Oral complications of bone marrow transplantation in adults with acute leukemia

Case report: An unusual presentation of oral acute graft-versus-host-disease in a haploidentical hematopoietic stem cell transplant recipient

Oral acute graft-versus-host disease (aGVHD) is a significant sequelae of allogeneic hematopoietic stem cell transplantation (HSCT). Presently, transplant physicians have to diagnose GVHD based on clinical judgment by interpreting available clinical and relevant laboratory findings. As such, characterization of diagnostic and distinctive clinical signs and symptoms of GVHD is essential for diagnosis and grading. The oral features of aGVHD have been reported infrequently and remain ill defined, unlike in oral chronic GVHD. The report describes an atypical and painful presentation of oral aGVHD in a 15-year-old boy, 16 days after haploidentical HSCT, who presented with swollen lips, herpetiform ulcerations, and erythematous fungiform papilla.

Characterization of oral involvement in acute graft-versus-host disease

Acute graft-versus-host-disease (aGVHD) is a major complication of allogeneic hematopoietic stem cell transplantation (HSCT). The purpose of this study was to characterize the oral features associated with aGVHD in patients who underwent HSCT between 1995 and 2010 and developed prominent oral aGVHD. Data was collected from patient medical records and analyzed descriptively. Twenty-one cases were identified, of which 5 (24%) demonstrated only oral features; the remaining 16 had variable involvement of skin (n = 14), liver (n = 7), and gut (n = 5). The median time to onset of any sign of aGVHD was 22 days (range, 8 to 154 days), and that for onset of oral aGVHD was 35 days (range, 11 to 159 days). Sites affected by nonspecific erythema and ulcerations included buccal mucosa (19 of 21; 90%) tongue (18 of 21; 86%; dorsum in 8), labial mucosa (16 of 21; 76%), palatal mucosa (15 of 21; 71%; hard palate in 7), and floor of mouth (7 of 21; 33%). Eight cases (38%) presented with lip ulceration and crusting. In addition to systemic therapies, topical solutions of dexamethasone, tacrolimus, and morphine were used for ancillary support. Oral features of aGVHD may be the initial manifestation and include nonspecific erythema and ulcerations of keratinized and nonkeratinized mucosa and lips. Intensive topical therapies may help reduce symptoms and promote healing.

Clinical and Experimental Applications of NIR-LED Photobiomodulation

This review presents current research on the use of far-red to near-infrared (NIR) light treatment in various in vitro and in vivo models. Low-intensity light therapy, commonly referred to as "photobiomodulation," uses light in the far-red to near-infrared region of the spectrum (630-1000 nm) and modulates numerous cellular functions. Positive effects of NIR-light-emitting diode (LED) light treatment include acceleration of wound healing, improved recovery from ischemic injury of the heart, and attenuated degeneration of injured optic nerves by improving mitochondrial energy metabolism and production. Various in vitro and in vivo models of mitochondrial dysfunction were treated with a variety of wavelengths of NIR-LED light. These studies were performed to determine the effect of NIR-LED light treatment on physiologic and pathologic processes. NIRLED light treatment stimulates the photoacceptor cytochrome c oxidase, resulting in increased energy metabolism and production. NIR-LED light treatment accelerates wound healing in ischemic rat and murine diabetic wound healing models, attenuates the retinotoxic effects of methanol-derived formic acid in rat models, and attenuates the developmental toxicity of dioxin in chicken embryos. Furthermore, NIR-LED light treatment prevents the development of oral mucositis in pediatric bone marrow transplant patients. The experimental results demonstrate that NIR-LED light treatment stimulates mitochondrial oxidative metabolism in vitro, and accelerates cell and tissue repair in vivo. NIR-LED light represents a novel, noninvasive, therapeutic intervention for the treatment of numerous diseases linked to mitochondrial dysfunction.

