Optimum dental radiography in bone marrow transplant patients

OBJECTIVE: The purpose of this study was to establish an optimum radiographic examination regimen for patients undergoing bone marrow transplantation. Two radiographic examinations were compared: the panoramic radiograph and the full mouth series of radiographs. STUDY DESIGN: A prospective analysis of 65 consecutive patients undergoing bone marrow transplantation was undertaken. All patients were examined through use of both panoramic and full mouth series intraoral radiographs, including bitewings. Significant findings were recorded and compared by means of paired t test analysis for parametric data, such as caries, periapical inflammation and subgingival calculus, and by means of McNemar's test for nonparametric data, such as the presence or absence of severe periodontal disease. RESULTS: Acquired findings, such as caries, periodontal disease, and clinically significant faulty restorations, were detected more frequently from the full mouth series (P < .05). There was no significant difference in the detection of periapical pathosis. In 8 of 65 patients, clinically significant information, such as evidence of impacted wisdom teeth, neoplasms, and multiple myeloma, was better detected from the panoramic radiographs. CONCLUSIONS: The results suggest a combination of both modalities as the optimum means of radiologic survey in this "high-risk" patient population.     

Effects of total body irradiation on salivary gland function and caries-associated oral microflora in bone marrow transplant patients.

Forty-one cancer patients who received chemoradiotherapy conditioning with bone marrow transplantation were examined for changes in salivary gland function and caries-associated oral microflora. Salivary flow rates (stimulated and unstimulated) and Streptococcus mutans levels decreased after pretransplant cytoreductive therapy and posttransplant prophylactic antibiotic therapy. Normal levels returned with time after the patients left the protected environment. Lactobacillus counts were not affected. Chronic graft-versus-host disease did not significantly influence saliva production. Results indicate that irradiation is probably the major factor responsible for the transient xerostomia.     

Oral gram-negative bacilli in bone marrow transplant patients given chlorhexidine rinses

Fifteen bone marrow transplant (BMT) patients who received three 0.12% chlorhexidine digluconate (CHX) mouthrinses daily for eight weeks were monitored weekly for the occurrence of oral opportunistic Gram-negative bacilli (GNB). Tongue and buccal mucosa were sampled with use of Culturette swabs that were streaked on plates containing selective MacConkey agar. After incubation, colony-forming units were scored and putative GNB classified with use of the API 20E rapid identification system and supplemental biochemical tests. After identification, the susceptibilities of all GNB to CHX were determined by means of a disk diffusion sensitivity assay. Sixty-seven percent (10) of the BMT subjects had at least one GNB-positive tongue culture, and 53% (8) had GNB in samples taken from the buccal mucosa. Of 218 samples taken, 26% and 24% from the tongue and buccal mucosa, respectively, were GNB-positive. The predominant clinical GNB isolates were Enterobacter cloacae (46%) and Klebsiella pneumoniac (30%). Their respective CHX minimum inhibitory concentrations (MICs) were similar to those of ATCC reference strains. Although the CHX MIC values of the clinical GNB isolates were high (less than or equal to 37.5 to less than or equal to 300 micrograms/mL), they were not dependent upon length of exposure to the agent. Therefore, changes in sensitivity or resistance to CHX did not appear to occur. The results suggest that the mouths of BMT patients--and perhaps of other immunosuppressed individuals--should be routinely monitored for GNB, as are other clinically important sites, such as the throat and the urinary and gastro-intestinal tracts.     

Therapeutic use of chlorhexidine in bone marrow transplant patients: case studies

Patients undergoing cytotoxic chemotherapy and radiation therapy often experience severe oral complications during and after treatment despite supervised oral hygiene and conventional antimicrobial regimens. The antimicrobial compound chlorhexidine is an effective topical prophylactic agent against oral mucositis and candidiasis. Oral mucositis developed in four patients who underwent bone marrow transplantation; the condition was severe enough to prompt use of chlorhexidine. In each case, there was clinical resolution of mucositis and a concomitant decrease in the oral microbial burden 1 week after chlorhexidine use began. This strongly suggests that, in addition to its value in protecting these severely immunocompromised patients from oral infection, chlorhexidine also offers a therapeutic benefit in the resolution of existing oral infections and of mucositis.     

