Effect of antiseptic mouthwashes on some clinical and microbiological findings in the mouths of lymphoma patients receiving cytostatic drugs

Host impairments in patients with neoplastic diseases

Healthy individuals possess an immune system comprising physical barriers, innate and acquired immunity as well as the indigenous microflora that populate the body surfaces. The immune system maintains constant vigilance over the body at the cellular level as well as at the interface between the host integument and the resident microflora. However, neoplastic diseases and their treatment often lead to impaired immunity resulting in an increased risk of infections due to viruses, bacteria, fungi, and protozoa. This chapter explores the various aspects of host impairment focusing on the components of immunity and the interplay between them to explain why it is that these patients succumb to infections per se. In so doing, we hope that the reader will be better equipped to understand the risks patients face so as to anticipate potential infectious complications and implement appropriate measures to help attain successful remission of the neoplastic diseases and maintain the best quality of life for the patient.

Oral health promotion interventions on oral yeast in hospitalised and medically compromised patients: a systematic review

Yeast are major aetiological agents of localised oral mucosal lesions, and are also leading causes of nosocomial bloodstream infections. The purpose of this systematic review was to examine the effectiveness of oral health promotion interventions on the prevalence and incidence of these opportunistic oral pathogens in hospitalised and medically compromised patients. The PubMed, ISI Web of Science and Cochrane Library databases were searched for clinical trials assessing the effect of oral health promotion interventions on oral yeast. Chlorhexidine delivered in a variety of oral hygiene products appeared to have some effect on oral yeast, although some studies found equivocal effects. Although a wide array of other compounds have also been investigated, their clinical effectiveness remains to be substantiated. Likewise, the utility of mechanical oral hygiene interventions and other oral health promotion measures such as topical application of salivary substitute, remains unsettled. Although many chemical agents contained in oral hygiene products have proven in vitro activity against oral yeast, their clinical effectiveness and potential role as adjuncts or alternative therapies to conventional treatment remains to be confirmed by further high-quality randomised controlled trials. This is pertinent, given the recent emergence of yeast resistance to conventional antifungal agents.

Late Effect of the Cervical Irradiation on Periodontal Status and Cariogen Flora in Hodgkin Lymphoma Patients

Cervical radiotherapy may leads to elevated caries risk in Hodgkin-lymphoma (HL) patients. Our aim was to estimate the late effect of cervical irradiation on periodontal status in HL patients. Patients filled out query-form, their clinical data were collected, periodontal status was examined, decayed-missing-filled-teeth and periodontal-indexes were calculated. We examined 68 patients who received, 64 patients who did not received cervical radiotherapy and 51 control person. 23.5% of cervical irradiated, 18.15% of not irradiated patients and 17.64% of controls had subjective xerostomia, but it was not objective by sialometry. Mean decayed-missing-filled-teeth-index was 22.53 among irradiated, 21.54 among not irradiated patients while it was 17.23 in control group. Periodontal index was 2.47, 2.42, and 2.14 in different groups. Difference between decayed-missing-filled-teeth indexes of irradiated patients and controls was significant. We have to emphasize the importance of prevention and closer dental observation of HL patients.

Oral microbiota and cancer

Inflammation caused by infections may be the most important preventable cause of cancer in general. However, in the oral cavity the role of microbiota in carcinogenesis is not known. Microbial populations on mouth mucosa differ between healthy and malignant sites and certain oral bacterial species have been linked with malignancies but the evidence is still weak in this respect. Nevertheless, oral microorganisms inevitably up-regulate cytokines and other inflammatory mediators that affect the complex metabolic pathways and may thus be involved in carcinogenesis. Poor oral health associates statistically with prevalence of many types of cancer, such as pancreatic and gastrointestinal cancer. Furthermore, several oral micro-organisms are capable of converting alcohol to carcinogenic acetaldehyde which also may partly explain the known association between heavy drinking, smoking, poor oral health and the prevalence of oral and upper gastrointestinal cancer. A different problem is the cancer treatment-caused alterations in oral microbiota which may lead to the emergence of potential pathogens and subsequent other systemic health problems to the patients. Hence clinical guidelines and recommendations have been presented to control oral microbiota in patients with malignant disease, but also in this area the scientific evidence is weak. More controlled studies are needed for further conclusion.

