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Siripornkitti W, Pengpis N, Chanswangphuwana C, Prueksrisakul T. Therapeutic response of oral chronic graft-versus-host disease to topical corticosteroids according to the 2014 National Institutes of Health (USA) consensus criteria. Med Oral Patol Oral Cir Bucal 2024; 29:e219-e226. [PMID: 37823294 PMCID: PMC10945877 DOI: 10.4317/medoral.26203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 09/03/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Chronic graft-versus-host-disease (cGVHD) is a major cause of morbidity and mortality after allogeneic hematopoietic stem cell transplantation. The oral cavity is one of the most frequently affected anatomic sites and is affected in 70% of all patients who develop cGVHD. The objective of this study was to determine the therapeutic response to topical corticosteroids and clinical outcome of patients with oral cGVHD using the 2014 NIH consensus criteria. MATERIAL AND METHODS The oral manifestations of cGVHD were collected at the first and the follow-up (FU) visits after the therapeutic treatment of oral GVHD. The FU intervals were: FU0, first visit; FU1, 0-1 month; FU2, 1-3 months; FU3, 3-6 months; FU4, 6-9 months; and FU5, 9-12 months. The oral cGVHD activity was assessed using the NIH modification of the Schubert Oral Mucosa Rating Scale (OMRS) and Thongprasom sign score. The functional impact was assessed by the organ-specific severity score. RESULTS Fourteen patients (93.3%) at FU0 were being treated with at least one form of systemic immunosuppressive therapy, i.e., prednisolone, cyclosporin, and tacrolimus. The OMRS was reduced between FU0 and FU3 (p < 0.001), FU0 and FU4 (p < 0.001), and FU0 and FU5 (p = 0.004). The organ-specific severity scores were also reduced between FU0 and FU4 (p = 0.016), and FU0 and FU5 (p = 0.001). There was no significant difference in the highest Thongprasom sign score between all follow-up intervals (FU0-FU5) (p = 0.201). One patient (6.7%) at FU4 and three patients (20.0%) at FU5 did not receive topical corticosteroid therapy for oral cGVHD. CONCLUSIONS The oral cGVHD lesions and functional impacts improved within 6 months and 9 months, respectively. However, most of the patients required topical corticosteroid therapy for more than 1 year to control their symptoms and lesions.
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Affiliation(s)
- W Siripornkitti
- Oral Medicine Department, Faculty of Dentistry Chulalongkorn University Bangkok 10330, Thailand
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Aboalela AA, Farook FF, Alazaz NN, Alshahrani N, Alharthi A, Hagr R. The effect of oral chronic graft-versus-host disease on bodyweight: A cohort study. PLoS One 2024; 19:e0293873. [PMID: 38236925 PMCID: PMC10796034 DOI: 10.1371/journal.pone.0293873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 08/24/2023] [Indexed: 01/22/2024] Open
Abstract
AIM This retrospective cohort study aimed to evaluate the association between body weight and oral cGVHD (chronic graft versus host disease). METHODS Patients with oral cGVHD were compared with an age and gender-matched non-GVHD cohort in terms of demographic information, body mass index (BMI), date of transplant, length of hospitalization, and oral complications. Weight was stratified in pre-and post-transplant weight, mean weight after acquiring cGVHD for the first year, and post-oral cGVHD BMI. Each patient was matched and compared with two controls at a 1:2 ratio. Firth's penalized likelihood logistic regression was used to investigate the association between oral complications and weight loss greater than 5% in the oral cGVHD group. RESULTS This study included 137 patients (n = 42 oral cGVHD, n = 12 non oral-cGVHD and n = 83 non-GVHD). The oral cGVHD cohort had a 1.44 times higher risk (RR) of being underweight (BMI<18.5 kg/m2) compared to the non-GVHD cohort. Oral mucositis was an independent predictor of weight loss above 5% in the oral cGVHD cohort (p < 0.001). CONCLUSION The weight loss was more prevalent among oral cGVHD, and oral mucositis was linked to significant weight loss. Weight loss may indicate the need to initiate early and aggressive symptomatic oral cGVHD treatment.
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Affiliation(s)
- Ali Anwar Aboalela
- Maxillofacial Surgery and Diagnostic Sciences Department, College of Dentistry, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Fathima Fazrina Farook
- Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Preventive Dental Science Department, College of Dentistry, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Norah N. Alazaz
- Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
- College of Dentistry, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Nada Alshahrani
- Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
- College of Dentistry, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Aalia Alharthi
- College of Dentistry, Princess Nourah Bint Abdul Rahman University, Riyadh, Saudi Arabia
| | - Roa Hagr
- College of Dentistry, Princess Nourah Bint Abdul Rahman University, Riyadh, Saudi Arabia
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3
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Bulthuis MS, van Gennip LLA, Thomas RZ, Bronkhorst EM, Laheij AMGA, Raber-Durlacher JE, Rozema FR, Brennan MT, von Bültzingslöwen I, Blijlevens NMA, Huysmans MCDNJM, van Leeuwen SJM. The effect of conditioning regimen and prescribed medications on hyposalivation in haematopoietic cell transplantation (HCT) patients: an 18-month prospective longitudinal study. Clin Oral Investig 2023; 27:7369-7381. [PMID: 37853264 PMCID: PMC10713764 DOI: 10.1007/s00784-023-05327-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 10/10/2023] [Indexed: 10/20/2023]
Abstract
OBJECTIVES Haematopoietic cell transplantation (HCT) preceded by a conditioning regimen is an established treatment option for (non)malignant haematologic disorders. We aim to describe the development of hyposalivation over time in HCT recipients, and determine risk indicators. MATERIALS AND METHODS A multi-centre prospective longitudinal observational study was conducted. Unstimulated (UWS) and stimulated (SWS) whole saliva was collected before HCT, early post-HCT, and after 3, 6, 12, and 18 months. The effect of type of transplantation (allogeneic vs autologous) and intensity (full vs reduced) of the conditioning regimen on hyposalivation (UWS < 0.2 mL/min; SWS < 0.7 mL/min) was explored. RESULTS A total of 125 HCT recipients were included. More than half of the patients had hyposalivation early post-HCT; a quarter still had hyposalivation after 12 months. The conditioning intensity was a risk indicator in the development of hyposalivation of both UWS (OR: 3.9, 95% CI: 1.6-10.6) and SWS (OR: 8.2, 95% CI: 2.9-24.6). After 3 and 12 months, this effect was not statistically significant anymore. CONCLUSIONS Hyposalivation affects the majority of patients early post-HCT. The conditioning intensity and the type of transplantation were significant risk indicators in the development of hyposalivation. The number of prescribed medications, total body irradiation as part of the conditioning regimen and oral mucosal graft-versus-host disease did not influence hyposalivation significantly. CLINICAL RELEVANCE Because of the high prevalence of hyposalivation, HCT recipients will have an increased risk of oral complications. It might be reasonable to plan additional check-ups in the dental practice and consider additional preventive strategies.
