomia in HSCT recipients is high in comparison to the general population. The severity of complaints is raised during the first year post-HSCT. The intensity of the conditioning plays a key role in the short-term development of xerostomia, while factors affecting the recovery in the long term remain largely unknown.

Perspectives on oral chronic graft-versus-host disease from immunobiology to morbid diagnoses

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.

Oral health status after hematopoietic stem cell transplantations: Outcomes from an adult Italian population

AIM

To describe oral cavity changes in patients who underwent a hematopoietic stem cell transplantation (HSCT).

METHODS AND RESULTS

A group of 32 patients was studied after a mean period of 48.8 months (±11.22) from HSCT; oral, dental, and periodontal status were collected and compared with those of healthy matched controls. Unstimulated whole salivary flow (UWS) and salivary pH were also measured. A validated questionnaire (EORTC QLQH&N-35) was used for reported quality of life. Fifty-nine percent of patients were affected by chronic graft-versus-host disease (cGVHD). Dental health and periodontal status were statistically worse than in controls (P = .003 and P = .008, respectively). Regarding the HSCT group, UWS was statistically lower, and EORTC QLQH&N-35 significantly higher than those reported in controls (P = .000 for both). There was no statistical correlation between hypo-salivation and conditioning, presence of cGVHD, type of medication used before and after transplantation, and time of follow-up. A reduction in salivary pH has been noted only for patients with erosive oral lesions.

CONCLUSION

The oral cavity of HSCT patients appeared to undergo substantial modifications and the quality of life was deeply compromised.

Oral chronic GVHD after allogeneic stem cell transplantation without total body irradiation performed at a young age

Purpose

Long-term survivors (LTSs) of allogeneic hematopoietic stem cell transplantation (allo-HCT) may experience oral long-term effects like chronic graft-versus-host disease (oral cGVHD). The aim of this study was to investigate oral cGVHD in patients treated at a young age (< 30 years) more than 5 years after allo-HCT without total body irradiation (TBI).

Methods

All 94 participants went through a semi-structured interview, and an oral examination. Diagnosis of oral cGVHD was based on the “National Institutes of Health (NIH) cGVHD diagnosis and staging consensus criteria” from 2014.

Results

Mean age at transplantation was 17.5 years (range 0.4–29.9 years), and mean time since transplantation was 16.7 years (range 6–26 years). Oral cGVHD was diagnosed in 26 (28%) of 94 LTSs. Of which 20 (21.5%) showed lichen planus-like (LPL) changes, and additionally six (6.5%) also fulfilled the diagnostic criteria of oral cGVHD since they had one or more distinctive signs and symptoms of oral cGVHD combined with definite cGVHD in another organ. No LTSs reported oral cGVHD (NIH) grade 3. There was a significant association between cGVHD in the oral cavity and cGVHD in another organ (77% vs 29%, p < 0.001). Out of 72 LTSs, who answered the questions regarding taste disturbances, 16 (22%) reported dysgeusia. No LTSs developed secondary malignancies in the oral cavity during follow-up time.

Conclusion

Oral long-term effects, such as oral cGVHD, may persist for many years after allo-HCT without TBI-conditioning in patients treated at a young age.

The oral histopathological and immunological characteristics of a xenogeneic mouse chronic graft-versus-host disease model

BACKGROUND

Oral lesions are important clinical manifestations of chronic graft-verse-host disease (cGVHD). However, the oral characteristics of cGVHD mouse model are not yet clear. This study aims to demonstrate oral histopathological and immunological characteristics of a xenogeneic cGVHD mouse model.

MATERIALS AND METHODS

2.5 × 10⁶ , 5.0 × 10⁶ , 7.5 × 10⁶ , and 10.0 × 10⁶  human peripheral blood mononuclear cells (hPBMCs) were intravenously transplanted into NCG mice to induce cGVHD. After transplantation, clinical observations were recorded. Tissue samples from salivary glands and oral mucosa were stained with H&E, Masson Trichrome, and immunofluorescence, and the histopathology of oral tissues was scored according to our modified criteria.

