Increased morbidity associated with oral infection in patients with acute nonlymphocytic leukemia

The proper dental management of patients with leukemia is complicated by the compromised host defenses against infection. This compromised state is a result of the chemotherapeutic agents used in cancer treatment as well as the natural existing disease state. Infection remains the leading immediate cause of death in persons with leukemia. Previous reports have described oral complications secondary to this neoplasm and its medical management; however, relatively few studies of the incidence of systemic complications secondary to oral disease have been reported. This study analyzed the incidence of acute infectious episodes in patients with acute nonlymphocytic leukemia (ANLL). Thirty-eight patients were randomly selected for review; of these patients, twelve (32 percent) had identifiable acute oral infection associated with the presence of a febrile state (> 101° F). Seven of the twelve (58 percent) had no other identifiable sources of infection. The periodontium was the oral site most frequently involved, followed by mucosal and periapical loci. Most acute oral infections were associated with profound granulocytopenia (< 100/μl). The data suggest that oral disease plays a clinically important role in the development of systemic complications in ANLL patients.     

Effects of chlorhexidine mouthrinse on oral health in patients with acute leukemia

The effects of chlorhexidine mouthrinses, used as a supplement to mechanical oral hygiene measures, were studied in patients receiving treatment for acute leukemia. Twenty-eight patients were randomly divided into two groups. During two periods, when the patients were taking medication for the leukemia, one group rinsed with a 0.2% chlorhexidine solution twice daily and the other group did not. Chlorhexidine had no effects of any clinical significance on parameters such as number of days with fever, number of oral lesions, plaque score, gingival bleeding score, or occurrence of candidiasis. There was, however, an increased number of patients who had a burning sensation in the mouth, and a tendency toward increased numbers of salivary enterococci, enterobacteria, and/or Pseudomonas in patients who rinsed with chlorhexidine. The results of the present study do not support the use of chlorhexidine mouthrinses in patients who are able to maintain good oral hygiene by mechanical means during their illness.     

Effect of granulocytopenia on oral microbial relationships in patients with acute leukemia

Risk for acute infection increases as granulocyte levels decrease secondary to myelosuppressive chemotherapy in patients with acute nonlymphocytic leukemia (ANLL). Acute exacerbations of concomitant inflammatory periodontal diseases can result in systemic infections in these patients. However, host-oral bacterial relationships in the periodontium in patients with ANLL are not well understood. Twenty-one adult patients with ANLL with periodontal disease ranging from gingivitis to severe periodontitis were studied. Supragingival and subgingival plaque specimens were collected before chemotherapy (prechemotherapy), and at a defined midpoint of myelosuppression (midchemotherapy; day 14). All specimens were extensively cultured both aerobically and anaerobically. Data were submitted to a partial correlational analysis, controlling for covariation relation to oral hygiene intervention and antibiotic administration. Levels of total yeast exhibited a significant association with Staphylococcus sp. at supragingival sites midchemotherapy (r = 0.68, p less than or equal to 0.05). Levels of total yeast also correlated positively with Pseudomonas aeruginosa at subgingival sites both prechemotherapy (r = 0.70, p less than or equal to 0.01) and midchemotherapy (r = 0.61, p less than or equal to 0.05). Significant correlations of levels of Veillonella sp. with Neisseria sp. and gram-negative enteric bacilli were observed in both supragingival (r = 0.95, 0.77, p values less than or equal to 0.01) and subgingival (r = 0.69, 0.61, p values less than or equal to 0.05) plaque specimens midchemotherapy but not prechemotherapy. These data suggest that potentially pathogenic bacteria occur in plaque simultaneous with granulocytopenia in these patients. Multiple mechanisms, including intergeneric coaggregation and other symbiotic relationships, may influence infectivity of the mixed plaque flora and thus contribute to the oral ecology observed in these patients.     

Chemotherapy-associated oral hemorrhages in adults with acute leukemia

The frequency, nature, and management of chemotherapy-associated oral hemorrhages were studied in 1,093 adult inpatients undergoing treatment for acute leukemia or the blastic phase of chronic leukemia. Of this number, 163 (14.9%) manifested gross bleeding from the mouth during the course of treatment. The most common oral bleeding sites were the lips, tongue, and gingiva. Thrombocytopenia was the underlying cause in 88% of the cases, disseminated intravascular coagulation in 6%, and combinations of thrombocytopenia and hypofibrinogenemia and of thrombocytopenia and vitamin K deficiency in 5.5% and 0.6%, respectively. The vast majority of the patients with mouth bleeding had platelet counts below 40,000 / mm³. Approximately 50% had indirect evidence of a coagulation factor deficiency in the blood. The oral hemorrhages were best managed by transfusions of HLA-compatible fresh platelets and fresh frozen plasma, together with topically applied clot-promoting agents, until hemostatic control was restored.     

