Herpes simplex virus and oral mucositis in children with cancer

Changes of Dentition State in Leukemic Patients during Chemotherapy

A number of systemic diseases including hematological disorders have manifestations in the oral cavity region. These manifestations may often represent early signs of the underlying hematopoietic disease and occur frequently in leukemia. Despite the fact that leukemia has long been known to be associated with oral health deterioration, the available literature on this topic consists mostly of case reports, without data to conclude these. The aim of the study was to assess dentition state in leukemic patients during one cycle of chemotherapy and its correlation with blood parameters. The study included 102 adults treated because of leukemia at the Clinic of Haemato-Oncology and Bone Marrow Transplantation at the university hospital in Lublin, Poland. The sample group consisted of 51 women and 51 men aged 22 to 72 (54.07 ± 10.33) with following diagnoses: Acute myelogenous leukemia (AML)-55 patients (53.92%), Chronic lymphocytic leukemia (CLL)-17 patients (16.67%), Acute lymphoblastic leukemia (ALL)-16 patients (15.69%), Chronic myelogenous leukemia (CML)-10 patients (9.80%), Acute promyelocytic leukemia (APL) -3 patients (2.94%), Chronic hairy cell leukemia (HCL)-1 patient (0.98%). DMFT index was used to assess dentition state. After the cycle of chemotherapy, their dentition state changed in terms of decayed, missing and filled teeth and correlated with hematological parameters. Adult patients with leukemia have high dental treatment needs, and high number of missing teeth; thus, a comprehensive and fast dental treatment is necessary to avoid systemic complications and ensure better quality of life.

Strong association between herpes simplex virus-1 and chemotherapy-induced oral mucositis in patients with hematologic malignancies

BACKGROUND/AIMS

A link between oral cavity infections and chemotherapy-induced oral mucositis (CIOM) in patients with hematological malignancies (HMs) undergoing intensive chemotherapy (IC) or hematopoietic stem cell transplantation (HSCT) has been suggested. However, conclusive data are lacking, and there are no current guidelines for the prophylactic use of antimicrobials to prevent CIOM in these populations.

METHODS

The relationships between herpes simplex virus (HSV) reactivation and Candida colonization in the oral cavity and CIOM in patients with HMs undergoing IC or HSCT were evaluated. Patients aged ≥ 19 years with HMs undergoing IC or HSCT were enrolled. Each patient was evaluated for HSV and Candida in the oral cavity along with CIOM at baseline and during the 2nd, 3rd, and 4th weeks.

RESULTS

Seventy presentations among 56 patients were analyzed. CIOM was observed in 23 presentations (32.9%), with a higher incidence associated with HSCT (17 of 35 presentations, 48.6%) than with IC (six of 35 presentations, 8.6%). The reactivation of HSV-1 was significantly associated with an increased incidence of CIOM after adjusting for age, sex, type of disease, and treatment stage. A higher HSV-1 viral load was associated with an increased incidence of CIOM. The presence of Candida was not associated with CIOM.

CONCLUSION

HSV-1 reactivation in the oral cavity was highly associated with CIOM in patients with HMs undergoing high-dose chemotherapy.

A systematic review of oral herpetic viral infections in cancer patients: commonly used outcome measures and interventions

PURPOSE

To review the literature for outcome measures for oral viral infections in cancer patients. A secondary aim was to update the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) clinical practice guidelines for the management of oral viral infections in cancer patients.

METHODS

Databases were searched for articles published in the English language, 1981-2013. Studies that met the eligibility criteria were reviewed systematically. The data about the outcome measures were classified according to the aim of the study: prevention, treatment, or non-interventional. The results of interventional studies were compared to the 2010 MASCC/ISOO publication.

RESULTS

Multiple clinical and laboratory tests were used to measure oral viral infections, with great variability between studies. Most of the studies were about Herpes Simplex Virus (HSV). The outcome measure that was most commonly used was the presence of HSV infection diagnosed based on a combination of suggestive clinical presentation with a positive laboratory result. HSV culture was the most commonly reported laboratory outcome measure. Acyclovir and valacyclovir were consistently reported to be efficacious in the management of oral herpetic infections. No new data on the quality of life and economic aspects was found.