RESULTS

NCG mice showed signs of cGVHD onset after transplantation. The oral histopathological lesion incidences in each group were 37.50%, 50.00%, 62.50%, and 75.00%, respectively. Oral histopathological lesion incidence and histopathological scores were positively correlated with the amount of infused hPBMCs. Epithelial atrophy, epithelial cells vacuolar degeneration, and basal cells liquefaction denaturation were observed in oral mucosa, and acinar destruction and collagen deposition were observed in the salivary glands. Human CD45⁺ , CD4⁺ , CD8⁺ , IL-17⁺ , and FoxP3⁺ cells infiltrated into oral tissues. In the 5.0 × 10⁶  hPBMCs group, oral histopathological changes mainly began between days 30 and 45 post-transplantation, and became more severe after day 45. The oral histopathological scores also gradually increased.

CONCLUSION

Inflammation in oral mucosa epithelium and salivary glands, and CD4⁺ and CD8⁺ T cells dominating infiltration are the main oral features in the xenogeneic cGVHD mouse model. The severity of oral histopathological lesions shows a dose and time correlation. These may be helpful to oral cGVHD research.

Late Post-Operative Occurrence of Dentin Hypersensitivity in Adult Patients Following Allogeneic Hematopoietic Stem Cell Transplantation-A Preliminary Report

Allogeneic hematopoietic stem cell transplantation (alloHSCT) is one of the most commonly performed transplantation procedures nowadays. Despite the significant progress made in the treatment, alloHSCT is still associated with numerous complications also affecting the oral cavity. One of them is dentin hypersensitivity (DH)-a sharp, short-term pain that occurs when stimuli act on exposed dentin. Various authors point out that DH may result in a significantly lower quality of life, among other things by impeding the consumption of food as well as causing difficulties in daily oral hygiene. The aim of the study was a preliminary analysis of the incidence rate and severity of DH pain in adult patients during late period after alloHSCT. The impact of chronic graft-versus-host disease (cGvHD) and time after alloHCT were also considered. A total of 80 patients were examined. cGvHD was identified in 52 participants. The incidence rate and severity of DH pain was assessed on the basis of a questionnaire and a clinical examination. DH pain appeared a serious problem in late period after alloHSCT regardless of post-transplant time. DH primarily affected cGvHD patients. The prevention-treatment protocol for DH should be developed for this group.

Oral chronic graft-versus-host disease: What the general dental practitioner needs to know

BACKGROUND

Long-term survivors of allogeneic hematopoietic cell transplantation will increasingly seek care from dental providers.

METHODS

The authors highlight the importance of minimizing oral symptoms and complications associated with oral chronic graft-versus-host-disease (cGVHD).

RESULTS

Chronic GVHD is the result of an immune response of donor-derived cells against recipient tissues. Oral cGVHD can affect the mucosa and damage salivary glands and cause sclerotic changes. Symptoms include sensitivity and pain, dry mouth, taste changes, and limited mouth opening. Risk of developing caries and oral cancer is increased. Food intake, oral hygiene, and dental interventions can represent challenges. Oral cGVHD manifestations and dental interventions should be managed in close consultation with the medical team, as systemic treatment for cGVHD can have implications for dental management.

CONCLUSIONS

General dental practitioners can contribute substantially to alleviating oral cGVHD involvement and preventing additional oral health deterioration.

PRACTICAL IMPLICATIONS

Frequent examinations, patient education, oral hygiene reinforcement, dry mouth management, caries prevention, and management of dental needs are indicated. In addition, oral physical therapy might be needed. Invasive dental interventions should be coordinated with the transplantation team. Screening for oral malignancies is important even years after resolution of GVHD symptoms. Management of the oral manifestations of cGVHD might require referral to an oral medicine professional.

