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Hong J, Park HK, Chang SH, Byun JM, Shin DY, Koh Y, Yoon SS, Choi Y, Kim I. A randomized phase II study of acyclovir for the prevention of chemotherapy-induced oral mucositis in patients undergoing autologous hematopoietic stem cell transplantation. BMC Oral Health 2023; 23:1008. [PMID: 38102638 PMCID: PMC10724996 DOI: 10.1186/s12903-023-03623-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 11/04/2023] [Indexed: 12/17/2023] Open
Abstract
OBJECTIVES To prove our hypothesis that acyclovir prophylaxis in autologous hematopoietic stem cell transplantation (AHSCT) recipients with hematologic malignancies (HM) reduces the incidence of chemotherapy-induced oral mucositis (CIOM) by inhibiting the intraoral HSV reactivation during the neutropenic period, we conducted a randomized phase II study of acyclovir for the prevention of CIOM in adult HSV sero-positive AHSCT recipients. METHODS Patients were randomized to either the study group (acyclovir 400 mg PO bid until neutrophil engraftment) or the control group (no prophylaxis) and received AHSCT. Oral examination and sampling for HSV were performed at three timepoints of AHSCT. RESULTS In 54 patients who were randomized (for intention-to-analysis), the incidence of CIOM was 16.0% (4/25 patients) and 58.6% (17/29 patients) in the study group and the control group, respectively (P = 0.001). In 49 patients who completed the study (for per-protocol analysis), the incidence of CIOM was 13.0% (3/23 patients) and 61.5% (16/26 patients) in the study group and the control group, respectively (P = 0.001). In addition, HSV-1 PCR positivity in the study group was significantly lower than that the control group (4.3% vs. 46.2%, P = 0.001). A strong association between the HSV-1 reactivation status and CIOM was reconfirmed. CONCLUSIONS Prophylactic use of oral acyclovir effectively reduced the incidence of CIOM in patients with HM who were undergoing AHSCT. TRIAL REGISTRATIONS This trial was registered at the Clinical Research Information Service in the Republic of Korea under the number KCT0003885 (registration date 03/05/2019).
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Affiliation(s)
- Junshik Hong
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
- Cancer Research Institute, Seoul National University, Seoul, Korea
| | - Hee-Kyung Park
- Department of Oral Medicine and Oral Diagnosis, Seoul National University Dental Hospital, Seoul National University School of Dentistry, Seoul, Korea
| | - Sung-Ho Chang
- Department of Immunology and Molecular Microbiology, School of Dentistry and Dental Research Institute, Seoul National University, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Ja Min Byun
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
- Cancer Research Institute, Seoul National University, Seoul, Korea
| | - Dong-Yeop Shin
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
- Cancer Research Institute, Seoul National University, Seoul, Korea
| | - Youngil Koh
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
- Cancer Research Institute, Seoul National University, Seoul, Korea
| | - Sung-Soo Yoon
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
- Cancer Research Institute, Seoul National University, Seoul, Korea
| | - Youngnim Choi
- Department of Immunology and Molecular Microbiology, School of Dentistry and Dental Research Institute, Seoul National University, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea.
| | - Inho Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea.
- Cancer Research Institute, Seoul National University, Seoul, Korea.
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Brennan PG, Wright K, Miles MVP, Lintner AC, Alexander KM, Kahn SA. Delineating the Role of Serum Immunoglobulin Titers in Burn Patients at High Risk for Herpes Simplex Virus Infection. J Burn Care Res 2021; 42:646-650. [PMID: 33861351 DOI: 10.1093/jbcr/irz197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Herpes simplex virus (HSV) is common in the population and reactivation of latent infection often occurs in times of physiologic stress, including postburn injury. Active HSV infection complicates burn injury recovery and increases morbidity. A retrospective chart review of high-risk burn patients (≥20%TBSA and/or facial burns) who had screening HSV immunoglobulin titers drawn from 2015 to 2018 was conducted. Titer levels and morbidity-related outcomes were compared between patients who developed active infection and those who did not. Fifty-six patients had serum HSV titers measured. Twenty-nine patients (52%) developed clinical signs of HSV infection, almost all of which (97%) suffered facial burns. Titers were ordered on median hospital day 1.5 (0.00-4.0) and infection occurred on day 8.0 (2.0-16). Median HSV-1,2 IgM titers were significantly increased in patients who developed clinically active HSV infection (0.71 [0.44-1.1] vs 0.52 [0.34-0.74], P = .02). Median HSV-1 IgG (P = .65) and HSV-2 IgG titers (P = .97) were not different between groups. Patients who developed active infection had a comparable hospital length of stay (27 [9.5-40] days vs 20 [8.0-28] days, P = .17) and ICU length of stay (26 [13-49] days vs 19 [11-27] days, P = .09) to those who did not develop infection. There was no difference in mortality. Increased HSV-1 and 2 IgM screening levels were associated with an increased risk of developing active HSV infection, and offer a specific screening modality in high-risk patients. Elevated IgM titers warrant further consideration for administration of HSV prophylaxis, as earlier intervention may prevent infection onset and minimize morbidity.
