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Bowen J, Cross C. The Role of the Innate Immune Response in Oral Mucositis Pathogenesis. Int J Mol Sci 2023; 24:16314. [PMID: 38003503 PMCID: PMC10670995 DOI: 10.3390/ijms242216314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 11/11/2023] [Accepted: 11/12/2023] [Indexed: 11/26/2023] Open
Abstract
Oral mucositis (OM) is a significant complication of cancer therapy with limited management strategies. Whilst inflammation is a central feature of destructive and ultimately ulcerative pathology, to date, attempts to mitigate damage via this mechanism have proven limited. A relatively underexamined aspect of OM development is the contribution of elements of the innate immune system. In particular, the role played by barriers, pattern recognition systems, and microbial composition in early damage signaling requires further investigation. As such, this review highlights the innate immune response as a potential focus for research to better understand OM pathogenesis and development of interventions for patients treated with radiotherapy and chemotherapy. Future areas of evaluation include manipulation of microbial-mucosal interactions to alter cytotoxic sensitivity, use of germ-free models, and translation of innate immune-targeted agents interrogated for mucosal injury in other regions of the alimentary canal into OM-based clinical trials.
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Affiliation(s)
- Joanne Bowen
- School of Biomedicine, University of Adelaide, Adelaide 5005, Australia;
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Ji L, Hao S, Wang J, Zou J, Wang Y. Roles of Toll-Like Receptors in Radiotherapy- and Chemotherapy-Induced Oral Mucositis: A Concise Review. Front Cell Infect Microbiol 2022; 12:831387. [PMID: 35719331 PMCID: PMC9201217 DOI: 10.3389/fcimb.2022.831387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 05/12/2022] [Indexed: 11/13/2022] Open
Abstract
Radiotherapy and/or chemotherapy-induced oral mucositis (RIOM/CIOM) is a common complication in cancer patients, leading to negative clinical manifestations, reduced quality of life, and impacting compliance with anticancer treatment. The composition and metabolic function of the oral microbiome, as well as the innate immune response of the oral mucosa are severely altered during chemotherapy or radiotherapy, promoting the expression of inflammatory mediators by direct and indirect mechanisms. Commensal oral bacteria-mediated innate immune signaling via Toll-like receptors (TLRs) ambiguously shapes radiotherapy- and/or chemotherapy-induced oral damage. To date, there has been no comprehensive overview of the role of TLRs in RIOM/CIOM. This review aims to provide a narrative of the involvement of TLRs, including TLR2, TLR4, TLR5, and TLR9, in RIOM/CIOM, mainly by mediating the interaction between the host and microorganisms. As such, we suggest that these TLR signaling pathways are a novel mechanism of RIOM/CIOM with considerable potential for use in therapeutic interventions. More studies are needed in the future to investigate the role of different TLRs in RIOM/CIOM to provide a reference for the precise control of RIOM/CIOM.
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Affiliation(s)
- Ling Ji
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Pediatric Dentistry, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Siyuan Hao
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Pediatric Dentistry, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Jiantao Wang
- State Key Laboratory of Biotherapy and Department of Lung Cancer Center and Department of Radiation Oncology, West China Hospital, Sichuan University, Chengdu, China
| | - Jing Zou
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Pediatric Dentistry, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Yan Wang
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Pediatric Dentistry, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- *Correspondence: Yan Wang,
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Yousefi H, Gholami M, Zoughi M, Rezaei N, Chuppani A, Nikfar S, Amoli MM. Role of genetic polymorphisms in recurrent aphthous stomatitis: A systematic review and meta-analysis. Cytokine 2022; 153:155864. [DOI: 10.1016/j.cyto.2022.155864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 08/25/2021] [Accepted: 03/08/2022] [Indexed: 11/03/2022]
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Occurrence of Recurrent Aphthous Stomatitis (RAS) as a Rare Oral Manifestation in a Patient with Gilbert's Syndrome. Case Rep Dent 2021; 2021:6648729. [PMID: 33953989 PMCID: PMC8068538 DOI: 10.1155/2021/6648729] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 04/01/2021] [Accepted: 04/07/2021] [Indexed: 12/15/2022] Open
Abstract
Recurrent aphthous stomatitis is an ulcerative disease of the oral cavity and can occur in isolation or as a manifestation of many systemic diseases. It is a quite common entity and may hence often be overlooked as an isolated lesion. Gilbert's syndrome is a genetic disorder where a deficiency of an enzyme associated with the conjugation of bilirubin results in unconjugated hyperbilirubinemia. The disease is generally asymptomatic and is aggravated by certain trigger factors. No associated oral manifestations are known. In this case report, we discuss the concomitant presence of recurrent aphthous stomatitis in a patient of Gilbert's syndrome. The presence of such recurrent stomatitis may represent as an oral manifestation of Gilbert's syndrome. Early identification of these entities may improve the overall quality of life of the patient.
