Salivary Amylase-Responsive Buccal Tablets Wipe Out Chemotherapy-Rooted Refractory Oral Mucositis

Oral mucositis (OM) is the most common and refractory complication of cancer chemotherapy and radiotherapy, severely affecting patients' life quality, lowering treatment tolerance, and discouraging patient compliance. Current OM delivery systems mostly affect the comfort of patient use and lead to poor compliance and unsatisfactory effects. Herein, salivary amylases (SAs)-responsive buccal tablets consisting of porous manganese-substituted Prussian blue (PMPB) nanocubes (NCs), anti-inflammatory apremilast (Apr) and starch controller have been engineered. PMPB NCs with large surface area can serve as carriers to load Apr, and their multienzyme-mimicking activity enables them to scavenge reactive oxygen species (ROS), which thus synergize with Apr to mitigate inflammation. More significantly, the starch controller can respond to abundant SAs in the oral cavity and realize the cascade, continuous, and complete drug release after enzymatic decomposition, which not only aids with high tissue affinity to prolong the resistance time but also improves the comfort of use. The preclinical study reveals that contributed by the above actions, such buccal tablets mitigate inflammation, promote endothelium proliferation and migration, and accelerate wound healing for repressing chemotherapy-originated intractable OM with positive oral microenvironment and shorter recovery time, thus holding high potentials in clinical translation.

Influence of anxiety/depression on chemotherapy-induced oral mucositis and related quality of life: A prospective cohort study

OBJECTIVE

The impact of anxiety and depression on chemotherapy-induced oral mucositis has not been extensively explored in the literature. The aim of the present study was to evaluate anxiety/depressive symptoms, health-related quality of life, and oral health-related quality of life and their association with oral mucositis among individuals receiving chemotherapy.

METHODS

This is a prospective longitudinal study carried out at a Brazilian referral service. The Hospital Anxiety and Depression Scale (HADS), World Health Organization Quality of Life-BREF (WHOQOL-BREF), and Oral Health Impact Profile questionnaire (OHIP-14) were applied at D0 (before chemotherapy) and D15 of chemotherapy. Clinicodemographic data and oral mucositis severity scores were evaluated.

RESULTS

A total of 37 individuals (median age: 49 years) were included in the study. Nearly 38% of patients developed chemotherapy-induced oral mucositis and had higher anxiety/depression scores at baseline. Oral mucositis had a negative impact on oral health-related quality of life regarding functional limitation, physical pain, physical disability, and handicap.

CONCLUSION

Anxiety/depressive symptoms are associated with oral mucositis that affects overall health and oral health-related quality of life.

The salivary proteome in relation to oral mucositis in autologous hematopoietic stem cell transplantation recipients: a labelled and label-free proteomics approach

BACKGROUND

Oral mucositis is a frequently seen complication in the first weeks after hematopoietic stem cell transplantation recipients which can severely affects patients quality of life. In this study, a labelled and label-free proteomics approach were used to identify differences between the salivary proteomes of autologous hematopoietic stem cell transplantation (ASCT) recipients developing ulcerative oral mucositis (ULC-OM; WHO score ≥ 2) or not (NON-OM).

METHODS

In the TMT-labelled analysis we pooled saliva samples from 5 ULC-OM patients at each of 5 timepoints: baseline, 1, 2, 3 weeks and 3 months after ASCT and compared these with pooled samples from 5 NON-OM patients. For the label-free analysis we analyzed saliva samples from 9 ULC-OM and 10 NON-OM patients at 6 different timepoints (including 12 months after ASCT) with Data-Independent Acquisition (DIA). As spectral library, all samples were grouped (ULC-OM vs NON-OM) and analyzed with Data Dependent Analysis (DDA). PCA plots and a volcano plot were generated in RStudio and differently regulated proteins were analyzed using GO analysis with g:Profiler.

RESULTS

A different clustering of ULC-OM pools was found at baseline, weeks 2 and 3 after ASCT with TMT-labelled analysis. Using label-free analysis, week 1-3 samples clustered distinctly from the other timepoints. Unique and up-regulated proteins in the NON-OM group (DDA analysis) were involved in immune system-related processes, while those proteins in the ULC-OM group were intracellular proteins indicating cell lysis.

CONCLUSIONS

The salivary proteome in ASCT recipients has a tissue protective or tissue-damage signature, that corresponded with the absence or presence of ulcerative oral mucositis, respectively.

TRIAL REGISTRATION

The study is registered in the national trial register (NTR5760; automatically added to the International Clinical Trial Registry Platform).

White Tongue Because of Uremic Stomatitis as a Sign of Advanced Kidney Disease

We present a case of a previously healthy adolescent male who initially presented to his primary care physician with the chief complaint of a "large and white tongue," who subsequently was diagnosed with end-stage kidney disease (ESKD) and associated uremic stomatitis. This patient required admission to a PICU for acute renal replacement therapy with intermittent hemodialysis, and his hospital course was complicated by generalized tonic-clonic seizures. ESKD is difficult to diagnose in the pediatric population because these patients are often asymptomatic in the early stages given the insidiousness of underlying disorders. Renal disease should be considered in the differential diagnosis of a child with a white tongue not being the result of oral candidiasis.

Do Probiotics Cause a Shift in the Microbiota of Dental Implants—A Systematic Review and Meta-Analysis

Objective

The primary aim of this current systematic review and meta-analysis was to evaluate the potential microbiological effect of probiotics on the implant microbiota. The secondary aim was to evaluate if probiotics have any effect as an adjunct to non-surgical peri-implant treatment in reducing peri-implant mucositis and peri-implantitis clinical parameters—bleeding on probing, modified Gingival Index, and pocket depth.

