Oral Mucositis and Nutritional Status in Children Who Underwent Hematopoietic Cell Transplantation: A Comparison Between Nonmalignant and Malignant Primary Diseases.

BACKGROUND: There is a lack of studies analyzing the association between oral mucositis (OM) and nutritional imbalance in children during hematopoietic stem cell transplantation (HSCT). The aim of this study was to compare the risk factors for OM and nutritional imbalance during HSCT in pediatric patients with nonmalignant diseases (NMD) and malignant diseases (MD). METHODS: Data on age, sex, primary disease, transplantation type, conditioning regimen, GVHD prophylaxis, gastrointestinal toxicity, OM, percent body weight loss or gain, nutritional repositioning, and overall survival (OS) were retrospectively collected from the 132 medical records. The data were then compared between patients with NMD (n = 70) and MD (n = 62). RESULTS: OM had a similar severity between the groups. The primary risk factor for OM in the NMD group was the conditioning regimen with busulfan, while in the MD group it was GVHD prophylaxis with cyclosporin and methotrexate. OM did not have an impact on body weight loss or gain in any of the groups. In the NMD, body weight gain due to fluid overload was more pronounced and associated with a lower age range. OS was similar between the groups and was not affected by OM. CONCLUSIONS: OM pattern was similar in pediatric patients with or without MD, but the factors that determined these oral lesions were different. There were disparities in body weight changes between the two groups, and these changes were not associated to OM.

Photobiomodulation minimizes taste changes during hematopoietic cell transplantation: A randomized clinical trial.

Prevention and treatment protocols for taste changes observed during hematopoietic cell transplantation (HCT) are not well-established. The purpose of this study was to assess the efficacy of photobiomodulation (PBM) in relieving taste changes and preventing lingual papillae atrophy. HCT patients received PBM (n = 42) on the tongue dorsum using an InGaAIP laser (660 nm, 100 mW, 1.1 W/cm2, 8.8 J/cm2). During the HCT conditioning (T0), severe neutropenia (T1), and after neutrophil engraftment (T2), taste acuity for sweet, bitter, sour, and salty solutions, and clinical appearance of lingual papillae were compared with those of a placebo group (n = 43). PBM significantly reduced hypogeusia, ageusia, and parageusia at T1 and T2, and also successfully prevented papillae atrophy during all the analyzed HCT periods. In conclusion, PBM enhanced taste acuity during HCT. The decrease in papillae atrophy indicated a potential regenerative effect of this therapy on tongue mucosa.

Reduction of SARS-CoV-2 viral load in saliva after rinsing with mouthwashes containing cetylpyridinium chloride: a randomized clinical study.

Background: Symptomatic patients with COVID-19 typically have a high SARS-CoV-2 viral load in their saliva. Procedures to reduce the viral load in their oral cavity are important for mitigating the viral transmission. Methods: This randomized clinical trial investigated the impact of two mouthwashes (0.075% cetylpyridinium chloride plus 0.28% zinc lactate (CPC+Zn) (n = 32), and 0.075% cetylpyridinium chloride (CPC) (n = 31)) on the viral load of SARS-CoV-2 in saliva when compared to the distilled water negative control (n = 32). Saliva was collected before (T0) and after (5 min, T1; 30 min, T2; and 60 min, T3) the intervention. Viral load in saliva was measured by qRT-PCR assays. The data in both groups was normalized for T0 and Negative Control, resulting in fold change values. Results: CPC+Zn oral solution reduced the viral load in saliva by 6.34-fold at T1, 3.6-fold at T2 and 1.9-fold at T3. Rinsing with the CPC mouthwash reduced the viral load in saliva by 2.5-fold at T1, 1.9-fold at T2 and 2.0-fold at T3. Conclusion: CPC+Zn mouthwash or with the CPC mouthwash reduced the viral load in saliva of COVID-19 patients immediately after rinsing. These reductions extended up to 60 min.