T-cell independent production of salivary secretory IgA after hematopoietic stem cell transplantation in children

This study examined the recovery of secretory IgA (S-IgA) in saliva after hematopoietic stem cell transplantation (HSCT) in 35 children and young people between the ages of 3 and 27 years (mean=13.6), and compared this recovery with that of serum immunologic constituents. Reference values for human salivary S-IgA in saliva were obtained from 77 healthy control subjects between the ages of 7 and 25 years (mean=11.4). In the 35 patients, a nadir of secretory IgA concentrations in saliva (S-IgA) was observed between the 3rd and the 4th month, and a return to normal values 1 year after HSCT. Serum IgA concentrations reached their nadir in the 6th month, and normalized in the 18 months after HSCT. The recovery of T-helper cells (CD4+/3+) was also delayed to beyond 18 months. We found a significant correlation between the reconstitution pattern of S-IgA and that of T-helper lymphocytes, but no correlation was found between the post-transplant evolutions of S-IgA and serum IgA, or between S-IgA and T-helper cells. The recovery of S-IgA was more rapid than that of serum IgA and appeared to be T-helper cell independent.

Oral candidiasis in hematopoietic cell transplantation patients: an outcome-based analysis

OBJECTIVES

Despite aggressive antifungal prophylaxis, the increased risk for systemic fungal infection in recipients of hematopoietic cell transplants (HCT) continues to be a significant concern because Candida infection can cause morbidity and mortality in these patients. The objectives of this study were to examine the relationship of oral colonization by Candida species to systemic infection, mortality, and the impact of antifungal treatment on a population of recipients of HCT.

STUDY DESIGN

One hundred and fifteen consecutive patients undergoing hematopoietic cell transplantation were evaluated. Oral examinations and cultures for Candida were completed before transplantation and on a weekly basis until discharge. The oral complications were assessed, and the level of mucositis was scored by using the National Cancer Institute grade. Systemic antifungal prophylaxis was provided to all patients. Chlorhexidine oral rinses were also routinely provided.

RESULTS

Colonization by Candida species was identified in 31% of patients. Fifty-six percent of patients with colonization had clinical evidence of oral candidiasis. Significantly decreased Candida colonization was seen in patients using chlorhexidine alone compared with those using chlorhexidine and nystatin together (P <.046). Twenty-five patients died in the immediate posttransplantation period, 17 of whom were Candida-positive. The length of hospital stay ranged from 15 to 153 days; increased stay was also associated with Candida colonization (P =.04). Seventy-four percent of all patients developed ulcerative mucositis. More severe mucositis was seen in patients undergoing chemotherapy and radiation therapy. There was no significant difference between Candida colonization and the presence or severity of mucositis.

CONCLUSIONS

Despite systemic and topical antifungal prophylaxis, oropharyngeal colonization by Candida species was common in patients who had received HCT. Candidiasis was commonly present in those who did not survive the early transplant period. Of the 25 patients who died early after the transplantation, 92% had ulcerative mucositis in comparison with 70% of those who survived, reflecting the association of oral mucositis with the toxicity of HCT. There was a significant relationship among allogeneic and autologous HCT, length of stay, and colonization of Candida. In patients undergoing systemic antifungal prophylaxis, chlorhexidine rinse was statistically more effective in reducing colonization by Candida than chlorhexidine and nystatin combined (P =.046).

NASA light-emitting diodes for the prevention of oral mucositis in pediatric bone marrow transplant patients

OBJECTIVE

The purpose of this study was to determine the effects of prophylactic near-infrared light therapy from light-emitting diodes (LEDs) in pediatric bone marrow transplant (BMT) recipients.

BACKGROUND DATA

Oral mucositis (OM) is a frequent side effect of chemotherapy that leads to increased morbidity. Near-infrared light has been shown to produce biostimulatory effects in tissues, and previous results using near-infrared lasers have shown improvement in OM indices. However, LEDs may hold greater potential for clinical applications.