Methods

The research focus questions were constructed in accordance with the Participants, Intervention, Comparison, and Outcomes (PICO) criteria, and a PROSPERO protocol was registered. A comprehensive systematic search in MEDLINE via the PubMed, Scopus, and Web of Science Core Collection databases was conducted. Two independent reviewers screened the reports based on the PICO criteria—inclusion and exclusion criteria.

Results

In total, 467 records were identified, and ultimately, 7 papers were included: 3 papers in the qualitative synthesis of microbiological effect and 4 in the meta-analysis synthesis on pocket depth. The data synthesis showed that probiotics had no detectable effect on the implant microflora, and in the following data synthesis, no clinical peri-implantitis variable showed a significantly beneficial effect from probiotics in the test group compared to the control group.

Conclusion

Within the limitations of this review, the oral implant microflora is not affected by probiotics nor do probiotics add any effect to the conventional non-surgical treatment of peri-implant mucositis and peri-implantitis.

Oral mucositis-related neuropathic pain in head and neck cancer patients receiving radiotherapy or chemo-radiotherapy. A prospective study

PURPOSE

Pain due to oral-mucositis (OM) in head and neck cancer (HNC) patients receiving radiotherapy (RT) /chemo-radiotherapy (CRT) can be nociceptive and/or neuropathic. Neuropathic pain (NP) often remains underdiagnosed and untreated. This study's purpose was to identify the presence of OM-induced NP in HNC patients under RT/CRT.

METHODS

Pain was assessed using a 0-10 numeric scale (NRS). At an NRS≥5 score, patients completed the Douleur Neuropathique 4 (DN4) questionnaire, where a score ≥4/10 indicates the presence of NP. Mucositis and xerostomia were assessed using the European Organization for Research and Treatment of Cancer and the NRS scales accordingly. Pain medication was documented.

RESULTS

Forty patients were recruited; twenty-six (mean age 63.54±13.96 years) completed a DN4 (mean pain NRS 7.46±1.42); five (5/26, 19.23%) had a DN4≥4. The most common NP descriptors were "burning" (34.62%), "electric shocks" (30.77%) and "pins-and-needles" (30.77%). A direct correlation was observed between DN4 and pain, mucositis, and xerostomia (p<0.02). Pain medication was administered to fifteen patients (15/26, 57.69%). Adjuvant medication was administered to one patient with positive DN4 score.

CONCLUSIONS

Five (5/26, 19%) of the patients with NRS≥5 developed NP; adjuvant medication to address NP was prescribed to one patient. NP is likely underdiagnosed and undertreated in the HNC population undergoing RT/RC.

Managing dermatologic changes of targeted cancer therapy

Failure to control these dermatologic changes can lead to lower dosages of cancer agents or an interrupted course of Tx. These steps can help you to head off trouble.

Burden of Oral Mucositis: A Systematic Review and Implications for Future Research

BACKGROUND

Surprisingly little is known about the burden of oral mucositis (OM). We provide a systematic review of studies on the burden of OM (incidence, economic impact, health-related quality of life (HRQoL)).

METHODS

Systematic literature searches were made in BIOSIS, EMBASE, and MEDLINE. Inclusion criteria were studies on OM in hematology/oncology patients of ≥ 18 years, journal articles, English language, and published between 2000 and 2016; OM treatment studies were excluded. Quality assessment was performed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

We screened 4,996 hits, and identified 68 studies of which 13 were without transparency on OM grading. The evidence level of 65 studies was rated 'low' or 'very low' in 58.5%, 'moderate' in 20% and 'high' in 21.5%. Mean value of incidence (7 studies) was 83.5% for all grades of OM with hematopoietic stem cell transplantation. OM incidence for all grades in head and neck cancer patients was 59.4-100%. Considering the economic impact, 16 studies showed highly variable numbers. HRQoL was measured in 16 studies using 13 different instruments. Statistically significant changes in HRQoL scores were demonstrated.

CONCLUSION

OM is common, burdensome, costly and imposes major reductions in HRQoL. However, from a quality standpoint, the level of current evidence in OM is disappointing. The field needs continued attention to address methodological challenges.

Clinical and Radiographic Peri-Implant Parameters and Whole Salivary Interleukin-1β and Interleukin-6 Levels among Type-2 Diabetic and Nondiabetic Patients with and without Peri-Implantitis

OBJECTIVE

The aim was to assess the peri-implant clinical and radiographic parameters and whole salivary levels of interleukin (IL)-1β and IL-6 among type 2 diabetic and nondiabetic patients with and without peri-implantitis.

MATERIAL AND METHODS

Ninety-one implants were placed in patients without type 2 diabetes mellitus (39 patients with and 52 patients without peri-implantitis; group 1). Eighty implants were placed in patients with diabetes (35 patients with and 45 patients without peri-implantitis; group 2). Peri-implant plaque index, bleeding on probing, probing depth, and marginal bone loss were measured. Unstimulated whole saliva samples were collected and IL-1β and IL-6 levels were measured using standard techniques. p < 0.05 was considered statistically significant.

RESULTS

In group 1, plaque index (p < 0.001), bleeding on probing (p < 0.001), probing depth (p < 0.001), and whole salivary IL-1β (p < 0.001) and IL-6 (p < 0.001) levels were significantly higher in patients with peri-implantitis than in those without peri-implantitis. Plaque index, bleeding on probing, probing depth, and marginal bone loss were comparable among all of the patients in group 2. Among patients with peri-implantitis, plaque index (p < 0.001), bleeding on probing (p < 0.001), probing depth (p < 0.001), marginal bone loss (p < 0.001), and whole salivary IL-1β (p < 0.001) and IL-6 (p < 0.001) levels were significantly higher in those with diabetes than in those without diabetes.