CONCLUSIONS

Considering the variability in outcome measures reported to assess oral herpetic infections the researcher should select carefully the appropriate measures based on the objective of the study. Acyclovir and valacyclovir are effective in the management of oral herpetic infections in patients receiving treatment for cancer. Studies on newer anti-viral drugs may be useful to address the issue of anti-viral resistance.

Seroprevalence of HSV-1/2 and correlation with aggravation of oral mucositis in patients with squamous cell carcinoma of the head and neck region submitted to antineoplastic treatment

PURPOSE

Oral mucositis (OM) is a frequent side effect resulting from antineoplastic treatment and is described as an acute alteration characterized by ulcerative lesions, with the presence of a persistent chronic inflammatory infiltrate, erythema, and pain.

AIMS

The purpose of the study was to evaluate the presence of the herpes simplex virus (HSV-1/2) in patients with squamous cell carcinoma of the head and neck region (SCC) and its influence on the aggravation of oral mucositis after radiotherapy or radio/chemotherapy treatment.

METHODS

In this prospective cohort study, 91 patients were evaluated with regard to their serological status for IgG before treatment (initial time interval--TI) and for IgM before treatment (T1) and on the 30th day after the first day of radiotherapy application/radiation therapy (final time interval--TF), using immunoenzymatic assay (ELISA), and the results were correlated with the intensity of OM.

RESULTS

The seroprevalence for IgG was 97.8 %. IgM (TI) was positive in 18.7% and IgM (TF) in 20.9% of patients. All the patients developed some degree of oral mucositis; however, there was statistically significant correlation between positivity for IgM and degree of severity of OM, irrespective of the type of treatment to which the patient was submitted.

CONCLUSION

The reactivation of HSV-1/2 was shown to be relatively infrequent and there was no correlation between presence of the virus and aggravation of oral mucositis resulting from antineoplastic treatment.

A double blind randomised placebo controlled study of propolis (bee glue) effectiveness in the treatment of severe oral mucositis in chemotherapy treated children

OBJECTIVES

Chemotherapy-induced oral mucositis (OM) is a debilitating side effect. In addition to standard therapy, patients often use complementary and alternative medicine to treat OM.

DESIGN

Double blind randomised placebo controlled study assessing propolis (bee glue) efficacy for chemotherapy-induced severe OM treatment.

SETTING

University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia.

INTERVENTIONS

Paediatric patients undergoing chemotherapy were randomly assigned to propolis (n=19) or placebo groups (n=21). Patients were introduced to a unified oral care protocol and asked to apply propolis or placebo to vestibular mucosa twice daily. Oral mucosa was assessed with the Oral Assessment Guide (OAG) twice a week when the patients were in hospital. Patients were followed for the period of the chemotherapy or for the first 6 months of the chemotherapy. An OAG score of 3 was considered to be severe OM and analysed.

MAIN OUTCOME MEASUREMENTS

Three dependent variables (a) OM episode frequency, (b) mean number of assessment visits, at which an OAG 3 score was noted, expressing mean OM duration, (c) mean number of OAG 3 scores expressing mean OM severity) were reduced to a single variable using principal component analysis. A new variable (FDS) was used as the dependent variable in ANCOVA model analysis to show the differences between study groups.

RESULTS

Severe OM was seen in 42% and 48% of patients in the propolis and placebo group, respectively. FDS was not statistically significant between study groups (p=0.59).

CONCLUSIONS

According to our study results, propolis cannot be recommended for severe OM treatment.

Administration of Ratanhia-based herbal oral care products for the prophylaxis of oral mucositis in cancer chemotherapy patients: a clinical trial

Oral complications are a common side effect of cancer chemotherapy, as antineoplastic agents affect both the immune system and the oral mucosa. This study demonstrates preventive and therapeutic effects of dental treatment and regular use of Weleda Ratanhia-Mundwasser((R)) (herbal mouthwash) and Weleda Pflanzen-Zahngel((R)) (herbal toothgel) on oral mucositis during chemotherapy. Thirty-two female patients with breast cancer starting on chemotherapy were evaluated in this study. Plaque index, gingival index, degree of mucositis and 10 single symptoms were monitored once weekly for four consecutive weeks. After four weeks, plaque and gingival indexes were slightly decreased compared to baseline values. The degree of mucositis was increased by one grade in 15.6 % of the patients and over 70 % remained without symptoms. On the whole, single symptoms decreased from day 7 since beginning of chemotherapy to day 28. Mucositis symptoms were moderate in severity, and the results indicate a positive influence of using Weleda Ratanhia-Mundwasser and Weleda Pflanzen-Zahngel. Further studies might be promising.