Dental consensus on HSCT - Part II: dental Care during HSCT

ABSTRACT During the state of immune vulnerability in hematopoietic stem cell transplantation (HSCT), the patient has an increased risk of developing a vast number of complications, including severe problems in the oral cavity. These situations require professional oral care to act in the diagnosis and treatment of these conditions, as well as to develop prevention protocols to minimize patient's complications. Oral mucositis, opportunistic infections, bleeding, specific microbiota, taste, and salivary alterations are complications that can occur during HSCT and interfere with various aspects, such as pain control, oral intake, nutrition, bacteremia and sepsis, days of hospitalization and morbidity. Several guidelines have been published to address the role of professional oral care during the HSCT, we describe a consensus regarding these recommendations.

Brazilian dental consensus on dental management in hematopoietic stem cell transplantation−Part I−pre-HSCT

ABSTRACT The oral involvement in the Hematopoietic Stem Cell Transplantation is well described in the literature. The goal of the dental treatment and management of the oral lesions related to the HSCT is to reduce the harm caused by preexisting oral infection or even the worsening of oral acute/chronic GVHD and late effects. The aim of this guideline was to discuss the dental management of patients subjected to HSCT, considering three phases of the HSCT: pre-HSCT, acute phase, and late phase. The literature published from 2010 to 2020 was reviewed in order to identify dental interventions in this patient population. The selected papers were divided into three groups: pre-HSCT, acute and late, and were reviewed by the SBTMO Dental Committee's members. When necessary, an expertise opinion was considered for better translating the guideline recommendations to our population dental characteristics. This manuscript focused on the pre-HSCT dental management. The objective of the pre-HSCT dental management is to identify possible dental situations that On behalf of the Dental Committee of the Brazilian Society of Gene Therapy and Bone Marrow Transplantation (SBTMO) can worsening during the acute phase after the HSCT. Each guideline recommendations were made considering the Dentistry Specialties. The clinical consensus on dental management prior to HSCT provides professional health caregivers with clinical setting-specific information to help with the management of dental problems in patients to be subjected to HSCT.

Dentistry consensus on HSCT - Part III: Special topics - Dentistry on HSCT

ABSTRACT Patients undergoing hematopoietic stem cell transplantation (HSCT) might present acute and late toxicities and the oral tissues are frequently affected. With the survival increasing, patients show late and long-term morbidities, and there is an important association between the general and the oral health. The first and second parts of this Consensus have showed the importance of the adequacy of oral health in the pre-HSCT, and the main alterations and oral care during the period of admission for HSCT. This third part aims to review specific themes of post-HSCT dental care, such as graft-versus-host disease (GVHD) and the pediatric patient. It also aims to review pertinent subjects, both during the HSCT period and post-HSCT, concerning quality of life, pain, cost-effectiveness, and remote care. Based on this review, it is evident the importance of the work of the dental surgeon (DS) in the follow-up and treatment of the HSCT patient, always collaborating with the whole multidisciplinary team.

Dentistry consensus on HSCT - Part III: Special topics - Dentistry on HSCT.

Patients undergoing hematopoietic stem cell transplantation (HSCT) might present acute and late toxicities and the oral tissues are frequently affected. With the survival increasing, patients show late and long-term morbidities, and there is an important association between the general and the oral health. The first and second parts of this Consensus have showed the importance of the adequacy of oral health in the pre-HSCT, and the main alterations and oral care during the period of admission for HSCT. This third part aims to review specific themes of post-HSCT dental care, such as graft-versus-host disease (GVHD) and the pediatric patient. It also aims to review pertinent subjects, both during the HSCT period and post-HSCT, concerning quality of life, pain, cost-effectiveness, and remote care. Based on this review, it is evident the importance of the work of the dental surgeon (DS) in the follow-up and treatment of the HSCT patient, always collaborating with the whole multidisciplinary team.

Brazilian dental consensus on dental management in hematopoietic stem cell transplantation - Part I - pre-HSCT.