Postextraction osteomyelitis in a bone marrow transplant recipient

This report describes a case of mandibular osteomyelitis after a dental extraction in a patient who subsequently underwent bone marrow transplantation (BMT) for lymphoblastic lymphoma. Surgical guidelines consistent with National Cancer Institute recommendations were followed for the extraction, which was performed before initiation of the myelosuppressive conditioning regimen. However, moderate tenderness developed at the extraction site beginning 10 days after marrow infusion. On day 26 the patient became febrile and blood culture-positive for Staphylococcus epidermidis. Radiographs exposed on day 28 demonstrated changes consistent with low-grade osteomyelitis, including diffuse loss of lamina dura and an irregular osseous rarefaction extending 1 cm posterior to the extraction site. Although the indwelling Hickman catheter was the presumed source for bacteremia, clinical and radiographic data led to consideration of mandibular osteomyelitis as an alternative cause. Characteristics of this infection in BMT recipients are reviewed. Recommendations for dental extractions and prophylactic antibiotic regimens for catheterized BMT recipients are also discussed. Although mandibular osteomyelitic lesions are not common in profoundly immunosuppressed BMT recipients, prompt recognition and treatment are essential when the disease occurs.     

Mucositis and salivary antioxidants in patients undergoing bone marrow transplantation (BMT)

Objectives: High doses of chemotherapy generate DNA damage in patients undergoing bone marrow transplantation (BMT), due to the production of reactive oxygen species (ROS). In order to evaluate the local defensive effectiveness of the patient undergoing BMT, the concentrations of the antioxidants superoxide dismutase (SOD) and uric acid (UA) were measured in saliva. Study Design: Basal saliva samples were collected from 20 patients undergoing BMT at the Oncology Department, Sanatorio Allende (Córdoba), in the stages: initial, prior to conditioning therapy (I); middle: 7 to 10 days after BMT (M) and final stage, 30 days after discharge from isolation (F). SOD levels were determined using a RANDOX kit (RANSOD superoxide dismutase manual), and for uric acid enzymatic UOD / PAP spectrophotometric method, ( Trinder Color Kit , Wiener Lab) was used. Results: 85% of the patients developed oral mucositis. SOD concentration in the M stage was significantly higher (p<0.01) compared with stage I, and it reversed in stage F. UA concentration was significantly lower (p<0.001) in stage M compared with stage I, and in stage F it recovered the initial values. Conclusions: SOD increase in stage M coincided with the appearance of mucositis, which could be interpreted as a defensive mechanism of saliva against oxidative stress produced by chemotherapy. UA decrease in stage M would favour the development of higher degrees of mucositis. Key words:Bone marrow transplantation, mucositis, superoxide dismutase, uric acid.     

Severe oral hemorrhage and sepsis following bone marrow transplant failure

Aplastic anemia is a failure of all the cellular components of the bone marrow and, untreated, usually results in death from bleeding and/or infection within 4 months. Treatment by bone marrow transplantation offers the only means of survival. When a bone marrow graft fails, the patient is extremely susceptible to severe infection and/or hemorrhage. In this case, a bone marrow transplantation in a 34-year-old white man with aplastic anemia failed. Among the medical problems that subsequently developed were severe, prolonged and life-threatening oral bleeding and infection.     

Gingival health and salivary function in head and neck-irradiated patients: A five-year follow-up