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Tekcan A, Yigit S, Nursal AF, Tumer MK, Yerliyurt K, Kuruca N. Analysis of Interleukin-1 Receptor Antagonist Variable Number Tandem Repeat Variant in Recurrent Aphthous Stomatitis. Endocr Metab Immune Disord Drug Targets 2021; 21:139-144. [PMID: 32282310 DOI: 10.2174/1871530320666200413092239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 01/29/2020] [Accepted: 02/04/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND/AIMS Recurrent aphthous stomatitis (RAS) is one of the common oral inflammatory diseases. As immunological and genetic factors have been held responsible for the pathogenesis of RAS, the objective of this study was to determine whether the interleukin-1 receptor antagonist (IL-1Ra) gene variable number tandem repeat (VNTR) variant is a risk factor for the development of RAS in Turkish patients and to define its contribution to the increased risk. METHODS The IL-1Ra VNTR variant was evaluated in 169 RAS patients and 171 healthy controls by the polymerase chain reaction (PCR) method. RESULTS No statistically significant difference was found in the genotype distributions and allele frequencies of IL-1Ra VNTR variant between RAS patients and healthy controls. CONCLUSION Lack of association between IL-1Ra VNTR variant and RAS could indicate that IL-1Ra has no significant role in the pathophysiology of RAS. However, it still appears to be very worthwhile to continue to search for cytokine gene variants in order to predict the development of such disease.
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Affiliation(s)
- Akin Tekcan
- Department of Medical Biology, Faculty of Medicine, Amasya University, Amasya, Turkey
| | - Serbulent Yigit
- Gaziosmanpasa University, Faculty of Medicine, Department of Medical Biology, Tokat, Turkey
| | - Ayse F Nursal
- Hitit University, Faculty of Medicine, Department of Medical Genetics, Corum, Turkey
| | - Mehmet K Tumer
- Gaziosmanpasa University, Faculty of Dentistry, Department of Maxillofacial Surgery, Tokat, Turkey
| | - Kaan Yerliyurt
- Gaziosmanpasa University, Faculty of Dentistry, Department of Prosthodontics, Tokat, Turkey
| | - Nilufer Kuruca
- Ondokuz Mayıs University, Faculty of Veterinary Medicine, Department of Pathology, Samsun, Turkey
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Bankvall M, Östman S, Jontell M, Torinsson Naluai Å. A family-based genome-wide association study of recurrent aphthous stomatitis. Oral Dis 2020; 26:1696-1705. [PMID: 32558109 DOI: 10.1111/odi.13490] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 04/29/2020] [Accepted: 06/04/2020] [Indexed: 01/06/2023]
Abstract
OBJECTIVES The aetiology of recurrent aphthous stomatitis (RAS) remains unknown. Individuals may share features of genetic susceptibility, and there may also be a hereditary component. The aim was to identify patterns of association and segregation for genetic variants and to identify the genes and signalling pathways that determine the risk of developing RAS, through a family-based genome-wide association study (GWAS). SUBJECTS AND METHODS DNA was extracted from buccal swabs of 91 individuals in 16 families and analysed in an Illumina core exome single nucleotide polymorphism (SNP) array. A family-based association test (dFAM) was used to derive SNP association values across all chromosomes. RESULTS None of the final 288,452 SNPs reached the genome-wide significant threshold of 5 × 10-8 . The most significant pathways were the Ras and PI3K-Akt signalling pathways, pathways in cancer, circadian entrainment and the Rap 1 signalling pathway. CONCLUSIONS This confirms that RAS is not monogenic but results as a consequence of interactions between multiple host genes and possibly also environmental factors. The present approach provides novel insights into the mechanisms underlying RAS and raises the possibility of identifying individuals at risk of acquiring this condition.
