Screening Mouth for Chronic GVHD
Below are clinical manifestations that are potential early indicators of chronic GVHD of the mouth. If GVHD is suspected, timely collaboration with the patient’s transplant center is recommended to confirm the diagnosis and to develop and evaluate a treatment plan.
These guidelines are based on published diagnostic criteria from the National Institutes of Health (NIH) Consensus Development Project on chronic GVHD. [1,2,3]
Clinical Examination
- Visual inspection of the entire mouth
Diagnostic Testing
- Oral biopsy
Patient-Reported Symptoms and Signs
- Dryness
- Chapped lips
- Ulcers
- Swelling, redness, pain, and/or bleeding of gums
- Sensitivity to spicy foods, toothpaste, or carbonated drinks
- Pain
Possible Manifestations
Lichen Planus-Like Changes
Hyperkeratotic white lines and lacy-appearing lesions on the buccal mucosa and tongue, palate or lips
Xerostomia*
Abnormal dryness of the mouth
Mucoceles*
Vesicle-like or raised masses due to minor salivary gland inflammation and damage
Mucosal Atrophy*
Thinning of mucosal tissue
Pseudomembranes*
Loosely adherent fibrinous exudate on the surface of a mucous membrane
Ulcers*
Open sore inside mouth caused by a break in mucous membrane or epithelium on lips or surrounding mouth
Erythema***
Severity of erythema or "redness" can vary from mild to severe
Gingivitis***
Mucosal fiber damage causes smooth/inflamed gingival surface, in contrast to the dimpled or stippled appearance of normal gingivae. Entire width of the attached gingivae will be erythematous
Mucositis***
Inflammation of mucous membrane
Pain***
Notes
* Distinctive but insufficient alone to establish an unequivocal diagnosis of chronic GVHD without further testing or additional organ involvement
** Rare, controversial, or non-specific features of chronic GVHD
*** Common in both acute and chronic GVHD
References
- Jagasia MH, Greinix HT, Arora M, et al. National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease: I. The 2014 Response Criteria Working Group Report. Biol Blood Marrow Transplant. 2015; 21(3): 389-401.
- Lee SJ, Wolff D, Kitko C, et al. Measuring therapeutic response in chronic graft-versus-host disease. National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease: IV. The 2014 Response Criteria Working Group Report. Biol Blood Marrow Transplant. 2015; 21(6): 984-999.
- These guidelines have been developed by the National Marrow Donor Program® (NMDP)/Be The Match® in consultation with Sandra A. Mitchell, CRNP, MScN, AOCN; National Institutes of Health Clinical Center; and Steven Z. Pavletic, M.D.; National Cancer Institute, National Institutes of Health, Bethesda, Md. The information in this document does not represent the official position of the NIH or the U.S. Government.
Additional review from:
- Dennis L. Confer, M.D., NMDP/Be The Match, Minneapolis, Minn.
- Linda J. Burns, M.D., NMDP/Be The Match, Minneapolis, Minn.
- Madan Jagasia, M.D., Vanderbilt University Medical Center, Nashville, Tenn.
- Stephanie J. Lee, M.D., Fred Hutchinson Cancer Research Center, Seattle, Wash.
Text adapted from reports of the NIH Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease from Biology of Blood and Marrow Transplantation by American Society for Blood and Marrow Transplantation. Reproduced with permission of Elsevier, Inc.
Photo Credits
- Photos/ Keratosis Pilaris; Lichen Planus-like; Hypopigmentation; Sclerosis; Erosion; Maculopapular: Maria L. Turner, M.D.; Edward W.Cowen, M.D.; Dermatology Branch, National Cancer Institute, NIH, Bethesda, Md.
- Photos/ Poikiloderma; Morphea; Lichen Planus-like; Lichen Sclerosus-like; Hyperpigmentation; Sclerosis; Nail dystrophy; Alopecia; Edema: Edward W. Cowen, M.D.; Dermatology Branch, National Cancer Institute, NIH, Bethesda, Md.
- Photos/ Lichen planus; Mucoceles; Erythema: Mark M. Schubert, D.D.S., M.S.D.; Fred Hutchinson Cancer Research Center, Seattle, Wash.
- Photo/ Keratoconjunctivitis: Mary E.D. Flowers, M.D.; University of Washington, Seattle, Wash.
- Photo/ Blepharitis: Janine A. Smith, M.D.; National Eye Institute, NIH, Bethesda, Md.
All photos used with permission.