Gingival health and salivary gland function were evaluated for a period of 5 years in 14 patients who received head and neck irradiation for nasopharyngeal carcinoma (seven patients; total dose >60 Gy, nasopharyngeal field) and Hodgkin's lymphoma (seven patients; total dose <50 Gy, “mantle” field). Plaque index (PII), bleeding index (BI), gingival recession (GR), whole saliva flow rate (WSFR), left parotid sialographic morphology, and salivary gland radioisotopic activity were assessed immediately before radiotherapy and annually thereafter. The nasopharyngeal group had perfect correlation between postradiation depression of WSFR and the sialographic and scintigraphic scores (R = −1.00 and −0.96, respectively). The degree of gland dysfunction correlated negatively with BI and the BI/PII ratio (r = #x02212;0.497) and with GR (r = 0.681). The same correlations were noted in the group with Hodgkin's lymphoma during the first 3 years of follow-up. However, recovery of parotid gland function (WSFR and scintigraphic scores) and morphology (sialographic scores) and return to the preradiation relation between WSFR and both BI/PII ratio (r = 0.75) and GR (r = −0.71) were noted in the fourth year. The differences between the nasopharyngeal and Hodgkin's lymphoma groups are attributable to the delineation of the radiation field employed in each group.     

The relation between salivary IgA and caries in renal transplant patients

OBJECTIVE: The purpose of this study was to evaluate the effect of immunosuppressive drugs on the level of salivary immunoglobulin A (IgA) in patients who have received kidney transplants and the relation between the levels of salivary IgA and dental caries incidence.Study Design: Patients who had undergone renal transplantation (n = 28, aged 18-54) were divided into 3 groups according to postsurgical period (0-6 months [G(1)], 6-12 months [G(2)], and >12 months [G(3)]). A healthy control group (n = 10, aged 17-49) was also included in this study. Saliva samples were collected from all patients by the spitting method. After collection, the samples were frozen immediately at -40 degrees C until analysis by the single radial immunodiffusion method. All fissure caries were examined clinically, and proximal caries were examined clinically and radiographically; caries status was determined according to the decay surface index. The findings were evaluated statistically by means of correlation analysis, the Kolmogorov-Smirnov test, and the 1-way Kruskal Wallis analysis of variance method. RESULTS: Salivary IgA levels of the patients who had undergone renal transplantation were found to be significantly lower than those of the control patients (G(1) = 6.76 mg/dL, G(2) = 6.80 mg/dL, G(3) = 7.84 mg/dL, and control group = 10.84 mg/dL, P <.001). However, the caries status of the patients who had undergone renal transplantation was not different from that of the control subjects for the first year after the transplant operation. The salivary IgA values of the 3 groups of patients who had undergone transplantation were not significantly different from each other. Thus, it was observed that a decrease in the level of salivary IgA does not result in an increase in caries incidence within 12 months after renal transplantation. The caries rate in the third group of patients who had undergone renal transplantation was found to be significantly different from those in the first and second groups. CONCLUSION: Low salivary IgA levels caused by immunosuppression are not correlated or associated with higher levels of dental caries within the first 12 months after renal transplantation. However, the incidence of dental caries was higher for patients who had undergone renal transplantation than for control subjects 12 months after renal transplantation. Because of the diagnostic processes used, dental caries may not become evident until after 12 months.     

The relationship between bone marrow edema and bone changes in the mandibular condyle: A longitudinal study with MR imaging

PurposeDecreased signal intensity on T1- or proton-density weighted magnetic resonance imaging (MRI) and increased signal intensity on T2-weighted MRI in the bone marrow space are thought to reflect bone marrow edema (BME). The purpose of this study was to determine whether condyle BME is associated with condyle bone changes.MethodsThe subjects were 57 patients [65 temporomandibular joints (TMJs)] with TMJ disorders showing condyle BME on initial MRI. Condyle bone changes were compared between TMJs that showed a persistent BME pattern (group P, 43 TMJs in 40 patients) and those that showed normal bone marrow signals, indicating disappearance of BME (group D, 21 TMJs in 22 patients) on follow-up MRI.Results(1) In TMJs with a condyle with a normal shape on initial MRI, condyle bone changes were present in 53.9% of TMJs in group P in follow-up MRI, whereas the normally shaped condyle remained in all TMJs in group D. (2) In TMJs with condyle erosion on initial MRI, condyle erosion was also present in 35.7% of TMJs in group P in follow-up MRI, but had disappeared in all TMJs in group D. (3) In TMJs with condyle osteophytes on initial MRI, erosion was present in 22.2% of TMJs in group P, whereas osteophytes remained in all TMJs in group D.ConclusionsThe longitudinal study showed that condyle BME is associated with condyle bone changes and may cause condyle erosion.     

