Cirurgia Guiada para Instalação de Implantes em Paciente Submetido à Radioterapia em Região de Cabeça e Pescoço / Guided Surgery for Implant Surgery in a Patient Undergoing Radiotherapy in Head and Neck Region / Cirugía Guiada para la Colocación de Implantes en Pacientes Sometidos a Radioterapia en la Región de la Cabeza y el Cuello

Introdução: O uso dos implantes osseointegrados para reabilitação de pacientes com dificuldade de adaptação de próteses convencionais mostra-se mais frequente a cada dia. Um grande grupo candidato à reabilitação com essa modalidade são os pacientes tratados para as neoplasias de cabeça e pescoço (CP). A irradiação na região de CP pode ser limitante para a instalação de implantes, porém a literatura apresenta evidências de técnicas e planejamentos favoráveis ao procedimento nesse grupo de pacientes. As técnicas menos traumáticas para intervenções na cavidade oral devem ser avaliadas, e os guias cirúrgicos para colocação de implantes podem ser aliados nesses procedimentos. Relato do caso: Paciente do sexo feminino, 64 anos, tratada com cirurgia, quimioterapia e radioterapia em cavidade oral para um carcinoma espinocelular (CEC) em língua e, em um segundo momento, diagnosticada e tratada com cirurgia para CEC em região de rebordo alveolar maxilar esquerdo por meio de hemipalatecmia, necessitava de reabilitação com implantes osseointegrados na região onde havia sido tratada com radiação primariamente. Realizou-se a cirurgia de colocação dos implantes com a tecnologia guiada para acarretar o mínimo trauma às estruturas bucais. Conclusão: O procedimento cirúrgico foi executado com sucesso. Atualmente, aguarda-se o período de osseointegração para a posterior reabilitação protética

Introduction: The use of osseointegrated implants for the rehabilitation of patients with difficulty fitting conventional prostheses is becoming more frequent every day. A great eligible group for rehabilitation with this modality are patients treated for head and neck cancer (HNC). Irradiation in the region of HN may be limiting for implants, but there are evidences in the literature of techniques and planning favorable to the procedure in this group of patients. Less traumatic techniques for interventions in the oral cavity should be evaluated, and surgical guides for implant placement may be allies in these procedures. Case report: A 64-year-old female patient, treated with surgery, chemotherapy and radiotherapy in the oral cavity for a squamous cell carcinoma (SCC) in the tongue and, in a second moment, diagnosed and treated with surgery for SCC in the region of the left maxillary alveolar ridge by means of hemipalatectomy, needed rehabilitation with osseointegrated implants in the region where she had been primarily treated with radiation. The implant placement surgery was then planned and performed using guided technology so that minimal trauma to the oral structures could occur. Conclusion: The surgical procedure was successfully performed, and the patient is now waiting for the osseointegration period for posterior prosthetic rehabilitation

Introducción: El uso de implantes osteointegrados para la rehabilitación de pacientes con dificultades de adaptación de las prótesis convencionales es cada vez más frecuente. Un gran grupo de candidatos a la rehabilitación con esta modalidad son los pacientes tratados por neoplasias de cabeza y cuello (CC). La irradiación en la región del CC puede ser limitante para la instalación del implante, sin embargo, la literatura presenta evidencias de técnicas y planificación favorables al procedimiento en este grupo de pacientes. Deben evaluarse técnicas menos traumáticas para las intervenciones en la cavidad oral, y las guías quirúrgicas para la colocación de implantes pueden ser un aliado en estos procedimientos. Caso clínico: Paciente de 64 años, mujer, tratada con cirugía, quimioterapia y radioterapia en la cavidad oral por un carcinoma de células escamosas (CCE) en la lengua y en un segundo momento diagnosticada y tratada con cirugía por CCE en la región de la cresta alveolar maxilar izquierda mediante hemipalatectomía, necesitó rehabilitación con implantes osteointegrados en la región donde había sido tratada principalmente con radiación. La cirugía de colocación de implantes se realizó con tecnología guiada para causar el menor traumatismo en las estructuras orales. Conclusión: La intervención quirúrgica se llevó a cabo con éxito. Actualmente se espera el periodo de osteointegración para la posterior rehabilitación protésica

Mandibular radiomorphometric assessment of bone mineral density in survivors of pediatric hematopoietic stem-cell transplantation