Evaluation of treatment response in oral chronic graft-versus-host patients by power doppler ultrasound: a prospective study

OBJECTIVE

To date, imaging and non-invasive examination methods for evaluating the oral tissue of patients who with oral chronic graft-versus-host disease (GVHD) are still lacking. Herein, we assessed the ultrasonography imaging characteristics of chronic GVHD patients' buccal soft tissue and evaluated the response to treatment using gray-scale and power Doppler (PD) ultrasound. The overall objective of the study was to determine the potential of ultrasonography to provide an early and objective indication of a therapeutic response to treatment intervention in oral chronic GVHD.

METHODS

Buccal mucosa in 21 patients with clinically diagnosis of oral chronic GVHD were assessed before and after 14 day treatment between 2016 and 2018. Ultrasonography assessment included thickness and echogenicity evaluation, and PD. Echogenicity and PD were measured and scored according to a semi-quantitative method. Ultrasonography parameters were compared with clinical activity assessments of disease activity and patient-reported measures.

RESULTS

Following 14 day therapy, a significant decrease in PD scores and patient-reported measures was observed (p < 0.01), and clinical assessment scores also decreased (p < 0.05). Changes from baseline PD scores correlated significantly with patient-reported measures (r = 0.85, p < 0.01). Changes in PD scores correlated moderately with the changes in the clinical assessments from baseline (r = 0.46, p < 0.05). A significant decrease in PD scores was observed in the buccal soft tissue of patients that responded clinically to the treatment. A significant decrease in PD scores was also observed in patients that were failed to show clinical improvement (p < 0.05).

CONCLUSION

Ultrasonography is a novel and feasible imaging technique for measurement of the response of oral chronic GVHD to therapy. Ultrasonography yields additional information about buccal mucosa and is a complementaty to clinical examination.

Oral disorders in patients with newly diagnosed haematological diseases

OBJECTIVE

This study aimed to examine saliva flow rates and prevalence of dental and periodontal diseases of patients with newly diagnosed severe haematological diseases and compare these findings with age-matched controls of normal population.

METHODS

A total of 149 patients diagnosed with haematological diseases aimed to be treated with haematological stem cell transplantation between 2008 and 2018 and 154 controls were included in the study. A dental examination was performed for patients within a maximum of 6 months after diagnosis. Differences were compared in terms of the stimulated salivary flow rate (SSFR); decayed, missing and filled teeth (DMFT) index; number of teeth; caries prevalence; presence of periodontitis and acute infections.

RESULTS

The mean SSFR of the patient group was significantly lower (1.1 ml/min ± 0.7 ml/min) than the mean SSFR of the controls (1.3 ml/min ± 0.5 ml/min; p = 0.004). The number of caries lesions was significantly higher in the patient group (mean ± SD, 1.1 ± 1.9) than in the control group (mean ± SD, 0.4 ± 1.2; p < 0.001). There were fewer teeth and a higher DMFT index in the patient group compared to the control group, but the differences were not significant. Acute symptomatic infections were observed in eight (5.4%) patients and in none of the controls (p < 0.01).

CONCLUSIONS AND CLINICAL RELEVANCE

Oral examinations in patients with newly diagnosed severe haematological disease demonstrated a higher prevalence of caries, acute infections and lower mean SSFR compared with the controls. These findings support the recommendations for early dental examination at the time of diagnosis.

Dissociations of oral foci of infections with infectious complications and survival after haematopoietic stem cell transplantation

Introduction

Haematopoietic stem cell transplantation (HSCT) recipients are at increased risk for severe infections. This study examined the associations of common oral infections with survival and infectious complications in HSCT recipients.

Materials and methods

All autologous and allogeneic HSCT recipients transplanted in the University Hospital of Basel, Switzerland, between 2008 and 2016 and referred to oral infection control pre-HSCT were included in this retrospective case-control study. All patients had a clinical and a panoramic radiological dental examination taken immediately prior to HSCT. Presence of acute or chronic oral foci of infections, decayed, missing or filled tooth index (DMFT) and radiological attachment loss (RAL) were examined. Survival and infections of the subjects were followed up for 6 months post-HSCT.

