mkg - by treister [eng] - oral chronic gvhd - ppt

7/21/2019 MKG - By Treister [ENG] - Oral Chronic GVHD - PPT

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Oral chronic GVHD

Nathaniel S. Treister, DMD, DMSc

Division of Oral Medicine and Dentistry

Brigham and Women’s Hospital, Boston

Department of Oral Medicine, Infection and Immunity

Harvard School of Dental Medicine, Boston



Oral cGVHD is very common

Flowers M, et al. Blood 2002;100:415-419



Oral cGVHD features

• Similar to other

immune/autoimmune

diseases

– lichen planus – Sjögren syndrome

– scleroderma

• Frequently refractory to

systemic therapy

– important role for

ancillary care



Treister N, et al. Blood 2012;120:3407-3418

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How do we evaluate oral cGVHD?

Chronic GVHD Oral Cavity Severity Score

Chronic GVHD Activity Assessment – Patient Self Report (0-10)

Chronic GVHD Activity Assessment - Clinician



Management of mucosal cGVHD

• Topical corticosteroids – Gels

• clobetasol 0.05%

• fluocinonide 0.05%

– Solutions

• dexamethasone 0.1%• clobetasol 0.05%

• budesonide 0.03%

• Topical tacrolimus – Protopic 0.1% ointment (lips)

– tacrolimus 0.01% solution

• Combination therapy

• Secondary candidiasis

• (recrudescent HSV)



DC



(A) Oral cGVHD, symptomatic and untreated

(B) After 1 month of topical steroid therapy, no improvement, candidiasis

(C) Following addition of antifungal therapy, major improvement



Salivary gland cGVHD

• Functions of saliva

– lubrication/mastication

– antimicrobial

– buffering/remineralization

• Quantitative/Qualitativechanges

– xerostomia/pain/discomfort

– difficulty eating/swallowing

– dental caries• cervical, interproximal

– recurrent candidiasis

Kaufman E, et al. Crit Rev Oral Biol Med 2002;13:197-212



Management

• Saliva substitutes,stimulants, sialogoguetherapy

• Caries prevention –

brushing/flossing/diet – fluoride

• trays w/ 1.1%/0.4%

• varnish

– remineralizing agents

•Routine dentalvisits/radiographs – caries management

• Antifungal prophylaxis



Sclerotic oral cGVHD

• Tissues affected

– facial and perioral skin

– buccal mucosa “bands”

• Clinical impact – trismus

– pain, dysfunction

– periodontal complications

– impaired hygiene

Poorly described in literature



Oral cGVHD summary

• Common, may be initial site

• Range of signs/symptoms

• Management

– topical corticosteroids &

tacrolimus – avoid irritating

food/drink/toothpaste

– salivary stimulants &moisturizing agents,

sialogogues, fluoride,mild/child’s toothpaste

• Routine dental visits

• Oral cancer surveillance

Ades L, et al. Blood Reviews 2002;16:135-46

mkg - by treister [eng] - oral chronic gvhd - ppt

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