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Affiliation(s)
- Phillip G Brennan
- Department of Surgery, University of South Alabama College of Medicine, Mobile, Alabama
| | - Kelsea Wright
- Department of Surgery, University of South Alabama College of Medicine, Mobile, Alabama
| | - M Victoria P Miles
- Department of Surgery, University of South Alabama Medical Center, Mobile
| | - Alicia C Lintner
- Arnold Luterman Regional Burn Center, University of South Alabama Medical Center, Mobile
| | - Kaitlin M Alexander
- Department of Pharmacy Practice, Auburn University Harrison School of Pharmacy, Mobile, Alabama
| | - Steven A Kahn
- Arnold Luterman Regional Burn Center, University of South Alabama Medical Center, Mobile
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Hong J, Park HK, Park S, Lee A, Lee YH, Shin DY, Koh Y, Choi JY, Yoon SS, Choi Y, Kim I. Strong association between herpes simplex virus-1 and chemotherapy-induced oral mucositis in patients with hematologic malignancies. Korean J Intern Med 2020; 35:1188-1198. [PMID: 31487770 PMCID: PMC7487294 DOI: 10.3904/kjim.2018.469] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 03/25/2019] [Indexed: 11/27/2022] Open
Abstract
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.
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Affiliation(s)
- Junshik Hong
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Cancer Research Institute, Seoul National University, Seoul, Korea
| | - Hee-Kyung Park
- Department of Oral Medicine and Oral Diagnosis, Dental Research Institute, Seoul National University School of Dentistry, Seoul, Korea
- Department of Oral Medicine, Seoul National University Dental Hospital, Seoul, Korea
| | - Suhyun Park
- Department of Oral Medicine, Seoul National University Dental Hospital, Seoul, Korea
| | - Ahreum Lee
- Department of Immunology and Molecular Microbiology, Dental Research Institute, Seoul National University School of Dentistry, Seoul, Korea
| | - Yeon-Hee Lee
- Department of Orofacial Pain and Oral Medicine, Kyung Hee University Dental Hospital, Seoul, Korea
| | - Dong-Yeop Shin
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Cancer Research Institute, Seoul National University, Seoul, Korea
| | - Youngil Koh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Cancer Research Institute, Seoul National University, Seoul, Korea
| | - Ji-Yeob Choi
- Cancer Research Institute, Seoul National University, Seoul, Korea
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Biomedical Sciences, Seoul National University Graduate School, Seoul, Korea
| | - Sung-Soo Yoon
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Cancer Research Institute, Seoul National University, Seoul, Korea
| | - Youngnim Choi
- Department of Immunology and Molecular Microbiology, Dental Research Institute, Seoul National University School of Dentistry, Seoul, Korea
- Correspondence to Youngnim Choi, D.D.S. Department of Immunology and Molecular Microbiology, Dental Research Institute, Seoul National University School of Dentistry, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea Tel: +82-2-740-8643, Fax: +82-2-745-1906, E-mail:
| | - Inho Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Cancer Research Institute, Seoul National University, Seoul, Korea
- Inho Kim, M.D. Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea Tel: +82-2-2072-0834, Fax: +82-2-764-2199, E-mail:
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Samim F, Epstein JB, Zumsteg ZS, Ho AS, Barasch A. Oral and dental health in head and neck cancer survivors. CANCERS OF THE HEAD & NECK 2016; 1:14. [PMID: 31093344 PMCID: PMC6460838 DOI: 10.1186/s41199-016-0015-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 10/03/2016] [Indexed: 01/29/2023]
Abstract
Therapeutic improvements and epidemiologic changes in head and neck cancer (HNC) over the last three decades have led to increased numbers of survivors, resulting in greater need for continuing management of oral and dental health in this population. Generally, the HNC patient oral health needs are complex, requiring multidisciplinary collaboration among oncologists and dental professionals with special knowledge and training in the field of oral oncology. In this review, we focus on the impact of cancer treatment on oral health, and the oral care protocols recommended prior to, during and after cancer therapy. The management of oral complications such as mucositis, pain, infection, salivary function, taste and dental needs are briefly reviewed. Other complications and their management, including osteonecrosis of the jaw and recurrent/new primary malignancies are also described. This review offers clinical protocols and information for medical providers to assist in understanding oral complications and their management in HNC patients and survivors, and their oral and dental health care needs. Oral and dental care is impacted by the patient’s initial oral and dental status, as well as the specific cancer location, type, and its treatment; thus, close communication between the dental professional and the oncology team is required for appropriate therapy.