Results

Altogether 341 allogeneic and 125 autologous HSCT recipients were included in the study. Within 6 months post-HSCT, 47 (14%) of the allogeneic and 4 (3%) of the autologous recipients died. Oral foci of infections (acute or chronic), DMFT or periodontitis pre-HSCT were not associated with survival 6 months post-HSCT. Oral foci of infections were also not associated with hospital treated infectious diseases or blood culture positive bacteremia during the 6 month follow-up period. Untreated oral foci of infections were not associated with survival or severe infectious complications within 6 months post-HSCT.

Conclusion

The results of this study suggest that radical dental interventions to chronic oral infections could be postponed until post-HSCT.

HPV-related oral dysplasia in a multiple myeloma patient after stem cell transplantation

The development of dysplastic changes in oral epithelial lesions is a potential long-term complication after hematopoietic stem cell transplantation (HSCT). This may be related to mechanisms including radiation and chemotherapy regimens, chronic graft-versus-host disease (cGVHD), inflammation, and prolonged immunosuppression. The current case describes a 54-year-old male with multiple myeloma treated by autologous and allogenic HSCT followed by development of cGVHD (mouth, skin and the eyes) with the complaint of diffuse white lesions on the buccal mucosa, tongue, and palate. A biopsy performed with histopathological analysis revealed moderate to severe epithelial dysplasia with hyperkeratosis, positive for p16INK4A as a surrogate marker for human papillomavirus (HPV). Our finding suggests a possible association of oral dysplasia and HPV in patients after receiving allogenic HSCT with the necessity of more clinical follow-ups for those patients that may be at a higher risk for the development of oral dysplasia associated with HPV.

Two Cases and a Review of Graft-Versus-Host Disease and the Role of Hepatitis C Treatment in Liver Transplant Patients

Graft-versus-host disease (GvHD) is a rare but fatal complication after solid organ transplantation arising in 1% to 2% of cases. We report 2 cases of GvHD after orthotopic liver transplantation. Both patients had a history of hepatitis C virus (HCV) infection prior to transplantation. Both cases presented between 1 and 4 months after transplantation with rash, pancytopenia, and/or diarrhea. Our second case also developed oral and ocular manifestations after liver transplantation, which are more commonly described after stem cell transplantation. Diagnosis in both cases was made by clinical presentation in conjunction with histopathology and flow cytometry. Both patients were treated by increasing immunosuppression with tacrolimus and high-dose steroids. Response to treatment differed based on the degree of pancytopenia. Our case report is distinguished by several factors such as the context of GvHD presentation and the role of HCV treatment. Diagnosis of GvHD is difficult and often delayed due to nonspecific presentation that overlaps with other conditions. Furthermore, the relation between HCV treatment and potential initiation of GvHD in solid organ transplant patients is unclear.

Oral health and dental morbidity in long-term allogeneic blood and marrow transplant survivors in Australia

BACKGROUND

Oral and dental disease is a major cause of long-term morbidity following allogeneic blood and marrow transplantation (Allo-BMT). This study aimed to describe the extent and range of oral and dental complications in BMT recipients and to identify gaps in service provision provided to this high-risk group.

METHODS

Participants were Allo-BMT recipients, aged >18 years, and received transplants between 2000 and 2012 in NSW. They completed seven surveys, the purpose-designed Sydney Post-BMT Study survey and six other validated instruments.

RESULTS

Of 441 respondents, many reported dry mouth (45.1%), dental caries (36.7%), mouth ulcers (35.3%), oral GVHD (35.1%), gingivitis (16.2%), tooth abscess (6.1%) and oral cancer (1.5%). Regular dental visits were reported by 66.2% of survivors. Middle-high income, older age and geographic location showed a positive association with regular dental visits. Of those who did not visit the dentist regularly, 37% stated they did not feel it necessary, 36% reported cost and 20% stated it was not advised by the treating team.