CONCLUSION

Among individuals without diabetes, peri-implant plaque index, bleeding on probing, probing depth, marginal bone loss, and whole salivary IL-1 β and IL-6 levels were higher among patients with peri-implantitis compared to patients without peri-implantitis. Among patients with diabetes, the severity of the measured parameters appears to be influenced by the glycemic status rather than by peri-implantitis.

Is chronic ulcerative stomatitis a variant of lichen planus, or a distinct disease?

Chronic ulcerative stomatitis is an immune-mediated mucocutaneous disorder characterized clinically by erosions or ulcers. Most cases are limited to the mouth. The histopathological features are non-specific or mimic those of oral lichen planus, and studies by immunofluorescent microscopy are essential for definitive diagnosis. The defining immunopathogenic mechanism is the binding of IgG to the nuclear protein deltaNp63alpha of keratinocytes in the basal and parabasal cell layers of the oral stratified epithelium. DeltaNp63alpha functions as a regulator of epithelial stem cell activity and as an antiapoptotic agent and regulates the expression of cell-to-cell and cell-to-basement membrane adhesion molecules. The autoimmune IgG-deltaNp63alpha interaction is thought to result in damage to the structural attachment of keratinocytes to one another and to the epithelial basement membrane zone and in dysregulation of the cell cycle and apoptosis of basal keratinocytes with the development of erosions or ulcers. The aims of treatment are to suppress the pathogenic immunoinflammatory responses, to prevent local infection and to promote healing. The purpose of this article is to provide a succinct review of the diagnostic, clinical and etiopathogenic features of, and treatment guidelines for chronic ulcerative stomatitis, and to argue that this disease should be regarded as a variant of oral lichen planus, rather than as a distinct entity.

Treatment of severe mucositis pain with oral ketamine mouthwash

PURPOSE

Mucositis is a significant complication of intensive chemotherapy or hematopoietic cell transplantation (HCT), with few treatment options. Ketamine mouthwashes have been used for pain relief, but supporting evidence is limited. The primary objective of this study was to assess the reduction in pain intensity of stomatodynia and odynophagia compared to baseline assessment.

METHODS

This open-label, prospective, phase II interventional study (NCT01566448) was conducted from February 2012 through July 2015. Patients with grade 3 or 4 oral mucositis according to the World Health Organization (WHO) scale as a result of chemotherapy were treated with ketamine mouthwash 20 mg/5 mL four times daily and every 4 h as needed.

RESULTS

Thirty patients were enrolled and a total of 136 assessments were conducted. A statistically significant reduction in pain scores of 2 and 3 points was achieved after 1 h and 3 days, respectively (p < 0.0001, p = 0.0003). Pain scores were significantly improved while swallowing, reduced 1 and 4 points at 1-h and 3-day assessment, respectively (p = 0.0006, p = 0.0001). No patients developed adverse effects related to ketamine administration.

CONCLUSION

Ketamine mouthwashes resulted in clinically meaningful and statistically significant reduction in pain scores, have an acceptable safety profile, and can be a useful adjunctive treatment in the multi-modal management of severe mucositis.

[Management of Stomatitis Associated with Treatment with Everolimus]

Stomatitis is a characteristic adverse event of everolimus and other mTOR inhibitors, and occurs at a high incidence and impairs QOL owing to pain. Most cases of stomatitis are mild to moderate. However, when stomatitis becomes serious, it can interfere with the continuation of medication. Therefore, it is important to place more emphasis on the prevention as well as early detection and treatment. In addition, patient education is also important. The possible occurrence of stomatitis, its signs and symptoms, as well as the importance of oral care need to be thoroughly explained prior to starting treatment. In order to smoothly carry out these measures, it will also be essential that cancer-treating physicians coordinate and collaborate with dentists, nurses, and pharmacists. It is desirable to establish appropriate prevention and management methods on the basis of the results of the Phase III prospective study, Oral Care-BC, currently ongoing in Japan.

Dose-volume response in acute dysphagia toxicity: Validating QUANTEC recommendations into clinical practice for head and neck radiotherapy

PURPOSE

To determine the validity of QUANTEC recommendations in predicting acute dysphagia using intensity-modulated head and neck radiotherapy.

MATERIAL AND METHODS

Seventy-six consecutive patients with locally advanced squamous cell carcinoma (SCC) of the head and neck +/- systemic therapy were analyzed. Multiple dose parameters for the larynx (V50Gy, Dmean and Dmax) were recorded. Acute dysphagia toxicity was prospectively scored in all treatment weeks (week 1-6 or 1-7) using CTCAEv3 by three blinded investigators. QUANTEC larynx recommendations (V50Gy < 27%, Dmean < 44 Gy, Dmean < 40 Gy, Dmax < 66 Gy) were used to group the cohort (i.e. V50Gy < 27% vs. V50Gy > 27%). The proportion of patients with Grade 3 dysphagia was compared within each group.

RESULTS

There was a significant reduction in the incidence of grade 3 toxicity in the V50Gy < or > 27% group at week 5 (14.3% vs. 45.2%, p = 0.01) and 6 (25.9% vs. 65.9%, p < 0.01). A significant reduction at week 5 (14.7% vs. 50.0, p = 0.02) and 6 (32.4% vs. 67.6%, p = 0.01) was seen in Dmean < 44 Gy when compared to Dmean > 44 Gy. Dmean < 40 Gy also delivered a significant reduction at week 5 (5.6% vs. 42.3%, p < 0.01) and week 6 (23.5% vs. 59.3%, p = 0.01). A significant toxicity reduction at treatment week 6 (28.0% vs. 63.0%, p = 0 < 01) was seen from Dmax < 66 Gy to Dmax > 66 Gy. V50Gy > 27% (p < 0.01), Dmean > 40 Gy (p = 0.01) and Dmax > 66 Gy (p < 0.01) were also predictors of Grade 3 dysphagia when analyzed with multiple clinical risk factors.