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Affiliation(s)
- Maria Bankvall
- Department of Oral Medicine & Pathology, Institute of Odontology, University of Gothenburg, Gothenburg, Sweden
| | - Sofia Östman
- Department of Infectious Diseases, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
| | - Mats Jontell
- Department of Oral Medicine & Pathology, Institute of Odontology, University of Gothenburg, Gothenburg, Sweden
| | - Åsa Torinsson Naluai
- Department of Microbiology and Immunology, Institute of Biomedicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Yang Z, Cui Q, An R, Wang J, Song X, Shen Y, Wang M, Xu H. Comparison of microbiomes in ulcerative and normal mucosa of recurrent aphthous stomatitis (RAS)-affected patients. BMC Oral Health 2020; 20:128. [PMID: 32349736 PMCID: PMC7189554 DOI: 10.1186/s12903-020-01115-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 04/15/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Recurrent aphthous stomatitis (RAS) is the most common form of oral ulcerative disease, whose cause is still unknown. Researchers have found the association of many factors with the occurrence of RAS, and proposed oral bacterial infection could be a cause for this disease. METHODS To investigate whether the occurrence of RAS is associated with oral bacterial infection, we performed high throughput sequencing analysis of bacterial samples collected from the normal oral mucosa and aphthous ulcers of 24 patients. RESULTS Firmicutes, Proteobacteria and Bacteriodetes were the most abundant phyla in the microbiomes analysed. The alpha diversities of the oral mucosa and aphthous ulcer microbiomes were similar, suggesting a similar richness and diversity. The NMDS analysis showed the oral mucosa and aphthous ulcer microbiomes are significantly different. This suggestion is further supported by Anosim, MRPP, and Adonis analyses. More detailed comparison of the two groups of microbiomes suggested that the occurrence of RAS is significantly associated with the increase of Escherichia coli and Alloprevotella, as well as the decrease of Streptococcus. CONCLUSIONS Considering E. coli is a very common intestinal bacterium, we propose that E. coli colonization could be a cause for RAS, and controlling E. coli colonization could help curing RAS.
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Affiliation(s)
- Zhongjun Yang
- State Key Laboratory of Microbial Technology, Qilu Hospital, Shandong University, Qingdao, Shandong, China
| | - Qingyu Cui
- State Key Laboratory of Microbial Technology, Qilu Hospital, Shandong University, Qingdao, Shandong, China
| | - Ran An
- College of Food Science and Pharmaceutical Engineering, Zaozhuang University, Zaozhuang, Shandong, China
| | - Juan Wang
- State Key Laboratory of Microbial Technology, Qilu Hospital, Shandong University, Qingdao, Shandong, China
| | - Xiaobo Song
- Department of Medical Biology, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway
| | - Yu Shen
- State Key Laboratory of Microbial Technology, Qilu Hospital, Shandong University, Qingdao, Shandong, China
| | - Mingyu Wang
- State Key Laboratory of Microbial Technology, Qilu Hospital, Shandong University, Qingdao, Shandong, China.
| | - Hai Xu
- State Key Laboratory of Microbial Technology, Qilu Hospital, Shandong University, Qingdao, Shandong, China.
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Bilodeau EA, Lalla RV. Recurrent oral ulceration: Etiology, classification, management, and diagnostic algorithm. Periodontol 2000 2019; 80:49-60. [PMID: 31090148 DOI: 10.1111/prd.12262] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Recurrent oral ulcerations are manifestations of a heterogeneous set of both general and more-or-less specific oral diseases due to numerous potential etiologies, including, but not limited to, infections, medications, autoimmune disease, and other systemic disease. This review discusses the pathogenesis, clinical presentation, diagnosis, and management of the common causes of recurrent oral ulceration. The following types/etiologies of recurrent oral ulceration are covered: traumatic ulceration, chemical ulceration, recurrent aphthous stomatitis, medication-related ulceration, infectious ulceration, mucocutaneous disease, and autoimmune/systemic disease. A diagnostic algorithm for recurrent oral ulceration is also presented.