CONCLUSION

Despite oral complications commonly occurring after Allo-BMT, many survivors receive inadequate dental care. These results emphasize the need for improved oral health education, the importance of regular dental checks and improvement in the delivery of dental health services for BMT survivors.

Chemosensory changes and quality of life in patients undergoing hematopoietic stem cell transplantation

PURPOSE

To assess magnitude and characteristics of changes in chemosensory function and quality of life (QOL) for patients receiving hematopoietic stem cell transplantation (HSCT).

METHODS

Patients (aged 18 years and above) scheduled to undergo HSCT at the Seattle Cancer Care Alliance were tested for chemosensory function at three time points: pre-transplant (baseline), 30 ± 5 days (day 30), and 80 ± 5 days (day 80) post-HSCT. Gustatory function was assessed following procedures developed at the Monell-Jefferson Taste and Smell Clinic. Olfactory testing was conducted using the National Institute of Health Toolbox Odor Identification test. QOL was also assessed.

RESULTS

Twenty-nine patients were enrolled in the study between August 2014 and March 2015. Twenty-three patients were included in the analysis, with 16 tested at all three time points (baseline, day 30, and day 80). The primary finding is decreased taste sensitivity for 0.32 M NaCl, 0.0056 M citric acid, and 0.018 M citric acid on day 30 following HSCT. Increased taste sensitivity for 0.32 M sucrose at day 30 was also observed. Taste sensitivity largely recovered by day 80. Olfactory identification scores were unchanged from baseline to day 30. QOL was reduced at day 30 but was restored to an acceptable level of functioning and symptoms by day 80. However, some areas remain impaired.

CONCLUSIONS

Alterations in taste perception were confirmed in the early post-transplant period. This was largely resolved within 2.5 months. No obvious impairments were observed in olfactory function. QOL improved by day 80, though some oral symptoms lingered.

Economic and Practical Considerations in the Treatment of Oral Mucosal Chronic Graft-Versus-Host Disease

Chronic graft-versus-host disease (cGVHD) frequently affects the oral mucosa and is generally responsive to topical immunomodulatory therapies. Clinicians may benefit from guidance in choosing the most appropriate therapy with respect to practicality and cost. To assess the economic considerations related to topical immunomodulatory treatments for management of oral mucosal cGVHD and their practical implications. Topical treatments used for management of oral cGVHD were obtained from the National Institutes of Health Consensus document for ancillary and supportive care. Cost data for a standard 1-month prescription was obtained from national databases for commercially available formulations and from compounding pharmacies for formulations requiring compounding. There are numerous topical preparations used for the management of oral cGVHD, many of which require compounding. The average wholesale price of the commercially available agents ranges from $5 to $277/month, and the cost of the compounded preparations ranges from $43 to $499/month. Costs can be influenced by drug-, patient-, and pharmacy-related factors. The costs associated with topical treatment of oral cGVHD are substantial, particularly because the disease is chronic and expenses accumulate over time. Rational prescribing according to a proposed algorithm, including de-escalation of therapy when indicated, can help to minimize associated costs. This has practical implications for patients, physicians, pharmacies, and insurance providers.

Determinants of stimulated salivary flow among haematopoietic stem cell transplantation recipients

OBJECTIVES

The aetiology of hyposalivation in haematopoietic stem cell transplantation (HSCT) recipients is not fully understood. This study examined the effects of treatment-related aetiological factors, particularly medications, on stimulated salivary flow in HSCT recipients.

SUBJECTS AND METHODS

Adult HSCT recipients (N = 118, 66 males, 27 autologous and 91 allogeneic transplants) were examined. Stimulated whole salivary flow rates (SWSFR) were measured before HSCT and at 6 and 12 months post-HSCT. Linear regression models were used to analyse the associations of medications and transplant-related factors with salivary flow rates, which were compared to salivary flow rates of generally healthy controls (N = 247).