CONCLUSIONS

QUANTEC late toxicity recommendations for dose to larynx during IMRT are a useful predictor for acute dysphagia toxicity in this patient cohort. Furthermore, this included chemoradiotherapy regimes and post-operative radiotherapy patients, allowing for prophylactic implementation of supportive care measures.

[Integrated approach to the treatment of oral mucosa diseases in patients with chronic gastritis]

The article presents data on the clinical and microbiological short and long term efficacy of treatment of the oral mucosa diseases in patients with Helicobacter pylori associated and not associated chronic gastritis depending on the chosen treatment regimen.

Bacteria and Candida yeasts in inflammations of the oral mucosa in children with secondary immunodeficiency

BACKGROUND

Oral microbial flora and a damaged oral mucosa may increase the risk of bacteriemia, fungemia and complications in immunocompromised patients.

AIM OF THE STUDY

Assessment of presence: bacteria and Candida spp. in different oral lesions, and the incidence of bacteremia in the case of a damaged mucosa in transplant recipients and patients receiving anti-tumour chemotherapy.

MATERIAL AND METHOD

Forty-five patients – 18 months to 18 years of life, were included (20 – organ recipients, 14– anti-tumour chemotherapy, 11 – control group). Clinical, oral mucosa examination focused on the type, severity and site of lesions, and microbiology assessed the presence of bacteria and fungi in the material from lesions. Blood cultures were performed in ten immunocompromised patients with manifestations of systemic infection. The control material consisted of blood cultures made prior to the onset of oral lesions and after 4–6 weeks following their remission in a diagnosed bacteremia. The statistical analysis was performed.

RESULTS

In the subjects with secondary immunodeficiency, among other coagulase-negative Staphylococcus (CoNS), Candidia spp. were more frequent. In cancer patients, mucositis was associated with Candida spp., Streptococcus spp. Organ recipients with stomatitis exhibited the presence of CoNS, Streptococcus viridians and other. Oral lesions in the control group contained Haemophilus parainfluenzae, Neisseria spp. and Staphylococcus aureus. In 30% of immunocompromised patients, oral lesions were accompanied by bacteremia.

CONCLUSIONS

A correlation has been found between oral lesions and the presence of S. aureus in patients without secondary immunodeficiency, and of CoNS, Enterococcus spp., Candida spp. in immunocompromised patients.

A pilot randomized controlled trial of an oral care intervention to reduce mucositis severity in stem cell transplant patients

CONTEXT

Oral mucositis remains a significant problem in autologous stem cell transplantation (ASCT).

OBJECTIVES

This pilot trial assessed the effectiveness of oral cryotherapy plus an oral care protocol in reducing oral mucositis severity in ASCT patients.

METHODS

Patients admitted for ASCT were randomly allocated to either the experimental arm (n=23) or usual care (n=23). All participants received information on principles of good oral hygiene and skills training in oral self-care. Patients in the experimental arm had a 60-minute regimen of oral cryotherapy. The primary outcome of oral mucositis severity and secondary outcomes of mucositis-related pain and functional intake of food and fluids were measured at Days -1, 3, 6, 9, and 12. Length of hospital stay was determined by counting backward from discharge day to admission. Perception of tolerability and acceptability of the 60-minute cryotherapy and frequency of the oral care regimen also were assessed.

RESULTS

Forty-eight patients were recruited at the study site in six months. The overall mean (SE) of oral mucositis severity for the experimental arm was significantly lower than that for the control group: 0.43 (0.12) vs. 1.14 (0.12); P<0.001, on a 0-4 scale. The overall mean (SE) mucositis-related pain score for the experimental arm also was significantly lower than that for the control group: 0.30 (0.23) vs. 1.64 (0.24); P<0.001, on a 0-10 scale.

CONCLUSION

Oral cryotherapy plus an oral care protocol appears to be beneficial in reducing severity of mucositis compared with an oral care protocol alone.

Treatment of oral infections prior to heart valve surgery does not improve long-term survival

The objective was to evaluate the importance of preoperative elimination of oral infections and oral health for survival after heart valve surgery In a group of patients (n=149; treatment group, GP group), oral health was examined and dental treatment was performed 3-6 months prior to heart valve surgery. In a second group (n=103; control group, SP group), oral health was examined postoperatively, but patients did not receive dental treatment prior to surgery. Sixteen years after heart valve surgery was performed, morbidity endpoint data were obtained. Differences in survival between the two groups and the influence of differences in oral health were analyzed. Fewer patients survived in the study group (37%) compared with the control group (45%). Mean survival was 122.9 months in the GP group compared with 143.3 months in the SP group, including time to death and those alive at the endpoint (p=0.018). A positive relationship was found between the number of teeth and survival, with RR = 0.98 (95% CI 0962-0.996 (p=0.016)).The deaths from heart valve disease were 18% in the GP group and 7% in the SP group (chi2=3.65, df=1, p=0.56). At the long-term follow-up,the results of the present study show,that it was not possible to demonstrate that dental treatment before heart valve surgery improved survival. Therefore, the need for extensive dental treatment prior to heart valve surgery may be reconsidered.

Aspiration pneumonia: an underestimated cause of severe respiratory failure in patients with haematological malignancies and severe oral mucositis?

Aspiration pneumonia is rarely considered in the differential diagnosis of respiratory failure in patients suffering from haematologic malignancies in daily practice. We describe four patients who were admitted with severe respiratory failure in the ICU over a one-year-period prospective survey (a total of 72 patients with haematological malignancies of which 34 presented with respiratory failure). All of these patients had chemotherapy-induced severe oral mucositis (WHO grade ILL-IV) for which three of them received opioids. All had a history of cough after oral rinsing and two of them experienced sudden brief desaturation in the days before ICU referral. Two of these patients, both in allogeneic bone marrow transplant setting, died. With this data, we want to draw the attention to the diagnosis of aspiration pneumonia in this group of patients.