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Affiliation(s)
- Firoozeh Samim
- 1Department of Oral Medicine Oral Pathology, University of British Columbia, Vancouver, BC Canada
| | - Joel B Epstein
- 2Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA USA
| | - Zachary S Zumsteg
- 3Radiation Oncology, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA USA
| | - Allen S Ho
- 4Department of Surgery, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA USA
| | - Andrei Barasch
- 5Department of Medicine, Weill Cornell Medical College, New York, NY USA
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Dropulic LK, Lederman HM. Overview of Infections in the Immunocompromised Host. Microbiol Spectr 2016; 4:10.1128/microbiolspec.DMIH2-0026-2016. [PMID: 27726779 PMCID: PMC8428766 DOI: 10.1128/microbiolspec.dmih2-0026-2016] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Indexed: 12/12/2022] Open
Abstract
Understanding the components of the immune system that contribute to host defense against infection is key to recognizing infections that are more likely to occur in an immunocompromised patient. In this review, we discuss the integrated system of physical barriers and of innate and adaptive immunity that contributes to host defense. Specific defects in the components of this system that predispose to particular infections are presented. This is followed by a review of primary immunodeficiency diseases and secondary immunodeficiencies, the latter of which develop because of a specific illness or condition or are treatment-related. The effects of treatment for neoplasia, autoimmune diseases, solid organ and stem cell transplants on host defenses are reviewed and associated with susceptibility to particular infections. In conclusion, an approach to laboratory screening for a suspected immunodeficiency is presented. Knowledge of which host defects predispose to specific infections allows clinicians to prevent, diagnose, and manage infections in their immunocompromised patients most effectively.
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Affiliation(s)
- Lesia K Dropulic
- The National Institutes of Health, National Institute of Allergy and Infectious Diseases, Division of Intramural Research, Bethesda, MD 20892
| | - Howard M Lederman
- Departments of Pediatrics, Medicine, and Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD 21287
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Warkentin DI, Epstein JB, Campbell LM, Yip JG, Cox VC, Ransier A, Barnett MJ, Marra F. Valacyclovir versus Acyclovir for HSV Prophylaxis in Neutropenic Patients. Ann Pharmacother 2016; 36:1525-31. [PMID: 12243600 DOI: 10.1345/aph.1a434] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND: It is common practice to administer acyclovir as prophylaxis to patients with hematologic malignancies during neutropenia; however, effective therapy requires frequent dosing, which is difficult in this setting. Valacyclovir has greater oral bioavailability and requires less frequent dosing. OBJECTIVE: To evaluate the efficacy and safety of valacyclovir compared with acyclovir. METHODS: Patients who had been treated with chemotherapy or stem-cell transplantation were randomized to receive acyclovir 400 mg orally 3 × daily (n = 51), valacyclovir 500 mg orally twice daily (n = 48), or valacyclovir 250 mg orally twice daily (n = 52) during neutropenia. RESULTS: Clinical success, defined as the absence of an active herpes simplex virus (HSV) lesion or asymptomatic viral shedding, was similar between the 3 groups (acyclovir 96%, valacyclovir 500 mg 95%, valacyclovir 250 mg 100%). The overall rates of adverse events were similar in the 3 groups. CONCLUSIONS: Prophylactic treatment with valacyclovir is an effective and safe alternative to acyclovir for the prevention of HSV reactivation in patients with hematologic malignancies.
