The management of the oral complications of leukemia

Antiviral Agents for the Prevention and Treatment of Herpes Simplex Virus Type-1 Infection in Clinical Oncology: A Network Meta-Analysis

Cancer therapy may be complicated and compromised by viral infections, including oral herpes simplex virus (HSV) infection. This network meta-analysis aimed to identify the best antiviral agent to prevent or treat oral HSV infection in patients being treated for cancer. A search was conducted for trials published since inception until the 10th of May 2020 in MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials. A network meta-analysis was performed on the data from randomized controlled trials that assessed antiviral agents for preventive or therapeutic activity vs. placebo, no treatment or any other active intervention in patients being treated for cancer. The agents were ranked according to their effectiveness in the prevention of oral HSV using surface under the cumulative ranking (SUCRA). Grading of Recommendations, Assessment, Development and Evaluations (GRADE) was used to assess the certainty of the evidence. In total, 16 articles were included. The pooled relative risk (RR) to develop oral HSV infection in the acyclovir group was 0.17 (95% CI: 0.10, 0.30), compared to 0.22 (95% CI: 0.06, 0.77) in the valacyclovir group. Acyclovir ranked highest for the prevention of oral HSV followed by valacyclovir. Subgroup analysis with different acyclovir regimens revealed that the best regimens in terms of HSV-1 prevention were 750 mg/m2 acyclovir administered intravenously followed by 1600 mg per day orally. Acyclovir (250 mg/m2 per day) administered intravenously was the least effective against the prevention of oral HSV.

Oral Complications in Patients with Advanced Cancer

Disturbances caused by lesions of the oral cavity play an important part in the alteration of the qualtity of life of cancer patients. The main complications affecting the oral cavity are infections (fungal, viral, bacterial), neutropenic ulcers, drug-induced stomatitis, dry mouth, and taste alteration. Most of the information available about these entities has been acquired in the cancer patient without advanced disease. The little known about the epidemiology and physiopathology of such lesions in the advanced phase of cancer is presented and approaches to management are suggested.

A clinical and fine needle aspiration cytology study of gingiva in acute leukemia

Background:

Oral manifestations are frequently the initial signs of acute leukemia, prompting the patient to consult the dentist first. The gingival tissue is one site commonly involved either by leukemic infiltration or by inflammatory reactive hyperplasia, causing gingival enlargement. The gingival infiltration may also be present without gingival enlargement. Early recognition of clinical findings in the oral cavity leads to its timely diagnosis and management. Since biopsy is highly contraindicated, gingival fine needle aspiration cytology was performed to assess its diagnostic value in detecting gingival infiltration in acute leukemia patients.

Materials and Methods:

Fifty patients of acute leukemia received clinical and gingival cytological examination. The cases were diagnosed based on bone marrow aspiration findings and classified according to the French–American–British criteria. The absence or presence of intraoral findings was recorded. Site for gingival fine needle aspiration cytology was selected.

Results:

Leukemic gingival infiltration was found to be more common in acute lymphoblastic leukemia, while the characteristic oral findings were seen more commonly in acute myeloblastic leukemia. All the eight cases of acute lymphoblastic leukemia that were positive for leukemic gingival infiltration showed no clinical evidence of gingival enlargement. In terms of leukemic gingival infiltration, L2 subtype was the only subtype involved, while M5 was more commonly involved than M4 subtype. Two cases of L2 subtype showed gingival enlargement due to local factors like plaque/calculus rather than due to leukemic infiltration.

Conclusion:

The technique was found to be safe and of definitive diagnostic value in detecting gingival infiltration in acute leukemia patients.