[Oral manifestations in systemic diseases]

Systemic diseases may affect the oral tissues, i.e. oral mucosa, salivary glands, teeth or bone, and oral manifestations will frequently present early, i.e. in association with (non-fulminant) systemic disease. Thus, recognition and proper diagnosis is essential to initiate appropriate treatment schedules. Key examples of systemic disease groups with oral manifestations include dermatological, inflammatory connective tissue diseases, haematological and inflammatory gastrointestinal diseases, as well as neurological and endocrine diseases.

Management of oropharyngeal mucositis pain

Effective pain control for mucositis requires constant attention and willingness on the part of managing clinicians to evaluate and adapt pain-relieving strategies throughout the period of risk for oral mucositis. By utilizing the principles of an individualized, tiered approach to pain management that addresses the multidimensional components of a patient's pain, maximum comfort can be consistently provided while reducing the risk for side effects.

Oral infections and their influence on medical rehabilitation in kidney transplant patients

Infections seem to be the most common life-threatening complication of long-term immunosuppressive therapy following organ transplantation. Although sparse scientific evidence, potential oral infections are considered to contribute to these complications. The aim of this study was to examine whether there is an association between oral infections and rejections after kidney transplantation. A group of 46 kidney transplant candidates was enrolled. The patients were examined clinically and radiographically for dental caries, periodontal disease, mucosal lesions/infections, and general oral health problems. Examinations were conducted the day before transplantation, and one year post transplantation. Fifteen (32.6%) patients developed acute rejections during the first year. Six of these patients (40%) presented with oral opportunistic infections (candida or herpes infections of the oral mucosa). The number of dental infections and semi-impacted teeth were low. When rejections were related to probing pocket depths (PPDs) > or = 4 mm and apical lesions together, statistical significance was not reached (p=0.075, OR=3.17 [0.87; 11.55]). Similar results were obtained when PPDs > or = 4 mm, apical lesions, semi-impacted teeth, and opportunistic mucosal infections were compared to rejections. The results of the present study do not support that opportunistic oral mucosal infections or dental-related infections seem to increase the risk of rejection in kidney transplanted patients.

Stomatitis-related pain in women with breast cancer undergoing autologous hematopoietic stem cell transplant

The purpose of this cross-sectional, correlational study was to describe stomatitis-related pain in women with breast cancer undergoing autologous hematopoietic stem cell transplant. The hypotheses that significant, positive relationships would exist between oral pain and stomatitis, state anxiety, depression, and alteration in swallowing were tested. Stomatitis, sensory dimension of oral pain, and state anxiety were hypothesized to most accurately predict oral pain overall intensity. Thirty-two women were recruited at 2 East Coast comprehensive cancer centers. Data were collected on bone marrow transplantation day +7 +/- 24 hours using Painometer, Oral Mucositis Index-20, Oral Assessment Guide, State-Trait Anxiety Inventory, and Beck Depression Inventory. Data analysis included descriptive statistics, correlations, and stepwise multiple regression. All participants had stomatitis; 47% had oral pain, with a subset reporting continuous moderate to severe oral pain despite pain management algorithms. Significant, positive associations were seen between oral pain, stomatitis, and alteration in swallowing and between oral pain with swallowing and alteration in swallowing. Oral pain was not significantly correlated with state anxiety and depression. Oral sensory and affective pain intensity most accurately predicted oral pain overall intensity. Future research needs to explore factors that affect perception and response to stomatitis-related oropharyngeal pain and individual patient response to opioid treatment.

[Three cases of stomatitis caused by chemotherapy for gastrointestinal cancer that responded well to lafutidine]

We described 3 cases of stomatitis caused by chemotherapy with the fluoropyrimidine preparation S-1, alone or combined with other anticancer drugs. The stomatitis did not respond to conventional oral mucosal treatment such as triamcinolone acetonide(Kenalog)or allopurinol, but improved after treatment with the histamine H2-receptor antagonist lafutidine. The concurrent use of lafutidine allowed these 3 patients to continue chemotherapy with no recurrence of stomatitis. We concluded that lafutidine may be a viable treatment option for chemotherapy-induced stomatitis, allowing treatment to be continued.

Oral care protocols for patients undergoing cancer therapy

The purpose of this article is to educate dentists in the care and treatment of cancer patients and their families. One of the authors (JP) is a six-year cancer survivor of squamous cell carcinoma; many of these clinical suggestions are based on his experiences. In joint effort with Loyola University, Cardinal Bernadin Cancer Center, a retrospective study makes up the remainder of the recommended approaches and products and their effective uses.

Orofacial pain and neurosensory disorders and dysfunction in cancer patients

Orofacial pain and altered nerve sensation may be the initial sign of oropharyngeal or nasopharyngeal cancer. This article focuses on the most common orofacial pain conditions and neurosensory alterations that affect cancer patients, such as neuropathic pain, muscle spasm or contractures, mucositis, and increased or decreased sensory discrimination in the affected area. The various pharmacotherapeutic modalities for cancer pain management ranging from non steroidal anti-inflammatory drugs (NSAIDs) for mild pain to opioids for severe pain are discussed in detail.

