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Bassim CW, Fassil H, Mays JW, Edwards D, Baird K, Steinberg SM, Cowen EW, Naik H, Datiles M, Stratton P, Gress RE, Pavletic SZ. Oral disease profiles in chronic graft versus host disease. J Dent Res 2015; 94:547-54. [PMID: 25740857 DOI: 10.1177/0022034515570942] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
At least half of patients with chronic graft-versus-host-disease (cGVHD), the leading cause of morbidity and non-relapse mortality after allogeneic stem cell transplantation, have oral manifestations: mucosal lesions, salivary dysfunction, and limited mouth-opening. cGVHD may manifest in a single organ or affect multiple organ systems, including the mouth, eyes, and the skin. The interrelationship of the 3 oral manifestations of cGVHD with each other and with the specific manifestations of extraoral cGVHD has not been studied. In this analysis, we explored, in a large group of patients with cGVHD, the potential associations between: (1) oral mucosal disease and erythematous skin disease, (2) salivary gland dysfunction and lacrimal gland dysfunction, and (3) limited mouth-opening and sclerotic skin cGVHD. Study participants, enrolled in a cGVHD Natural History Protocol (NCT00331968, n = 212), underwent an oral examination evaluating: (1) mucosal cGVHD [NIH Oral Mucosal Score (OMS)], (2) salivary dysfunction (saliva flow and xerostomia), and (3) maximum mouth-opening measurement. Parameters for dysfunction (OMS > 2, saliva flow ≤ 1 mL/5 min, mouth-opening ≤ 35 mm) were analyzed for association with skin cGVHD involvement (erythema and sclerosis, skin symptoms), lacrimal dysfunction (Schirmer's tear test, xerophthalmia), Lee cGVHD Symptom Scores, and NIH organ scores. Oral mucosal disease (31% prevalence) was associated with skin erythema (P < 0.001); salivary dysfunction (11% prevalence) was associated with lacrimal dysfunction (P = 0.010) and xerostomia with xerophthalmia (r = 0.32, P = 0.001); and limited mouth-opening (17% prevalence) was associated with skin sclerosis (P = 0.008) and skin symptoms (P = 0.001). There was no association found among these 3 oral cGVHD manifestations. This analysis supports the understanding of oral cGVHD as 3 distinct diseases: mucosal lesions, salivary gland dysfunction, and mouth sclerosis. Clear classification of oral cGVHD as 3 separate manifestations will improve clinical diagnosis, observational research data collection, and the definitions of outcome measures in clinical trials.
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Affiliation(s)
- C W Bassim
- National Institute of Dental and Craniofacial Research, NIH, Bethesda, MD, USA
| | - H Fassil
- Experimental Transplantation and Immunology Branch, National Cancer Institute, NIH, Bethesda, MD, USA Tufts University School of Dental Medicine, Boston, MA, USA
| | - J W Mays
- National Institute of Dental and Craniofacial Research, NIH, Bethesda, MD, USA
| | - D Edwards
- National Institute of Dental and Craniofacial Research, NIH, Bethesda, MD, USA
| | - K Baird
- Pediatric Oncology Branch, National Cancer Institute, NIH, Bethesda, MD, USA
| | - S M Steinberg
- Biostatistics and Data Management Section, Office of the Clinical Director, Center for Cancer Research, National Cancer Institute, NIH, Bethesda, MD, USA
| | - E W Cowen
- Dermatology Branch, National Cancer Institute, NIH, Bethesda, MD, USA
| | - H Naik
- Dermatology Branch, National Cancer Institute, NIH, Bethesda, MD, USA
| | - M Datiles
- National Eye Institute, NIH, Bethesda, MD, USA
| | - P Stratton
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD, USA
| | - R E Gress
- Experimental Transplantation and Immunology Branch, National Cancer Institute, NIH, Bethesda, MD, USA
| | - S Z Pavletic
- Experimental Transplantation and Immunology Branch, National Cancer Institute, NIH, Bethesda, MD, USA
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Mays JW, Fassil H, Edwards DA, Pavletic SZ, Bassim CW. Oral chronic graft-versus-host disease: current pathogenesis, therapy, and research. Oral Dis 2012; 19:327-46. [PMID: 23107104 DOI: 10.1111/odi.12028] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Revised: 09/11/2012] [Accepted: 09/11/2012] [Indexed: 12/13/2022]
Abstract
Optimal management of complex autoimmune diseases requires a multidisciplinary medical team including dentists to care for lesions of the oral cavity. In this review, we discuss the presentation, prevalence, diagnosis, and treatment of oral manifestations in chronic graft-versus-host disease (cGVHD), which is a major late complication in patients treated by allogeneic hematopoietic stem cell transplantation. We assess current general knowledge of systemic and oral cGVHD and present general treatment recommendations based on literature review and our clinical experience. Additionally, we review areas where the understanding of oral cGVHD could be improved by further research and address tools with which to accomplish the long-term goal of providing better health and quality of life to patients with cGVHD.
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Affiliation(s)
- J W Mays
- Clinical Research Core, National Institute of Dental and Craniofacial Research, Bethesda, MD 20892-4320, USA.
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Fassil H, Bassim CW, Mays J, Edwards D, Baird K, Steinberg SM, Williams KM, Cowen EW, Mitchell SA, Hakim FT, Taylor T, Avila D, Zhang D, Grkovic L, Datiles M, Gress RE, Pavletic SZ. Oral chronic graft-vs.-host disease characterization using the NIH scale. J Dent Res 2012; 91:45S-51S. [PMID: 22699667 DOI: 10.1177/0022034512450881] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Chronic graft-vs.-host disease (cGVHD) is a complication of allogeneic hematopoietic stem cell transplantation (alloHSCT). Oral cGVHD is manifested by mucosal, salivary, and/or sclerotic changes that have been linked to pain and poor quality of life. Our aim was to describe the demographic, clinical, and laboratory markers of oral cGVHD in alloHSCT patients (N = 187) enrolled in a cGVHD cross-sectional study at the NIH (#NCT00331968). We propose a meaningful and reproducible measure of disease defined by a cut-off point reflecting clinical minimally detectable change (0-2 = no oral cGVHD, 3-15 = oral cGVHD) on the 15-point NIH cGVHD clinician assessment scale. Forty-four patients had oral cGVHD. Oral cGVHD was associated with a quiescent or de novo type of cGVHD onset (p = 0.05), higher cGVHD severity (p = 0.033), lower albumin (p = 0.0008), higher total complement (p = 0.012), greater bother from foods or oral ulcers and greater mouth pain, and sensitivity (p < 0.0001). Multivariable logistic regression modeling with albumin, mouth pain, and total complement was 74.3% predictive of oral cGVHD and 80.2% predictive of non-oral cGVHD. We propose the use of >2 points on the NIH scale as a reproducible definition of clinically significant oral cGVHD, which may be useful in clinical settings or as eligibility criterion or as an endpoint in clinical trials.
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Affiliation(s)
- H Fassil
- Experimental Transplantation and Immunology Branch, National Cancer Institute, NIH, 10 Center Drive, Bethesda, MD 20892, USA.
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