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Affiliation(s)
- Marjolein S Bulthuis
- Department of Dentistry, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Lucky L A van Gennip
- Department of Dentistry, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Renske Z Thomas
- Department of Dentistry, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ewald M Bronkhorst
- Department of Dentistry, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Alexa M G A Laheij
- Department of Oral Medicine, Academic Centre for Dentistry Amsterdam, University of Amsterdam and VU University, Amsterdam, The Netherlands
- Department of Preventive Dentistry, Academic Centre for Dentistry Amsterdam, University of Amsterdam and VU University, Amsterdam, The Netherlands
| | - Judith E Raber-Durlacher
- Department of Oral Medicine, Academic Centre for Dentistry Amsterdam, University of Amsterdam and VU University, Amsterdam, The Netherlands
- Department of Oral and Maxillofacial Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Frederik R Rozema
- Department of Oral Medicine, Academic Centre for Dentistry Amsterdam, University of Amsterdam and VU University, Amsterdam, The Netherlands
- Department of Oral and Maxillofacial Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Michael T Brennan
- Department of Oral Medicine/Oral & Maxillofacial Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC; Department of Otolaryngology/Head & Neck Surgery, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Inger von Bültzingslöwen
- Department of Oral Microbiology and Immunology, Institute of Odontology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Nicole M A Blijlevens
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
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Tollemar V, Garming Legert K, Sugars RV. Perspectives on oral chronic graft-versus-host disease from immunobiology to morbid diagnoses. Front Immunol 2023; 14:1151493. [PMID: 37449200 PMCID: PMC10338056 DOI: 10.3389/fimmu.2023.1151493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023] Open
Abstract
Chronic Graft-versus-Host Disease (cGVHD) is a major long-term complication, associated with morbidity and mortality in patients following allogenic hematopoietic cell transplantation (HCT) for immune hematopoietic disorders. The mouth is one of the most frequently affected organs after HCT (45-83%) and oral cGVHD, which may appear as the first visible sign. Manifestations present with mucosal lichenoid lesions, salivary gland dysfunction and limited oral aperture. Diagnosis of oral cGVHD severity is based on mucosal lesions with symptoms of sensitivity and pain and reduced oral intake. However, diagnostic difficulties arise due to subjective definitions and low specificity to cover the spectrum of oral cGVHD. In recent years there have been significant improvements in our understanding of the underlying oral cGVHD disease mechanisms. Drawing upon the current knowledge on the pathophysiology and biological phases of oral cGVHD, we address oral mucosa lichenoid and Sjogren's Syndrome-like sicca syndromes. We consider the response of alloreactive T-cells and macrophages to recipient tissues to drive the pathophysiological reactions and biological phases of acute inflammation (phase 1), chronic inflammation and dysregulated immunity (phase 2), and subsequent aberrant fibrotic healing (phase 3), which in time may be associated with an increased malignant transformation rate. When formulating treatment strategies, the pathophysiological spectrum of cGVHD is patient dependent and not every patient may progress chronologically through the biological stages. As such there remains a need to address and clarify personalized diagnostics and management to improve treatment descriptions. Within this review, we highlight the current state of the art knowledge on oral cGVHD pathophysiology and biological phases. We address knowledge gaps of oral cGVHD, with a view to facilitate clinical management and improve research quality on lichenoid biology and morbid forms of oral cGVHD.
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Affiliation(s)
| | | | - Rachael V. Sugars
- Division of Oral Diagnostics and Rehabilitation, Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden
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Tollemar V, Arvidsson H, Häbel H, Tudzarovski N, Legert KG, Le Blanc K, Warfvinge G, Sugars R. Grading of minor salivary gland immuno-histopathology post-allogenic hematopoietic cell transplantation. Heliyon 2023; 9:e15517. [PMID: 37128306 PMCID: PMC10148098 DOI: 10.1016/j.heliyon.2023.e15517] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 04/04/2023] [Accepted: 04/12/2023] [Indexed: 05/03/2023] Open
Abstract
The oral cavity commonly displays mucosal lichenoid lesions and salivary gland dysfunction, which are considered different chronic Graft-versus-Host Disease (cGVHD) pathophysiology's. However, diagnostics of salivary gland (sg-)cGVHD are limited. The objectives of the current study are to evaluate the minor salivary gland (MSG) histo-immunopathological profiles post allogenic hematopoietic cell transplantation based on sg-cGVHD criteria. Design: Histopathology was characterized according to two published grading strategies. Firstly, the National Institute of Health (NIH) assessed peri-ductal/acinar infiltration, exocytosis, damage, and fibrosis, and a points-based grading scheme was established (0-16 points, Grade (G) 0 to IV). Second, a modified Sjögren's Syndrome focus-score with parenchymal damage was also adapted, (0-10 points, Score 0 to 2). 146 MSG biopsies from 79 patients were compared, using the histopathological specific criteria for sg-cGVHD pathology. Quantitative immunohistochemistry for T-cells (CD4, CD8), B-cells (CD19, CD20), monocytic cells (CD68) and dendritic cells (CD1a) were also assessed. Results: The large-scale cohort validated the use of both grading schemes. GIII-GIV and score 2 signified a histopathological diagnosis of "likely" sg-cGVHD. Immunopathological severity was associated with increased T-cells (CD4 and CD8) and monocytic (CD68) infiltrate, with minimal involvement of B-cells (CD19 and CD20), and Langerhans cells (CD1a). Conclusions: Both schemes were verified as being suitable for histological grading to improve assessment and diagnosis of sg-cGVHD. The NIH cGVHD grading appears to be more beneficial for research purposes, including final diagnostics of "no/inactive", "possible" or "likely" cGVHD. The study highlights the intricacies of sg-cGVHD pathology; and the need for standardized assessment to improve patient management associated to sg-cGVHD.