A systematic review of dental disease in patients undergoing cancer therapy

INTRODUCTION

This purpose of this systematic review was to evaluate the literature and update our current understanding of the impact of present cancer therapies on the dental apparatus (teeth and periodontium) since the 1989 NIH Development Consensus Conference on the Oral Complications of Cancer Therapies.

REVIEW METHOD

A systematic literature search was conducted with assistance from a research librarian in the databases MEDLINE/PubMed and EMBASE for articles published between 1 January 1990 and 31 December 2008. Each study was independently assessed by two reviewers. Taking into account predetermined quality measures, a weighted prevalence was calculated for the prevalence of dental caries, severe gingival disease, and dental infection. Data on DMFT/dmft, DMFS/dmfs, plaque, and gingival indexes were also gathered. The level of evidence, recommendation, and guideline (if possible) were given for published preventive and management strategies.

RESULTS

Sixty-four published papers between 1990 and 2008 were reviewed. The weighted overall prevalence of dental caries was 28.1%. The overall DMFT for patients who were post-antineoplastic therapy was 9.19 (SD, 7.98; n = 457). The overall plaque index for patients who were post-antineoplastic therapy was 1.38 (SD, 0.25; n = 189). The GI for patients who were post-chemotherapy was 1.02 (SD, 0.15; n = 162). The weighted prevalence of dental infections/abscess during chemotherapy was reported in three studies and was 5.8%.

CONCLUSIONS

Patients who were post-radiotherapy had the highest DMFT. The use of fluoride products and chlorhexidine rinses are beneficial in patients who are post-radiotherapy. There continues to be lack of clinical studies on the extent and severity of dental disease that are associated with infectious complications during cancer therapy.

Self-perception of side effects by adolescents in a chlorhexidine-fluoride-based preventive oral health program

Objective:

The objective of this study was to evaluate the incidence of adverse effects reported by adolescents following 14 days of use of a mouthrinse containing 0.05% NaF+0.12% chlorhexidine.

Methods:

This double-blind study was developed as part of a randomized clinical trial. The adolescents enrolled to the study were randomly divided into two groups to use either: 0.05% NaF+0.12% chlorhexidine (G1, n=85) or 0.05% NaF (G2, n=85). Both groups used a 10mL solution of the mouthwash during 1 minute daily for 2 weeks under supervision. After that period, the subject's acceptance of taste was measured using a verbal descriptive scale (Labeled Magnitude Scale - LMS)¹¹. Participants were also interviewed regarding the occurrence of possible adverse effects during treatment (temporary palate disorders, tooth staining or unpleasant taste). The proportional differences between the groups were tested using the chi-square test.

Results:

Palate changes were reported by 26% of participants of each group; 17.7% of G1 and 32% of G2 reported an unpleasant taste (p = 0.062), while staining was reported by 55% of G1 and 68.9% of G2 (p = 0.117). Absenteeism rates were similar in both groups (G1= 2.58 ± 2.69; G2=2.81 ± 2.39), p=0.362.

Conclusion:

adherence was high in both groups and side effects reported by subjects were not perceived by them as being important. Since subjects' acceptance and compliance is fundamental to the success of an oral health program, chlorhexidine-fluoride could be a useful resource in a program of plaque control.

Effects of fluorides on Candida albicans

AIMS

To assess whether a short exposure of Candida albicans to commonly used fluorides would affect growth, cell surface hydrophobicity, and adherence to buccal epithelial cells.