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Affiliation(s)
- Dawn I Warkentin
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
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7
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Kumar N, Brooke A, Burke M, John R, O’Donnell A, Soldani F. The oral management of oncology patients requiring radiotherapy, chemotherapy and/or bone marrow transplantation. ACTA ACUST UNITED AC 2013. [DOI: 10.1308/204268513x13776914744952] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Patients undergoing cancer therapy may experience unwanted side-effects involving the oral cavity and more evidence is emerging regarding the management of these complications. These oral effects have both short and long-term implications. Dentists need to be aware of these implications and liaise closely with the oncology teams to establish pathways of oral care. This enables patients to have appropriate dental support in place before, during and after cancer therapy. This article is an executive summary of a review undertaken for a national clinical guideline, The Oral Management of Oncology Patients following Radiotherapy, Chemotherapy and/or Bone Marrow Transplanation. The full text is available on the FDS website: www.rcseng.ac.uk/fds/publications-clinical-guidelines/clinical_guidelines/
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Affiliation(s)
- Navdeep Kumar
- Navdeep Kumar,* Department of Special Care Dentistry, Eastman Dental Hospital, London
| | - Anthony Brooke
- Anthony Brooke, Bristol Dental Hospital and School, Bristol
| | - Mary Burke
- Mary Burke, Guy’s and St Thomas’ Foundation Trust, London
| | - Rebecca John
- Rebecca John, Bristol Dental Hospital and School, Bristol
| | - Amanda O’Donnell
- Amanda O’Donnell, Department of Paediatric Dentistry, Eastman Dental Hospital, London
| | - Francesca Soldani
- Francesca Soldani, Bradford District Care Trust, Salaried Dental Service, Bradford; The Rotherham NHS Foundation Trust, Salaried Dental Service, Barnsley
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8
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Saito K, Hatano Y, Okamoto T, Suenobu SI, Izumi T, Matsuda K, Shimizu F, Fujiwara S. Severe cutaneous necrosis due to mixed infection with herpes simplex virus and fungi in an unrelated cord blood stem cell transplantation recipient. J Dermatol 2013; 40:411-3. [DOI: 10.1111/1346-8138.12096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Kanami Saito
- Departments of Dermatology; University of Oita; Oita; Japan
| | - Yutaka Hatano
- Departments of Dermatology; University of Oita; Oita; Japan
| | - Tomoko Okamoto
- Pediatrics and Child Neurology; University of Oita; Oita; Japan
| | - So-ichi Suenobu
- Pediatrics and Child Neurology; University of Oita; Oita; Japan
| | - Tatsuro Izumi
- Pediatrics and Child Neurology; University of Oita; Oita; Japan
| | - Kaho Matsuda
- Plastic Surgery; Faculty of Medicine; University of Oita; Oita; Japan
| | - Fumiaki Shimizu
- Plastic Surgery; Faculty of Medicine; University of Oita; Oita; Japan
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9
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Abstract
The oral mucosa is a common site for collateral damage of cancer therapies, including radiation, cytotoxic medication, and newer targeted therapies. Ulcerative oral mucositis is typically painful and affects oral functions including speech, and oral intake of food and medications, thus impacting the quality of life. Denuded epithelium may also provide access of oral microbial flora to the deeper tissues and the circulation. Prevention of oral mucositis is an ongoing quest currently with relatively few answers. In this chapter, the present authors discuss the evidence and current practice for prophylaxis and management of this treatment side effect in cancer patients.
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Affiliation(s)
- Andrei Barasch
- Department of Dental Medicine, Winthrop University Hospital, Mineola, New York, USA.
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10
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The impact of oral herpes simplex virus infection and candidiasis on chemotherapy-induced oral mucositis among patients with hematological malignancies. Eur J Clin Microbiol Infect Dis 2011; 30:753-9. [PMID: 21225303 DOI: 10.1007/s10096-010-1148-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2010] [Accepted: 12/23/2010] [Indexed: 10/18/2022]
Abstract
The aim of this study was to evaluate the influences of oral candidiasis and herpes simplex virus 1 (HSV-1) infections in chemotherapy-induced oral mucositis (OM). The medical records of 424 consecutive patients with hematological malignancies who had received chemotherapy at a medical center in Taiwan from January 2006 to November 2007 were retrospectively reviewed. The results of swab cultures of fungus and HSV-1 for OM were correlated with associated clinical features. Younger age, myeloid malignancies, and disease status other than complete remission before chemotherapy were significantly correlated with the development of OM. Risks of fever (p < 0.001) and bacteremia were higher in patients with OM. Among 467 episodes of OM with both swab cultures available, 221 were non-infection (47.3%) and 246 were related to either fungal infections, HSV-1 infections, or both (52.7%); of the 246 episodes, 102 were associated with fungal infections alone (21.8%), 98 with HSV-1 infections alone (21%), and 46 with both infections (9.9%). Patients who had received antifungal agents prior to OM occurrence tended to have HSV-1 infection (p < 0.001). Our results suggest that Candida albicans and HSV-1 play an important role in chemotherapy-induced OM in patients with hematological malignancies.