The association between oral microorgansims and aspiration pneumonia in the institutionalized elderly: review and recommendations

Aspiration pneumonia is a leading cause of illness and death in persons who reside in long-term-care facilities and, combined with the lack of proper oral health care and services, the risk of aspiration pneumonia rises. The purpose of this article is to review recent literature on oral hygiene and oral care in long-term-care facilities and report new findings regarding associated risks for aspiration pneumonia, as well as research on oral care and health outcomes. The PubMed MeSH database was utilized to direct a specific search by entering terms "aspiration pneumonia" and "oral hygiene" from 1970 to 2009, which yielded 34 articles. The Ovid and Google Scholar databases were utilized as well and provided no additional references for the two terms. A manual search of references from other articles, including three systematic reviews published over the past decade, provided additional information regarding oral microorganisms and respiratory pathogens, as well as investigations of oral care. Finally, a brief but comprehensive introductory review was organized regarding oral microorganisms, biofilm, periodontal disease, and pneumonia to establish a framework for discussion. Overall, studies suggest (1) an association between poor oral hygiene and respiratory pathogens, (2) a decrease in the incidence of respiratory complications when patients are provided chemical or mechanical interventions for improved oral care, (3) the complex nature of periodontal disease and aspiration pneumonia make direct connections between the two challenging, and (4) additional studies are warranted to determine adequate oral hygiene protocols for nursing home patients to further reduce the incidence of aspiration pneumonia.

Severe Gingival Bleeding in a Myelodysplastic Patient: Management and Outcome

BACKGROUND

The myelodysplastic syndromes (MDS) are a group of stem cell disorders characterized by a reduction in one or more elements of the peripheral blood. Oral manifestations of the disease and oral complications of medical management may result in significant symptoms and have an impact on the systemic condition of the patient. The removal of the infectious focus, such active teeth infection or severe periodontal disease, remains controversial in these patients, due to the increased risk of bleeding and systemic infection.

METHODS

This paper reports a case of MDS with spontaneous gingival hemorrhage and generalized gingival hyperplasia associated with periodontal disease. This patient underwent several platelet transfusions due to these oral complications. The patient received periodontal therapy, resulting in an improvement of the oral clinical situation and a decrease of gingival hyperplasia.

RESULTS

The patient did not present any episode of gingival hemorrhage after the periodontal treatment.

CONCLUSION

The results of this study suggest that periodontal therapy should be performed in MDS patients presenting thrombocytopenia, gingival hyperplasia, and gingival bleeding, with the intent of preventing further hemorrhagic episodes and possible systemic infection.

Acute leukaemia presenting as oral ulceration to a dental emergency service

Leukaemia is a neoplastic disease characterized by an excessive proliferation of immature white blood cells and their precursors. Oral lesions may be the presenting feature of acute leukaemias, which can be rapidly fatal if left untreated. This report describes the case of a 22-year-old female who presented to a dental emergency department with oral manifestations of acute leukaemia. It outlines the role of oral lesions in the diagnosis of acute leukaemias and emphasizes the importance of immediate referral by general dental practitioners.

Oral complications associated with immunosuppression and cancer therapies

The oral manifestations of oropharyngeal infection in immunocompromised patients present a particular challenge for both medical and dental professionals because clinical signs and symptoms may be minimal and accurate diagnosis and appropriate treatment may be difficult. Effective control of infection and management of oral symptoms are important and may be achieved by the judicious use of topical and systemic agents and by maintaining good oral hygiene. Prevention of mucosal breakdown, suppression of microbial colonization, control of viral reactivation, and effective management of severe xerostomia are all critical steps to reduce the overall morbidity and mortality of oromucosal infections in the severely immunocompromised patient.

Local antimicrobial therapy of oral mucositis in paediatric patients undergoing bone marrow transplantation

The present investigation has examined the clinical benefits of tobramycin, polymyxin E and amphotericin therapy in the management of oral mucositis in children undergoing chemotherapy prior to bone marrow transplantation. Tobramycin, polymyxin E, and amphotericin reduced the degree of oral mucositis more than conventional therapy of diphenhydramine, Maalox, and local analgesic. While there was a statistically significant fall in the severity of the mucositis with tobramycin, polymyxin E and amphotericin, this was unlikely to be of practical benefit.

Analysis of oral manifestations of leukemia: a retrospective study

OBJECTIVE

To evaluate in detail the oral complications of leukemia at initial presentation. Associations between oral manifestations and laboratory data were also investigated.

STUDY DESIGN

A retrospective study of 230 cases was conducted to investigate the nature and incidence of oral manifestations at initial presentation. The following data were determined for each patient: age, sex, haemogram at diagnosis (which included haemoglobin, red blood cell counts, differential white blood cell counts, platelet counts), classification of the type of leukemia's systemic symptoms and oral manifestations at the initial physical examination including the dental consultation.