RESULTS

The SWSFR of recipients were lower pre-HSCT (mean ± standard deviation, 0.88 ± 0.56 ml/min; P < 0.001), 6 months post-HSCT (0.84 ± 0.61; P < 0.001) and 12 months post-HSCT (1.08 ± 0.67; P = 0.005) than the SWSFR of controls (1.31 ± 0.65). In addition, hyposalivation (<0.7 ml/min) was more frequent among HSCT recipients pre-HSCT (P < 0.001), 6 months post-HSCT (P < 0.001) and 12 months post-HSCT (P = 0.01) than among controls. The SWSFR was observed to improve over time being significantly higher 12 months post-HSCT compared to pre-HSCT (P < 0.001). The observed decrease of salivary flow could not be explained by the examined transplant-related factors and medications.

CONCLUSIONS

Decreased stimulated salivary flow rates could not be explained by the examined factors alone; these findings indicate that hyposalivation in HSCT recipients exhibits a multifactorial aetiology.

CLINICAL RELEVANCE

All HSCT recipients should be considered to be at high risk of hyposalivation and consequent oral diseases, and they should be treated accordingly.

Oral chronic GVHD outcomes and resource utilization: a subanalysis from the chronic GVHD consortium

OBJECTIVES

This study evaluated the extent to which oral chronic graft-versus-host disease (cGVHD) consensus assessments are predictive of management across institutions with and without oral medicine (OM) centers, and whether ancillary care guidelines are followed within clinical practice.

METHODS

Longitudinal oral cGVHD data were abstracted from the cGVHD Consortium, and additional mouth-specific management data were analyzed across five transplant centers.

RESULTS

Seventy-nine patients with 656 visits were observed for a median of 7.1 months with one visit per follow-up month. Ancillary therapies for oral cGVHD were prescribed for 67% of patients for a median of 0.46 months (per follow-up month) at OM centers and 0.78 months at non-OM centers. Patients treated with ancillary therapy were more likely to have an National Institutes of Health (NIH) mouth score of ≥1 (P < 0.001, odds ratio: 5.1) and mouth pain (P = 0.01, odds ratio: 2.6). The odds ratios of receiving ancillary therapy from OM experts were higher than transplant physicians (53%; P = 0.03).

CONCLUSIONS

Oral cGVHD consensus assessments corresponding with ancillary therapy use were mouth pain and NIH mouth score, with higher odds ratios of receiving therapy from OM experts. Ancillary care guidelines for oral cGVHD are reflected in academic clinical practice with respect to utilization of recommended prescriptions.

Dental treatment in patients with leukemia

Dental treatment of patients with leukemia should be planned on the basis of antineoplastic therapy which can be chemotherapy with or without radiotherapy and bone marrow transplantation. Many are the oral manifestations presented by these patients, arising from leukemia and/or treatment. In addition, performing dental procedures at different stages of treatment (before, during, or after) must follow certain protocols in relation to the haematological indices of patients, aimed at maintaining health and contributing to the effectiveness of the results of antineoplastic therapy. Through a literature review, the purpose of this study was to report the hematological abnormalities present in patients with leukemia, trying to correlate them with the feasibility of dental treatment at different stages of the disease. It is concluded in this paper that dental treatment in relation to haematological indices presented by patients with leukemia must follow certain protocols, mainly related to neutrophil and platelet counts, and the presence of the dentist in a multidisciplinary team is required for the health care of this patient.

Oral graft-versus-host disease

Allogeneic hematopoietic cell transplantation (allo-HCT) is used for the treatment of a variety of disorders, primarily hematologic malignancies. Graft-versus-host disease (GVHD) is a significant complication following allo-HCT and a major cause of morbidity and mortality. The oral cavity is frequently involved in GVHD, leading to pain, functional impairment, and reduced quality of life. Early diagnosis, management, and long-term follow-up of oral GVHD are important components of overall patient care.