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Affiliation(s)
- V. Tollemar
- Division of Oral Diagnostics and Rehabilitation, Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden
- Corresponding author.
| | - H. Arvidsson
- Division of Oral Diagnostics and Rehabilitation, Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - H. Häbel
- Medical Statistics Unit, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - N. Tudzarovski
- Division of Oral Diagnostics and Rehabilitation, Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - K. Garming Legert
- Division of Oral Diagnostics and Rehabilitation, Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - K. Le Blanc
- Division of Clinical Immunology and Transfusion Medicine, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
- Center of Allogeneic Stem Cell Transplantation and Cellular Therapy (CAST), Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - G. Warfvinge
- Department of Oral Pathology, Faculty of Odontology, Malmö University, Malmö, Sweden
| | - R.V. Sugars
- Division of Oral Diagnostics and Rehabilitation, Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden
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Pengpis N, Prueksrisakul T, Chanswangphuwana C. Clinical characteristics of oral chronic graft-versus-host disease according to the 2014 National Institutes of Health (USA) consensus criteria. Med Oral Patol Oral Cir Bucal 2023; 28:e167-e173. [PMID: 36173715 PMCID: PMC9985937 DOI: 10.4317/medoral.25629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 09/12/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Chronic graft-versus-host disease (cGVHD) is a serious and common complication of allogeneic hematopoietic cell transplantation (alloHCT). The oral cavity is the second most common site affected by cGVHD. In 2014, the 2005 National Institutes of Health (NIH) consensus criteria were revised to address areas of controversy. The aim of this study was to evaluate the clinical characteristics of oral cGVHD using the 2014 NIH consensus criteria. MATERIAL AND METHODS The baseline data of oral manifestation of patients, who were diagnosed with oral cGVHD, in the first dental visit were analyzed (n=22). The oral mucosal disease was evaluated by NIH modified Oral Mucosa Rating Scale (OMRS) and Thongprasom sign score. The salivary gland disease and sclerotic disease were determined by the presence of signs and symptoms. The functional impact was assessed by the organ-specific severity score. RESULTS The median time from transplant to oral cGVHD diagnosis was 11.9 months. White striae with an erosive area was found in 72.7% of the patients. The mean ± SD of NIH modified OMRS was 6.1 ± 3.0. The most common and severely affected site of lichen planus-like features was buccal mucosa. Xerostomia, superficial mucocele and limited mouth opening were found in 18.2%, 9.1%, and 9.1%, respectively, of the patients. Almost all patients (90.9%) had partial limitation of oral intake. There were no significant differences in NIH modified OMRS or organ-specific severity score among the patient characteristic groups. Moreover, there was no association between the oral manifestations of cGVHD and the patient characteristics. CONCLUSIONS The most common oral manifestation of cGVHD was white striae with an erosive area of oral mucosal disease, followed by xerostomia, superficial mucocele, and limited mouth opening. The 2014 NIH consensus criteria for diagnostic and severity assessment are informative and feasible in real-world practice.
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Affiliation(s)
- N Pengpis
- Oral Medicine Department Faculty of Dentistry, Chulalongkorn University Bangkok, 10330, Thailand
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Boor M, Raber-Durlacher JE, Hazenberg MD, Rozema FR, Laheij AMGA. Taste and smell disturbances in patients with chronic oral graft vs. host disease: An observational study. FRONTIERS IN ORAL HEALTH 2022; 3:934607. [PMID: 36160117 PMCID: PMC9500145 DOI: 10.3389/froh.2022.934607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 07/21/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundA common complication of allogeneic hematopoietic stem cell transplantation (alloHSCT) is chronic oral graft vs. host disease (cGvHD). Oral cGvHD may present as mucosal lesions, salivary gland dysfunction, and trismus. Moreover, taste and smell ability may be affected, but the prevalence, nature and severity of altered taste and smell function, and their impact on quality of life (QoL) are understudied.AimTo identify the prevalence, nature, and severity of taste and smell disturbances, their impact on QoL and to assess whether altered taste/smell ability is associated with oral mucosal cGvHD or hyposalivation.Materials and methodsAlloHSCT recipients at least 100 days post-HSCT and referred for oral cGvHD-related oral complaints were eligible for participation in this cross-sectional study. Manifestations of oral mucosal cGvHD were scored, the (un)stimulated salivary flow was measured, and objective taste and smell ability was evaluated. Subjective taste and smell alterations, and overall and oral health (OH)-related QoL were assessed.ResultsIn total, 45 patients were included, of which objective reduced taste ability (hypogeusia) was identified in 68.9%; 28.9% had reduced smell ability and 11.1% had complete loss of smell. Nevertheless, only 31.1% of patients reported severe taste alterations and 22% reported moderate taste alterations indicating that not all the patients were aware of their altered taste sense. Taste/smell disturbances were not related to oral mucosal cGvHD or hyposalivation. Most alloHSCT recipients reported a decreased OH-related QoL. However, a relation between taste/smell ability and global or OH-related QoL could not be identified.ConclusionTaste and smell disturbances are prevalent among alloHSCT recipients. Most patients reported a decreased OH-related QoL, but the specific impact of taste and smell disturbances remains to be elucidated.
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Affiliation(s)
- Marlou Boor
- Department of Oral Medicine, Academic Centre for Dentistry (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- *Correspondence: Marlou Boor
| | - Judith E. Raber-Durlacher
- Department of Oral Medicine, Academic Centre for Dentistry (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Department of Oral Maxillofacial Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Mette D. Hazenberg
- Department of Hematology Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Frederik R. Rozema
- Department of Oral Medicine, Academic Centre for Dentistry (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Department of Oral Maxillofacial Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Alexa M. G. A. Laheij
- Department of Oral Medicine, Academic Centre for Dentistry (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Department of Oral Maxillofacial Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Department of Preventive Dentistry, Academic Centre for Dentistry (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, Netherlands
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Dean D, Sroussi H. Oral Chronic Graft-Versus-Host Disease. FRONTIERS IN ORAL HEALTH 2022; 3:903154. [PMID: 35719318 PMCID: PMC9205403 DOI: 10.3389/froh.2022.903154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 04/18/2022] [Indexed: 11/30/2022] Open
Abstract
Chronic oral graft-versus-host disease (cGVHD) is a complex, frequent, and highly impactful complication of allogeneic hematopoietic cell transplantation (alloHCT). It represents the leading cause of morbidity and mortality in long-term alloHCT survivors. cGVHD can affect almost any visceral organ system and commonly affects the skin, eyes and mouth, manifesting with signs and symptoms similar to other known immune-mediated and autoimmune diseases. Oral manifestations of GVHD include inflammation, thinning, and ulceration of oral mucosal tissues (similar to lichen planus), lymphocyte-mediated salivary gland dysfunction (similar to Sjögren/Sicca Syndrome), and decreased oral opening (trismus) secondary to sclerosis of oral and perioral tissues (analogous to limitation in scleroderma). Potential sequelae include severe mucosal pain, compromised nutrition, weight loss, limitation in opening, and sometimes irreversible fibrosis of the salivary glands. While some cases can be managed with topical therapies, management may also require long-term targeted immunosuppressive and/or corticosteroid therapy with associated risk of local and systemic infection, hyperglycemia, kidney dysfunction, osteopenia/osteoporosis, and possibly secondary malignancies. The aim of this mini-review is to provide an up-to-date review of literature related to the diagnosis and management of oral cGVHD to aid dental and medical clinicians in optimizing oral cGVHD therapy while minimizing potential adverse effects.