Salivary secretion rate, yeast cells, and oral candidiasis in patients with acute leukemia

Stimulated salivary secretion rate was repeatedly determined in 29 patients with acute leukemia during two periods of cytotoxic treatment in myelosuppressive doses. For comparison, the salivary secretion rate was studied in 83 healthy persons and in three other groups of hospitalized patients without malignant disorders. At the start of cytotoxic treatment the secretion rate in the patients with leukemia was lower than in healthy persons. The rate fell significantly after 1 to 3 days and later rose to the level seen in the healthy persons. Several interacting factors may have contributed to the decrease in salivary secretion rate, but the most important factor was probably the use of antiemetic drugs during the first 3 days of the study periods. No relationship was found between salivary secretion rate and the number of gram-negative rods found in the mouth. Patients with low salivary secretion rates had high numbers of yeast cells and more often oral candidiasis.     

Rate of migration of oral leukocytes in patients with periodontitis

abstract — The rate of migration of leukocytes (OMR) was estimated by counts of sequential mouthrinses in 81 human subjects in order to evaluate its usefulness as a laboratory test of oral inflammation. Periodontitis was taken as a model, and neither patients nor controls had any other oral inflammation. Patients with advanced periodontitis, but with periodontal destruction of about the same level, were divided into two groups, acute phase and chronic phase. The mean number of leukocytes entering the oral cavity in 30 s was estimated in these two groups. In the same patients the difference between the cell count in the first rinse and the OMR level was estimated, to test whether it could be taken to indicate the grade of acuteness of the inflammation (GAI). OMR and GAI were assessed in the patients with periodontitts after the initial treatment and at Follow-up 1 year after completion of the full treatment, which almost always included surgical procedures. The results indicate that the OMR reflects the existence of oral inflammation and can be used as a laboratory test with the same reservations as white blood cell counts for systemic inflammation. The difference in GAI between patients in the acute and chronic phases of the disease was highly significant, indicating that this test gives information about the severity of the inflammation.     

The effect of polychemotherapy on the oral mucosa in patients with acute myeloblastic leukemia

Oral mucosa was examined in 23 patients with acute myeloblastic leukemia before and after cytostatic polychemotherapy. Lesions of the oral mucosa were observed in all patients after polychemotherapy: its color was changed, atrophic processes developed in it, and salivary secretion was impaired. Destructive ulcerative changes were revealed in 35% cases; terms of their appearance, regression, and epithelialization were established and a clear-cut correlation between their development and severity of leukocytopenia was detected. Ranging of stomatitis severity is proposed, according to which medium-severe stomatitis predominates in this patient population. The study will help develop more effective approaches to prevention and treatment of oral complications and improve the results of therapy of this most grave category of hematological patients.     

Rate of migration of oral leukocytes in patients with periodontitis.

The rate of migration of leukocytes (OMR) was estimated by counts of sequential mouthrinses in 81 human subjects in order to evaluate its usefulness as a laboratory test of oral inflammation. Periodontitis was taken as a model, and neither patients nor controls had any other oral inflammation. Patients with advanced periodontitis, but with periodontal destruction of about the same level, were divided into two groups, acute phase and chronic phase. The mean number of leukocytes entering the oral cavity in 30 s was estimated in these two groups. In the same patients the difference between the cell count in the first rinse and the OMR level was estimated, to test whether it could be taken to indicate the grade of acuteness of the inflammation (GAI). OMR and GAI were assessed in the patients with periodontitis after the initial treatment and at follow-up 1 year after completion of the full treatment, which almost always included surgical procedures. The results indicate that the OMR reflects the existence of oral inflammation and can be used as a laboratory test with the same reservations as white blood cell counts for systemic inflammation. The difference in GAI between patients in the acute and chronic phases of the disease was highly significant, indicating that this test gives information about the severity of the inflammation.     

Saliva collection methods for DNA biomarker analysis in oral cancer patients

Patients with head and neck cancers are predisposed to local recurrence and second primaries because of the phenomenon of field cancerisation, and clinical detection of recurrence remains challenging. DNA biomarkers in saliva may prove to be an adjunct to current diagnostic methods, but irradiation of the primary site often leads to xerostomia. We assessed 3 methods of collecting saliva for their ability to generate DNA of sufficient quantity and quality to use in biomarker assays. Paired saliva samples were collected from 2 groups of patients with oral squamous cell carcinoma (SCC). In the first group saliva was collected in Oragene^® vials and as saline mouthwash from non-irradiated patients (n = 21) (4 had had radiotherapy before collection); in the second group it was collected using Oragene^® sponge kits and as mouthwash from irradiated patients (n = 24). Quantitative polymerase chain reaction (qPCR) showed that Oragene^® vials contained DNA in significantly greater amounts (median 122 μg, range 4–379) than mouthwash (median 17 μg, range 2–194) (p = 0.0001) in the non-irradiated patients, while Oragene^® sponge kits (median 4 μg, range 0.1–61) and mouthwash (median 5.5 μg, range 0.1–75) generated comparable concentrations of DNA from the irradiated group. All 90 samples contained DNA of sufficient quantity and quality for p16 promoter quantitative methylation-specific PCR (qMSP). While Oragene^® vials contained the most DNA, all 3 methods yielded enough to detect DNA biomarkers using qMSP. The method of collection should depend on the compliance of the patient and oral competency.     