METHODS

Candida albicans ATCC 90028 and 11 clinical isolates were used. Minimal inhibitory concentrations (MICs) of sodium fluoride (NaF) and of an amine fluoride / stannous fluoride combination (AmF / SnF2) were determined. Yeasts were exposed to MICs of tested agents for 1 h. Subsequently, their growth was recorded spectrophotometrically. Their cell surface hydrophobicity was assessed with n-hexadecane. Adherence to buccal epithelial cells was determined microscopically. Phosphate buffered saline (PBS) and chlorhexidine digluconate (CHX) served as controls. All results were analyzed by one-way ANOVA.

RESULTS

MICs of AmF / SnF(2) and CHX varied between 1 and 4 microg ml(-1), whereas those of NaF were 15 000 microg ml(-1). Statistically significant growth inhibition was detected after AmF / SnF(2) (OD(24 h) +/- SD 0.457 +/- 0.059) and CHX (0.175 +/- 0.065) in comparison with PBS (0.925 +/- 0.087) and NaF (0.813 +/- 0.081). All strains demonstrated uniform behavior. Only minor changes in cell surface hydrophobicity and adherence to buccal epithelial cells (BEC) were detected.

CONCLUSION

Growth inhibition of AmF / SnF(2) was comparable with that of CHX whereas NaF had a weaker effect. Exposure to the fluorides did not seem to alter the cell surface hydrophobicity nor adherence to BEC.

Oral infections and systemic disease--an emerging problem in medicine

The relationship between oral and general health has been increasingly recognised during the past two decades. Several epidemiological studies have linked poor oral health with cardiovascular disease, poor glycaemic control in diabetics, low birth-weight pre-term babies, and a number of other conditions, including rheumatoid arthritis and osteoporosis. Oral infections are also recognised as a problem for individuals suffering from a range of chronic conditions, including cancer and infection with human immunodeficiency virus, as well as patients with ventilator-associated pneumonia. This review considers the systemic consequences of odontogenic infections and the possible mechanisms by which oral infection and inflammation can contribute to cardiovascular disease, as well as the oral conditions associated with medically compromised patients. A large number of clinical studies have established the clinical efficacy of topical antimicrobial agents, e.g., chlorhexidine and triclosan, in the prevention and control of oral disease, especially gingivitis and dental plaque. The possible risks of antimicrobial resistance are a concern, and the benefits of long-term use of triclosan require further evaluation. Oral infections have become an increasingly common risk-factor for systemic disease, which clinicians should take into account. Clinicians should increase their knowledge of oral diseases, and dentists must strengthen their understanding of general medicine, in order to avoid unnecessary risks for infection that originate in the mouth.

Do cancer patients with chemotherapy-induced leukopenia benefit from an antiseptic chlorhexidine-based oral rinse? A double-blind, block-randomized, controlled study

Patients undergoing cancer chemotherapy frequently suffer from mucositis, particularly if they become leukopenic (leucocytes <1000/microL). To identify a possible benefit from antiseptic rinsing of the oral cavity, 47 patients were randomized to rinse either with a chlorhexidine-based product (chlorhexidine concentration 0.3%; N=24) or with an amine-stannous fluoride combination (control group; N=23). Patients were asked to rinse three times a day for 30s from the beginning of chemotherapy until the end of leukopenia. Before rinsing, as well as during and after leukopenia, aerobic and anaerobic bacteria in the oral cavity were counted. At the same time, the patients were assessed for mucositis. In the chlorhexidine-based group, a significant decrease of the aerobic (P=0.042) and anaerobic (P=0.008) bacterial flora was identified. In the control group, the numbers of aerobic and anaerobic bacteria remained unchanged (P>0.05). Fifteen patients in the chlorhexidine-based group had a C-reactive protein (CRP) increase >50mg/L, compared with only eight patients in the control group [odds ratio: 3.13, confidence interval (CI) 0.82-12.39]. Nine patients in the chlorhexidine-based group but only two patients in the control group developed severe mucositis. This difference was statistically significant with an odds ratio of 6.30 (CI: 1.02-49.67). As not all of the 47 patients developed severe leukopenia, a separate analysis was carried out for patients with <1000 leucocytes/microL for a minimum of three days. The results of the microbial counts were very similar, with a clear reduction in the chlorhexidine group and no major alterations in the control group. Twelve of 15 patients in the chlorhexidine-based group had a CRP >50mg/L whereas only eight of 15 patients did so in the control group, which can be regarded as a slightly elevated risk for a CRP increase in the former group. Seven of 15 patients developed severe mucositis in the chlorhexidine-based group, but only two of 15 patients in the control group. These differences were not significant, but patients treated with chlorhexidine-based product seemed to have more problems with inflammation of the oral mucous membranes, resulting in an elevated mucositis score and a CRP increase. Other parameters such as body temperature or application of antibiotics did not differ between the two groups. We conclude that treatment with the chlorhexidine-based product did not provide a clinical benefit for cancer chemotherapy patients. On the contrary, the risk of mucositis and clinical sequelae seems to be enhanced, although the counts of micro-organisms on the oral mucous membranes are significantly reduced.