MATERIALS AND METHODS

We recruited 32 consecutive pediatric patients undergoing myeloablative therapy in preparation for BMT. Patients were examined by two of three pediatric dentists trained in assessing the Schubert oral mucositis index (OMI) for left and right buccal and lateral tongue mucosal surfaces, while the patients were asked to rate their current left and right mouth pain, left and right xerostomia, and throat pain. LED therapy consisted of daily treatment at a fluence of 4 J/cm(2) using a 670-nm LED array held to the left extraoral epithelium starting on the day of transplant, with a concurrent sham treatment on the right. Patients were assessed before BMT and every 2-3 days through posttransplant day 14. Outcomes included the percentage of patients with ulcerative oral mucositis (UOM) compared to historical epidemiological controls, the comparison of left and right buccal pain to throat pain, and the comparison between sides of the buccal and lateral tongue OMI and buccal pain.

RESULTS

The incidence of UOM was 53%, compared to an expected rate of 70-90%. There was also a 48% and 39% reduction of treated left and right buccal pain, respectively, compared to untreated throat pain at about posttransplant day 7 (p < 0.05). There were no significant differences between sides in OMI or pain.

CONCLUSION

Although more studies are needed, LED therapy appears useful in the prevention of OM in pediatric BMT patients.

Pyogenic granuloma of the tongue early after allogeneic bone marrow transplantation for multiple myeloma

Oral complications occur frequently after bone marrow transplantation (BMT). Some of them are caused by regimen-related toxicity of the preparative regimen, and others by infections. In addition, oral tissues are targets of graft-versus-host disease (GVHD). Oral granulomatous lesions are not a common complication after BMT, and are especially rare on the tongue. Such rare lesions reported in the literature, developed late after BMT with oral chronic GVHD. We present here a patient who developed pyogenic granuloma of the tongue early after allogeneic BMT done for multiple myeloma. Regimen-related mucositis, oral acute GVHD, the administration of cyclosporine A, and the preexisting macroglossia might be responsible for the formation of granuloma.

Histopathological study of the human submandibular gland in graft versus host disease

Major salivary gland dysfunction and severe xerostomia is one of the manifestations of graft versus host disease (GVHD). The histopathological evaluation of the major salivary gland in patients with GVHD has never been reported. The pathological findings of the submandibular glands in a GVHD patient who succumbed to the disease are described. Lymphocytic infiltration, parenchymal destruction, and fibrosis were observed, which may provide the pathophysiological mechanism for the xerostomia and hyposalivation observed in GVHD.

Parotid gland dysfunction in a murine model of acute graft versus host disease [aGVHD]

BACKGROUND

The major salivary glands are target organs affected by acute graft versus host disease (aGVHD), resulting in severe xerostomia.

METHODS

We evaluated the function of the major salivary glands in an animal model of aGVHD (B10.S-->SJL/J). For the induction of aGVHD, SJL/J mice were sublethally irradiated with 900 cGy and injected with 2 x 10(7) splenocytes. The SJL/J mice that received 900 cGy total-body irradiation (TBI) and nonirradiated mice served as controls. Major salivary gland function was evaluated in vivo at the peak of aGVHD (proven both clinically and histologically). The volume, flow rate, salivation lag phase, and composition of secreted saliva were evaluated following intraperitoneal (IP) administration of pilocarpine (5 mg/kg) by cannulation of the main parotid excretory duct with polyethylene tubing.

RESULTS

We observed a significant decrease in the secreted saliva volume in the aGVHD mice, 12.4+/-1.7 microl/30 min, in comparison with 27.8+/-3.9 and 31.9+/-3.0 microl/30 min in the intact control and irradiated control mice, respectively (p < .001). Sialochemical evaluation revealed a significant decrease in total protein and a significant increase in potassium in the saliva secreted by the aGVHD mice, 2.6+/-0.4 mg/mL and 22.0+/-3.2 mEq/L, compared with 4.4+/-0.6 mg/mL and 14.9+/-2.0 mEq/L in the control mice, respectively (p < .05). A decrease in sodium concentration secreted by the aGVHD mice in comparison with the nonirradiated mice was statistically nonsignificant. Histopathologic evaluation of the parotid tissue of the aGVHD mice revealed massive infiltration of lymphocytes and almost total destruction of the normal parenchyma.