RESULTS

It was revealed that the type of leukemia diagnosed, except with CML, is related to the age prediliction of patients. The incidence of leukemia is higher in males than in females. The most common manifestations of leukemia are lymphadenopathy (71.4% in ALL; 45% in AML), laryngeal pain (52.7% in ALL; 37.3% in AML), gingival bleeding (43.2% in AML; 28.6% in ALL), oral ulceration, and gingival enlargement. Fever (92.2%) was the most common symptom in patients with all types of leukemia. Platelet counts from 25,000 mm-3 to 60,000 mm-3 are at sufficiently low levels to result in spontaneous bleeding. Most of the patients had WBC counts of greater than 10,000 mm-3. Only 12.6% of patients had normal WBC counts.

CONCLUSIONS

It was concluded that the age prediliction and prevalence of oral manifestations are closely related to the type of leukemia.

Gingival enlargement as a diagnostic indicator in leukaemia. Case report

The acute leukaemias are a group of neoplastic diseases that are characterized by proliferation of immature white cells in the bone marrow and/or blood and are often associated with severe leukopenia, anaemia and thrombocytopenia. Oral manifestations are more common in patients with acute leukaemia. Oral bleeding, gingival enlargement, ulceration and infection in patients with leukaemia have been described. Leukaemic infiltrates in the gingivae are commonly seen in acute monocytic leukaemia. A case of acute monocytic leukaemia in a 34-year-old female who reported with gingival enlargement is presented here. The role of oral lesions as a diagnostic indicator is discussed.

The symptom experience of mucositis, stomatitis, and xerostomia

OBJECTIVE

To provide an overview of mucositis, stomatitis, and xerostomia, the symptom experience, risk factors, current therapies, nursing interventions, and implications for practice, research, and education.

DATA SOURCES

Published articles pertaining to mucositis, stomatitis, and xerostomia.

CONCLUSIONS

Complete and consistent assessment of the oral cavity are needed. Frequent and meticulous oral care remains an important factor in preventing the development of or reducing the severity of oral mucositis, stomatitis, and xerostomia. Additional research of these symptoms is needed.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses can perform an essential role in promoting oral hygiene and optimal status of the oral cavity during cancer and its treatment.

Pharmacological control of periodontal disease. I. Antiplaque agents

Inhibition of the development of dental plaque remains one of the primary aims of periodontal care. Many patients, however, are unable to master completely the mechanical methods of plaque control and for this reason, considerable research efforts have been directed towards the development and use of chemical agents to inhibit the growth of plaque. This first of two articles, therefore, examines the pharmacological properties and efficacy of commercially available antiplaque agents. We have also summarized the findings of some of the major clinical trials that have provided the scientific basis for the introduction of these agents for the management of gingival inflammation.

Gastrointestinal manifestations in the child with cancer

Pediatric oncology nurses provide a major role in the assessment and management of gastrointestinal complications in children resulting from cancer therapies. The clinical problems most frequently seen in this area include stomatitis, nausea, vomiting, constipation, and diarrhea. These areas are reviewed in detail according to various nursing diagnoses including definitions and pathophysiology, recent studies and interventions, special considerations for children, and patient and parent education.

Efficacy of chlorhexidine and nystatin rinses in prevention of oral complications in leukemia and bone marrow transplantation

The goal of reducing oral complications during chemotherapy and bone marrow transplantation has received attention at several centers. The current randomized study of 86 adults with leukemia treated with chemotherapy or bone marrow transplantation assessed the potential role of chlorhexidine, nystatin, and saline solution rinses to reduce the findings of oral mucositis, gingivitis, and oral infection. The results of this study did not show a reduction in mucositis with the use of these rinses. However, potential bacterial and fungal pathogens were identified less frequently in the patients using chlorhexidine rinse.