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Affiliation(s)
- David Dean
- Department of Oral Medicine, University of Washington/Seattle Cancer Care Alliance, Seattle, WA, United States
- *Correspondence: David Dean
| | - Herve Sroussi
- Division of Oral Medicine and Dentistry, Brigham and Women's Hospital and Dana Farber Cancer Institute Department of Oral Medicine, Infection and Immunity, Harvard School of Dental Medicine, Boston, MA, United States
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Wu T, Liu Z, Yong X, Mei G, Jiang Q, Fang M, Li P, Zhang Z, Tao R. P16-positive secondary tongue squamous cell carcinoma following allogeneic hematopoietic stem cell transplantation: A case report and literature review. Oral Oncol 2021; 121:105399. [PMID: 34217620 DOI: 10.1016/j.oraloncology.2021.105399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 06/11/2021] [Accepted: 06/15/2021] [Indexed: 10/21/2022]
Abstract
As a method to improve the survival rate of patients with hematological malignancies, allogeneic hematopoietic stem cell transplantation (allo-HSCT) has increasingly been used for treatment. However, some potentially serious complications after allo-HSCT, including graft-versus-host disease, graft failure, infection, end-organ toxicity, and secondary malignancies, will determine the success of hematopoietic reconstitution. Here, we describe a case of a patient with p16-positive tongue squamous cell carcinoma (TSCC) following allo-HSCT. A 62-year-old man who had previously received allo-HSCT due to acute lymphocytic leukemia (AML) presented with erosions on the back of the tongue surrounded by multiple white patches, which were compatible with oral chronic graft-versus-host disease (cGVHD). During follow-up, a circular-like erosive lesion appeared on the right dorsal surface of the tongue. Biopsy of this lesion confirmed early invasive TSCC (T2N0M0). Partial glossectomy and tongue reconstruction were performed after cessation of immunosuppressants. Immunohistochemical (IHC) staining was positive for p16 and ki-67, suggesting a probable active human papillomavirus (HPV) infection. Six months after surgery, the patient showed no signs of metastasis or recurrence nor progression of oral GVHD.
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Affiliation(s)
- Tiantian Wu
- Department of Periodontics and Oral Medicine, College of Stomatology, Guangxi Medical University, Nanning, Guangxi, China; Guangxi Health Commission Key Laboratory of Prevention and Treatment for Oral Infectious Diseases, China; Guangxi Key Laboratory of Oral and Maxillofacial Rehabilitation and Reconstruction, Guangxi Universities and Colleges Key Laboratory of Oral and Maxillofacial Surgery Disease Treatment, Guangxi Clinical Research Center for Craniofacial Deformity, China; Guangxi Key Laboratory of AIDS Prevention and Treatment, Guangxi Medical University, Nanning, Guangxi, China
| | - Zhenmin Liu
- Department of Periodontics and Oral Medicine, College of Stomatology, Guangxi Medical University, Nanning, Guangxi, China; Guangxi Health Commission Key Laboratory of Prevention and Treatment for Oral Infectious Diseases, China; Guangxi Key Laboratory of Oral and Maxillofacial Rehabilitation and Reconstruction, Guangxi Universities and Colleges Key Laboratory of Oral and Maxillofacial Surgery Disease Treatment, Guangxi Clinical Research Center for Craniofacial Deformity, China
| | - Xiangzhi Yong
- Department of Periodontics and Oral Medicine, College of Stomatology, Guangxi Medical University, Nanning, Guangxi, China; Guangxi Health Commission Key Laboratory of Prevention and Treatment for Oral Infectious Diseases, China; Guangxi Key Laboratory of Oral and Maxillofacial Rehabilitation and Reconstruction, Guangxi Universities and Colleges Key Laboratory of Oral and Maxillofacial Surgery Disease Treatment, Guangxi Clinical Research Center for Craniofacial Deformity, China
| | - Guocheng Mei
- Department of Periodontics and Oral Medicine, College of Stomatology, Guangxi Medical University, Nanning, Guangxi, China; Guangxi Health Commission Key Laboratory of Prevention and Treatment for Oral Infectious Diseases, China; Guangxi Key Laboratory of Oral and Maxillofacial Rehabilitation and Reconstruction, Guangxi Universities and Colleges Key Laboratory of Oral and Maxillofacial Surgery Disease Treatment, Guangxi Clinical Research Center for Craniofacial Deformity, China
| | - Qiaozhi Jiang
- Department of Periodontics and Oral Medicine, College of Stomatology, Guangxi Medical University, Nanning, Guangxi, China; Guangxi Health Commission Key Laboratory of Prevention and Treatment for Oral Infectious Diseases, China; Guangxi Key Laboratory of Oral and Maxillofacial Rehabilitation and Reconstruction, Guangxi Universities and Colleges Key Laboratory of Oral and Maxillofacial Surgery Disease Treatment, Guangxi Clinical Research Center for Craniofacial Deformity, China; Guangxi Key Laboratory of AIDS Prevention and Treatment, Guangxi Medical University, Nanning, Guangxi, China
| | - Meifei Fang
- Department of Periodontics and Oral Medicine, College of Stomatology, Guangxi Medical University, Nanning, Guangxi, China; Guangxi Health Commission Key Laboratory of Prevention and Treatment for Oral Infectious Diseases, China; Guangxi Key Laboratory of Oral and Maxillofacial Rehabilitation and Reconstruction, Guangxi Universities and Colleges Key Laboratory of Oral and Maxillofacial Surgery Disease Treatment, Guangxi Clinical Research Center for Craniofacial Deformity, China; Guangxi Key Laboratory of AIDS Prevention and Treatment, Guangxi Medical University, Nanning, Guangxi, China
| | - Ping Li
- Department of Pathology, College of Stomatology, Guangxi Medical University, Nanning, Guangxi, China
| | - Zhongming Zhang
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Renchuan Tao
- Department of Periodontics and Oral Medicine, College of Stomatology, Guangxi Medical University, Nanning, Guangxi, China; Guangxi Health Commission Key Laboratory of Prevention and Treatment for Oral Infectious Diseases, China; Guangxi Key Laboratory of Oral and Maxillofacial Rehabilitation and Reconstruction, Guangxi Universities and Colleges Key Laboratory of Oral and Maxillofacial Surgery Disease Treatment, Guangxi Clinical Research Center for Craniofacial Deformity, China; Guangxi Key Laboratory of AIDS Prevention and Treatment, Guangxi Medical University, Nanning, Guangxi, China.