CONCLUSIONS

We observed salivation hypofunction develop concomitantly with salivary tissue lymphocyte infiltration in an aGVHD animal model. We suggest that the lymphocytes and the secreted lymphokines are the cause of the salivary changes. This finding may provide an explanation for the severe oral changes and xerostomia observed in aGVHD patients.

Graft-vs.-host disease

Bone marrow transplantation (BMT) is the treatment of choice for many leukemias, lymphomas, bone marrow failure syndromes, and immunodeficiency disorders, and is the primary and salvage therapy for many solid malignancies. With the establishment of national and international marrow banks, unrelated allogeneic BMT is being performed with increasing frequency. Graft-vs.-host disease (GVHD) remains a major complication of allogeneic BMT, occurring in 25% to 70% of patients despite GVHD prophylaxis, with the skin, gastro-intestinal tract, and liver as primary target organs. Oral findings are seen in both acute and chronic GVHD. In acute GVHD, the oral lesions are often painful, erythematous, ulcerative, and desquamative. In chronic GVHD, they are lichenoid with associated erythema and ulcerations; additionally, they may be associated with a sicca syndrome characterized by xerostomia and progressive salivary gland atrophy. General principles of BMT are discussed, as are systemic and local therapeutic options for oral GVHD.

Caries-related salivary microorganisms and salivary flow rate in bone marrow recipients

Cancer treatments often induce oral complications. In this study we investigate longitudinally the salivary gland function, the salivary caries-related microorganisms, and buffer capacity in bone marrow recipients. Stimulated saliva samples were taken midmorning. The salivary factors were studied in 42 patients from before transplant until 4 months after transplant. A dramatic reduction (66%) of salivary flow rate is noticed in all patients at 1 month after transplant, and only a partial recovery (42% reduction) is seen after 4 months. A clear shift toward a lower buffer capacity and a higher amount of cariogenic microorganisms is seen posttransplant. This shift is more pronounced when total body irradiation was included in the pretransplant conditioning therapy. These findings indicate that the studied parameters in transplant recipients can contribute to a higher caries risk and oral complications during the early posttransplant period.

A longitudinal follow-up of salivary secretion in bone marrow transplant patients

Salivary gland dysfunction is a common sequela of the bone marrow transplantation procedure. We determined the effect of different bone marrow transplantation protocols on parotid salivary flow rate. Salivary secretion was substantially reduced during conditioning of all the recipients. A gradual flow rate reconstitution could be detected as soon as a few days after the bone marrow transplantation. Eight patients conditioned with total lymph node irradiation and chemotherapy or chemotherapy alone displayed earlier and complete recovery of saliva secretions 2 to 5 months after the grafting. Recovery was delayed and incomplete when total body irradiation was added to the conditioning regimen (seven patients). Six of these patients also developed graft-versus-host disease. The results suggest that total body irradiation induces irreversible damage to the parotid glands resulting in profound xerostomia followed by opportunistic infections. Chemotherapy with or without total lymph node irradiation does not induce such damage.

Intraoral pyogenic granuloma after allogeneic bone marrow transplant. Report of three cases

Allogeneic bone marrow transplant patients commonly have oral complications related to their disease or its treatment. Those reported include: xerostomia, mucositis, caries, infection, gingival hyperplasia, periodontitis, and graft-versus-host disease. These complications may be responsible for significant morbidity. This article reviews commonly reported oral complications of bone marrow transplantation and presents three cases in which intraoral pyogenic granuloma occurred. The cause of these lesions in post-bone marrow transplant patients is discussed.