One-year compliance and effects of amine and stannous fluoride on some salivary biochemical constituents and oral microbes in institutionalized elderly

Due to old age and poor general health, the institutionalized elderly have often not been used as research subjects for the investigation of oral health protocols. Because the number of elderly is increasing, they are an important target group for the development of oral hygiene aids. This trial was designed to investigate whether the institutionalized elderly could successfully use an amine-fluoride- and stannous-fluoride-containing mouthwash and toothpaste during a 12-month period. A dental hygienist visited the subjects weekly, instructed them, and recorded their self-reported compliance. Plaque and saliva samples were taken at three-month intervals. Some salivary biochemical constituents reflecting mucosal integrity were analyzed. The carrier status of Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, Bacteroides forsythus, Prevotella intermedia, and Prevotella nigrescens was studied by the polymerase chain-reaction method, and acidogenic bacteria and yeasts by dip-slide methods (Orion Diagnostica, Espoo, Finland). Of those 98 subjects originally included, 44 elderly (30 women and 14 men; mean age, 81.7 +/- 5.9 yrs) completed the trial. Their observations were positive or very positive regarding the use of mouthwash and toothpaste. The number of residents with P. gingivalis decreased statistically significantly throughout the trial, while the carrier status of the other periodontal bacteria and mutans streptococci remained on the same level. The number of subjects with high counts (> or = 10(5) cfu/mL) of yeasts decreased during the study: 26.2% at baseline, 9.1% one year later, respectively. Biochemical analyses of salivary immunoglobulins showed no effect on IgA and IgM levels, but IgG reduced significantly. Albumin and other salivary protein concentrations were found to have a decreasing tendency. Thus, the overall effect of the protocol was beneficial with regard to subjects' oral health as measured in this study. The residents were pleased to participate, but the number of drop-outs was very high, confirming the expected difficulties with the utilization of a group of frail elderly as research subjects.

Five-year follow-up study of saliva, mutans streptococci, lactobacilli and yeast counts in lymphoma patients

Twenty-two patients out of the 79 that were originally included were examined 5 years after beginning anticancer therapy for lymphomas. The patients' cumulative data on salivary flow rate, buffering capacity and acidogenic microbial counts were compared with respective data of 17 patients who died during the follow-up. Stimulated saliva samples had been taken at baseline and during the cytostatic treatment with combination chemotherapy, and 1 year and 5 years later. Chair-side kits were used at the hospital ward for the assessment of the study parameters. Mean saliva flow at baseline was 1.5 +/- 0.7 ml/min in the surviving group and 1.5 +/- 0.8 ml/min in the deceased. Salivary flow rates were not affected by the anticancer treatment and there was no statistically significant difference between the groups in this respect. A significant difference was observed between the groups in salivary buffering capacity values at baseline: only 32% of the survived had low buffering capacity in comparison to 69% of those who later died (P < 0.02). Buffering capacity values remained low in 50% of the surviving patients 5 years later. Higher mutans streptococci and lactobacilli counts were seen among the deceased than in the survived patients but mutans streptococci decreased significantly in both groups after the start of the anticancer therapy (P < 0.05). The number of positive yeast counts increased consistently during the chemotherapy in both groups, being higher in the survived when compared with the deceased patients. Yeast counts remained positive 5 years later in 73% of the survived patients, while the mean mutans streptococci and lactobacilli counts decreased below baseline values. The results showed that persistently high salivary microbial counts and low buffering capacity may be linked with poor prognosis.