Disturbances in dental development after total body irradiation in bone marrow transplant recipients

The dental status of 16 children who had been treated with bone marrow transplantation (BMT) for serious bone marrow diseases was followed for up to 6 years. Several types of disturbances in dental development were observed in children who had been conditioned with total body irradiation (TBI) at 10 Gy before BMT. Thus, impaired root development that caused short V-shaped roots was found in all patients, a complete failure of root development and premature apical closure were found in five patients, enamel hypoplasia was observed in four patients, and microdontia was observed in three patients conditioned with TBI. Patients younger than 6 years of age at BMT exhibited the most severe and extensive dental aberrations. The TBI at 10 Gy appeared to be the major cause of the disturbances found.     

Vascular endothelial growth factor (VEGF) and chronic graft-versus-host disease (cGVHD) in salivary glands of bone marrow transplant (BMT) recipients

BACKGROUND: The purpose of this study was to compare the immunolocalization of vascular endothelial growth factor (VEGF) in salivary glands of bone marrow transplant (BMT) recipients with normal controls and between the different stages of chronic graft-versus-host disease (cGVHD). In addition, the impact of the immunolocalization of VEGF on the survival rate of BMT patients was investigated as well. METHODS: Labial salivary glands obtained at the day 100+ from 36 consecutive patients, who underwent BMT, were included in the study. The streptavidin-biotin-peroxidase complex stain was used to detect VEGF in the salivary glands. Time of death after BMT was displayed by means of the Kaplan-Meier method for the following parameters: age and gender of the patients, donor gender, acute GVHD, cGVHD staging at the labial salivary glands, primary disease, platelet and neutrophils counts on day of biopsy, stem cell, oral mucositis, parenteral nutrition, oral lichenoid lesions of GVHD, conditioning regimen and immunolocalization degree of VEGF in labial salivary glands. The data were initially analyzed by means of the log-rank test and then included in the Cox's proportional hazard model. RESULTS: No differences on the immunolocalization of VEGF in the labial salivary glands of BMT recipients and control group or between the different stages of glandular cGVHD were noted. Both univariate and multivariate analysis of the survival rate showed significance of 5% only for platelet count over 100 x 109/l on the day of biopsy and male donor gender. CONCLUSIONS: Platelet count over 100 x 109/l and male donor gender are positive predictive factors on the survival rate after BMT. In addition, the immunolocalization of VEGF in salivary glands is not altered in BMT recipients at day 100+ and is not influenced by the stage of cGVHD.     

Oral Candida albicans in bone marrow transplant patients given chlorhexidine rinses: occurrence and susceptibilities to the agent

The tongue and buccal mucosa of 26 bone marrow transplant recipients given three 0.12% chlorhexidine digluconate (CHX) oral rinses daily for 8 weeks were sampled weekly for oral Candida albicans. Putative C. albicans colony-forming units on selective bismuth sulfite glucose glycine yeast agar plates were identified with the API 20C system. The CHX minimum inhibitory concentrations (MICs) of oral C. albicans isolates obtained at all 8 sample weeks was determined with a microbroth dilution sensitivity assay. The CHX MIC range for yeast isolates selected randomly at all sample weeks was up to 2.5 to up to 20 micrograms/ml (mean MIC less than or equal to 8.5 micrograms/ml). The CHX MIC range for isolates at week 1 was less than or equal to 5 to less than or equal to 10 micrograms/ml (mean MIC less than or equal to 7.9 micrograms/ml) compared with less than or equal to 2.5 to less than or equal to 20 micrograms/ml at week 8 (mean MIC less than or equal to 8.8 micrograms/ml). Therefore the persistence of oral C. albicans in bone marrow transplant recipients using CHX rinses was due neither to low CHX susceptibilities nor to the development of resistance to the agent.     