A longitudinal study of oral ulcerative mucositis in bone marrow transplant recipients

BACKGROUND

Few longitudinal studies have investigated the onset, duration, and resolution of ulcerative mucositis in bone marrow transplant recipients. This study prospectively followed a group of such patients on a daily basis to obtain data on the incidence of ulcerative mucositis, location and duration of lesions, severity with different conditioning regimens, and the relationship of such mucositis to the absolute neutrophil count.

METHODS

Fifty-nine bone marrow transplant recipients on prophylactic acyclovir were examined daily for 26 days after marrow infusion, and all oral ulcerative lesions were recorded.

RESULTS

Oral ulcers occurred in 76.3% of patients, began at a mean of 5 days after marrow infusion (day + 5), and lasted for a median of 6 days. More than 90% of patients showed complete resolution of ulcers on or before day + 15, and all showed resolution when the absolute neutrophil count was > 500 cells/ml. Persistence of ulcers was noticed in patients who had oral graft-versus-host disease and in some patients who initially developed more severe ulcerations. Ninety-six percent of ulcers were located on nonkeratinized mucosa.

CONCLUSIONS

Ulcerative mucositis occurs in about 75% of bone marrow transplant recipients in the absence of herpes simplex virus infection. Most lesions occur on nonkeratinized mucosae which are vulnerable to trauma, especially if such mucosae are rendered atrophic by conditioning regimens. Oral ulcers may persist beyond day + 15 and after recovery of the neutrophil count in patients who initially develop more severe ulcerations or in patients who develop graft-versus-host disease.

Oral and nutritional status in allogeneic marrow recipients treated with T-cell depletion or cyclosporine combined with methotrexate to prevent graft-versus-host disease

To investigate how the use of T-cell-depleted marrow or a combination of cyclosporine and methotrexate to prevent graft-versus-host disease affect oral health and the ability to maintain adequate nutrition during the neutropenic phase after allogeneic bone marrow transplantation, 48 allogeneic bone marrow recipients were studied. From a group of adult leukemic marrow recipients of HLA identical sibling marrow, 23 patients were randomly chosen to receive T-cell-depleted marrow and 25 were selected to receive cyclosporine and four doses of methotrexate to prevent graft-versus-host disease. Before the transplantation, all patients were given all necessary dental treatment as well as oral hygiene and nutrition instructions. The oral mucosal and nutritional status in all patients (except one who died) were followed from 5 days before the procedure, during the neutropenic period after transplantation, and until discharge from the hospital. The number of oral lesions was similar in both groups. The subjective experience of orally related problems, such as pain from the oral cavity and number of days with total parenteral nutrition, was less in the T-cell-depleted recipients compared with those who received a graft-versus-host disease prophylaxis with cyclosporine and methotrexate (p less than 0.005). The oral cavity was considered to be the port of entry in four of six patients in the cyclosporine and methotrexate group who developed septicemia, compared with only one of six patients in the T-cell-depleted group with septicemia. The difference in the frequency of septicemia derived from the oral cavity did not, however, reach the significant level.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of total body irradiation on salivary gland function and caries-associated oral microflora in bone marrow transplant patients

Forty-one cancer patients who received chemoradiotherapy conditioning with bone marrow transplantation were examined for changes in salivary gland function and caries-associated oral microflora. Salivary flow rates (stimulated and unstimulated) and Streptococcus mutans levels decreased after pretransplant cytoreductive therapy and posttransplant prophylactic antibiotic therapy. Normal levels returned with time after the patients left the protected environment. Lactobacillus counts were not affected. Chronic graft-versus-host disease did not significantly influence saliva production. Results indicate that irradiation is probably the major factor responsible for the transient xerostomia.

Efficacy of chlorhexidine and nystatin rinses in prevention of oral complications in leukemia and bone marrow transplantation

The goal of reducing oral complications during chemotherapy and bone marrow transplantation has received attention at several centers. The current randomized study of 86 adults with leukemia treated with chemotherapy or bone marrow transplantation assessed the potential role of chlorhexidine, nystatin, and saline solution rinses to reduce the findings of oral mucositis, gingivitis, and oral infection. The results of this study did not show a reduction in mucositis with the use of these rinses. However, potential bacterial and fungal pathogens were identified less frequently in the patients using chlorhexidine rinse.

