A scoring system for the quantitative evaluation of oral mucositis during bone marrow transplantation

Traumeel S in preventing and treating mucositis in young patients undergoing SCT: a report of the Children's Oncology Group

Mucositis can be a serious complication of hematopoietic SCT (HSCT). A previous phase II trial in 32 children undergoing HSCT reported a beneficial effect of the homeopathic remedy Traumeel S. The Children's Oncology Group sought to replicate the results in a multi-institutional trial. The study was an international multi-center, double-blind, randomized trial comparing Traumeel with placebo in patients aged 3-25 years undergoing myeloablative HSCT. Traumeel/placebo was started on Day -1 as a five-time daily mouth rinse. Efficacy of the treatment was assessed using the modified Walsh scale for mucositis, scored daily from Day -1 to 20 days after HCST. The main outcome was the sum of Walsh scale scores (area-under-the-curve (AUC)) over this period. Other outcomes included narcotic use, days of total parenteral feeding, days of nasogastric feeding and adverse events. In 181 evaluable patients, there was no statistical difference in mucositis (AUC) in the Traumeel group (76.7) compared with placebo (67.3) (P=0.13). There was a trend towards less narcotic usage in the Traumeel patients. No statistically beneficial effect from Traumeel was demonstrated for mucositis. We could not confirm that Traumeel is an effective treatment for mucositis in children undergoing HSCT.

Clinical assessment and management of the oral environment in the oncology patient

The dental care of oncology patients is an important component of general dental practice. Oncology patients have additional requirements for their outpatient care in the dental office. Intense involvement of the general dental practitioner in the patient's overall plan of care is essential so that appropriate preventive and therapeutic strategies are followed prior to chemotherapy, radiation and other medical treatments. This paper provides an overview of the role of the dental practitioner in the pre-treatment workup and post-treatment maintenance of oncology patients, and discusses the complications which occur during the intensive and in-hospital phases of care, in the context of approaches that show promise for reducing or preventing these. The role of the general dental practitioner in the maintenance of oral health for the remainder of the patient's life is stressed, with evidence-based recommendations given for optimal use of home care products which support oral health and improve quality-of-life.

A systematic review of oral assessment instruments: what can we recommend to practitioners in children's and young people's cancer care?

BACKGROUND

Observing and recording the signs and symptoms of oral mucositis are an important part of oral care, essential to the prevention and treatment of mucositis. Structured oral assessment enables a more informed and accurate identification of signs and symptoms and will enable early and individualized interventions.

OBJECTIVE

A United Kingdom-based mouth-care group conducted a systematic review of the published literature through to March 2004 and repeated in 2008. The goal of this review was to identify and evaluate the range of instruments used to assess oral mucositis to recommend in evidence-based guidelines the "best" instrument to use in the field of children's and young people's cancer care.

METHODS

Search sources included the Cochrane Library, MEDLINE, EMBASE, and CINAHL. Studies were selected using defined criteria and reviewed by 3 pairs of group members.

RESULTS

Fifty-four individual oral assessment instruments were identified with only 15 reporting evidence of reliability and validity testing. Only 3 articles reported on oral assessment exclusively in our population.

CONCLUSIONS

The guidelines recommend only 1 assessment instrument, the Oral Assessment Guide, or adaptations of this instrument, to be used in clinical practice. Five factors influenced this recommendation: purpose of assessment, population, outcomes assessed, and quality of the instrument and ease of use.

IMPLICATIONS FOR PRACTICE

The Oral Assessment Guide has been consistently judged to be user-friendly and appropriate for everyday clinical practice with both adults and children, as well as a useful research tool.

Designing an oral mucositis assessment instrument for use in children: generating items using a nominal group technique

GOALS OF WORK

There was a need to develop a mucositis instrument that would be specific for use with children. This paper describes the step of generating items in the process of developing a new instrument for the assessment of oral mucositis in children.

MATERIALS AND METHODS

Nine health care professionals with expertise in pediatric cancer, mucositis assessment, and oral assessment in children were invited to participate in a nominal group technique to generate items that should be included in an instrument.

RESULTS

Thirty items were generated initially. Voting processes established that six of these items were thought to be necessary for inclusion: (1) presence of ulcers, (2) pain assessment, (3) amount of pain medication received, (4) effect on eating, (5) drooling-pooling of saliva, and (6) effect on drinking. Using these six items, an initial draft of an instrument was developed that could be used to assess oral mucositis in children, namely, the Children's International Mucositis Evaluation Scale.

CONCLUSION

The six items generated by this process provided the basis for a simple, feasible, and reliable instrument. With increased clinical research investigating interventions to reduce and prevent oral mucositis, such an instrument will be critical to the effective conduct of this research in children. Further testing of this instrument is necessary.