Dental extractions in patients with acute nonlymphocytic leukemia

Dental extractions in patients with leukemia are controversial, since they may lead to hemorrhage, delayed wound healing and infection. However, the retention of diseased teeth in these patients may also lead to infectious complications during chemotherapy. With adequate hematologic values and specific surgical techniques, 119 extractions were performed on 28 patients with acute nonlymphocytic leukemia. No serious adverse sequelae occurred, and the prevalence of other adverse affects was comparable with that in nonleukemic patients. It is concluded that with proper precautions, extractions can be performed on these patients.     

Immunohistochemical studies on colloid bodies (Civatte bodies) in oral lesions of discoid lupus erythematosus

By electron microscopy colloid bodies have been shown to be derived from epithelial cells. It has been suggested, however, that connective tissue cells or components from the basement membrane zone contributed to the formation of colloid bodies. In order to examine these possibilities we stained oral lesions of discoid lupus erythematosus (DLE) with antibodies against intermediate filaments (keratin, vimentin), basement membrane components (laminin, collagen type IV) and fibronectin. IgM was used as a marker for colloid bodies. Colloid bodies were stained positive for keratin, whereas vimentin was never found in colloid bodies. Laminin and collagen type IV were occasionally seen in their periphery probably owing to adherence of basement membrane fragments during apoptosis. Fibronectin was frequently seen at the entire periphery of colloid bodies which may facilitate their elimination by macrophages. In conclusion, connective tissue cells or basement membrane components do not seem to contribute to the formation of colloid bodies in oral DLE.     

Changes in the oral microflora in patients with acute leukemia and related disorders during the period of induction therapy

The present study reports changes occurring within the oral microflora in 20 patients with leukemia during and after the period of high-dose cytotoxic therapy. The relationship between the presence of enterobacteria, yeast cells, and staphylococci and the occurrence of oral ulcers/angular cheilitis was also studied. To make a comparison, three groups of patients without malignant disorders (acute disorders, long-term hospitalization, antibiotic treatment) were also studied. The total number of salivary microorganisms remained unchanged during the period. Fourteen of twenty patients with leukemia harbored enterobacteria on at least one occasion. No differences were found in the number of enterobacteria before, during, and after treatment with cytotoxic or antimicrobial drugs. Enterobacteria were also found in the reference group with long-term hospitalization, but seldom in the other reference groups. Staphylococci and lactobacilli were present in all patients in the leukemia group and in the majority in the reference groups. Yeast cells were found in 80% of the patients with leukemia. Patients with ulcers and/or angular cheilitis had higher numbers of yeast cells than the other patients. There was no relationship between enterobacteria or staphylococci and oral lesions.     

Immunohistochemical studies on colloid bodies (Civatte bodies) in oral lesions of discoid lupus erythematosus

Abstract – By electron microscopy colloid bodies have been shown to be derived from epithelial cells. It has been suggested, however, that connective tissue cells or components from the basement membrane zone contributed to the formation of colloid bodies. In order to examine these possibilities we stained oral lesions of discoid lupus erythematosus (DLE) with antibodies against intermediate filaments (keratin, vimentin), basement membrane components (laminin, collagen type IV) and fibronectin. IgM was used as a marker for colloid bodies. Colloid bodies were stained positive for keratin, whereas vimentin was never found in colloid bodies. Laminin and collagen type IV were occasionally seen in their periphery probably owing to adherence of basement membrane fragments during apoptosis. Fibronectin was frequently seen at the entire periphery of colloid bodies which may facilitate their elimination by macrophages. In conclusion, connective tissue cells or basement membrane components do not seem to contribute to the formation of colloid bodies in oral DLE.     

急性髓系白血病患者化疗前口腔治疗预防化疗性口腔黏膜炎的初步研究

目的探讨急性髓系白血病患者化疗前给予口腔治疗对化疗期间口腔黏膜炎发生率及炎症程度的影响,为临床造血系统恶性肿瘤患者化疗前口腔治疗效果提供初步依据。 方法74例患有急性髓系白血病的患者根据患者是否愿意化疗前接受口腔治疗,分为口腔治疗+化疗组和化疗组,口腔治疗+化疗组在化疗前给予全面的口腔检查以及对存在问题进行处理,化疗组则不给予任何口腔治疗。评价和记录口腔黏膜炎的发生率及程度。采用卡方检验及Mann-Whitney U检验,比较两组间差异。 结果口腔治疗+化疗组的口腔黏膜炎发生率要小于化疗组(χ²=5.659,P=0.017),炎症程度也低于化疗组(U=0,P=0)。 结论化疗前口腔治疗有利于减低急性髓系细胞患者化疗期间口腔黏膜炎的发生率,减轻口腔黏膜炎的炎症程度,具有重要的临床意义。