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Imanguli MM, Alevizos I, Brown R, Pavletic SZ, Atkinson JC. Oral graft-versus-host disease. Oral Dis 2008; 14:396-412. [PMID: 18593456 DOI: 10.1111/j.1601-0825.2008.01448.x] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Graft-versus-host disease (GVHD) is a leading cause of morbidity and mortality in patients receiving hematopoietic cell transplant. It is estimated that 40-70% of engrafted patients surviving the initial transplant eventually develop chronic GVHD (cGVHD), which can persist for months to years and require long-term management from multiple disciplines. This review describes the oral component of this transplant complication. DESIGN The search related to GVHD patho-biology, salivary gland disease after hematopoietic cell transplant and treatments for oral GVHD encompassed literature from 1966 through 2008. Searches were limited to the MEDLINE/PubMed database and English language literature in peer-reviewed journals. RESULTS Our understanding of the patho-biology of oral cGVHD is based on studies of other affected tissues. It is difficult to determine the prevalence and incidence of salivary gland disease after transplant because there is no universally accepted case definition. In general, clinical trials for treatment of oral cGVHD have been too small to make strong recommendations for use in clinical practice. CONCLUSIONS Larger well-designed clinical studies are needed to understand the patho-biology of oral cGVHD and determine best treatments for this disease.
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Affiliation(s)
- M M Imanguli
- Experimental Transplantation and Immunology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
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Quinn B, Potting CM, Stone R, Blijlevens NM, Fliedner M, Margulies A, Sharp L. Guidelines for the assessment of oral mucositis in adult chemotherapy, radiotherapy and haematopoietic stem cell transplant patients. Eur J Cancer 2008; 44:61-72. [DOI: 10.1016/j.ejca.2007.09.014] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2007] [Revised: 09/11/2007] [Accepted: 09/20/2007] [Indexed: 10/22/2022]
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Abstract
Oral mucositis is a serious complication of cancer therapy and in severely immunosuppressed patients. In immunosuppressed patients, the signs and symptoms of infection often are muted because of limited host response, and accurate diagnosis and appropriate treatment may be difficult. Prevention of mucosal breakdown, suppression of microbial colonization, control of viral reactivation, and effective management of severe xerostomia are all critical steps to reducing the overall morbidity and mortality of oromucosal infections.
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Affiliation(s)
- Joel B Epstein
- Department of Oral Medicine and Diagnostic Sciences, College of Dentistry, 801 South Paulina St., Chicago, IL 60612, USA.
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Geddes M, Storek J. Immune reconstitution following hematopoietic stem-cell transplantation. Best Pract Res Clin Haematol 2007; 20:329-48. [PMID: 17448965 DOI: 10.1016/j.beha.2006.09.009] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Hematopoietic stem-cell transplantation is associated with a profound immune deficiency manifested as an increased propensity to develop infections and probably also malignancies. Innate immunity, including epithelial barriers and phagocytes, typically recovers within weeks after grafting, and B-cell counts and CD8 T-cell counts recover within months. CD4 T-cell counts are low for years, and their recovery is particularly slow in older patients with poor thymic function. Therapies to improve immune function include vaccinations, immunoglobulins for recurrent infections, cytokines, and antigen-specific donor lymphocyte infusions.
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Affiliation(s)
- Michelle Geddes
- Division of Hematology and Hematologic Malignancies, University of Calgary, Canada.
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15
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Epstein JB, Klasser GD. Emerging approaches for prophylaxis and management of oropharyngeal mucositis in cancer therapy. Expert Opin Emerg Drugs 2006; 11:353-73. [PMID: 16634706 DOI: 10.1517/14728214.11.2.353] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Oral mucositis is a common treatment-limiting side effect of cancer therapy that may have a significant impact on quality of life and on the cost of care. Oral mucositis is the most distressing complication of cancer therapy as reported by head and neck cancer patients, in patients receiving dose-dense myelosuppressive chemotherapy and in patients receiving haematopoietic stem cell transplant. Mucositis may increase the risk of local and systemic infection, particularly in myelosuppressed patients. Severe oral mucositis can lead to the need to interrupt or discontinue cancer therapy, and thus may impact cure of the primary disease. Current care of patients with mucositis is essentially palliative, and includes appropriate oral hygiene, nonirritating diet and oral care products, topical palliative mouth rinses, topical anaesthetics and use of systemic opioid analgesics. Emerging approaches for prevention and treatment of oral mucositis are developing based on an increasing understanding of the pathobiology of mucosal damage and repair. New interventions are expected to be administered based on the mechanisms of initiation, progression and resolution of the condition. The approval by the FDA of keratinocyte growth factor (palifermin; Amgen) in 2004 represents a new step in prevention of oral mucositis in stem cell transplant patients based on the increasing understanding of the pathogenesis of mucositis. Progress in the prevention and management of mucositis will improve quality of life, reduce cost of care and facilitate completion of more intensive cancer chemotherapy and radiotherapy protocols. Improved management of mucositis may allow implementation of cancer treatment protocols that are currently excessively mucotoxic, but have potentially higher cure rates of the malignant disease.