Xerostomia due to systemic disease: a review of 20 conditions and mechanisms

Xerostomia is a common complaint of nearly half of the elderly population and about one-fifth of younger adults. It causes several signs and symptoms, and compromise oral functions and health-related quality-of-life. Multiple reasons are proposed to describe the etiology of xerostomia such as local factors, psychogenic factors, and systemic diseases. In order to manage xerostomia effectively, identification of the main causality is mandatory. The aim of this review was to present systemic diseases leading to xerostomia with their mechanisms of action. We used various general search engines and specialized databases such as Google, Google Scholar, Yahoo, PubMed, PubMed Central, MedLine Plus, Medknow, EBSCO, ScienceDirect, Scopus, WebMD, EMBASE, and authorized textbooks to find relevant topics by means of Medical Subject Headings keywords such as "xerostomia," "hyposalivations," "mouth dryness," "disease," and "systemic." We appraised 97 English-language articles published over the last 40 years in both medical and dental journals including reviews, meta-analysis, original papers, and case reports. Upon compilation of relevant data, it was concluded that autoimmune diseases most frequently involve salivary glands and cause xerostomia followed by diabetes mellitus, renal failure, and graft-versus-host disease. Moreover, the underlying mechanisms of systemic disease-related xerostomia are: autoimmunity, infiltration of immunocompetent cells, granuloma formation, fibrosis and dehydration, deposition of proteinaceous substances, bacterial infection, and side-effects of medications.

Oral complications in hematopoietic stem cell recipients: the role of inflammation

Hematopoietic stem cell transplantation (HSCT) is widely used as a potentially curative treatment for patients with various hematological malignancies, bone marrow failure syndromes, and congenital immune deficiencies. The prevalence of oral complications in both autologous and allogeneic HSCT recipients remains high, despite advances in transplant medicine and in supportive care. Frequently encountered oral complications include mucositis, infections, oral dryness, taste changes, and graft versus host disease in allogeneic HSCT. Oral complications are associated with substantial morbidity and in some cases with increased mortality and may significantly affect quality of life, even many years after HSCT. Inflammatory processes are key in the pathobiology of most oral complications in HSCT recipients. This review article will discuss frequently encountered oral complications associated with HSCT focusing on the inflammatory pathways and inflammatory mediators involved in their pathogenesis.

The impact of morphological and immunohistological changes in minor salivary glands on the health of the oral cavity in HSCT patients

The objective of this study was to test the relationship between histological changes in minor salivary glands (MSG) and chronic GVHD (cGVHD) severity and OS of hematopoietic SCT (HSCT) patients, and to discriminate the participation of events preceding HSCT that damage MSG, from those linked to cGVHD. The MSG of 57 HSCT patients who were divided into two groups-oral cGVHD (36 cases) and non-cGVHD (21 cases)-were compared with the MSG of a control group of 19 non-HSCT individuals. cGVHD changes were assessed according to National Institutes of Health (NIH) consensus and the systems of Horn et al. Acinar areas and mononuclear cell subsets were set through morphometry. Horn's 'periductal lymphocytic infiltrate' correlated with an extensive form of cGVHD and NIH 'periductal lymphocytes with exocytosis into duct' correlated with global survival. Measurements of the acinar area differed between the three groups, being the lowest in cGVHD patients, but also reduced in non-cGVHD patients. Significant differences among CD45, CD45RO, CD4 and CD8 immunomarked cells/mm(2) were found by comparing the two groups of HSCT patients. In brief, periductal lymphocytic infiltrate and exocytosis implies inflammatory activity and, consequently, might reflect the cGVHD status and influence survival. Acini loss in non-cGVHD patients may be due to pre-transplant events, but massive lymphocyte infiltrate is part of the cGVHD process.