[Primary and secondary stomatodynia: a difficult diagnosis]

Primary stomatodynia involves mainly women after menopause presenting somatization, depression and anxiety at values higher than control subjects. This chronic pain is often an intense burning pain beginning in the tongue the entire oral cavity, increasing in intensity through the day with a high level of emotional after effects. These patients often describe two associated symptoms: mouth dryness sensation and altered taste. The causes remain uncertain. The participation of female sexual hormones and neuropathic factors has been suggested possibly through a sensory neuropathy of small fibers of the oral mucosa. Normal clinical examinations and non clinical tests differentiate primary from secondary stomatodynia. The management consists in using low doses of topical clonazepam without swallowing or systemic clonazepam. The association of this drug with tricyclic antidepressants has given variable results. A cognitive behavioural management has been successfully attempted.

Dental health status in children with acute lymphoblastic leukemia

Acute Lymphoblastic Leukemic (ALL) children were selected to evaluate the dental health status from Regional Cancer Centre, Kerala. A 12 item questionnaire was distributed to all selected 104 children's parents who were present in the hospital and the children's oral cavity was examined. The results revealed moderate gingival inflammation in most of the samples irrespective of treatment. Tenderness on temporo mandibular joint, oral mucositis, high DMFT values were observed in children who were under treatment. History of halitosis before diagnosis of ALL was a predominant feature in a statistically significant number of children.

HPV oral infection. Case report of an HIV-positive Nigerian sex worker

HPV infections have become a major problem in immunocompromised patients, particularly in HIV-positive subjects. HPV lesions are observed more frequently in the ano-genital area and rarely in different body areas, such as the skin and oral cavity. However, in HIV-positive subjects there is an increased risk of oral condylomas. We describe the case of an HIV-positive Nigerian young woman, who came to our notice due to the appearance of small labial and mouth mucous membrane lesions, related to HPV infection, as shown by a biopsy. These lesions were not evident in the genital area. After two years in which the patient no longer received therapy, there was a progressive reduction in CD4 count, associated with the development of the oral condylomas. Hence the patient began a new HAART combination, but after seven months, although a slight improvement emerged in the CD4 count with the disappearance of HIV-RNA, there has been no regression of oral condylomas.

Interventions for treating oral mucositis for patients with cancer receiving treatment

BACKGROUND

Treatment of cancer is increasingly effective but associated with short and long term side effects. Oral side effects, including oral mucositis (mouth ulceration), remain a major source of illness despite the use of a variety of agents to treat them.

OBJECTIVES

To assess the effectiveness of interventions for treating oral mucositis or its associated pain in patients with cancer receiving chemotherapy or radiotherapy or both.

SEARCH STRATEGY

Computerised searches of Cochrane Oral Health Group's Trials Register; Cochrane Pain, Palliative and Supportive Care Group's Trials Register; CENTRAL; MEDLINE and EMBASE were undertaken. Reference lists from relevant articles were searched and the authors of eligible trials were contacted to identify trials and obtain additional information. Date of the most recent searches June 2006: CENTRAL (The Cochrane Library 2006, Issue 2).

SELECTION CRITERIA

All randomised controlled trials comparing agents prescribed to treat oral mucositis in people receiving chemotherapy or radiotherapy or both. Outcomes were oral mucositis, time to heal mucositis, oral pain, duration of pain control, dysphagia, systemic infection, amount of analgesia, length of hospitalisation, cost and quality of life.

DATA COLLECTION AND ANALYSIS

Data were independently extracted, in duplicate, by two review authors. Authors were contacted for details of randomisation, blindness and withdrawals. Quality assessment was carried out on these three criteria. The Cochrane Oral Health Group statistical guidelines were followed and risk ratio (RR) values calculated using fixed effect models.

MAIN RESULTS

Twenty-six trials involving 1353 patients satisfied the inclusion criteria. Four agents, each in single trials, were found to be effective for improving (allopurinol RR 3.33, 95% confidence interval (CI) 1.06 to 10.49; granulocyte macrophage-colony stimulating factor RR 4.23, 95% CI 1.35 to 13.24; immunoglobulin RR 1.81, 95% CI 1.24 to 2.65; human placentral extract RR 4.50, 95% CI 2.29 to 8.86) or eradicating mucositis (allopurinol RR 19.00, 95% CI 1.17 to 307.63). Three of these trials were rated as at moderate risk of bias and one as at high risk of bias. The following agents were not found to be effective: benzydamine HCl, sucralfate, tetrachlorodecaoxide, chlorhexidine and 'magic' (lidocaine solution, diphenhydramine hydrochloride and aluminum hydroxide suspension). Six trials compared the time to heal and mucositis was found to heal more quickly with two interventions: granulocyte macrophage-colony stimulating factor when compared to povidone iodine, with mean difference -3.5 days (95% CI -4.1 to -2.9) and allopurinol compared to placebo, with mean difference -4.5 days (95% CI -5.8 to -3.2). Three trials compared patient controlled analgesia (PCA) to the continuous infusion method for controlling pain. There was no evidence of a difference, however, less opiate was used per hour for PCA, and the duration of pain was shorter. One trial demonstrated that pharmacokinetically based analgesia (PKPCA) reduced pain compared with PCA: however, more opiate was used with PKPCA.

AUTHORS' CONCLUSIONS

There is weak and unreliable evidence that allopurinol mouthwash, granulocyte macrophage-colony stimulating factor, immunoglobulin or human placental extract improve or eradicate mucositis. There is no evidence that patient controlled analgesia (PCA) is better than continuous infusion method for controlling pain, however, less opiate was used per hour, and duration of pain was shorter, for PCA. Further, well designed, placebo-controlled trials assessing the effectiveness of allopurinol mouthwash, granulocyte macrophage-colony stimulating factor, immunoglobulin, human placental extract, other interventions investigated in this review and new interventions for treating mucositis are needed.