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Affiliation(s)
- Elizabeth A Bilodeau
- Department of Diagnostic Sciences, University of Pittsburgh School of Dental Medicine, Pittsburgh, Pennsylvania, USA
| | - Rajesh V Lalla
- Department of Oral Health and Diagnostic Sciences, University of Connecticut School of Dental Medicine, Farmington, Connecticut, USA
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Rivera C. Essentials of recurrent aphthous stomatitis. Biomed Rep 2019; 11:47-50. [PMID: 31384457 DOI: 10.3892/br.2019.1221] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 06/05/2019] [Indexed: 12/17/2022] Open
Abstract
Recurrent aphthous stomatitis (RAS), also known as canker sores, is the most common disease of the oral mucosa. Unlike caries and periodontal disease, patients with RAS are unable to prevent it. The clinical picture of RAS is characterized by recurrent episodes of solitary or multiple painful ulcerations without association with systemic diseases. The objective of this review is to present the essential characteristics of RAS, including its definition, pathogenesis, clinical and microscopic characteristics, proposed experimental models and recommended pharmacological management. This understanding can serve as a theoretical framework for research proposals.
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Affiliation(s)
- César Rivera
- Oral Medicine and Pathology Research Group, Department of Basic Biomedical Sciences, Faculty of Health Sciences, University of Talca, Talca, Maule 3460000, Chile
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Najafi S, Mohammadzadeh M, Rajabi F, Zare Bidoki A, Yousefi H, Farhadi E, Rezaei N. Interleukin-4 and Interleukin-4 Receptor Alpha Gene Polymorphisms in Recurrent Aphthous Stomatitis. Immunol Invest 2018; 47:680-688. [PMID: 29985726 DOI: 10.1080/08820139.2018.1480033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Recurrent aphthous stomatitis (RAS) is a common oral condition with a major impact on the quality of life. The condition is thought to be due to the overexpression of T helper-1(Th1)-related cytokines. Since interleukin-4 (IL-4) and its receptor (IL-4Rα) are antagonistic to Th-1 pathways, polymorphisms in their genes may also be involved in the pathogenesis of aphthous stomatitis. METHODS Sixty-four patients diagnosed with minor RAS and 141 (age- and sex-matched) healthy controls were assessed for 3 single-nucleotide polymorphisms (SNPs) within the promoter region of the IL-4 gene (-1098G/T, -590C/T, and -33C/T), and 1 SNP in IL-4Rα gene (+1902 A/G). RESULTS No significant differences were detected between the patient and the control group regarding IL-4 allele frequencies. However, the patient group demonstrated a higher frequency of IL-4 -590 CC genotype and a lower rate of IL-4 -590 TC genotype. The TCT, GTT, GCT, and GTC haplotypes of the IL-4 gene (-1098, -590, -33) were significantly more frequent in the patients and the GCC, and TTT haplotypes were more common in healthy controls. No significant differences were found in IL-4Rα gene polymorphism between the 2 groups. CONCLUSIONS Certain polymorphisms of IL4 gene could predispose individuals to RAS.
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Affiliation(s)
- Shamsolmoulouk Najafi
- a Department of Oral Medicine , School of Dentistry, Tehran University of Medical Sciences , Tehran , Iran.,b International Campus, Dental Research Center , Tehran University of Medical Sciences , Tehran , Iran
| | | | - Fateme Rajabi
- d Department of Dermatology , School of Medicine, Shahid Beheshti University of Medical Sciences , Tehran , Iran.,e Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA) , Universal Scientific Education and Research Network (USERN) , Tehran , Iran
| | - Alireza Zare Bidoki
- f The John Curtin School of Medical Research , Australian National University , Canberra Australia.,g Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA) Universal Scientific Education and Research Network (USERN) , Canberra , Australia
| | - Hila Yousefi
- c Dental Branch , Islamic Azad University , Tehran , Iran
| | - Elham Farhadi
- h Molecular Immunology Research Center , Tehran University of Medical Sciences , Tehran , Iran
| | - Nima Rezaei
- i Research Center for Immunodeficiencies, Children's Medical Center , Tehran University of Medical Sciences , Tehran , Iran.,j Department of Immunology , School of Medicine, Tehran University of Medical Sciences , Tehran , Iran.,k Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA) , Universal Scientific Education and Research Network (USERN) , Sheffield , UK
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Saikaly SK, Saikaly TS, Saikaly LE. Recurrent aphthous ulceration: a review of potential causes and novel treatments. J DERMATOL TREAT 2018; 29:542-552. [PMID: 29278022 DOI: 10.1080/09546634.2017.1422079] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Purpose of article: This review examines studies published between May 2012 and 2017 with a specific interest in potential recurrent aphthous ulceration (RAU) etiologies and treatment modalities/efficacy, including topical treatments, systemic regimens, vitamin repletion, and laser therapy, among others. MATERIALS AND METHODS PubMed MEDLINE and Cochrane Database of Systematic Reviews were searched using various combinations of: 'aphthous', 'ulcer', and 'treatment'. The titles and abstracts from the initial literature search were appraised to identify articles for full review and reference sections from each article were searched manually for relevant publications. Both randomized controlled trials and observational reports were included in this review, as some treatment types have not been formally examined in randomized trials. Relevant studies were reviewed, compared, and summarized. RESULTS RAU can result from systemic disease and trauma, but recent studies have shown a variety of potential etiologies, ranging from vitamin deficiencies, oral microbiota derangements, hematological considerations, stress, genetic polymorphisms to oxidant-antioxidant imbalances, among others. Many modalities of therapy are available and have proven efficacious. CONCLUSIONS As the exact etiology of RAU is still unknown, therapy is based on symptomatic relief.