Oral sources of septicaemia in patients with malignancies

This article reviews papers dealing with oral infections of adult septicaemia patients, searched from MEDLINE, Current Contents and Core Biomedical Collection databases from January 1966 to November 1996. Case reports were excluded. The systematic review of literature revealed that our knowledge of the topic is mostly based on very small patient material. There are no multicentre studies on the effects of various oral health treatment modes on the prevention of septicaemia of oral origin. The number of controlled and comparative studies on the efficacy of the different treatment protocols of oral infections is also small. Current recommendations in this respect are mainly empirical and not evidence based. Clinical practice guidelines are therefore urgently needed. Nevertheless, close co-operation between oncological and oral health units is emphasised because many studies have shown that the oral cavity is indeed an important source of bacteraemia. Life-threatening infections may follow if maintenance of oral health is neglected during anticancer therapy and if potential oral infection foci are left untreated before immunosuppressive therapy.

Periodontal implications: medically compromised patients

The presence of systemic disease in patients requiring periodontal therapy creates challenges for management. Alteration of treatment plans, with emphasis on physician consultation and preventive periodontal care, is frequently needed to minimize the impact of periodontal disease on the systemic condition. Conversely, detection and treatment of systemic disorders may impact upon the status of the periodontium and the success of periodontal therapy. The goal of holistic patient management is facilitated by a free flow of information between the patients and their medical and dental health care providers.

Oral pathoses caused by Candida albicans during chemotherapy: update on development mechanisms

Oral candidiasis occurs at a high frequency among immunocompromised hosts. The development mechanisms of oral pathoses associated with Candida are complex and certainly multifactorial. In immunocompromised patients, they include the evolution of the buccal flora associated with the influence of antineoplastic treatments and immunosuppression. They also include adherence of Candida to epithelial cells of the oral cavity as a function of host cell-related and yeast-related factors. Interaction and cooperation between Candida and bacteria could be a third influence in the development of oral candidiasis. It seems important to determine these mechanisms more precisely so as to improve preventive and therapeutic measures.

The effect of prebrushing mouthrinse solutions on the desorption of albumin from apatite

This study evaluated the desorption of radiolabelled albumin from synthetic hydroxypatite by 4 commercial prebrushing solutions: Lysoplac (containing chlorhexidine), Plax (sodium benzoate), Acti-Brush (triclosan), and Sanogyl (sodium fluoride). In 3 min, Lysoplac and Plax were found to desorb about 90% of albumin while Acti-Brush and Sanogyl failed to desorb hardly any albumin in 15 min. The desorbing effectiveness of the test solutions was not due to their pH, because when buffer solution was being tested in different ionic strengths at pH range 6-8, it appeared to desorb less than 3% of adsorbed albumin, irrespective of the pH used. The results obtained cannot, however, be directly applied to the clinical situation where much more complex interactions occur than what were tested under the present in vitro conditions.