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10
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Elad S, Aljitawi O, Zadik Y. Oral Graft-Versus-Host Disease: A Pictorial Review and a Guide for Dental Practitioners. Int Dent J 2021; 71:9-20. [PMID: 33616057 PMCID: PMC9275209 DOI: 10.1111/idj.12584] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Graft-versus-host disease (GVHD) is a complication of haematopoietic stem cell transplantation (HSCT). GVHD may also develop following solid transplants or blood transfusions if white blood cells are transferred. GVHD affects multiple organs, including the oral tissues. OBJECTIVE This pictorial review provides a background of GVHD to dental practitioners, describes the most common oral manifestations of GVHD and highlights the main treatment modifications needed to deliver dental care to patients with GVHD. METHODS A narrative review enhanced with clinical photographs. RESULTS Acute GVHD may manifest in the oral mucosa; however, it often develops immediately following HSCT when routine dental treatment is postponed. Chronic GVHD may manifest in the oral mucosa, the salivary glands and the musculoskeletal compartment. It may indirectly affect the teeth and the oral flora, putting the patient at risk for infections. Importantly, GVHD poses an increased risk for oral cancer. CONCLUSION GVHD has a wide range of oral manifestations, some of which may affect dental treatment.
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Affiliation(s)
- Sharon Elad
- Division of Oral Medicine, Eastman Institute for Oral Health, University of Rochester Medical Center, Rochester, NY, USA.
| | - Omar Aljitawi
- Department of Hematology and Oncology, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA
| | - Yehuda Zadik
- Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
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11
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Fall-Dickson JM, Pavletic SZ, Mays JW, Schubert MM. Oral Complications of Chronic Graft-Versus-Host Disease. J Natl Cancer Inst Monogr 2020; 2019:5551350. [PMID: 31425593 DOI: 10.1093/jncimonographs/lgz007] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 03/15/2019] [Accepted: 04/01/2019] [Indexed: 02/07/2023] Open
Abstract
The increasing clinical indications for hematopoietic stem cell transplantation (HSCT) and improved clinical care throughout and following HSCT have led to not only long-term survival but also to an increasing incidence and prevalence of graft-versus-host disease (GVHD). Chronic GVHD (cGVHD) affects almost 50% of adult patients post-HSCT, with increasing incidence in pediatric patients as well. Oral cGVHD specifically has a reported prevalence ranging from 45% to 83% in patients who develop cGVHD and is more extensive in adult patients than in children. Oral cGVHD affects patients through clinically significant oral symptoms that may lead to significantly decreased caloric intake, oral infections, and increased health service utilization, and may thus affect overall health and survival. The most commonly used therapy for mucosal involvement of oral cGVHD is topical high-dose and ultra-high potency corticosteroids, and calcineurin inhibitors. This review of oral complications of cGVHD presents the clinical significance of oral cGVHD to HSCT survivors, our current understanding of the pathobiology of oral cGVHD and gaps in this evidence, and the global targeted interdisciplinary clinical research efforts, including the National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease. Current challenges regarding the management of oral cGVHD and strategies to advance our scientific understanding of this clinically significant chronic oral disease are presented.
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Affiliation(s)
- Jane M Fall-Dickson
- Department of Professional Nursing Practice, Georgetown University School of Nursing & Health Studies, Washington, DC
| | - Steven Z Pavletic
- Experimental Transplantation and Immunology Branch, National Cancer Institute, Division of Intramural Research, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD
| | - Jacqueline W Mays
- Experimental Transplantation and Immunology Branch, National Cancer Institute, Division of Intramural Research, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD
| | - Mark M Schubert
- Department of Oral Medicine, University of Washington, School of Dentistry and Seattle Cancer Care Alliance and Oral Medicine, Fred Hutchinson Cancer Research Center, Seattle, WA
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Kilgour JM, Wali G, Gibbons E, Scherwath A, Barata Badiella A, Peniket A, Schoemans H, Matin RN. Systematic Review of Patient-Reported Outcome Measures in Graft-versus-Host Disease. Biol Blood Marrow Transplant 2020; 26:e113-e127. [DOI: 10.1016/j.bbmt.2020.01.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 01/23/2020] [Accepted: 01/28/2020] [Indexed: 11/12/2022]
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13
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Yuan A, Chai X, Martins F, Arai S, Arora M, Correa ME, Pidala J, Cutler CS, Lee SJ, Treister NS. Oral chronic GVHD outcomes and resource utilization: a subanalysis from the chronic GVHD consortium. Oral Dis 2015; 22:235-40. [PMID: 26708609 DOI: 10.1111/odi.12429] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 11/25/2015] [Accepted: 12/16/2015] [Indexed: 01/03/2023]
Abstract
OBJECTIVES This study evaluated the extent to which oral chronic graft-versus-host disease (cGVHD) consensus assessments are predictive of management across institutions with and without oral medicine (OM) centers, and whether ancillary care guidelines are followed within clinical practice. METHODS Longitudinal oral cGVHD data were abstracted from the cGVHD Consortium, and additional mouth-specific management data were analyzed across five transplant centers. RESULTS Seventy-nine patients with 656 visits were observed for a median of 7.1 months with one visit per follow-up month. Ancillary therapies for oral cGVHD were prescribed for 67% of patients for a median of 0.46 months (per follow-up month) at OM centers and 0.78 months at non-OM centers. Patients treated with ancillary therapy were more likely to have an National Institutes of Health (NIH) mouth score of ≥1 (P < 0.001, odds ratio: 5.1) and mouth pain (P = 0.01, odds ratio: 2.6). The odds ratios of receiving ancillary therapy from OM experts were higher than transplant physicians (53%; P = 0.03). CONCLUSIONS Oral cGVHD consensus assessments corresponding with ancillary therapy use were mouth pain and NIH mouth score, with higher odds ratios of receiving therapy from OM experts. Ancillary care guidelines for oral cGVHD are reflected in academic clinical practice with respect to utilization of recommended prescriptions.