Assessing and Managing Chemotherapy-Induced Mucositis Pain

Acute pain is the major clinical problem associated with mucositis. Mucosal tissue injury is a dose-limiting toxicity of many cancer therapies. Because the number of patients treated with combinations of high-dose chemotherapy agents is likely to increase, more patients are at risk for mucositis. Currently, no consensus exists regarding mucositis prevention, assessment, or treatment. Similarly, research is needed in methods to accurately assess and manage pain for mucositis. Multiple interventional approaches are needed to decrease the emotional and physical distress caused by acute oral pain and mucositis. An assessment tool that includes physical, functional, and pain parameters is presented. Although approaches to prevent and treat mucositis are increasing, appropriate assessment and timely directed interventions can minimize patient distress.

Absorption of Fentanyl from Fentanyl Buccal Tablet in Cancer Patients With or Without Oral Mucositis

BACKGROUND AND OBJECTIVES

Patients with cancer, particularly those undergoing chemotherapy or radiotherapy, may develop oral mucositis. This is the first study to investigate the absorption profile of fentanyl buccal tablet (FBT) - an effervescent formulation of fentanyl indicated for the management of breakthrough pain in opioid-tolerant cancer patients - in patients with or without oral mucositis.

METHODS

In this open-label study, patients with or without oral mucositis self-administered a single 200 microg dose of FBT by placing the tablet between the upper gum and cheek above a molar tooth. Venous blood samples for measurement of plasma fentanyl concentrations were collected at regular intervals up to 8 hours following FBT administration. Parameters of interest included maximum plasma concentration (C(max)), time to reach C(max) (t(max)), area under the plasma concentration-time curve from time zero to 8 hours (AUC(8)), and AUC from time zero to the median t(max) (AUC(tmax)(')). Adverse events were monitored throughout the study. Oral mucosal examinations and measurements of vital signs were performed at intervals up to 8 hours following FBT administration.

RESULTS

Sixteen patients, 8 with and 8 without oral mucositis, received FBT and completed the study. The severity of oral mucositis was mild in the patients exhibiting this condition. Median C(max) values were comparable: 1.14 ng/mL (range 0.26-2.69 ng/mL) in patients with mucositis, and 1.21 ng/mL (range 0.21-2.34 ng/mL) in patients without mucositis. The t(max) was not significantly different in the two groups: median t(max) was 25.0 min (range 15-45 min) in patients with mucositis and 22.5 min (range 10-121 min) in patients without mucositis. Median AUC(tmax') values were 0.17 ng . h/mL (range 0.04-0.52 ng . h/mL) in patients with mucositis, and 0.20 ng . h/mL (range 0.00-0.65 ng . h/mL) in patients without mucositis. The corresponding AUC(8) values were 2.05 ng . h/mL (range 1.16-3.83 ng . h/mL) and 1.55 ng . h/mL (range 0.74-3.07 ng . h/mL), respectively. FBT was generally well tolerated in this small group. No application site adverse events or changes in oral mucosal assessments were reported.

CONCLUSION

The absorption profile of a single dose of FBT 200 microg was similar in patients with or without mild oral mucositis. The compound was generally well tolerated.

Rosacea fulminans, Pyostomatitis und Pyovulvitis bei Morbus Crohn

Rosacea fulminans (also known as pyoderma faciale) has been reported to occur in association with Crohn's disease. It is still unclear whether the papulopustules and confluent nodules of rosacea fulminans represent a manifestation of mucocutaneous Crohn's disease or whether this association is a mere coincidence. A 46-year-old woman presented with the spontaneous outbreak of rosacea fulminans and pyostomatitis/pyovulvitis. Complete remission of the mucocutaneous symptoms was achieved with 2 months combination therapy with methylprednisolone, isotretinoin and dapsone. The patient's Crohn's disease, already diagnosed for 3 years, did not flare during this period.

Oral mucositis

Mucositis and xerostomia are the most common oral complications of the non-surgical therapy of cancer. Mucositis, a common sequel of radio- (DXR), chemo-(CXR) and radiochemo-therapy in patients with cancer, or patients requiring haemopoietic stem cell transplants (HSCT), has a direct and significant impact on the quality of life and cost of care, and also affects survival--because of the risk of infection. Apart from dose reduction, preventive and treatment options for mucositis are scarce, although multiple agents have been tested. Evidence suggests that cryotherapy, topical benzydamine and amifostine might provide some benefit in specific situations. The recombinant human keratinocyte growth factor Palifermin (Kepivance) was recently approved as a mucositis intervention in patients receiving conditioning regimens before HSCT for the treatment of haematological malignancies. A number of mechanistically based interventions are in various stages of development. Unfortunately, many other approaches have not been rigorously tested. This paper reviews the clinical features, prevalence, diagnosis, complications, pathogenesis, prophylaxis and management of mucositis.

Reliability and validity of a patient self-administered daily questionnaire to assess impact of oral mucositis (OM) on pain and daily functioning in patients undergoing autologous hematopoietic stem cell transplantation (HSCT)

Oral mucositis (OM) is a frequent complication of myeloablative therapy and HSCT. We evaluated the feasibility, reliability, and validity of a new patient self-reported daily questionnaire on OM and its impact on daily functions. This OM Daily Questionnaire (OMDQ), containing 10 items, was developed for use in palifermin clinical trials. In a phase 3 study, 212 patients received palifermin or placebo for three consecutive days before conditioning and three consecutive days after HSCT. Compliance rates were consistently >80% for most patients. Mouth and throat soreness (MTS) and MTS-Activity Limitations (MTS-AL) (swallowing, drinking, eating, talking, and sleeping) scores on consecutive days were highly correlated (days 7,8 = 0.70-0.86; test-retest reliability). Correlations among items measuring the same construct ranged between 0.5 and 0.8 (internal consistency reliability). The WHO Oral Toxicity scale was the clinical comparator to assess the criterion, discriminative, and evaluative validities of MTS-related questions. Most correlation coefficients between the WHO and MTS ranged between 0.45 and 0.55. Patients with more severe WHO OM grades had higher MTS mean scores. Changes in MTS scores were similar, but patients detected changes 1-3 days earlier than clinicians. In conclusion, the OMDQ is a feasible, reliable, valid, and responsive patient-reported measure of OM severity.