Establishing Literature-Based Items for an Oral Mucositis Assessment Tool in Children

Although there are numerous instruments for oral mucositis (OM) assessment in adults, there is a lack of validated instruments for use in children. The objectives of this systematic review were to describe literature-based items that should be considered for a pediatric mucositis scale and other issues that should be considered when assessing mucositis in children. Literature search of PubMed and bibliography searches identified articles relevant to the assessment of mucositis and mucositis assessment studies in children. The elements established from the literature were grouped under objective, subjective, and functional items. Other issues that require consideration include the conditions for the assessment of the oral cavity and the etiology of OM. The resultant list included 23 items that have been used in mucositis assessment scales. This list of items may be used as an initial step in developing a new pediatric OM scale that particularly focuses on the unique issues in children.

Measurement of oral mucositis in children: a review of the literature

GOALS OF WORK

The assessment of oral mucositis is important. There is a paucity of validated oral mucositis assessment instruments for use in children. This paper reviews the available mucositis measurement tools and their applicability to a paediatric population.

MATERIALS AND METHODS

Literature search of PUBMED and bibliography searches identified articles relevant to mucositis measurement tools and the measurement of mucositis in paediatrics.

RESULTS

The relevant issues in the literature could be grouped into three categories: (1) development and evaluation of oral assessment tools, (2) oral assessment in the paediatric population, and (3) challenges to the assessment of oral mucositis in children. There were numerous validated mucositis assessment scales for use in adults. Only three of these scales have received limited evaluation for use in the paediatric population. The unique challenges presented by the paediatric population are excluded from much of the discussion in the literature.

CONCLUSION

The paper demonstrates the need to consider the issues specific to children. It must be determined whether previously developed tools are ideally suited for children enrolled on mucositis clinical trials.

Low-power laser in the prevention of induced oral mucositis in bone marrow transplantation patients: a randomized trial

We investigated the clinical effects of low-power laser therapy (LPLT) on prevention and reduction of severity of conditioning-induced oral mucositis (OM) for hematopoietic stem cell transplantation (HSCT). We randomized 38 patients who underwent autologous (AT) or allogeneic (AL) HSCT. A diode InGaAlP was used, emitting light at 660 nm, 50 mW, and 4 J/cm2, measured at the fiberoptic end with 0.196 cm2 of section area. The evaluation of OM was done using the Oral Mucositis Assessment Scale (OMAS) and the World Health Organization (WHO) scale. In the LPLT group, 94.7% of patients had an OM grade (WHO) lower than or equal to grade 2, including 63.2% with grade 0 and 1, whereas in the controls group, 31.5% of patients had an OM grade lower than or equal to grade 2 (P < .001). Remarkably, the hazard ratio (HR) for grades 2, 3, and 4 OM was 0.41 (range, 0.22-0.75; P = .002) and for grades 3 and 4 it was 0.07 (range, 0.11-0.53; P < .001). Using OMAS by the calculation of ulcerous area, 5.3% of the laser group presented with ulcers of 9.1 cm2 to 18 cm2, whereas 73.6% of the control group presented with ulcers from 9.1 cm2 to 18 cm2 (P = .003). Our results indicate that the use of upfront LPLT in patients who have undergone HSCT is a powerful instrument in reducing the incidence of OM and is now standard in our center.

Cytoprotection by Amifostine during Autologous Stem Cell Transplantation for Advanced Refractory Hematologic Malignancies

This study evaluated whether amifostine protects against mucositis and other toxicities in patients with advanced, refractory, or recurrent hematologic malignancies undergoing high-dose chemotherapy and total body irradiation. Thirty-five patients (20 with non-Hodgkin lymphoma, 12 with Hodgkin disease, and 3 with acute myelogenous leukemia) who underwent autologous stem cell transplantation were conditioned with total body irradiation 2 Gy twice daily on days -8 through -6; cyclophosphamide 6 g/m(2), etoposide 1.8 g/m(2), and carboplatin 1 g/m(2) on days -5 through -3; and amifostine 500 mg/m(2) on days -8 through -2. Prior institutional experience in patients treated without amifostine was used as a historical comparison (no-amifostine group). Severe mucositis occurred in 14 (40%) of 35 patients in the amifostine group, compared with 33 (94%) of 35 in the no-amifostine group (P < .0001). Total parenteral nutrition was used by 4 (11%) of 35 amifostine-treated patients and 34 (97%) of 35 no-amifostine patients (P < .0001). The median duration of narcotic use decreased from 15.5 days with no amifostine to 11 days with amifostine (P = .002). Granulocyte and platelet engraftment times were similar. Prospective trials with innovative designs and clearly defined stopping rules are warranted to confirm whether amifostine reduces the toxicities of a myelosuppressive conditioning regimen before autologous stem cell transplantation without compromising therapeutic response.