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Affiliation(s)
- A Yuan
- Division of Oral Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Oral Medicine, Infection and Immunity, Harvard School of Dental Medicine, Boston, MA, USA
| | - X Chai
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - F Martins
- Department of Oral Pathology and Oral Diagnosis, University of São Paulo School of Dentistry, São Paulo, Brazil
| | - S Arai
- Division of Blood and Marrow Transplantation, Stanford University Medical Center, Stanford, CA, USA
| | - M Arora
- Department of Medicine, University of Minnesota, Boston, MA, USA
| | - M E Correa
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,Oral Medicine Ambulatory, Bone Marrow Transplantation Unit, Hematology and Blood Transfusion Center, State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - J Pidala
- Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
| | - C S Cutler
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, MA, USA
| | - S J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - N S Treister
- Division of Oral Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Oral Medicine, Infection and Immunity, Harvard School of Dental Medicine, Boston, MA, USA
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Lee SJ, Wolff D, Kitko C, Koreth J, Inamoto Y, Jagasia M, Pidala J, Olivieri A, Martin PJ, Przepiorka D, Pusic I, Dignan F, Mitchell SA, Lawitschka A, Jacobsohn D, Hall AM, Flowers MED, Schultz KR, Vogelsang G, Pavletic S. Measuring therapeutic response in chronic graft-versus-host disease. National Institutes of Health consensus development project on criteria for clinical trials in chronic graft-versus-host disease: IV. The 2014 Response Criteria Working Group report. Biol Blood Marrow Transplant 2015; 21:984-99. [PMID: 25796139 PMCID: PMC4744804 DOI: 10.1016/j.bbmt.2015.02.025] [Citation(s) in RCA: 266] [Impact Index Per Article: 29.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 02/26/2015] [Indexed: 12/17/2022]
Abstract
In 2005, the National Institutes of Health (NIH) Chronic Graft-versus-Host Disease (GVHD) Consensus Response Criteria Working Group recommended several measures to document serial evaluations of chronic GVHD organ involvement. Provisional definitions of complete response, partial response, and progression were proposed for each organ and for overall outcome. Based on publications over the last 9 years, the 2014 Working Group has updated its recommendations for measures and interpretation of organ and overall responses. Major changes include elimination of several clinical parameters from the determination of response, updates to or addition of new organ scales to assess response, and the recognition that progression excludes minimal, clinically insignificant worsening that does not usually warrant a change in therapy. The response definitions have been revised to reflect these changes and are expected to enhance reliability and practical utility of these measures in clinical trials. Clarification is provided about response assessment after the addition of topical or organ-targeted treatment. Ancillary measures are strongly encouraged in clinical trials. Areas suggested for additional research include criteria to identify irreversible organ damage and validation of the modified response criteria, including in the pediatric population.
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Affiliation(s)
- Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Daniel Wolff
- Department of Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Carrie Kitko
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - John Koreth
- Division of Hematologic Malignancies, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Yoshihiro Inamoto
- Division of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Madan Jagasia
- Division of Hematology-Oncology, Vanderbilt University, Nashville, Tennessee
| | - Joseph Pidala
- Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Attilio Olivieri
- Department of Clinical and Molecular Sciences, University of Ancona, Ancona, Italy
| | - Paul J Martin
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Donna Przepiorka
- US Food and Drug Administration, Center for Drug Evaluation and Research, Silver Spring, Maryland
| | - Iskra Pusic
- Department of Medicine, Washington University, St. Louis, Missouri
| | - Fiona Dignan
- Department of Clinical Haematology, University of Manchester, Manchester, United Kingdom
| | - Sandra A Mitchell
- Outcomes Research Branch, National Cancer Institute, Bethesda, Maryland
| | - Anita Lawitschka
- Stem Cell Transplant Unit, St. Anna Children's Hospital, Medical University Vienna, Vienna, Austria
| | - David Jacobsohn
- Division of Blood and Marrow Transplantation, Children's National Health System, Washington, District of Columbia
| | - Anne M Hall
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Mary E D Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Kirk R Schultz
- BC Children's Hospital, University of British Columbia, Vancouver, Canada
| | | | - Steven Pavletic
- Outcomes Research Branch, National Cancer Institute, Bethesda, Maryland.
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15
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Bassim CW, Fassil H, Mays JW, Edwards D, Baird K, Steinberg SM, Cowen EW, Naik H, Datiles M, Stratton P, Gress RE, Pavletic SZ. Oral disease profiles in chronic graft versus host disease. J Dent Res 2015; 94:547-54. [PMID: 25740857 DOI: 10.1177/0022034515570942] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
At least half of patients with chronic graft-versus-host-disease (cGVHD), the leading cause of morbidity and non-relapse mortality after allogeneic stem cell transplantation, have oral manifestations: mucosal lesions, salivary dysfunction, and limited mouth-opening. cGVHD may manifest in a single organ or affect multiple organ systems, including the mouth, eyes, and the skin. The interrelationship of the 3 oral manifestations of cGVHD with each other and with the specific manifestations of extraoral cGVHD has not been studied. In this analysis, we explored, in a large group of patients with cGVHD, the potential associations between: (1) oral mucosal disease and erythematous skin disease, (2) salivary gland dysfunction and lacrimal gland dysfunction, and (3) limited mouth-opening and sclerotic skin cGVHD. Study participants, enrolled in a cGVHD Natural History Protocol (NCT00331968, n = 212), underwent an oral examination evaluating: (1) mucosal cGVHD [NIH Oral Mucosal Score (OMS)], (2) salivary dysfunction (saliva flow and xerostomia), and (3) maximum mouth-opening measurement. Parameters for dysfunction (OMS > 2, saliva flow ≤ 1 mL/5 min, mouth-opening ≤ 35 mm) were analyzed for association with skin cGVHD involvement (erythema and sclerosis, skin symptoms), lacrimal dysfunction (Schirmer's tear test, xerophthalmia), Lee cGVHD Symptom Scores, and NIH organ scores. Oral mucosal disease (31% prevalence) was associated with skin erythema (P < 0.001); salivary dysfunction (11% prevalence) was associated with lacrimal dysfunction (P = 0.010) and xerostomia with xerophthalmia (r = 0.32, P = 0.001); and limited mouth-opening (17% prevalence) was associated with skin sclerosis (P = 0.008) and skin symptoms (P = 0.001). There was no association found among these 3 oral cGVHD manifestations. This analysis supports the understanding of oral cGVHD as 3 distinct diseases: mucosal lesions, salivary gland dysfunction, and mouth sclerosis. Clear classification of oral cGVHD as 3 separate manifestations will improve clinical diagnosis, observational research data collection, and the definitions of outcome measures in clinical trials.