Oral mucositis after bone marrow transplantation. A marker of treatment toxicity and predictor of hepatic veno-occlusive disease

Oral mucositis and hepatic veno-occlusive disease (HVOD) are common complications after bone marrow transplantation (BMT). Forty-seven patients were prospectively examined for development of ulcerative oral mucositis (UOM) and HVOD after allogeneic BMT. In 17 patients (36%) UOM developed between 2 days before and 18 days after transplant (median 4 days after BMT). In seven patients (15%) HVOD developed with onset between 3 and 21 days after transplant (median 18 days after BMT). In a time-dependent analysis, in patients given busulfan plus cyclophosphamide or busulfan, etoposide, and cyclophosphamide UOM was 19 times more likely to develop than in patients treated by cyclophosphamide plus total body irradiation or by cyclophosphamide alone (p less than 0.001). Patients in whom UOM developed were 6.5 times more likely to develop HVOD than those in whom UOM did not develop (p less than 0.03). The sensitivity (86%), specificity (73%), and negative predictive value (97%) of UOM to predict HVOD were high, but the positive predictive value (35%) was low. The association of UOM and HVOD support the concept that both are toxic effects of treatment. Patients with hepatic abnormalities but without UOM are unlikely to have HVOD, and other causes of the hepatic dysfunction should be investigated.

Oral mucous membrane lesions in children treated with bone marrow transplantation

Oral mucous membrane lesions were studied in 54 children below 12 yr of age treated with allogeneic bone marrow transplantation mainly because of hematological malignancies. Sixty-two percent of the children exhibited a wide range of oral side effects during therapy. Lesions observed during the first 2 wk prior to engraftment of the donor marrow were related to the chemo- and radiotherapy given. Oral ulcerations were seen in 34% of the children. Children given methotrexate as graft-versus-host disease (GVHD) prophylaxis exhibited oral ulcerations significantly (P less than 0.05) more often than those given cyclosporin. Oral lesions related to acute GVHD were only observed in two patients. Reactivating herpes simplex virus infection was seen in 35% of the children who were seropositive prior to BMT. An extensive oral candidiasis was observed in 15% of the patients. All six children with a chronic GVHD exhibited changes in the oral mucosa 2-4 yr after transplantation such as erythma of the mucous membranes, tongue atrophy and also lichenoid changes in the buccal mucosa.

Early oral changes following bone marrow transplantation

This study assessed and analyzed the early oral changes following chemoradiotherapy and bone marrow transplantation. The most notable changes involved mucosal color (white and red), atrophy, vascularity, ulceration, increased salivary viscosity and xerostomia, and the patients' subjective complaints of dryness and oral pain. The ventral tongue, buccal and labial mucosa, and marginal gingiva manifested the most notable changes, while the palate was least affected. The overall trend was for the oral changes to begin slightly before transplantation, to worsen over the first 2 weeks after transplantation, and then to resolve progressively over the remainder of the study period. These oral changes appear to result from a number of insults, including the conditioning chemoradiotherapy, posttransplant immunosuppressive chemotherapy, xerostomia, local trauma, oral infections (especially those caused by HSV), and possibly acute GVHD. Oral HSV infection and/or acute GVHD should especially be considered if the oral status markedly worsens 21 days or more after transplant.

Oral complications of high-dose melphalan in multiple myeloma

Four patients with multiple myeloma refractory to conventional chemotherapy received high-dose melphalan. All experienced multiple oral complications. Extensive neutropenic ulceration and orofacial herpes simplex virus infection caused considerable morbidity in three patients during prolonged periods of neutropenia.