Prospective evaluation of HSV, Candida spp., and oral bacteria on the severity of oral mucositis in pediatric acute lymphoblastic leukemia

BACKGROUND

Oral mucositis is a common collateral effect among the secondary complications resulting from chemotherapy. The objective of this study was to prospectively evaluate the association of HSV-1, Candida spp., and oral bacteria on the severity of oral mucositis in pediatric acute lymphoblastic leukemia (ALL).

PROCEDURE

Seventy-one prospective patients were included. Analyses of oral microbiota were conducted on days 14 (D14) and 56 (D56) of the Brazilian GBTLI-99 treatment protocol. Herpes simplex virus (HSV) identification was performed by PCR followed by DNA sequencing analysis. Bacteria and fungi identification was obtained by standard microbiological culture tests.

RESULTS

HSV-1 was found in 10.37% of individual patient samples. One sample was positive for HSV-4. On D14, we found an association between the severity of mucositis and the presence of HSV (p = 0.0347) and Candida spp. (p = 0.0078). At D56, we found an association between the severity of mucositis and the presence of HSV on D14 (p < 0.0001) and HSV presence (p = 0.0317).

CONCLUSION

The presence of HSV, mainly HSV-1, and Candida spp. was associated with mucositis severity in pediatric ALL. No association could be found between bacterial CFU and severity of mucositis.

A systematic review of viral infections associated with oral involvement in cancer patients: a spotlight on Herpesviridea

PURPOSE

Our aim was to evaluate the literature for the prevalence of and interventions for oral viral infections and, based on scientific evidence, point to effective treatment protocols. Quality of life (QOL) and economic impact were assessed if available in the articles reviewed.

METHODS

Our search of the English literature focused on oral viral infections in cancer patients within the timeframe of 1989-2007. Review methods were standardized. Cohort studies were used to determine the weighted prevalence of oral viral infection in cancer patients. The quality of selected articles were assessed and scored with respect to sources of bias, representativeness, scale validity, and sample size. Interventional studies were utilized to determine management guidelines. Literature search included measures of QOL and economic variables.

RESULTS

Prevalence of oral herpes simplex virus (HSV) infection in neutropenic patients was higher than in patients treated with radiotherapy for head and neck cancer (49.8% vs. 0%, respectively). In patients treated with radiochemotherapy for head and neck cancer, the prevalence of oral HSV infection increases up to 43.2% (CI, 0-100%). Prevalence of HSV infection was higher when oral ulcers existed. Information about other oral viral infections is sparse. There was a significant benefit of using acyclovir to prevent HSV oral infection (at 800 mg/day). Various dosing protocols of valacyclovir achieved prevention of HSV reactivation (500 or 1,000 mg/day). The prevalence of HSV reactivation was similar for acyclovir and valacyclovir. No information about impact on QOL and economic burden was available.

CONCLUSIONS

Acyclovir and valacyclovir are equally effective in preventing oral HSV infection. Neutropenic patients, who were primarily treated for hematological malignancies in the studies reviewed, are at a greater risk for viral infection.

Considerations in the pediatric population with cancer

This article is divided into three time periods according to the different phases of cancer treatment: pre, inter, and postcancer therapy. The purpose of dental protocols prior to cancer therapy and the incidence and management of acute and long term oral complications from cancer therapy in the pediatric population are discussed.

Herpes simplex virus in febrile neutropenic children undergoing chemotherapy for cancer: a prospective cohort study

BACKGROUND

The primary objective of this study was to determine the prevalence of oral herpes simplex virus (HSV) as detected by polymerase chain reaction, in pediatric oncology patients with febrile neutropenia. Our secondary objectives were to describe the association between oral HSV and prolonged fever, neutropenia, mucositis, and response to initial antimicrobial therapy.