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Affiliation(s)
- C W Bassim
- National Institute of Dental and Craniofacial Research, NIH, Bethesda, MD, USA
| | - H Fassil
- Experimental Transplantation and Immunology Branch, National Cancer Institute, NIH, Bethesda, MD, USA Tufts University School of Dental Medicine, Boston, MA, USA
| | - J W Mays
- National Institute of Dental and Craniofacial Research, NIH, Bethesda, MD, USA
| | - D Edwards
- National Institute of Dental and Craniofacial Research, NIH, Bethesda, MD, USA
| | - K Baird
- Pediatric Oncology Branch, National Cancer Institute, NIH, Bethesda, MD, USA
| | - S M Steinberg
- Biostatistics and Data Management Section, Office of the Clinical Director, Center for Cancer Research, National Cancer Institute, NIH, Bethesda, MD, USA
| | - E W Cowen
- Dermatology Branch, National Cancer Institute, NIH, Bethesda, MD, USA
| | - H Naik
- Dermatology Branch, National Cancer Institute, NIH, Bethesda, MD, USA
| | - M Datiles
- National Eye Institute, NIH, Bethesda, MD, USA
| | - P Stratton
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD, USA
| | - R E Gress
- Experimental Transplantation and Immunology Branch, National Cancer Institute, NIH, Bethesda, MD, USA
| | - S Z Pavletic
- Experimental Transplantation and Immunology Branch, National Cancer Institute, NIH, Bethesda, MD, USA
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Abstract
Allogeneic hematopoietic cell transplantation (allo-HCT) is used for the treatment of a variety of disorders, primarily hematologic malignancies. Graft-versus-host disease (GVHD) is a significant complication following allo-HCT and a major cause of morbidity and mortality. The oral cavity is frequently involved in GVHD, leading to pain, functional impairment, and reduced quality of life. Early diagnosis, management, and long-term follow-up of oral GVHD are important components of overall patient care.
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Affiliation(s)
- Michal Kuten-Shorrer
- Department of Oral Medicine, Infection, and Immunity, Harvard School of Dental Medicine, 188 Longwood Avenue, Boston, MA 02115, USA
| | - Sook-Bin Woo
- Division of Oral Medicine and Dentistry, Brigham and Women's Hospital, 1620 Tremont Street, 3rd Floor, Boston, MA 02115, USA
| | - Nathaniel S Treister
- Division of Oral Medicine and Dentistry, Brigham and Women's Hospital, 1620 Tremont Street, 3rd Floor, Boston, MA 02115, USA.
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17
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Oral manifestations compatible with chronic graft-versus-host disease in patients with Fanconi anemia. Biol Blood Marrow Transplant 2014; 21:275-80. [PMID: 25316110 DOI: 10.1016/j.bbmt.2014.10.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 10/07/2014] [Indexed: 01/19/2023]
Abstract
Fanconi anemia (FA) is a genetic disease that is characterized by several congenital abnormalities and progressive bone marrow failure and is associated with an increased susceptibility to malignant disorders. Currently, the only potential cure for hematological disorders is hematopoietic stem cell transplantation (HSCT). However, 1 of the most common complications after HSCT is the development of oral chronic graft-versus-host disease (cGVHD), which is also a risk factor for the development of cancer, particularly oral squamous cell carcinoma. Therefore, the purpose of this study was to describe the prevalence and characteristics of oral manifestations compatible with cGVHD in patients diagnosed with FA according to the National Institutes of Health (NIH) consensus criteria. A total of 96 patients (51 females, 45 males; median age, 16 years) with FA, who were in medical follow-up after HSCT at the outpatient clinic of the bone marrow transplantation unit (Hospital de Clínicas from the Universidade Federal do Paraná) underwent an oral evaluation between January 2013 and December 2013. Post-HSCT periods varied from 1 to 261 months and were divided into 3 periods: immediate post-HSCT period; intermediate post-HSC period, and late post-HSCT period. Among the evaluated patients, 40 of 96 (42%) presented with oral manifestations of cGVHD, with 29 of 40 (73%) of these patients in the late post-HSCT period. NIH scale scores varied from 0 to 10, and lichenoid and hyperkeratotic lesions were the abnormalities most frequently observed (100%). Overall, a high prevalence of oral manifestations was observed for cGVHD patients with FA. These data highlight the importance of monitoring oral manifestations compatible with cGVHD to identify and treat individuals with a higher risk of developing oral cancer.
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Herrmann RP, Sturm MJ. Adult human mesenchymal stromal cells and the treatment of graft versus host disease. STEM CELLS AND CLONING-ADVANCES AND APPLICATIONS 2014; 7:45-52. [PMID: 24627644 PMCID: PMC3945047 DOI: 10.2147/sccaa.s37506] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Graft versus host disease is a difficult and potentially lethal complication of hematopoietic stem cell transplantation. It occurs with minor human leucocyte antigen (HLA) mismatch and is normally treated with corticosteroid and other immunosuppressive therapy. When it is refractory to steroid therapy, mortality approaches 80%. Mesenchymal stromal cells are rare cells found in bone marrow and other tissues. They can be expanded in culture and possess complex and diverse immunomodulatory activity. Moreover, human mesenchymal stromal cells carry low levels of class 1 and no class 2 HLA antigens, making them immunoprivileged and able to be used without HLA matching. Their use in steroid-refractory graft versus host disease was first described in 2004. Subsequently, they have been used in a number of Phase I and II trials in acute and chronic graft versus host disease trials with success. We discuss their mode of action, the results, their production, and potential dangers with a view to future application.
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Affiliation(s)
- Richard P Herrmann
- Cell and Tissue Therapies, Western Australia, Royal Perth Hospital, Wellington Street, Perth, WA, Australia
| | - Marian J Sturm
- Cell and Tissue Therapies, Western Australia, Royal Perth Hospital, Wellington Street, Perth, WA, Australia
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19
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Symptom distress predicts long-term health and well-being in allogeneic stem cell transplantation survivors. Biol Blood Marrow Transplant 2013; 20:387-95. [PMID: 24355521 DOI: 10.1016/j.bbmt.2013.12.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Accepted: 12/02/2013] [Indexed: 11/21/2022]
Abstract
The number of survivors after allogeneic hematopoietic stem cell transplantation (HSCT) continues to increase, yet their survivorship experience has not been fully characterized. This study examines the health status and health-related quality of life (HRQL) of HSCT survivors. The aims of the study were to: (1) explore the baseline and change over time in these health outcomes, and (2) characterize subgroups experiencing adverse outcomes. In this longitudinal study, adults who survived >3 years from date of allogeneic HSCT completed a series of patient-reported outcome measures annually, including measures of health status, HRQL, and symptoms. Data were analyzed using hierarchical linear modeling. Subjects (N = 171) were on average 44 (±13.5) years of age and primarily male (62.6%); 40% were Hispanic. Mean scores for physical and mental health and HRQL were preserved relative to population norms. Hierarchical linear modeling revealed no significant change in the mean trajectories of these outcomes, although significant between-individual variability was observed. When controlling for demographic and clinical factors, physical symptom distress negatively affected all outcomes. The impact of symptom distress on physical health varied based on time since HSCT; impairment in physical health was greatest in survivors experiencing high symptom distress and who were within the first decade post transplantation. Extended treatment with systemic immunosuppressive therapy also predicted inferior physical health. These findings suggest that patient-centered outcomes are preserved relative to normative values and are generally stable after allogeneic HSCT, although survivors with persistent symptoms and those receiving systemic immunosuppression experience impairments in health status and HRQL.