The oral involvement in the Hematopoietic Stem Cell Transplantation is well described in the literature. The goal of the dental treatment and management of the oral lesions related to the HSCT is to reduce the harm caused by preexisting oral infection or even the worsening of oral acute/chronic GVHD and late effects. The aim of this guideline was to discuss the dental management of patients subjected to HSCT, considering three phases of the HSCT: pre-HSCT, acute phase, and late phase. The literature published from 2010 to 2020 was reviewed in order to identify dental interventions in this patient population. The selected papers were divided into three groups: pre-HSCT, acute and late, and were reviewed by the SBTMO Dental Committee's members. When necessary, an expertise opinion was considered for better translating the guideline recommendations to our population dental characteristics. This manuscript focused on the pre-HSCT dental management. The objective of the pre-HSCT dental management is to identify possible dental situations that can worsening during the acute phase after the HSCT. Each guideline recommendations were made considering the Dentistry Specialties. The clinical consensus on dental management prior to HSCT provides professional health caregivers with clinical setting-specific information to help with the management of dental problems in patients to be subjected to HSCT.

Dental consensus on HSCT - Part II: dental Care during HSCT.

During the state of immune vulnerability in hematopoietic stem cell transplantation (HSCT), the patient has an increased risk of developing a vast number of complications, including severe problems in the oral cavity. These situations require professional oral care to act in the diagnosis and treatment of these conditions, as well as to develop prevention protocols to minimize patient's complications. Oral mucositis, opportunistic infections, bleeding, specific microbiota, taste, and salivary alterations are complications that can occur during HSCT and interfere with various aspects, such as pain control, oral intake, nutrition, bacteremia and sepsis, days of hospitalization and morbidity. Several guidelines have been published to address the role of professional oral care during the HSCT, we describe a consensus regarding these recommendations.

Efficacy of mouthrinses in reducing oral SARS-COV-2 load: a review.

Accumulated evidence has shown that the oral cavity may be an important reservoir for SARS-CoV-2. Some authors have suggested that the use of mouthrinses could reduce SARS-CoV-2 viral load in the saliva. Thus, the aim of this review was to synthesize evidence about the efficacy of mouthrinses in reducing the salivary viral load of SARS-CoV-2. 2. Nine randomized controlled trials (RCTs) have investigated the efficacy of different mouthrinses in reducing salivary SARS-CoV-2 loads. Various active ingredients have been tested in these trials: 0.5%,1% and 2% povidone-iodine, 0.2% and 0.12% chlorhexidine (CHX), 0.075% cetylpyridinium chloride (CPC), 0.075% CPC with Zinc lactate, 1% and 1.5% hydrogen peroxide (HP), 1.5% HP + 0.12% CHX and ß-cyclodextrin and citrox. The studies reported an intra-group reduction in the salivary levels of the virus, when compared with the baseline. However, the majority of these trials failed to demonstrate a significant inter-group difference between active groups and the control group relative to the decrease in salivary SARS-CoV-2 loads. Although promising, these results should be confirmed by larger trials.

Antimicrobial oral lavage reduces the SARS-CoV-2 load in intubated patients: randomized clinical trial.

Background: The oral cavity can be a reservoir for SARS-CoV-2 and may play a crucial role in the viral transmission in the hospital environment. Objective: To investigate whether an oral hygiene protocol with chlorhexidine (CHX) used alone and in combination with hydrogen peroxide (HP) in the intensive care unit was effective in reducing the SARS-CoV-2 viral load in the oral cavity. Methods: SARS-CoV-2 viral load was measured on oral fluid samples collected from patients undergoing orotracheal intubation. The study sample was randomly in: CHX group (n = 19) - oral rinse using only 0.12% CHX solution; HP+CHX group (n = 24) - oral rinse with 1.5% HP and 0.12% CHX. The samples were collected before the interventions (T0), immediately (T1), 30 minutes (T2) and 60 minutes (T3) after the procedure. Results: A significant viral load reduction was observed at T1 (mean ± SD:-0.57 ± 0.19 log10;-73.2%;p = 0.022) in the HP+CHX group. No statistically significant differences between any time points were observed in the CHX group. Conclusion: The HP+CHX oral rinses significantly reduced the SARS-CoV-2 viral load in the oral fluid immediately after the procedure. The CHX oral rinse alone did not result in any significant viral load reductions.