A double-blind randomized placebo-controlled study of oral glutamine in the prevention of mucositis in children undergoing hematopoietic stem cell transplantation: a pediatric blood and marrow transplant consortium study

Severe mucositis is a common cause of morbidity in hematopoietic stem cell transplant (HSCT) recipients. Glutamine has been shown to reduce mucositis in children receiving chemotherapy. Patients were randomized in a double-blind manner to receive glutamine or glycine at a dose of 2 g/m(2)/dose (maximum dose 4 g) twice daily until 28 days post transplant or discharge if sooner. Mucositis was graded by use of a modified Walsh scale. A total of 120 children were evaluable: 57 children received glutamine and 63 received glycine. The mean mucositis score was 3.0+/-0.3 vs 3.9+/-0.4 (P=0.07) in the glutamine and glycine groups, respectively. The glutamine group demonstrated a reduction in mean number of days of intravenous narcotics use (12.1+/-1.5 vs 19.3+/-2.8 in the glycine group, P=0.03) and total parenteral nutrition (17.3+/-1.7 vs 27.3+/-3.6 in glycine group, P=0.01). There was no statistically significant difference in toxicity between the two groups. Glutamine appears to be safe and beneficial in reducing the severity of mucositis. Strong consideration should be given to include oral glutamine supplementation as a routine part of supportive care of SCT patients.

Perspectives on cancer therapy-induced mucosal injury: pathogenesis, measurement, epidemiology, and consequences for patients

BACKGROUND

A frequent complication of anticancer treatment, oral and gastrointestinal (GI) mucositis, threatens the effectiveness of therapy because it leads to dose reductions, increases healthcare costs, and impairs patients' quality of life. The Multinational Association of Supportive Care in Cancer and the International Society for Oral Oncology assembled an international multidisciplinary panel of experts to create clinical practice guidelines for the prevention, evaluation, and treatment of mucositis.

METHODS

The panelists examined medical literature published from January 1966 through May 2002, presented their findings at two separate conferences, and then created a writing committee that produced two articles: the current study and another that codifies the clinical implications of the panel's findings in practice guidelines.

RESULTS

New evidence supports the view that oral mucositis is a complex process involving all the tissues and cellular elements of the mucosa. Other findings suggest that some aspects of mucositis risk may be determined genetically. GI proapoptotic and antiapoptotic gene levels change along the GI tract, perhaps explaining differences in the frequency with which mucositis occurs at different sites. Studies of mucositis incidence in clinical trials by quality and using meta-analysis techniques produced estimates of incidence that are presented herein for what to our knowledge may be a broader range of cancers than ever presented before.

CONCLUSIONS

Understanding the pathobiology of mucositis, its incidence, and scoring are essential for progress in research and care directed at this common side-effect of anticancer therapies.

The effect of oral mucositis on morbidity and mortality in bone marrow transplant

Oral mucosal ulceration is a frequent complication in bone marrow transplantation, resulting from epithelial injury caused by cytotoxic chemotherapy and radiation conditioning, as well as from pre-existing infection. Oral mucositis causes pain, interferes with patient nutrition, and can lead to systemic infection and other complications that increase patient morbidity and mortality; this complication also markedly increases the expense of bone marrow transplantation. A variety of interventions have been assessed for preventing oral mucositis or reducing the severity of mucositis and its sequelae. These include meticulous pretransplantation and ongoing mouth care, calcium phosphate solution, near-infrared light and lower-energy laser treatment, interleukin-11, sucralfate, oral glutamine, granulocyte-macrophage colony-stimulating factor rinse, tretinoin, and keratinocyte growth factor; particularly promising results have been observed with use of the cytoprotectant/radioprotectant agent amifostine. Reduction in the severity and duration of oral mucositis and its sequelae in patients undergoing bone marrow transplantation can have a substantial impact on morbidity and mortality and cost of care. Further systematic evaluation of approaches to prevention and management of oral mucositis is necessary to define optimal strategies in the transplantation setting.

Changes in the periodontal status of patients undergoing bone marrow transplantation

BACKGROUND

Patients receiving an HLA-matched bone marrow transplant (BMT) from a relative or unrelated donor undergo a permanent alteration of their immune system, followed by a prolonged period of immunodeficiency. This study aimed to examine alterations in the periodontal status of patients over 6 months post-bone marrow transplantation.