[Dysphagia in oral medicine]

Dysphagia, defined as a difficulty in swallowing of fluids and/or food, is one of the most frequent symptoms of oesophageal, gastrointestinal or ENT diseases. Interestingly, dysphagia can be also the initial or late symptom of several oral diseases: e.g. traumatic ulcerations, immunomediated or infectious lesions, malignant neoplastic disease or mucositis in chemio-radiotherapy. The presence of this frequent symptom, with or without oral evident lesions, can suggest the presence of oral or perioral diseases, promoving adequate diagnostic-therapeutic management. In this paper, authors describe aetiology, pathogenesis and clinical aspects of oral diseases, as being more frequently associated with dysphagia; moreover, they describe the most important clinical and epidemiological features of systemic diseases associated with dysphagia.

Pyodermatitis-pyostomatitis vegetans complicated by methicillin-resistant Staphylococcus aureus infection

Pyodermatitis-pyostomatitis vegetans (PPV), a rare disorder of the skin and oral mucosa, is considered a highly specific marker for inflammatory bowel disease, especially ulcerative colitis (UC). Oral lesions (pyostomatitis vegetans) are seen without skin involvement but rarely without gastrointestinal symptoms. Bowel symptoms may be minimal and precede the onset of other lesions by months or years. Dermatologically, PPV is characterized by annular, pustular lesions, which may precede or appear at the same time as the oral lesions. We report a case of PPV and UC in which presentation was confused by acneiform lesions and methicillin-resistant Staphylococcus aureus colonization. Management was complicated because of the patient's job commitments and need to travel, and the involvement of a number of different specialties at different locations.

Suspected wood poisoning caused by Simarouba amara (marupá/caixeta) shavings in two dogs with erosive stomatitis and dermatitis

Two male Labrador retrievers developed bleeding erosions/ulcerations involving the oral mucosa, mucocutaneous junctions of the lips, nose, prepuce and anus, ulcerated nodules on the chin, and crusting lesions on the elbows, hocks and scrotum. One of the dogs was anorexic and depressed, had haematological abnormalities consistent with damage to the liver and signs of neurological disease. As these dogs had recently been exposed to bedding containing Simarouba amara shavings and because of the striking similarities of clinical signs to those described for horses, a probable diagnosis of wood poisoning was made. This assumption was supported by the clinical course as healing of skin lesions occurred when the dogs were no longer exposed to the bedding.

Moraxella osloensis blood and catheter infections during anticancer chemotherapy: clinical and microbiologic studies of 10 cases

Moraxella osloensis, a gram-negative bacterium that is saprophytic on skin and mucosa, rarely causes infections. Moreover, infections in patients with cancer have not been reported. We describe 10 cases of M. osloensis blood or catheter infections that occurred during anticancer chemotherapy with or without preexisting neutropenia. The organism was identified definitively by sequencing analysis of the 16S ribosomal RNA gene. Fever (up to 39.7 degrees C) with substantial neutrophilia characterized these infections. The infections were monomicrobic for 3 patients and polymicrobic for 7 patients. Nine patients acquired the infection through central venous catheter colonization. The likely sources of the organism were sinusitis (3 cases), bronchitis (1 case), presumed subclinical mucositis from anticancer therapy (4 cases), and cutaneous graft-vs-host disease (2 cases). The infections resolved, without catheter removal, after antibiotic therapy with cell wall-active agents, to which all strains were shown to be susceptible. The M. osloensis strains exhibited significant morphologic variations on gram stain, and sheep blood agar was the preferred culture medium for 9 strains.

Managing pain in mucositis

OBJECTIVE

To discuss pharmacologic and nonpharmacologic approaches available to manage pain.

DATA SOURCE

Published journal articles, book chapters, clinical experience.

CONCLUSION

Pain management requires treatment directed at the various factors involved in the pain experience.

IMPLICATIONS FOR NURSING PRACTICE

Nurses need to assess pain daily and follow patients closely until mucositis resolves. Management targeted to specific dimensions of pain can improve the effectiveness of pain control.

Pyostomatitis vegetans

Pyostomatitis vegetans is a rare oral disorder often associated with gastrointestinal and/or cutaneous diseases and sometimes with other disorders. The association of pyostomatitis vegetans with inflammatory bowel disease, particularly ulcerative colitis, is well known and in most cases bowel disease precedes the onset of oral lesions by months or years. A peripheral eosinophilia has been observed in most reported cases. Pyostomatitis vegetans is characterized by erythematous, thickened oral mucosa with multiple pustules and superficial erosions. Histopathologically, it is characterized by intraepithelial and/or subepithelial abscesses containing large numbers of eosinophils. The pathogenesis is as yet unknown although immunological and microbial factors have been suggested as possible aetiological factors. Management of pyostomatitis vegetans consists mainly of immunosuppression using topical or systemic corticosteroids with medical and/or surgical treatment of any underlying inflammatory bowel disease.

Clinical consequences of oral mucositis

OBJECTIVE

To identify the clinical manifestations, risk factors, secondary complications, and assessment and management of oral mucositis.

DATA SOURCES

Professional journals, websites, and books.

CONCLUSION

Secondary consequences of oral mucositis include infection, xerostomia, hemorrhage, and nutritional deficits.

IMPLICATIONS FOR NURSING PRACTICE

Nurses should have an extensive knowledge base about the appropriate interventions that can be used to alleviate or lessen the consequences often associated with oral mucositis.