Diagnostic and Management Practices for Oral Chronic Graft-Versus-Host Disease (cGVHD)

2012    The Oral Care Study Group conducted a study on the diagnosis and treatment of oral chronic graft-versus-host disease (cGVHD). The study was designed to assess common practices, as well as to determine use of the National Institute of Health scale for the diagnosis and grading of oral cGVHD. The project was headed by Sharon Elad, DMD, MSc, Eastman Institute for Oral Health, University of Rochester Medical Center.

A survey was distributed to Oral Care Study Group and MASCC/ISOO members in order to identify medical centers with experience in managing patients with oral cGVHD. The structured survey contained questions about the respondents’ demographics, whether or not they treat oral cGVHD, evaluation tools, diagnostic aids, topical treatments, and preventive measures. Seventeen MASCC/ISOO members responded to the survey, 12 of whom reported that they treat oral cGVHD patients on a regular basis. Of these 12, 6 practice in the US, and 6 practice in Europe. Eleven of the 12 are dentists. 

Of these 12 respondents, 75% did not use biopsy to diagnose oral cGVHD. This is consistent with NIH guidelines, which consider clinical observation of oral lesions sufficient for diagnosing oral cGVHD. The first-line topical treatment for oral mucosal cGVHD was predominantly steroids (91.7 %), and the second preferred topical treatment was tacrolimus (41.7 %). The preferred treatment for hyposalivation was systemic pilocarpine (41.7 %). Most practitioners recommend regular topical fluoride use for prevention of dental caries and most recommend an oral cancer screening protocol. While the recommended frequency varied, 50% suggested a follow-up every 6 months. 

This study also sought to assess the level of implementation of existing cGVHD diagnostic and assessment tools. The results showed that 42% of represented sites have adopted the NIH guideline approach for diagnosis of oral cGVHD. Most clinics use a standard tool for evaluating symptoms, but not for evaluating clinical signs of oral cGVHD. And the NIH scale for grading response is not used routinely by most responders. The use of standard assessment tools would facilitate data collection across medical centers, thereby allowing for conclusions regarding optimal management. 

Although the number of respondents was small, the study provides a snapshot of current practice among a specialized group of professionals with expertise in this disease. The study highlights the importance of standardizing assessment methods across clinics, which would enable standard data collection, thereby allowing for conclusions regarding optimal diagnosis and management of oral cGVHD.

For full results of the study, see: Elad S, Jensen SB, Raber-Durlacher JE, Mouradian N, Correa EM, Schubert MM, Blijlevens NM, Epstein JB, Saunders DP, Waltimo T, Yarom N, Zadik Y, Brennan MT. Clinical approach in the management of oral chronic graft-versus-host disease (cGVHD) in a series of specialized medical centers. Supportive Care Cancer, 2014 Nov 23. [Epub ahead of print]

The authors would like to acknowledge the support of the Oral Care Study Group and its Chair, Dr. Siri Beier Jensen, DDS, PhD, and also thank the members who participated in this study.

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