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Affiliation(s)
- Sami Kameel Saikaly
- a Orlando Regional Medical Center , Orlando , FL , USA.,b University of Central Florida College of Medicine , Orlando , FL , USA
| | - Tanya Siham Saikaly
- c University of Alabama at Birmingham School of Dentistry , Birmingham , AL , USA
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Peterson DE, O'Shaughnessy JA, Rugo HS, Elad S, Schubert MM, Viet CT, Campbell-Baird C, Hronek J, Seery V, Divers J, Glaspy J, Schmidt BL, Meiller TF. Oral mucosal injury caused by mammalian target of rapamycin inhibitors: emerging perspectives on pathobiology and impact on clinical practice. Cancer Med 2016; 5:1897-907. [PMID: 27334013 PMCID: PMC4971919 DOI: 10.1002/cam4.761] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Revised: 04/13/2016] [Accepted: 04/14/2016] [Indexed: 12/21/2022] Open
Abstract
In recent years oral mucosal injury has been increasingly recognized as an important toxicity associated with mammalian target of rapamycin (mTOR) inhibitors, including in patients with breast cancer who are receiving everolimus. This review addresses the state-of-the-science regarding mTOR inhibitor-associated stomatitis (mIAS), and delineates its clinical characteristics and management. Given the clinically impactful pain associated with mIAS, this review also specifically highlights new research focusing on the study of the molecular basis of pain. The incidence of mIAS varies widely (2-78%). As reported across multiple mTOR inhibitor clinical trials, grade 3/4 toxicity occurs in up to 9% of patients. Managing mTOR-associated oral lesions with topical oral, intralesional, and/or systemic steroids can be beneficial, in contrast to the lack of evidence supporting steroid treatment of oral mucositis caused by high-dose chemotherapy or radiation. However, steroid management is not uniformly efficacious in all patients receiving mTOR inhibitors. Furthermore, technology does not presently exist to permit clinicians to predict a priori which of their patients will develop these lesions. There thus remains a strategic need to define the pathobiology of mIAS, the molecular basis of pain, and risk prediction relative to development of the clinical lesion. This knowledge could lead to novel future interventions designed to more effectively prevent mIAS and improve pain management if clinically significant mIAS lesions develop.
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Affiliation(s)
- Douglas E Peterson
- School of Dental Medicine and Neag Comprehensive Cancer Center, UConn Health, Farmington, Connecticut
| | | | - Hope S Rugo
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California
| | - Sharon Elad
- Eastman Institute for Oral Health, University of Rochester Medical Center, Rochester, New York.,Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York
| | - Mark M Schubert
- School of Dentistry, University of Washington and Seattle Cancer Care Alliance, Seattle, Washington
| | - Chi T Viet
- New York University College of Dentistry, New York, New York
| | | | - Jan Hronek
- Tennessee Oncology/Sarah Cannon Research Institute, Nashville, Tennessee
| | - Virginia Seery
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Josephine Divers
- Texas Oncology-Baylor Charles A. Sammons Cancer Center, Dallas, Texas
| | - John Glaspy
- Jonsson Comprehensive Cancer Center, UCLA, Los Angeles, California
| | - Brian L Schmidt
- New York University College of Dentistry, New York, New York
| | - Timothy F Meiller
- School of Dentistry and the Marlene and Stewart Greenebaum Cancer Center, University of Maryland, Baltimore, Maryland
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