The efficacy of chlorhexidine gel in reduction of Streptococcus mutans and Lactobacillus species in patients treated with radiation therapy

Xerostomia may develop in patients with cancer who receive radiotherapy that includes the salivary glands in the field. These patients are at high risk of rampant dental caries. Streptococcus mutans and Lactobacillus species have been associated with dental caries. Quantitative counts of these organisms demonstrated high caries risk due to streptococci in 66% and due to lactobacilli in 100% of patients studied. Use of chlorhexidine rinse was shown to reduce S. mutans counts 1.1 logs and lactobacilli 1.1 logs. The use of chlorhexidine gel resulted in a reduction of S. mutans 1.2 logs and lactobacilli 2.2 logs. In the subjects using the rinse, caries risk due to streptococci was reduced to low levels in 44% and due to lactobacilli in only one subject, with reduction to moderate risk in one third and no change in risk in the remaining patients. The use of chlorhexidine gel was found to reduce the caries risk associated with streptococci to low levels in all patients, and the risk associated with lactobacilli to low and moderate risk in two thirds of patients.

The oral complications of specific anticancer therapy

Oral complications commonly affect cancer patients undergoing active treatment. These include oral infection, gingival bleeding, stomatitis/mucositis, xerostomia, dental caries and periodontal disease. The oral cavity also acts as an entry site for systemic infection, particularly in those who are myelosuppressed. This paper reviews the structure and function of the oral cavity and how this may be affected by anticancer therapy. Oral care procedures are discussed and controversial areas highlighted showing that, although it is generally agreed that oral care is essential in preventing/minimizing complications and maintaining general comfort, there is no general agreement about the frequency with which care is required or about the tools and agents to be employed. Areas for future research are highlighted.

Antifungal therapy in oropharyngeal mycotic infections

Oral and pharyngeal candidiasis is a significant infection, particularly in immunosuppressed persons. Candidiasis may be evident as red or white lesions and may produce symptoms. In immunosuppressed persons, oral candidiasis may lead to extensive regional involvement and to systemic infection and can result in death. Because of the significance and prevalence of candidiasis, the recognition and management of infection are important.

Chlorhexidine rinse in prevention of dental caries in patients following radiation therapy

Patients who receive cancer radiotherapy, which compromises salivary gland function, may develop xerostomia. These patients are at increased risk to develop rampant dental caries. Streptococcus mutans and species of lactobacillus have been associated with dental caries. Quantitative counts of these organisms demonstrated high caries risk in 85% of patients studied. The use of chlorhexidine rinse to reduce the counts of S. mutans and lactobacillus was studied. A modest reduction in S. mutans was seen, but little effect was demonstrated on lactobacillus counts. Caries activity was shown to be related to lactobacillus count.

Issues in symptom control. Part 4. Oral complications in patients with advanced cancer

Disturbances caused by lesions of the oral cavity play an important part in the alteration of the quality of life of cancer patients. The main complications affecting the oral cavity are infections (fungal, viral, bacterial), neutropenic ulcers, drug-induced stomatitis, dry mouth, and taste alteration. Most of the information available about these entities has been acquired in the cancer patient without advanced disease. The little knowledge about the epidemiology and physiopathology of such lesions in the advanced phase of cancer is presented, and approaches to management are suggested.

Primary gingival enlargement as a diagnostic indicator in acute myelomonocytic leukemia. A case report

A 25-YEAR-OLD CHINESE FEMALE, five months pregnant, came to our dental clinic with a chief complaint of slight gingival inflammation. A diagnosis of pregnancy gingivitis was made. One week later, there was a sudden onset of extremely generalized gingival enlargement and very high WBC count (144,000/cmm) was noted. Physical, laboratory, and microscopic examination led to the diagnosis of acute myelomonocytic leukemia. The observations of good oral hygiene and clinical course suggested that leukemic cell infiltration was the major cause of sudden onset of gingival enlargement. This article emphasizes the importance of primary gingival enlargement in the initial diagnosis of leukemia.

Acute nonlymphocytic leukemia, monocytic variant. Report of a case

This report documents a case of a patient presenting unusual oral features of one of the rarer variants of acute nonlymphocytic leukemia, a malignancy whose oral manifestations may be the first indication of the presence of an underlying blood dyscrasia. The findings at the initial appointment and the patient's progress for the following 13 months until his death are presented. Initial suspicion of the clinical symptoms and an immediate, subsequent hospital hematology report established the diagnosis. The histologic features of a gingival biopsy taken during the oral examination were strongly suggestive of leukemia. Since the leukemias may imitate other oral conditions, especially various diseases of the periodontium, it is of paramount importance that the dental clinician recognize their clinical manifestations. As future treatment modalities improve, the dental clinician is seeing more leukemic patients in remission as well as more cases that have relapsed.