A review of chlorhexidine and its use in special populations

The purpose of this paper is to review the mechanism of the action, safety, and side-effects of chlorhexidine, and to provide guidelines for its use in special populations. Chlorhexidine has been used orally since 1959, primarily for the control of dental plaque. Chlorhexidine is a safe material, with low toxicity potential when used correctly. The most conspicuous side-effects are the development of yellow-brown stains on the teeth, tongue, and at the margins of anterior restorations, and an alteration in taste sensation. The use of chlorhexidine is indicated in developmentally disabled, medically compromised patients, and in dependent elderly populations, since these groups are often physically unable to remove plaque by mechanical means. Clinicians should not prescribe chlorhexidine indiscriminately for all patients, however, until analyzing its efficacy, safety, and side-effects.

Effect of anticancer drugs on patients with and without initially reduced saliva flow

We reported earlier that despite the well-known cytolytic effect of anticancer drugs, mean stimulated salivary flow rates were not significantly affected during a 12-month follow-up of patients undergoing treatment for lymphomas (Laine et al. Oral Oncol, Eur J Cancer 1992, 28B, 125-128). Therefore, we set out to investigate in more detail the flow rates and composition of salivas in these patients, but now grouped according to their initial flow rate values, which had been assessed before the start of treatment. 49 patients of the original material (30 men and 19 women, mean age 49.9 years) were divided into hyposalivation and normal flow rate groups, according to their baseline values. Stimulated saliva flow > or = 0.8 ml/min was regarded as the limit for a normal flow rate. 11 patients were found to have reduced flow at baseline (hyposalivation group), while 38 patients had normal flow rate. Analysis of repeated saliva samples taken during the 12-month follow-up showed that flow rates remained significantly lower in the hyposalivation group compared with those of the other group (P < 0.001). Further, the concentrations of total protein, albumin, lysozyme, amylase, IgG, IgA and IgM were, and remained, all significantly higher in patients of the hyposalivation group. Counts for salivary mutans streptococci and yeasts were higher and remained significantly so among patients with hyposalivation than among those with normal flow rate while lactobacilli counts were higher in patients with normal initial flow rate.(ABSTRACT TRUNCATED AT 250 WORDS)

One-year trial of the effect of rinsing with an amine fluoride-stannous-fluoride-containing mouthwash on gingival index scores and salivary microbial counts in lymphoma patients receiving cytostatic drugs

This double-blind study was undertaken to evaluate the effect of twice-daily use of a mouthwash containing 0.025% of fluoride as amine fluoride-stannous fluoride (AmF + SnF) or 0.05% of fluoride as sodium fluoride (NaF) on visible plaque index (VPI) and gingival bleeding index (GBI) and on some salivary micro-organisms in patients suffering from non-Hodgkin or Hodgkin lymphomas. 79 patients were allocated at random to the two mouthwash groups. Mouthwashing began at the start of cancer chemotherapy. Results relating to 45 patients who completed a 1-year rinsing protocol showed a significant decrease in VPI and GBI in the AmF + SnF group. An increase was found in the NaF group. Mean values for stimulated salivary secretion rates and buffering capacities mostly did not differ significantly from baseline values during the study. In both groups, mutans streptococci counts decreased significantly after the study began and remained low in the AmF + SnF group. No corresponding effect was seen in relation to lactobacilli and yeast counts. In the NaF group, lactobacilli counts increased significantly over a year. Significantly more patients reported adverse or unpleasant effects in the AmF + SnF group (52%) than in the NaF group (6%), although both solutions had the same colour and taste. However, all patients continued with rinsing.

Report of the Committee on Scientific Investigation of the American Academy of Restorative Dentistry

The committee screened several hundred articles, citing 518 published papers. Some are present quality in research, others provide clinical interest, and some are identified as misleading. New techniques in pulp physiology and pathology are reported. Laser use and techniques in prevention, restorative dentistry, and materials use are reported. Epidemiology of selected diseases and the results of various formulations for treatment are cited. Diagnosis of craniomandibular dysfunction is well represented as well as references to literature reviews and other sophisticated scientific investigation. Research on adhesives is presented in respect to bonding agents for dentin and enamel. Several clinical studies are included, along with customary laboratory reports on several materials.