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Affiliation(s)
- Joel B Epstein
- Department of Oral Medicine and Diagnostic Sciences, University of Illinois at Chicago, College of Dentistry, 801 South Paulina St, MC 838, Chicago, Illinois 60612, USA
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Raber-Durlacher JE, Barasch A, Peterson DE, Lalla RV, Schubert MM, Fibbe WE. Oral Complications and Management Considerations in Patients Treated with High-Dose Chemotherapy. ACTA ACUST UNITED AC 2004; 1:219-29. [DOI: 10.3816/sct.2004.n.014] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Abstract
Chemotherapy and radiotherapy, whilst highly effective in the treatment of neoplasia, can also cause damage to healthy tissue. In particular, the alimentary tract may be badly affected. Severe inflammation, lesioning and ulceration can occur. Patients may experience intense pain, nausea and gastro-enteritis. They are also highly susceptible to infection. The disorder (mucositis) is a dose-limiting toxicity of therapy and affects around 500 000 patients world-wide annually. Oral and intestinal mucositis is multi-factorial in nature. The disruption or loss of rapidly dividing epithelial progenitor cells is a trigger for the onset of the disorder. However, the actual dysfunction that manifests and its severity and duration are greatly influenced by changes in other cell populations, immune responses and the effects of oral/gut flora. This complexity has hampered the development of effective palliative or preventative measures. Recent studies have concentrated on the use of bioactive/growth factors, hormones or interleukins to modify epithelial metabolism and reduce the susceptibility of the tract to mucositis. Some of these treatments appear to have considerable potential and are at present under clinical evaluation. This overview deals with the cellular changes and host responses that may lead to the development of mucositis of the oral cavity and gastrointestinal tract, and the potential of existing and novel palliative measures to limit or prevent the disorder. Presently available treatments do not prevent mucositis, but can limit its severity if used in combination. Poor oral health and existing epithelial damage predispose patients to mucositis. The elimination of dental problems or the minimization of existing damage to the alimentary tract, prior to the commencement of therapy, lowers their susceptibility. Measures that reduce the flora of the tract, before therapy, can also be helpful. Increased production of free radicals and the induction of inflammation are early events in the onset of mucositis. Prophylactic administration of scavengers or anti-inflammatories can partially counteract or limit some of these therapy-mediated effects, as can the use of cryotherapy. The regular use of mouthwashes, mouth coatings, antibiotics and analgesics is essential, prior to and during loss and ablation of the epithelial layer. Granulocyte-macrophage colony-stimulating factor/granulocyte colony-stimulating factor or the use of laser light therapy may aid restitution and repair. Glutamine supplements may be beneficial in the repair/recovery phase.
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Affiliation(s)
- M Duncan
- Rowett Research Institute, Bucksburn, Aberdeen, UK
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19
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Epstein JB, Gorsky M, Hancock P, Peters N, Sherlock CH. The prevalence of herpes simplex virus shedding and infection in the oral cavity of seropositive patients undergoing head and neck radiation therapy. ORAL SURGERY, ORAL MEDICINE, ORAL PATHOLOGY, ORAL RADIOLOGY, AND ENDODONTICS 2002; 94:712-6. [PMID: 12464896 DOI: 10.1067/moe.2002.127585] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Herpes viruses are characterized by their ability to establish and maintain a latent infection that can reactivate. Only 2 preliminary studies have examined herpes simplex virus (HSV) reactivation in patients receiving head and neck radiotherapy. The role of radiation therapy in the reactivation of a latent virus has not been established. The purpose of the present study was to evaluate the incidence of HSV reactivation in patients receiving radiation treatment for head and neck malignancies. METHODS Twenty patients, 19 of whom were HSV seropositive, undergoing head and neck radiation therapy were assessed weekly before and during radiation therapy, and HSV cultures were completed during cancer treatment. RESULTS Only 3.6% of the cultures were positive for HSV during radiation therapy. HSV was cultured in 4 men receiving a mean of 6,000 cGy to the head and neck area. Recovery from HSV was seen in patients nearing completion of radiation therapy. CONCLUSIONS The results of this study suggest that HSV reactivation is not common during radiation therapy. Therefore, this study does not support prophylaxis of HSV in patients undergoing head and neck irradiation.