METHODS

In this prospective cohort study, we obtained a mouth swab and blood specimen from oncology patients with febrile neutropenia, and tested them for HSV by polymerase chain reaction. Prolonged fever was defined as the presence of fever 48 hours after initiation of broad-spectrum antibiotic therapy.

RESULTS

Of the 75 oral and blood specimens obtained, only 7 oral swabs (9%) and 2 blood samples (3%) were positive for HSV. Oral HSV was not associated with prolonged fever or neutropenia. However, oral HSV was associated with longer median duration of mucositis (8 days; interquartile range, 0-12 days) compared with negative episodes (0 days; interquartile range, 0-2.5 days); P = 0.005. Oral HSV also was associated with inferior successful response to initial antimicrobial therapy (1 of 7, 14.3%) compared with negative episodes (51 of 67, 76.1%); P = 0.002.

CONCLUSIONS

The prevalence of HSV infection in pediatric oncology patients with febrile neutropenia was low and was not associated with prolonged fever. However, oral HSV was associated with prolonged mucositis and poorer response to initial therapy. It is unknown whether early intervention with acyclovir can alter these associations.

Involvement of intracellular free Ca2+ in enhanced release of herpes simplex virus by hydrogen peroxide

Background

It was reported that elevation of the intracellular concentration of free Ca²⁺ ([Ca²⁺]i) by a calcium ionophore increased the release of herpes simplex virus type 1 (HSV-1). Freely diffusible hydrogen peroxide (H₂O₂) is implied to alter Ca²⁺ homeostasis, which further enhances abnormal cellular activity, causing changes in signal transduction, and cellular dysfunction. Whether H₂O₂ could affect [Ca²⁺]i in HSV-1-infected cells had not been investigated.

Results

H₂O₂ treatment increased the amount of cell-free virus and decreased the proportion of viable cells. After the treatment, an elevation in [Ca²⁺]i was observed and the increase in [Ca²⁺]i was suppressed when intracellular and cytosolic Ca²⁺ were buffered by Ca²⁺ chelators. In the presence of Ca²⁺ chelators, H₂O₂-mediated increases of cell-free virus and cell death were also diminished. Electron microscopic analysis revealed enlarged cell junctions and a focal disintegration of the plasma membrane in H₂O₂-treated cells.

Conclusion

These results indicate that H₂O₂ can elevate [Ca²⁺]i and induces non-apoptotic cell death with membrane lesions, which is responsible for the increased release of HSV-1 from epithelial cells.

Herpes simplex virus-1 (HSV-1) infection in radiation-induced oral mucositis

GOAL OF WORK

The aim of the study was to investigate the incidence of herpes simplex virus-1 (HSV-1) infection in mucositis during head and neck cancer radiotherapy.

PATIENTS AND METHODS

Sixty patients with malignant head and neck tumor, eligible to receive radiotherapy, who were referred to the Dental Oncology Unit, entered the study. Sixteen patients (26.6%) received concomitant chemotherapy. Mucositis was recorded weekly. Smears taken from the ulcers of mucositis grade 2, or 3, or 4 were stained with Papanicolaou and alkaline phosphatase/antialkaline phosphatase immunocytochemical method to identify HSV-1.

MAIN RESULTS

Forty-eight of all 60 patients developed ulcerative mucositis. Smear was available from 29 of 48 patients with ulcerations. HSV-1 infection was identified in 14 of 29 smears available (48.2%). Mucositis healed or was reduced after 1 week of antiviral treatment in 11 of those 14 HSV-1-positive patients; 3 patients responded to 1 g/day of valacyclovir, 7-2 g/day, and 1 patient responded to i.v. acyclovir. Ulcerations recurred after quitting antivirals. Three patients did not respond to 1 g/day of valacyclovir. No HSV-1-negative patient responded to acyclovir (P = 0.000).

CONCLUSION

HSV-1 was isolated from 14 of 29 available smears taken from 48 patients with ulcerative mucositis. The incidence of HSV-1 infection during radiotherapy was estimated as being 14 of all 48 patients at risk (29.1%). Healing or reduction in the grade of mucositis after antivirals in HSV-1 positive patients, combined with the negative response to antivirals in HSV-1 negative patients, denoted that HSV-1 infection was a component of ulcerative radiation mucositis in those HSV-1-positive patients.