Efficacy of mouthrinses in reducing oral SARS-COV-2 load: a review

Abstract Accumulated evidence has shown that the oral cavity may be an important reservoir for SARS-CoV-2. Some authors have suggested that the use of mouthrinses could reduce SARS-CoV-2 viral load in the saliva. Thus, the aim of this review was to synthesize evidence about the efficacy of mouthrinses in reducing the salivary viral load of SARS-CoV-2. 2. Nine randomized controlled trials (RCTs) have investigated the efficacy of different mouthrinses in reducing salivary SARS-CoV-2 loads. Various active ingredients have been tested in these trials: 0.5%,1% and 2% povidone-iodine, 0.2% and 0.12% chlorhexidine (CHX), 0.075% cetylpyridinium chloride (CPC), 0.075% CPC with Zinc lactate, 1% and 1.5% hydrogen peroxide (HP), 1.5% HP + 0.12% CHX and ß-cyclodextrin and citrox. The studies reported an intra-group reduction in the salivary levels of the virus, when compared with the baseline. However, the majority of these trials failed to demonstrate a significant inter-group difference between active groups and the control group relative to the decrease in salivary SARS-CoV-2 loads. Although promising, these results should be confirmed by larger trials.

Special care in dental curriculum: A transversal axis for integrating oral health with systemic health.

AIMS: Distance between dentistry and medicine is a traditional and historical obstacle that affects multiple levels of the health system, especially the health policies to improve health service quality. Changes in dental education, especially involving the adoption of integrative health models in professional development, are considered essential for reducing this gap. We aimed to show a dental curriculum focused on special care as a tool for medicine-dentistry integration. METHODS: In this study, we present a new proposal for an undergraduate dental curriculum in which topics related to special care are addressed transversally and are the core for interdisciplinary integration of oral health with systemic health. We also describe how themes related to dental home care and hospital dentistry were included in this course as basic professional competencies. RESULTS AND CONCLUSION: This initiative is aligned with the global trend to adopt educational systems that contribute to the reduction of health care inequalities and improve health service quality.

Effectiveness of Toothpastes on SARS-CoV-2 Viral Load in Saliva.

INTRODUCTION: The effect of toothpastes on viruses, such as SARS-CoV-2, is unknown. This study investigated the short-term effect of toothpastes containing antimicrobial properties in patients with novel coronavirus disease 2019 (COVID-19) to determine whether they could reduce the SARS-CoV-2 salivary viral load. METHODS: Hospitalised patients with COVID-19 (n = 83) were instructed to perform toothbrushing with 1 of 3 arms: a toothpaste containing 0.96% zinc (zinc oxide, zinc citrate) in a silica base (Test 1), a toothpaste containing 0.454% SnF2 in a silica base (Test 2), and a nonantibacterial toothpaste (control). Saliva was collected before intervention (T0), immediately after intervention (T1), and 30 (T2) and 60 minutes (T3) after intervention. The SARS-CoV-2 salivary viral load was measured using quantitative real-time polymerase chain reaction (qRT-PCR) assays. For Test 1 and Test 2 toothpastes, the fold reductions were normalised to baseline and to the control toothpaste at each time point after brushing. A fold change of ≥2 is considered clinically effective. RESULTS: Brushing with the Test 1 toothpaste reduced the SARS-CoV-2 salivary viral load by 4.06-fold at T1, by 2.36-fold at T2, and by 1.42-fold at T3. Similarly, brushing with a Test 2 toothpaste reduced the SARS-CoV-2 salivary viral load by 2.33-fold at T1, by 2.38-fold at T2, and by 0.77-fold at T3. CONCLUSIONS: Immediately after brushing, the use of antimicrobial toothpastes reduced the salivary viral load of patients with COVID-19. The trial was registered on https://clinicaltrials.gov/ (NCT04537962).