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20
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Dignani MC, Mykietiuk A, Michelet M, Intile D, Mammana L, Desmery P, Milone G, Pavlovsky S. Valacyclovir prophylaxis for the prevention of Herpes simplex virus reactivation in recipients of progenitor cells transplantation. Bone Marrow Transplant 2002; 29:263-7. [PMID: 11859400 DOI: 10.1038/sj.bmt.1703354] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2001] [Accepted: 10/21/2001] [Indexed: 11/08/2022]
Abstract
HSV can cause oral lesions that exacerbate chemotherapy-related mucositis. Intravenous acyclovir is effective in preventing HSV reactivations, but expensive. Valacyclovir has good bioavailability and has not been studied for prophylaxis of HSV among PCT patients. We compared the efficacy and costs of valacyclovir in preventing HSV reactivation among HSV seropositive autologous progenitor cell transplantation (APCT) patients with historical controls in whom intravenous acyclovir or no HSV prophylaxis were used. Valacyclovir group: From October 1997 to April 1999 108 adult patients received valacyclovir 500 mg twice daily from day -3 of APCT until neutropenia recovery or day +30. Valacyclovir was switched to intravenous acyclovir in cases of oral intolerance (17 patients) or suspected HSV reactivation (five patients). Intravenous acyclovir group: From January 1996 to October 1997 43 patients received 5 mg/kg twice-daily intravenous acyclovir from day -3 until recovery from neutropenia. No prophylaxis group: 38 patients from January 1996 to October 1997 did not receive HSV prophylaxis. HSV reactivations were seen in 2.7%, 2% and 45% of patients in the valacyclovir, intravenous acyclovir, and no prophylaxis groups, respectively. Valacyclovir was well tolerated and was the least expensive strategy. Oral valacyclovir was as effective as intravenous acyclovir for the prophylaxis of HSV reactivation in APCT patients.
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Affiliation(s)
- M C Dignani
- Myeloma and Transplantation Research Center, University of Arkansas for Medical Sciences, Little Rock, Arkansas 72205, USA
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21
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Abstract
Periodontal infection may exacerbate during cancer therapy and may result in oral pain and infection, and systemic infection, which may cause morbidity and can lead to mortality in neutropenic cancer patients. Periodontal disease in head and neck cancer patients treated with radiation therapy may lead to acute and chronic complications. The literature was reviewed by a search of Medline of the National Library of Medicine. The search was conducted to identify publications assessing periodontal disease in cancer patients. In addition, a review of papers referenced in the retrieved papers was conducted to identify additional publications for review. Periodontal disease should be assessed and managed prior to medical treatment of cancer for those with oropharyngeal cancer, and for patients in whom neutropenia may develop during treatment. Pretreatment assessment and management, and maintenance of oral hygiene have been shown to be effective in preventing oral and systemic complications during treatment. A complete oral and periodontal examination is appropriate for all patients planned to receive head and neck radiation therapy and those to be treated with medical protocols that are anticipated to result in neutropenia. Oral and periodontal care must continue following cancer therapy, and requires that the health care provider have an understanding of the malignant disease, oral manifestations of the disease, medical management of the disease, and of the oral complications that may develop.
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Affiliation(s)
- J B Epstein
- British Columbia Cancer Agency, Vancouver Hospital and Health Sciences Centre, 600 West 10th Avenue, Vancouver, BC, Canada V5Z 4E6.
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22
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Epstein JB, Chow AW. Oral complications associated with immunosuppression and cancer therapies. Infect Dis Clin North Am 1999; 13:901-23. [PMID: 10579115 DOI: 10.1016/s0891-5520(05)70115-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- J B Epstein
- Division of Hospital Dentistry, University of British Columbia, Vancouver, Canada
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23
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Bez C, Demarosi F, Sardella A, Lodi G, Bertolli VG, Annaloro C, Rimondini L, Porter SR, Carrassi A. GM-CSF mouthrinses in the treatment of severe oral mucositis: a pilot study. ORAL SURGERY, ORAL MEDICINE, ORAL PATHOLOGY, ORAL RADIOLOGY, AND ENDODONTICS 1999; 88:311-5. [PMID: 10503860 DOI: 10.1016/s1079-2104(99)70034-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of this open trial was to test the efficacy of granulocyte-macrophage colony-stimulating factor (GM-CSF) mouthrinses as a potential treatment in reducing the duration of severe oral mucositis in patients undergoing bone marrow transplantation for hematologic malignancies. STUDY DESIGN The study group was composed of 10 consecutive patients suffering from severe oral mucositis during bone marrow transplantation procedures. The control group was similar to the study group in age and gender and comprised 29 historical patients with similar clinical characteristics. Freshly prepared GM-CSF mouthwash (0.5 microg/mL) was administered to the study population for 1 minute 3 times per day after oral hygiene procedures, starting from the first day of mucositis until clinical improvement of oral lesions. The study and control populations were compared with respect to duration of severe oral mucositis (1-9 days, 10-19 days, > or =20 days). RESULTS There was no statistically (chi2 exact test) significant difference in mean mucositis score between the study group (11.9+/-6.1) and the control group (16.6+/-8.9). However, the duration of severe mucositis appeared to be reduced; 60% of the GM-CSF mouthrinse patients had severe mucositis for less than 9 days, whereas only 28% of the controls had severe mucositis for less than 9 days. In addition, 10% of the GM-CSF mouthrinse patients experienced severe mucositis lasting 20 or more days, whereas 34% of the controls experienced severe mucositis for 20 or more days. CONCLUSIONS These findings suggest that GM-CSF may reduce the duration of severe mucositis, but controlled, double-blind clinical trials are now required.
