Graft-versus-host disease (GVHD) can lead to many physical and psychological complications that persist for months or years after allogeneic stem cell transplantation (SCT). Likewise, patients who receive a transplant at a young age may continue to experience GVHD symptoms decades later. Many late complications, like oral chronic GVHD (cGVHD), can significantly impact quality of life and activities of daily living. Oncology nurses have a critical role in identifying patient needs, providing education and support, and helping facilitate appropriate referrals.
To better understand oral cGVHD, Tanem and colleagues from Oslo University Hospital (OUH) in Norway investigated the prevalence, symptoms, and characteristics of oral cGVHD in patients treated at a young age (<30 years at transplantation) more than 5 years after allogeneic SCT without total body irradiation (TBI) as part of the conditioning regimen. This research was part of a large, national multidisciplinary Norwegian Allo Survivorship study (AlloSS-young) inclusive of patients treated for malignant and nonmalignant conditions.
The investigators included data from 94 participants who underwent an allogeneic SCT for leukemia, lymphoma, or a nonmalignant condition at OUH between April 1974 and August 2009. The mean age at transplant was 17.5 years, and the mean follow-up since transplant was 16.7 years. Most survivors were treated for blood cancer with busulfan and cyclophosphamide myeloablative conditioning regimen.
Participants went through a semi-structured interview conducted by a Norwegian dentist asking about xerostomia (dry mouth) and dysgeusia (taste changes):
- “Does your mouth often feel dry?”
- “[Do] food and beverages taste [differently] after treatment?”
- “Do you experience alterations in the sense of taste?”
In addition, a dentist performed a thorough oral examination with clinical photographs of the oral mucosa. If the participant admitted to dry mouth, the mirror friction test was used to screen for saliva lubrication. This test simply involves dragging a dental mouth mirror over the buccal mucosa to test for friction. Finally, cotton swabs over 2 oral sites were tested for fungal infection.
In this study, 26 (28%) of the 94 long-term survivors were diagnosed with oral cGVHD. The majority of patients who had oral cGVHD also had cGVHD in another organ (77% vs 29%, p < 0.001). No relations were seen between gender, age at transplantation, age at oral examination, follow-up time, diagnosis, conditioning regimen, history of acute GVHD, donor type, and the occurrence of oral cGVHD.
Among all participants of the study, oral candidiasis was diagnosed in 4 (4.3%) long-term survivors. In addition, 22% reported dysgeusia, and 46% reported xerostomia even 5 years after transplant. Researchers suggest that it is unclear whether there is an association between the presence of oral cGVHD and taste disturbances. Limitations of the study include lack of a pre-transplant baseline oral exam, influence of diet and tobacco, and lack of a control group.
Implications for Oncology Nurses
All oncology nurses can glean information from this research when assisting with transplant survivorship care, both at the transplant center and the referring oncologists, given that almost one third of long-term survivors had oral cGVHD, which can significantly affect oral health-related quality of life. Oral cGVHD can lead to severe pain causing problems with eating, drinking, and talking. Living with these complications is a significant challenge for survivors and their loved ones as these are primary activities of daily living. With early identification of complications, nurses can advocate for patient consultation with an oral health care professional to alleviate symptoms and improve quality of life.