Effectiveness of oral chlorhexidine for reducing stomatitis in a pediatric bone marrow transplant population

Disruption of the oral mucosal lining and the lack of normal defense mechanisms predispose bone marrow transplant (BMT) patients to life-threatening infections, often caused by oral flora. Chlorhexidine, used as an oral antiseptic, appears promising in limiting oral bacteria and fungi, and therefore, may decrease oral complications associated with BMT. The purpose of this study was to determine in pediatric BMT recipients if a 0.12% chlorhexidine mouthrinse, used as an adjunct to normal in-hospital oral care regimens, would decrease the severity of oral mucositis as measured by oral ulcerations, bacteremia, and length of hospital stay. Forty-seven pediatric BMT subjects were included in this double-blind study. Subjects were instructed to use 15 ml of a mouthrinse 3 times daily to be swished and gargled for 30 sec. Each subject had 7 oral sites scored for the percentage of ulcerated mucosa twice weekly until day +35 or hospital discharge or death. Blood was cultured daily during neutropenia. Additionally, the number of days from onset of cytoreduction to hospital discharge or death was recorded for each subject. Alpha was set at .05. There was no significant difference in the severity of oral ulceration between the chlorhexidine and placebo groups (P = .18). Chlorhexidine did not reduce the development of bacteremia (P greater than .5), nor did it significantly decrease the length of hospital stay (P = .68).(ABSTRACT TRUNCATED AT 250 WORDS)     

Oral mucositis in patients undergoing bone marrow transplantation

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

Relationship of subgingival and salivary microbiota to gingival overgrowth in heart transplant patients following cyclosporin A therapy

BACKGROUND: Severe gingival overgrowth (GO) is induced in patients taking cyclosporin A (CsA) following organ transplantation. Determining which patient will develop GO is still not possible. The purpose of this study was to establish an association between CsA and gingival overgrowth in heart transplant patients taking into account periodontal and microbiological conditions. METHODS: Thirty patients (10 female, 20 male; range: 13 to 67 years; mean age: 44.89) undergoing CsA treatment were evaluated using the gingival index (GI), plaque index (PI), probing depth (PD), and clinical attachment level (CAL). Subgingival samples collected from the deepest site of each quadrant and saliva samples were submitted to microbial analysis. All patients had at least 12 teeth. Exclusion criteria were the use of antibiotics and/or having undergone periodontal treatment 6 months prior to the study. Patients were divided in two groups: with gingival (GO+) and without gingival overgrowth (GO-). RESULTS: There were no statistically significant differences between the GO+ and GO- groups when CsA dosage, time since transplant, GI, PI, PD, and CAL were compared. Microbiological examination of the subgingival samples detected the following microorganisms: Actinobacillus actinomycetemcomitans (23%), Porphyromonas gingivalis (36%), Prevotella intermedia (93%), Fusobacterium sp. (66%), Campylobacter rectus (30%), Micromonas micros (66%), enteric rods (0%), and yeasts (30%). A positive association between M. micros and the GO+ group was found (P < 0.001). Yeasts were detected in 30% of the subgingival and saliva samples. CONCLUSIONS: Clinical parameters were not sufficient to determine which patients would develop GO. However, colonization by M. micros might play a role in the etiology of GO.     

Chewing stimulates secretion of human salivary secretory immunoglobulin A

Immunoglobulin A (IgA) is the most abundant immunoglobulin in saliva and other mucosal secretions and plays an important role in mucosal immunity. The present study examined whether secretion of IgA, like other salivary proteins, is increased by reflex stimulation. Parotid saliva was collected from subjects into separate vials under resting conditions and during chewing-stimulated secretion over 45 min. Enzyme-linked immunosorbent assay (ELISA) indicated that chewing increased IgA secretion. The extent and pattern of the increase were similar to those of total protein and acinar cell amylase. SDS gel electrophoresis and Western blotting showed that high-molecular-weight forms of IgA-containing secretory component predominated in all saliva samples. Secretory component, the cleaved epithelial receptor for polymeric IgA, was secreted in a pattern very similar to that of IgA. It is concluded that chewing stimulates epithelial cell transcytosis of IgA and increases secretion of secretory IgA into saliva.