Few but severe viral infections in children with cancer: a prospective RT-PCR and PCR-based 12-month study

BACKGROUND

Treatment of low-risk febrile episodes with oral administered antibiotics at home is a new approach in pediatric oncology and protective isolation is loosened in more centers. The impact of viral respiratory infections in febrile diseases in this population is still unclear in terms of occurrence and morbidity.

PROCEDURE

A prospective follow-up study of all febrile episodes during 12 months in a pediatric oncology department with a high level of protective isolation was set-up with expanded molecular viral examinations. Reverse transcriptase polymerase chain reaction (RT-PCR) and PCR diagnostics of ten viruses, two atypical bacteria, and one fungus were performed and clinical information on all infections was registered.

RESULTS

A total of 250 febrile episodes in 66 patients were registered. In all, 198 respiratory secretions, predominantly oral washes, and 165 anal swabs were analyzed. Twenty-two infections were diagnosed: 7 rhinovirus infections, 4 respiratory syncytial virus (RSV) infections, 2 herpes simplex virus (HSV) infections, 2 varicella-zoster-virus (VZV) infections, 1 influenza B virus infection, 1 parainfluenza virus type 3 infection (PIV3), 1 human metapneumovirus (HMPV) infection, 1 enterovirus infection, 0 adenovirus infections, 0 influenza A virus infections, and 3 non-viral pneumonias: 1 M. Pneumonia, 1 C. Pneumonia, and 1 P. Carinii. The detected pathogens correlated well to the clinical disease. Patients with viral infections were as affected as patients with bacteria in the blood. One of 19 viral infections was lethal, a RSV pneumonia. C-reactive protein concentrations were not able to distinguish viral infections from bacteremias.

CONCLUSIONS

The applied sampling method was acceptable and molecular diagnosis of viruses, atypical bacteria and P. Carinii increased the microbiological verification of infections by 35%. Viral infections were few in our protected population but caused severe infectious complications in these patients.

Evaluation of an oral preventive protocol in children with acute lymphoblastic leukemia

This study was designed to assess the effectiveness of a preventive oral protocol in children receiving antineoplastic treatment for acute lymphoblastic leukemia (ALL) before initiating a larger intervention study. During a seven month period, fourteen children from two to ten years old with a diagnosis of ALL were evaluated. Patients with ALL who received a 0.12% chlorhexidine mouth rinse (seven children) were compared to a control group of patients who were not given the same preventive treatment (seven children) as to the occurrence of oral mucosal complications. Children in both groups received daily oral hygiene care, and were examined daily by the pediatric dentistry team until discharge. A significant decrease in the incidence of oral mucositis and ulceration was observed in the children who received a 0.12% chlorhexidine mouth rinse (p < 0.05 by Fisher's exact test). The findings obtained in the present trial are encouraging, and suggest that the systematic application of a preventive protocol reduces the incidence of oral complications in children with ALL receiving chemotherapy.

Defining clinically meaningful outcomes in the evaluation of new treatments for oral mucositis: oral mucositis patient provider advisory board

Oral mucositis (OM)-related outcomes constituting a meaningful clinical advance in bone marrow transplant patients were considered by an interdisciplinary panel. Meaningful outcomes are essential in product development for OM, a condition without effective prevention or treatment. The most important outcomes to measure, the feasibility of measuring these in a clinical trial, and clinically meaningful differences in these outcomes were determined by the panel. Most important are reduction in oral pain and use of opioid analgesics, improvement in oral intake and quality of life, and reduction of hospitalization duration. Reduction in the severity of OM measured by an objective evaluation of oral mucosa could provide insight regarding the biologic activity of an intervention. Further data are required to define the precise relationship between reduction in visible OM and improvement in outcome. Minimally, clinical trials for OM should assess oral pain, opioid use, oral intake, and include objective assessment of OM.

A pilot study evaluating the safety and microbiologic efficacy of an economically viable antimicrobial lozenge in patients with head and neck cancer receiving radiation therapy

BACKGROUND

Mucositis occurs in almost all radiotherapy-treated head and neck cancer patients, in approximately 75% of patients receiving hematopoietic marrow transplantation, and in approximately 40% of all patients who receive chemotherapy. Mucositis is painful, may affect all oral functions, and is a dose- and rate-limiting toxicity of therapy for cancer. Radiation-associated mucositis (onset, intensity, and duration) has been shown in recent clinical trials to be modified by the use of antibacterial/antifungal lozenges.