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Affiliation(s)
- C Bez
- Department of Oral Pathology and Medicine, School of Dentistry, University of Milan, Italy
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24
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Abstract
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.
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Affiliation(s)
- P Plevová
- Department of Radiotherapy, University Hospital of Ostrava, Ostrava-Poruba, Czeck Republic.
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25
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Epstein JB, Schubert MM. Oral mucositis in myelosuppressive cancer therapy. ORAL SURGERY, ORAL MEDICINE, ORAL PATHOLOGY, ORAL RADIOLOGY, AND ENDODONTICS 1999; 88:273-6. [PMID: 10503852 DOI: 10.1016/s1079-2104(99)70026-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Because the etiology of mucositis is multifactorial , approaches to prevention and management have also been multifactorial. Effective prevention and management of mucositis will reduce the pain and suffering experienced during cancer treatment. Oropharyngeal pain in cancer patients frequently requires systemic analgesics, adjunctive medications, physical therapy, and psychologic therapy in addition to oral care and topical treatments. Good oral hygiene reduces the severity of oral mucositis and does not increase the risk of bacteremia. Current approaches to management include frequent oral rinsing with saline or bicarbonate rinses, maintaining excellent oral hygiene, and using topical anesthetics and analgesics. Cryotherapy is a potential adjunctive approach in some cases. There are a number of approaches that appear to represent viable candidates for further study. Biologic response modifiers offer the potential for prevention and for acceleration of healing. Various cytokines will enter clinical trials in the near future; these offer the potential for reduction of epithelial cell sensitivity to the toxic effects of cancer therapy or for stimulation of repair of the damaged tissue. Other approaches include the use of medications to reduce exposure of the oral mucosa to chemotherapeutic drugs that are secreted in saliva. Antimicrobial approaches have met with conflicting results, little effect being seen with chlorhexidine and systemic antimicrobials in the prevention of mucositis in radiation patients. In patients with BMT and patients with leukemia, chlorhexidine may not be effective in preventing mucositis, although there may be reduction in oral colonization by Candida. Initial studies of topical antimicrobials that affect the gram-negative oral flora have shown reductions in ulcerative mucositis during radiation therapy but have not been assessed in leukemia/BMT. Among other approaches that require further study are low-energy lasers and anti-inflammatory medications. These approaches to management have undergone initial study, but additional investigation is needed to determine their effectiveness with respect to the prevention of mucositis and symptom management and to determine appropriate doses and frequencies of intervention. Current studies and our increasing understanding of the pathogenesis of oral mucositis will lead to new approaches to management and improved quality of life for these patients.
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Affiliation(s)
- J B Epstein
- Vancouver Hospital, Dentistry Department, BC, Canada
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26
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Abstract
Herpes simplex virus type 1 (HSV-1) and, to a lesser extent, type 2 (HSV-2) are the aetiological agents of recrudescent herpes labialis (RHL). The available literature on patterns of HSV-1 shedding into the oral cavity at the prodromal stage of disease, during recrudescences and also during asymptomatic periods, is reviewed, as are the potential sources of virus and the known trigger factors leading to viral reactivation. Attention is given to the methodologies in use for the detection of HSV-1 and the relevance to the risk of cross-infection in surgery. This review also discusses the increase in incidence of HSV-1 genital infections and the significance of salivary inhibitors of the herpes simplex type 1 virus.
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Affiliation(s)
- D A Scott
- School of Clinical Dentistry, Queen's University of Belfast, N. Ireland
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27
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de Jong MD, Boucher CA, Cooper DA, Galasso GJ, Gazzard B, Lange JM, Montaner JS, Richman DD, Thomas HC. Summary of the II International Consensus Symposium on Combined Antiviral Therapy and implications for future therapies. Antiviral Res 1997; 35:65-82. [PMID: 9217244 PMCID: PMC7173273 DOI: 10.1016/s0166-3542(97)00020-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- M D de Jong
- Department of Medical Microbiology, Academic Medical Center, Amsterdam, The Netherlands.
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