Oral lesions and saliva alterations of COVID-19 patients in an intensive care unit: A retrospective study.

AIM: To detect the type and frequency of oral lesions and clinical conditions suggestive of saliva alterations in COVID-19 patients in an intensive care unit (ICU), as well as to describe the patient´s management in each case METHODS: Information about oral conditions and mechanical ventilation was collected from oral medicine records of COVID-19 patients in an ICU (n = 519) RESULTS: From the total collected, 472 patients (90.9%) were examined by the oral medicine staff. In 242/472 patients (51.3%), alterations in the oral cavity were noted. The most frequent changes were mechanical trauma (18.1%, derived mainly from intubation), vascular/coagulation disturbances (24.1%, petechiae, bruises, varicoses, and oral bleeding), and saliva alterations (24.4%, dry mouth, and sialorrhea). Infectious lesions were mentioned in the oral medicine records (16.9%), most associated with a viral infection (15.7%), mainly herpesvirus. Improved oral change protocols included oral hygiene, use of specific medications, and laser therapy CONCLUSION: COVID-19 patients in the ICU often showed dryness in the oral and mucosa oral lesions related to vascular/coagulation disturbances, and mechanical trauma derived from orotracheal tube. An oral medicine staff must be aligned with the ICU multidisciplinary team to manage COVID-19 patients, as well as to establish diagnoses and oral cavity treatments.

Oral ulcers and sarcoid-like reaction in lymph nodes after cemiplimab therapy for locally advanced cutaneous squamous cell carcinoma: a case report.

Cemiplimab is a novel programmed death-1 inhibitor recently approved for advanced cutaneous squamous cell carcinoma. Immune-related adverse events derived from cemiplimab are similar to other anti-PD-1 drugs, including gastrointestinal and cutaneous toxicities. Oral immune-related adverse events were not reported with cemiplimab in previous studies; thus this case report warns of the fact that the oral cavity may be a site of immune-related adverse events during programmed death-1 block therapy and that this can lead to significant limitations when not properly treated. The present report describes the case of a patient with locally advanced cutaneous squamous cell carcinoma metastatic to cervical lymph nodes who developed dysphagia due to large and painful oral ulcers after a single dose of cemiplimab. The patient also exhibited a sarcoid-like reaction in mediastinal lymph nodes. No immune-related adverse events were found in any other organs. The oral lesions showed significant improvement after topical and short-course systemic corticosteroids, and low-level laser therapy was also performed in the oral lesions. The patient achieved a near-complete response and treatment was discontinued. This article discusses in detail the clinical outcomes and oral toxicity management of cemiplimab therapy for cutaneous squamous cell carcinoma.

Severe oral ulcerative and lichenoid lesions associated with adrenal insufficiency in a patient treated with nivolumab: Report of a case and review of literature.

Nivolumab, an antibody against anti-programmed death type 1, has been used for treatment of advanced non-small cell lung cancer with improvement of overall survival. Usually, diarrhea, cutaneous rash, and pruritus are reported as the most common immune-related adverse effects of nivolumab therapy. Oral lesions and secondary adrenal insufficiency sometimes occur but usually are rare events. We report a case of a patient treated with nivolumab who then showed persistent oral ulcerative and lichenoid lesions, which were refractory to topical corticosteroids. The oral lesions were concomitant to nivolumab-induced adrenal insufficiency. These adverse events led to nivolumab discontinuation, which favored oral lesion healing and adrenal insufficiency remission. Through a brief review of the literature concerning nivolumab toxicity in the oral cavity, we discuss the clinical aspect and management of these lesions.

Self-collected unstimulated saliva, oral swab, and nasopharyngeal swab specimens in the detection of SARS-CoV-2.