METHODS

Thirty-seven patients scheduled for bone marrow transplantation participated in this study. One calibrated examiner carried out periodontal examinations (clinical and radiographic) immediately prior to and at 3 and 6 months after transplantation. All patients followed an intense oral care program. Subgingival plaque samples were analyzed by enzyme-linked immunosorbent assay (ELISA) for the presence of Porphyromonas gingivalis, Actinobacillus actinomycetemcomitans, and Prevotella intermedia. Data were subjected to statistical analyses to determine the relationships between the frequency distribution of the radiographic and clinical variables over time.

RESULTS

Gains in clinical attachment level (CAL) of > or =2 mm at 4 or more sites from baseline to 6 months post-BMT were noted in 9/16 patients (56%), while 6/16 (38%) patients experienced a loss of CAL > or =2 mm at 4 or more sites in the same period. At a site level, 4.8% of sites exhibited a gain in CAL > or =2 mm between baseline and 3 months post-BMT while 2.3% of sites showed a loss of CAL > or =2 mm in the same period. From baseline to 6 months, a gain in CAL of > or =2 mm was recorded at 3.1% of sites, and 2.4% of sites experienced a loss of > or =2 mm. A significant improvement in the gingival index occurred between all sequential time periods when assessed at a site level. At a patient level, 11/18 (61%) patients showed a significant change in gingival index between baseline and 3 months and 10/16 (63%) between baseline and 6 months. There was no significant relationship between clinical changes and the prevalence of the periodontal pathogens at the various time periods.

CONCLUSIONS

An improvement in periodontal health was recorded between baseline and 6 months post-transplantation. Most of the improvement in periodontal status was noted in the first 3 months after BMT, with a slight decline in periodontal health between 3 and 6 months post-transplant. No significant alteration was noted in the prevalence of periodontal pathogens during the study period.

Quantitative scale of oral mucositis associated with autologous bone marrow transplantation

Acute oral complications are serious and disabling secondary effects for patients undergoing cancer therapy. Therefore, the authors wanted to develop a sensitive and specific method to measure oral mucosal changes associated with autologous with autologous bone marrow transplantation. 14 patients, all volunteers, 18-56 years old, receiving conditioning regimens of cyclophosphamide and total body irradiation were included. The clinical changes of the oral mucosa and functional modifications were scored daily, over 21 days with a 16 item scale, ranging from 0 to 3. A daily index of mucositis (DIM) was established by adding the scores obtained for the 16 items and a cumulative score of oral mucositis was obtained by the addition of the 21 DIM for assessing the severity of oral mucositis throughout its duration. The internal consistency measures (Chronbach alpha) were strong (range 0.80-0.97). A scale of equivalence, pre-established in comparison with pre-existing general mucositis rating scales, permitted a day by day simple classification in a 4-grade scale, to be obtained. Support for the validity of the suggested scale is presented. This scale may help to improve the study of oral complications of cancer therapy.

Reconstitution of cutaneous neural-immunological networks following bone marrow transplantation

During allogeneic bone marrow transplantation (BMT), host epidermal Langerhans cells (LC) are depleted and replaced by LC derived from the bone marrow inoculum. LC have recently been shown to form intimate spatial associations with intraepithelial nerves (IEN), which release regulatory peptides. The present study investigated whether the IEN network within skin remains intact during BMT, and whether repopulating LC re-established contacts with IEN. Double-labeling immunohistochemical techniques were employed using antibodies to CD1a and neural cell adhesion molecule (CD56) to identify LC and IEN, respectively. LC were depleted by conditioning for BMT, and repopulating LC reached normal values after day +100. In contrast to fluctuations in the LC network, the frequency of IEN remained unchanged during the post-BMT period. Contacts between LC and IEN were present both before and after BMT, and repopulating LC established a spatial interaction with IEN similar to that seen before BMT. These data provide the first evidence for the dynamic nature of the spatial relationship of LC with IEN, and raise intriguing questions regarding the mechanisms that direct homing of LC within epithelia.

Australian Dental Research Fund Trebitsch Scholarship. Efficacy of antifungal prophylaxis in bone marrow transplantation

Oral candidal infection is a common problem in bone marrow transplantation. This prospective study compared the effectiveness of antifungal prophylaxis with topical antifungals (nystatin and amphotericin B suspensions) versus oral fluconazole in 196 patients undergoing bone marrow transplantation. Oral candidosis occurred frequently in the group receiving topical antifungals (61/113, 54%), but was rare in the group receiving fluconazole (6/83, 7%). The difference in efficacy between the two groups was highly significant (p < 0.00001). There was no difference in the incidence of suspected systemic fungal infection between the two groups. While nausea was a problem with antifungal suspensions, no significant adverse reactions to fluconazole occurred. Because of greater efficacy in preventing oral candidosis and better patient tolerance, oral fluconazole is preferred to antifungal suspensions for prophylactic use in patients undergoing bone marrow transplantation.