A review of the literature on use of chlorhexidine in dentistry

In addition to its plaque-inhibiting effect, chlorhexidine possesses other properties beneficial for use in dentistry. These effects are outlined, and specific recommendations are given regarding chlorhexidine's use by general practitioners. The side effects of long-term use, such as staining, and the availability of chlorhexidine also are discussed.

Oral manifestations in myelodysplastic syndrome. Review of the literature and report of a case

Gingival hyperplasia in a patient with myelodysplastic syndrome is described. Gingival infiltration was the first sign of acceleration of a stable disease process and was followed by development of a more aggressive phase of chronic myelomonocytic leukemia that was not responsive to therapy. Oral and dental assessment of patients with the myelodysplastic syndromes should be a part of routine management.

Oral complications of multimodality therapy for advanced squamous cell carcinoma of head and neck

Investigational treatment of advanced localized stage III or stage IV squamous cell carcinoma of the head and neck may include chemotherapy in addition to radiotherapy and surgery. Such therapy, while effective in eradicating local tumors, often produces considerable oral toxicity. In this study we reviewed the oral complications of 22 patients receiving multimodality cancer treatment. The addition of chemotherapy to the treatment regimen did not increase the incidence of complications (osteoradionecrosis, mucositis, xerostomia, radiation caries, or infection) when compared with historical controls receiving radiotherapy alone. Pretreatment dental evaluation and close follow-up of these patients are encouraged.

A long-term prospective clinical study of orofacial herpes simplex virus infection in acute leukemia

Orofacial mucocutaneous infections resulting from herpes simplex virus (HSV) were detected in 40% of patients with acute leukemia. Of the 34 separate episodes, oral mucosal sites were involved in 22 cases. Evidence to support dissemination of HSV was found in 3 patients on 4 separate occasions. The relationship of neutrophil levels to the onset and resolution of lesions is examined. The value of acyclovir for treatment of these HSV-induced lesions is reported, and the question of administering this agent for routine prophylaxis against HSV in these patients is addressed.

Oral mucositis in patients undergoing bone marrow transplantation

Thirty patients who received bone marrow transplantation treatment from HLA identical sibling donors for immunologic and malignant diseases were studied. In essentially all of the patients oral changes developed during the first 30 days following transplant. Oral symptoms frequently constituted the major complaints of the patients during the follow-up period. The oral changes included mucositis, xerostomia, pain, and bleeding. Mucositis was more severe and of longer duration when associated with herpes simplex infections and when optimal oral hygiene was not maintained. Xerostomia which accompanies engraftment was an early sign of acute graft-versus-host disease. A nonbrushing method of oral hygiene was effective in reducing the severity and duration of mucositis. This technique offers a short-term alternative to brushing in pancytopenic patients who are susceptible to bleeding or trauma.

Evaluation of nystatin in prevention and elimination of oropharyngeal Candida in immunosuppressed patients

Thirty-three patients with acute leukemia or lymphoma received an ongoing topical treatment with an oral suspension of nystatin during prolonged periods of intensive chemotherapy and severe granulocytopenia. The preparation proved ineffective in eliminating colonized Candida species from the oropharynx in ten of eleven patients at the time of admission and was of questionable value in preventing later colonization in others. The difficulties surrounding the identification of systemic candidiasis, its significance in the immunosuppressed patient, and the role of topical antifungal prophylaxis are discussed.

Immunology in dentistry

Implications of immunology in dental treatment are explained through discussion of the basic scientific principles of allergy, autoimmunity, immunization, immune dysfunction, tumor immunology, immunosuppression, and transplantation immunobiology.

Dental management of leukemic patients

Three cases involving the oral management of patients with acute leukemia are described. Of particular interest is that the patients had abnormal responses to oral disease, probably related to their compromised host defenses. Because of the difficulty in treating oral disease in leukemic persons while they are undergoing chemotherapy, it is extremely important that such patients have dental evaluations and, if possible, treatment prior to initiation of medical management for their neoplasia.