OBJECTIVE: Hematopoietic stem-cell transplantation (HSCT) childhood survivors of hematologic malignancies are prone to develop late osteopenia and osteoporosis. The purpose of this retrospective study was to quantitatively and qualitatively assess bone mineral density (BMD) in HSCT childhood survivors and to compare the effectiveness of both qualitative and quantitative assessment methods. METHODS: DESIGN BMD assessment using panoramic radiographs of childhood HSCT survivors aged 3.69-18.88 years using two radiomorphometric indexes. Case-control double-blinded comparison of panoramic radiographic images from childhood HSCT survivors and age- and sex-matched healthy controls. Quantitative assessment was performed by measuring the cortical bone width bilaterally at the mental foramen level. Qualitative assessment was performed using the mandibular cortical index bilaterally on all panoramic images. RESULTS: Radiographs were taken 6.59-83.95 months after bone marrow transplantation [median±SD=25.92±24.9 months]. Fifty-two panoramic radiographic images were analyzed: 21 from HSCT survivors and 31 from healthy controls aged 3.69-25.1 years [mean±SD=11.89±5.28 years]. The mandibular cortical bone width was 17% smaller in childhood HSCT survivors than in healthy controls (case group: 2.420, control group: 3.307; p=0.00617). Qualitative analysis revealed an increased frequency of severe mandibular cortical erosion in childhood HSCT survivors, although no significant difference was observed (case group: 1.540, control group: 1.490; p=0.32). The interobserver agreement was 85% (Kappa index). CONCLUSIONS: HSCT childhood survivors exhibit quantitative and qualitative mandibular bone impairments. Further studies are needed to establish an association between mandibular cortical bone impairment and osteoporosis.

Long-term dental follow-up in hematological stem cells transplantation children / Acompanhametnto a longo prazo das alterações dentárias em pacientes pediátricos submetidos ao transplante de celulas tronco hematopoieticas

The aim of this paper is to update the current published content about the craniofacial long-term development disturbances of childhood hematopoietic stem-cell transplantation (HSCT) and the preparative regimens for the onco-hematological malignancies treatments. Methods: Two author sindependently reviewed the published articles about long-term effects of childhood HSCT that fitted into predetermined inclusion/exclusion criteria: clear definition of exposure or intervention, standard outcomes measurement and appropriate statistical analysis. Results: Twelve papers matched all the previous established eligibility criteria and were included in this review. The children’s age at HSCT were related to a higher risk of dental development disturbances, such as agenesis, dental hypoplasia, root stunting, crown-root proportion alterations, and microdontia. Craniofacial vertical growth was impaired in the irradiated patients without antero-posterior or latero-lateral impairment. Temporomandibular joint dysfunction was found to be more prevalent in the patients diagnosed withgraft-versus-host disease. Conclusion: The late effects of craniofacial development disturbances lead to several aesthetic and functional impairment, periodontal bone resorption with consequent impairment of chewing ability, and risk of early tooth loss often associated with life’s quality impairment. Further investigations should be performed to provide accurate information for patients, parent sand health care professionals...

Este artigo visa revisar o conteúdo publicado sobre as alterações tardias em crianças submetidas ao transplante de células-tronco hematopoiéticas(TCTH) e o regime pré-transplante para tratamento das doenças onco-hematológicas. Método: Dois autores independentes conduziram uma revisão simples dos artigos recentemente publicados sobre o tema, utilizando os critérios de exclusão/inclusão pré determinados: definição clara da intervenção clínica realizada, mensuração dos resultados padronizada e análise estatística adequada. Resultados: Doze artigos enquadraram-se em todos os critérios de avaliação pré-determinados para esta revisão. Houve correlação entre a idade da criança no momento do TCTH e maior risco de distúrbios de desenvolvimento dentário, como agenesia, hipoplasia dentária, encurtamento radicular,alterações da proporção coroa-raiz e microdontia.Houve alteração do crescimento craniofacial no sentido vertical sem, no entanto, alterar o crescimento anteroposterior e latero-lateral. Disfunção da articulação temporomandibular foi mais prevalente entre os pacientes com diagnostico de Doença do Enxerto contra o Hospedeiro. Conclusão: Os efeitos tardios do desenvolvimento craniofacial podem levara diversas alterações estéticas e funcionais, reabsorção óssea periodontal, diminuição da capacidade de mastigação e perda dentária precoce com possíveis impactos negativos sobre a qualidade de vida. Mais estudos são necessários para fornecer informações precisas aos pacientes, cuidadores e profissionais de saúde...

Analysis of the feasibility of early hospital discharge after autologous hematopoietic stem cell transplantation and the implications to nursing care

INTRODUCTION: Autologous hematopoietic stem cell transplantation is a conduct used to treat some hematologic diseases and to consolidate the treatment of others. In the field of nursing, the few published scientific studies on nursing care and early hospital discharge of transplant patients are deficient. Knowledge about the diseases treated using hematopoietic stem cell transplantation, providing guidance to patients and caregivers and patient monitoring are important nursing activities in this process. Guidance may contribute to long-term goals through patients' short-term needs. AIM: To analyze the results of early hospital discharge on the treatment of patients submitted to autologous transplantation and the influence of nursing care on this conduct. METHODS: A retrospective, quantitative, descriptive and transversal study was conducted. The hospital records of 112 consecutive patients submitted to autologous transplantation in the period from January to December 2009 were revisited. Of these, 12 patients, who remained in hospital for more than ten days after transplantation, were excluded from the study. RESULTS: The medical records of 100 patients with a median age of 48.5 years (19-69 years) were analyzed. All patients were mobilized and hematopoietic stem cells were collected by leukapheresis. The most common conditioning regimes were BU12Mel100 and BEAM 400. Toxicity during conditioning was easily managed in the outpatient clinic. Gastrointestinal toxicity, mostly Grades I and II, was seen in 69% of the patients, 62% of patients had diarrhea, 61% of the patients had nausea and vomiting and 58% had Grade I and II mucositis. Ten patients required hospitalization due to the conditioning regimen. Febrile neutropenia was seen in 58% of patients. Two patients died before Day +60 due to infections, one with aplasia. The median times to granulocyte and platelet engraftment were 12 days and 15 days, respectively, with median...