Clinical characteristics and mechanisms involved in chemotherapy-induced oral ulceration

The clinical characteristics of chemotherapy-induced oral mucosal ulceration in a group of patients with acute leukemia were examined in detail in a long-term prospective clinical study. Differences in regional susceptibility within the mouth to the effects of chemotherapy were apparent. A reconstruction of the probable mechanisms involved is presented.

Effects of resistive exercise on skeletal muscle in marrow transplant recipients receiving total parenteral nutrition

Skeletal muscle protein loss occurs during marrow transplantation despite total parenteral nutrition. To determine if muscle atrophy could be minimized with exercise therapy, 30 patients undergoing marrow transplantation for acute leukemia completed a prospective randomized trial to receive: (1) no therapy (controls), (2) physical therapy thrice weekly (PT3), or (3) physical therapy five times weekly (PT5). Patients were studied through 35 days posttransplant. Muscle protein status and turnover was assessed by weekly nitrogen balance, and creatinine and 3-methylhistidine excretion. Results favored a muscle protein-sparing effect of exercise, as a significant decrease in creatinine excretion in controls only suggested muscle protein loss associated with inactivity. Changes in arm muscle area correlated with energy, but not protein intake. Large individual variation, inadequate nutritional support and differences in admission arm muscle area may have clouded these results.

The incidence of oral herpes simplex virus infection in patients undergoing cancer chemotherapy

Oral lesions in twenty-nine immunocompromised patients were evaluated for the incidence of herpes simplex virus (HSV) infections during either cancer chemotherapy or cancer chemotherapy plus bone marrow transplantation (BMT). Patients' HSV antibody titers were not determined, and positive diagnoses were based solely on the results of viral cultures. Fourteen patients (48%) were found to have herpetic infections, which is comparable with incidence rates of 50% to 90% in antibody-positive patients and 40% to 50% in mixed antibody populations reported in the medical literature. However, this finding is in conflict with the 10.7% to 15.1% incidence rate cited in the dental literature for patients undergoing cancer chemotherapy. This underestimation is believed to reflect insensitivity in the criteria used for diagnosis in these studies.

Oral mucositis in patients undergoing bone marrow transplantation

Thirty patients who received bone marrow transplantation treatment from HLA identical sibling donors for immunologic and malignant diseases were studied. In essentially all of the patients oral changes developed during the first 30 days following transplant. Oral symptoms frequently constituted the major complaints of the patients during the follow-up period. The oral changes included mucositis, xerostomia, pain, and bleeding. Mucositis was more severe and of longer duration when associated with herpes simplex infections and when optimal oral hygiene was not maintained. Xerostomia which accompanies engraftment was an early sign of acute graft-versus-host disease. A nonbrushing method of oral hygiene was effective in reducing the severity and duration of mucositis. This technique offers a short-term alternative to brushing in pancytopenic patients who are susceptible to bleeding or trauma.

Overdentures for the irradiated patient

A rationale that stresses the biologic and mechanical advantages of overdenture therapy for the irradiated patient has been presented.

Increased morbidity associated with oral infection in patients with acute nonlymphocytic leukemia

The proper dental management of patients with leukemia is complicated by the compromised host defenses against infection. This compromised state is a result of the chemotherapeutic agents used in cancer treatment as well as the natural existing disease state. Infection remains the leading immediate cause of death in persons with leukemia. Previous reports have described oral complications secondary to this neoplasm and its medical management; however, relatively few studies of the incidence of systemic complications secondary to oral disease have been reported. This study analyzed the incidence of acute infectious episodes in patients with acute nonlymphocytic leukemia (ANLL). Thirty-eight patients were randomly selected for review; of these patients, twelve (32 percent) had identifiable acute oral infection associated with the presence of a febrile state (greater than 101 degrees F). Seven of the twelve (58 percent) had no other identifiable sources of infection. The periodontium was the oral site most frequently involved, followed by mucosal and periapical loci. Most acute oral infections were associated with profound granulocytopenia (less than 100/microliters). The data suggest that oral disease plays a clinically important role in the development of systemic complications in ANLL patients.