OBJECTIVES: The presence of SARS-CoV-2 virus in the saliva of patients infected with COVID-19 has been confirmed by several studies. However, the use of saliva for the diagnosis of COVID-19 remains limited, because of the discrepancies in the results, which might be due to using different saliva sampling methods. The purpose of this study was to compare the consistency of SARS-CoV-2 detection using two different saliva sampling methods (oral swab and unstimulated saliva) to that of the standard nasopharyngeal swab. METHODS: Fifty-five subjects were recruited from a pool of COVID-19 inpatient at the Hospital Israelita Albert Einstein (HIAE), Brazil. Nasopharyngeal swab, oral swab, and self-collected unstimulated saliva samples were examined for SARS-CoV-2 using RT-PCR. RESULTS: Self-collected unstimulated saliva demonstrated 87.3% agreement in the detection of SARS-CoV-2 virus as compared with the nasopharyngeal swab, while oral swab displayed 65.9% agreement when compared to nasopharyngeal swab and 73% when compared to self-collected unstimulated saliva. CONCLUSION: Unstimulated self-collected saliva samples have shown a higher agreement with the nasopharyngeal swab samples for SARS-COV-2 detection than that obtained when using oral swab samples. CLINICAL RELEVANCE: This study compares the accuracy of COVID-19 test using different saliva sampling methods to that of nasopharyngeal swab. Given the need for a simple self-applied test that can be performed at home, our findings support the efficacy of self-collected unstimulated saliva samples in the diagnosis of SARS-CoV-2 infection, alleviating the demands for swab supplies, personal protective equipment, and healthcare personnel.

Oral ulcers and sarcoid-like reaction in lymph nodes after cemiplimab therapy for locally advanced cutaneous squamous cell carcinoma: a case report

ABSTRACT Cemiplimab is a novel programmed death-1 inhibitor recently approved for advanced cutaneous squamous cell carcinoma. Immune-related adverse events derived from cemiplimab are similar to other anti-PD-1 drugs, including gastrointestinal and cutaneous toxicities. Oral immune-related adverse events were not reported with cemiplimab in previous studies; thus this case report warns of the fact that the oral cavity may be a site of immune-related adverse events during programmed death-1 block therapy and that this can lead to significant limitations when not properly treated. The present report describes the case of a patient with locally advanced cutaneous squamous cell carcinoma metastatic to cervical lymph nodes who developed dysphagia due to large and painful oral ulcers after a single dose of cemiplimab. The patient also exhibited a sarcoid-like reaction in mediastinal lymph nodes. No immune-related adverse events were found in any other organs. The oral lesions showed significant improvement after topical and short-course systemic corticosteroids, and low-level laser therapy was also performed in the oral lesions. The patient achieved a near-complete response and treatment was discontinued. This article discusses in detail the clinical outcomes and oral toxicity management of cemiplimab therapy for cutaneous squamous cell carcinoma.

Oral care and photobiomodulation protocol for the prevention of traumatic injuries and lip necrosis in critically ill patients with COVID-19: an observational study.

It is well reported that severe cases of COVID-19 frequently need critical care in the ICU to manage respiratory complications, often requiring orotracheal intubation (OTI). Due to complex systemic conditions, the patient may remain intubated for a long period of time and be placed in prone position. This positioning and the pressure of the intubation device on the lips may lead to the development of traumatic injuries. Oral care and the use of photobiomodulation (PBM) can be successfully implemented to promote oral mucosa healing and prevent soft tissue necrosis. We describe the outcomes of the management protocol that was routinely used by the ICU oral medicine team, leading to the implementation of a preventive protocol for the OTI-related oral injuries. We retrospectively analyzed the records of 472 patients with COVID-19 in the ICU from May 2020 to February 2021. 60/472 patients developed traumatic injuries and were managed with the oral care protocol and PBM, to prevent the progress to lip necrosis. When appropriated, in addition to oral care and PBM, other measures were taken to prevent further local trauma (lip hydration, changes in tube fixation). The proposed oral care protocol associated with PBM successfully prevented the progress of traumatic lesions, ulceration, necrosis, and loss of tissue associated with IOT. The quality of life of patients in the ICU and after their recovery was preserved.