Sicca symptoms and their impact on quality of life among very long-term survivors after hematopoietic SCT

The objective of this prospective cross-sectional case-control study was to examine the prevalence of dryness symptoms and its impact on quality of life (QoL) among very long-term survivors after hematopoietic SCT (HSCT) in comparison with their respective sibling donors. Forty-four allogeneic HSCT recipients with a long-term survival (median: 17.5; range: 11-26 years) were included. Their respective, HLA-identical sibling donors served as controls. Clinical examinations included saliva flow rates (SFR) and the Schirmer's test. The presence of sicca symptoms of mouth, eyes and skin were inquired. The social functioning (SF)-36 questionnaire was applied. Recipients had lower (P<0.01) unstimulated and stimulated mean SFR than donors. Schirmer's test results <5 mm was found in 45% of the recipients in comparison with 27% of the donors (P = 0.07). Xerostomia (34 vs 4 subjects), xerophtalmia (23 vs 3) and dry skin (32 vs 12) were reported more often by the recipients than donors (P<0.001). Sicca symptoms and their objective findings correlated with QoL. The mean SF-36 scores of the donors were significantly higher than those of the recipients for physical component summary. In conclusion, sicca symptoms are common amongst long-term survivors of HSCT and affect remarkably the QoL.

Oral chronic graft-versus-host disease: current pathogenesis, therapy, and research

Optimal management of complex autoimmune diseases requires a multidisciplinary medical team including dentists to care for lesions of the oral cavity. In this review, we discuss the presentation, prevalence, diagnosis, and treatment of oral manifestations in chronic graft-versus-host disease (cGVHD), which is a major late complication in patients treated by allogeneic hematopoietic stem cell transplantation. We assess current general knowledge of systemic and oral cGVHD and present general treatment recommendations based on literature review and our clinical experience. Additionally, we review areas where the understanding of oral cGVHD could be improved by further research and address tools with which to accomplish the long-term goal of providing better health and quality of life to patients with cGVHD.

How we treat oral chronic graft-versus-host disease

Chronic graft-versus-host disease (cGVHD) is a major complication of allogeneic hematopoietic cell transplantation that is associated with a diminished quality of life. The oral cavity is frequently affected, with a wide variety of signs and symptoms that can result in significant short- and long-term complications ranging from mucosal sensitivity and limited oral intake to secondary malignancy and early death. This article provides a comprehensive approach to the diagnosis and clinical management of patients with oral cGVHD, with particular attention to differential diagnosis, control of symptoms, and prevention of and screening for secondary complications. The clinical considerations and recommendations presented are intended to be practical and relevant for all clinicians involved in the care of patients with oral cGVHD, with the ultimate goal of improving care and outcomes.

Orofacial diseases in solid organ and hematopoietic stem cell transplant recipients

OBJECTIVE

Solid organ transplant (SOT) and hematopoietic stem cell transplant (HSCT) recipients are at risk of several diseases, principally attributable to immunosuppression. This global overview of SOT/HSCT-associated orofacial diseases is aimed at providing a practical instrument for the oral healthcare management of SOT/HSCT recipients.

METHODS

Literature search was made through MEDLINE. The associations between orofacial diseases and SOT/HSCT were assessed using observational studies and case series and were classified into 'association', 'no association', and 'unclear association'.

RESULTS

Lip/oral cancers, drug-induced gingival overgrowth (DIGO), infections, including hairy leukoplakia and, less frequently, post-transplantation lymphoproliferative disorders (PTLDs) and oral lichenoid lesions of graft-versus-host disease (GVHD), were associated with SOT. Lip/oral cancers, GVHD, mucositis, DIGO, infections and, less frequently, PTLDs were associated with HSCT. Associations of orofacial granulomatosis-like lesions and oral mucosa-associated lymphoid tissue-type lymphoma with SOT, and of pyogenic granuloma and hairy leukoplakia with HSCT were unclear. Periodontal disease and dental caries were not associated with SOT/HSCT. For none of the local treatments was there a strong evidence of effectiveness.

CONCLUSIONS

Solid organ transplant/HSCT recipients are at risk of orofacial diseases. Adequate management of these patients alleviates local symptoms responsible for impaired eating, helps prevent systemic and lethal complications, and helps where dental healthcare has been neglected.