PURPOSE

The aim of this collaborative two-center phase II study was to assess the toxicity and microbiologic efficacy of an economically viable antimicrobial lozenge in the management of patients receiving radiation therapy for head and neck cancer.

MATERIALS AND METHODS

Seventeen patients scheduled to receive radical or postoperative radiotherapy were provided with bacitracin, clotrimazole, and gentamicin (BCoG) lozenges (one lozenge dissolved in the mouth qid from day 1 of radiotherapy until completion). Ease of use and palatability of the lozenges, patients' symptoms (swallowing and pain), and quantitative and qualitative microbiologic evaluation of an oral rinse collection was conducted at least once weekly during radiation therapy.

RESULTS

No significant side effects were reported from the use of the lozenges. The lozenges were well tolerated at the beginning of treatment by all patients, with some minor difficulty associated with oral discomfort toward the end of the treatment. Microbiologic evaluation showed consistent elimination of yeast organisms in all patients. In four patients there was no growth of gram-negative bacilli on culture, whereas in two patients, fluctuating counts were seen, and one patient had increased counts. The remaining patients had significant reduction in the gram-negative bacilli counts.

CONCLUSIONS

This study demonstrated that the BCoG lozenge is tolerable and microbiologically efficacious, achieving elimination of Candida in all patients and reduction in gram-negative flora in most patients. A phase III study is underway to evaluate the clinical efficacy of this lozenge.

Diagnostic investigations in cancer pain

Defining the specific cause of pain in patients with cancer often has substantial therapeutic and prognostic implications. This process often requires the use of specific diagnostic investigations. Here we critically review the diagnostic investigations used in the evaluation of common pain problems in patients with cancer. Familiarity with this information facilitates the development of efficient and rational diagnostic strategies.

Prevention and treatment of chemotherapy- and radiotherapy-induced oral mucositis: a review

Oral mucositis is a distressing toxic effect of systemic chemotherapy with many commonly utilized drugs and of head and neck irradiation in patients with cancer. The agents and methods that have been used and studied in chemotherapy- and radiotherapy-induced oral mucositis, their mechanisms of action, and the current knowledge of their efficiency to reduce the incidence, severity or shorten the duration of oral mucositis are reviewed in this article. Oral cooling is a cheap and available method to lower the severity of bolus 5-fluorouracil-induced oral mucositis. However, more effective methods are needed. Results of studies with granulocyte-macrophage colony-stimulating factor or granulocyte colony-stimulating factor are promising. Lasers are partly beneficial, but equipment-demanding. Modification of the chemotherapy regimen resulting in shortening of the exposition time to chemotherapy agents or chronomodulation of chemotherapy has been shown to lower mucosal toxicity of some regimens. Results of animal studies with locally applied transforming growth factor beta 3 and interleukin-11 are also promising. Based on the findings of the role of the inflammatory cascade in the response of normal tissues to chemotherapy and radiotherapy, anti-inflammatory drugs might be beneficial. At the present time, no agent has been shown to be uniformly efficacious and can be accepted as standard therapy of chemotherapy- and radiotherapy-induced oral mucositis. Further intensive research is needed.

Intravenous acyclovir treatment for extensive herpetic keratitis in a liver transplant patient

Herpetic infection is a common complication among immune suppressed patients following heart, kidney and bone marrow transplantations, in leukemia patients, in AIDS patients, and during treatment with cytotoxic drugs. In the cases described in the literature, oral acyclovir was recommended as a treatment for the acute infection, as well as for prophylaxis. Intravenous acyclovir is not a routine treatment for herpetic keratitis, but is recommended for cases of insufficient clinical response to oral treatment, and defective absorption of acyclovir by the gastrointestinal tract. We present a patient who underwent 4 liver transplantations, was treated regularly with immunosuppressive drugs, and who developed extensive herpetic keratitis. The keratitis was resistant to both topical ointment and oral acyclovir treatment. Recovery was only achieved following the intravenous administration of acyclovir. We recommend intravenous acyclovir treatment at a very early stage for immune suppressed patients with extensive herpes simplex keratitis.