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Validation of the National Institutes of Health chronic GVHD Oral Mucosal Score using component-specific measures. Bone Marrow Transplant 2013; 49:116-21. [PMID: 23995099 DOI: 10.1038/bmt.2013.137] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Revised: 07/01/2013] [Accepted: 07/02/2013] [Indexed: 11/09/2022]
Abstract
Oral chronic GVHD (cGVHD) is a common, late complication of alloSCT that is associated with significant patient morbidity. The NIH Oral Mucosal Score (NIH OMS) was developed to assess oral cGVHD therapeutic response, but has not been fully validated. This study's purpose was to conduct a rigorous construct validity and internal consistency analysis of this score and its components (erythema, lichenoid, ulcers, mucoceles) using established measures of oral pain, oral function, oral-related quality-of-life, nutrition and laboratory parameters in 198 patients with cGVHD. The construct validity of the NIH OMS was supported: a moderate correlation was observed between NIH OMS and mouth pain (rho=0.43), while a weaker correlation was observed with low albumin (rho=-0.26). Total NIH OMS, erythema and lichenoid components were associated with malnutrition, oral pain and impaired oral QOL, while ulcers were only associated with oral pain. No associations were found between mucoceles and any indicator evaluated, including salivary function or xerostomia. Kappa determined between scale components was low overall (all 0.35), supporting a conclusion that each component measures a distinct manifestation of oral cGVHD. This study supports the use of the NIH OMS and its components (erythema, lichenoid and ulcerations) to measure clinician-reported severity of oral cGVHD.
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Mays JW, Sarmadi M, Moutsopoulos NM. Oral manifestations of systemic autoimmune and inflammatory diseases: diagnosis and clinical management. J Evid Based Dent Pract 2013; 12:265-82. [PMID: 23040353 DOI: 10.1016/s1532-3382(12)70051-9] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
CONTEXT Systemic autoimmune and inflammatory diseases often manifest oral lesions in their earliest stages, and early diagnosis, which may be spurred by a dental examination, is key for improved outcomes. After systemic diagnosis, oral lesions benefit from specialized care by dentists in collaboration with the medical team. This review aims to educate dental clinicians about the most relevant systemic autoimmune and inflammatory conditions with accompanying oral lesions, their implications for health, and management strategies supported by the biomedical literature and clinical experience. Ulcerative conditions including Behcet and Crohn diseases are discussed, along with rheumatic conditions including Sjögren syndrome, lupus erythematosus, and rheumatoid arthritis. EVIDENCE ACQUISITION Evidence was accumulated through PubMed searches using pertinent keywords for each subsection. References were reviewed and original publications examined to verify the accuracy of the information. We focused on evidence included in current reviews and randomized trials. Recommendations were supported by multiple studies and consensus expert opinion. EVIDENCE SYNTHESIS Disease phenotypes described and clinical recommendations were synthesized from best-quality evidence available for each disease. Efforts were made to describe evidence selection within each disease section. CONCLUSIONS Dentists play an important role in the early detection and multidisciplinary medical management of complex autoimmune diseases. It is important to recognize prevalent medical and dental issues and special needs of patients with autoimmune conditions. The management of many inflammatory conditions is similar, and often begins with the use of topical steroids, analgesics, and antimicrobial treatments, in addition to careful attention to oral hygiene and appropriate fluoride usage. In this brief review, we aim to discuss the presentation/prevalence, diagnosis, and treatment of oral manifestations encountered in autoimmune, autoinflammatory and systemic chronic inflammatory diseases. Systemic autoimmune conditions are estimated to affect 5% to 8% of Americans.(1) Oral manifestations are encountered with high frequency, and are often the first clinical signs or symptoms of the general disease. Optimal management of complex autoimmune diseases requires a multidisciplinary medical team including dentists to care for lesions of the oral cavity. The dental practitioner may be asked to play a primary role in the diagnosis of such conditions and to participate with other health professionals working together to achieve effective clinical management. To aid in this process, we discuss in this article the current general knowledge of systemic autoimmune conditions that present with prevalent oral manifestations. The focus is on the diagnosis and management of the oral component of each disease. Importantly, whereas the etiology and pathogenesis and systemic clinical presentation may vary, presentation in the oral cavity is often similar and many conditions involve oral ulcerations. For this reason, we discuss the differential diagnosis and management of the most common oral ulcerations in a general section and subsequently address individual conditions that present with oral ulcerations. Similarly, treatment of various autoimmune/inflammatory oral conditions is often common and involves modulation or suppression of the immune response locally and/or systemically and will be therefore addressed in a common section as well as individually for each disease when unique treatment regimens are recommended. We present here our general treatment recommendations based on clinical experience and literature review; however, it is critical that good clinical judgment and specifics of an individual case should determine the appropriate dental/oral medicine intervention for a specific patient.
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Affiliation(s)
- Jacqueline W Mays
- Clinical Research Core, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD 20892, USA
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Chainani-Wu N, Purnell DM, Silverman S. A Case Report of Conservative Management of Extensive Proliferative Verrucous Leukoplakia Using a Carbon Dioxide Laser. Photomed Laser Surg 2013; 31:183-7. [DOI: 10.1089/pho.2012.3414] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Nita Chainani-Wu
- Department of Orofacial Sciences, School of Dentistry, University of California, San Francisco, California
- Private Practice in Oral Medicine, Mountain View, California
| | | | - Sol Silverman
- Department of Orofacial Sciences, School of Dentistry, University of California, San Francisco, California
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Mays JW, Fassil H, Edwards DA, Pavletic SZ, Bassim CW. Oral chronic graft-versus-host disease: current pathogenesis, therapy, and research. Oral Dis 2012; 19:327-46. [PMID: 23107104 DOI: 10.1111/odi.12028] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Revised: 09/11/2012] [Accepted: 09/11/2012] [Indexed: 12/13/2022]
Abstract
Optimal management of complex autoimmune diseases requires a multidisciplinary medical team including dentists to care for lesions of the oral cavity. In this review, we discuss the presentation, prevalence, diagnosis, and treatment of oral manifestations in chronic graft-versus-host disease (cGVHD), which is a major late complication in patients treated by allogeneic hematopoietic stem cell transplantation. We assess current general knowledge of systemic and oral cGVHD and present general treatment recommendations based on literature review and our clinical experience. Additionally, we review areas where the understanding of oral cGVHD could be improved by further research and address tools with which to accomplish the long-term goal of providing better health and quality of life to patients with cGVHD.
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Affiliation(s)
- J W Mays
- Clinical Research Core, National Institute of Dental and Craniofacial Research, Bethesda, MD 20892-4320, USA.
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