Histopathologic diagnosis of chronic graft-versus-host disease of the oral mucosa according to the National Institutes of Health Consensus / Diagnóstico histopatológico da doença do enxerto contra hospedeiro crônica da mucosa oral conforme Consenso do National Institutes of Health

Objective To validate the minimal criteria of the histopathologic diagnosis of oral chronic graft-versus-host disease, based on the histopathologic classification of the National Institutes of Health and correlate them with clinical features. Methods Forty-one specimens containing both oral mucosa and salivary glands were analyzed in slides stained with hematoxylin-eosin. The histological specimens were blindly examined by two trained pathologists using criteria recommended for the histopathologic diagnosis of chronic graft-versus-host disease proposed by the National Institutes of Health Consensus. The clinical classification of chronic graft-versus-host disease was correlated with analysis of slides. Results: Our data showed that the epithelium was involved in 39/41 specimens, presenting acanthosis (29/70.7%), exocytosis of lymphocytes (29/70.7%), thickening of basal lamina (29/70.7%), and apoptosis (15/36.6%). Connective tissue presented interstitial inflammatory infiltrate (38/92.7%). Minor salivary glands showed periductal fibrosis (38/92.7%), mixed periductal inflammatory infiltrate (32/78%), ductal ectasia (30/73.2%), lymphocytes around and into acinar units (30/73.2%), and interstitial fibrosis (29/70.7%). The most common clinical manifestations were lichenoid aspect (40/97.6%), complaints of sensitivity to oral feeding (38/92.7%), and dry mouth sensation (36/87.8%). Conclusion This study validated the National Institutes of Health Consensus of minimal histologic criteria for diagnosis of oral chronic graft-versus-host disease and has not found an association between the severity of clinical manifestation and the histopathological stage. .

Objetivo Validar os critérios mínimos de diagnóstico histopatológico da doença do enxerto contra hospedeiro crônica oral, com base em critérios de classificação do National Institutes of Health, e correlacioná-los com as características clínicas. Métodos Quarenta e um espécimes contendo mucosa oral e glândulas salivares foram analisados em lâminas coradas por hematoxilina-eosina. Os espécimes histológicos foram avaliados de forma cega, por dois patologistas calibrados, utilizando os critérios recomendados para diagnóstico histopatológico de doença do enxerto contra hospedeiro crônica propostos pelo Consenso do National Institutes of Health. A classificação clínica da doença do enxerto contra hospedeiro crônica foi correlacionada após a análise das lâminas. Resultados Nossos resultados mostraram que o epitélio estava comprometido em 39/41 espécimes, apresentando acantose (29/70,7%), exocitose de linfócitos (29/70,7%), espessamento da lâmina basal (29/70,7%) e apoptose (15/36,6%). O tecido conjuntivo apresentou infiltrado inflamatório intersticial em 38 (92,7%) casos. Nas glândulas salivares menores, observaram-se fibrose periductal (38/92,7%), infiltrado inflamatório periductal misto (32/78%), ectasia ductal (30/73,2%), linfócitos em torno e migrando para dentro dos ácinos (30/73,2%), e fibrose intersticial (29/70,7%). As manifestações clínicas mais comuns foram mucosa de aspecto liquenoide (40/97,6%), queixa de sensibilidade bucal ao se alimentar (38/92,7%), e sensação de boca seca (36/87,8%). Conclusão Os critérios mínimos para o diagnóstico histopatológico da doença do enxerto contra hospedeiro crônica oral, com base no Consenso do National Institutes of Health, foram ...

Oral health as a predictive factor for oral mucositis

OBJECTIVES: Oral mucositis is a complication frequently associated with hematopoietic stem cell transplantation, decreasing a patient's quality of life and increasing the occurrence of opportunistic infections. The purpose of this study was to determine the incidence and severity of oral mucositis and to assess the correlation of this disease with the oral health of an individual at the time of hematopoietic stem cell transplantation. METHODS: Before transplantation, patients' oral health and inflammatory conditions were determined using the gingival index and the plaque index, which are based on gingival bleeding and the presence of dental plaque, respectively. Additionally, the dental health status was determined using the decayed, missing, and filled teeth index. The monitoring of oral mucositis was based on the World Health Organization grading system and was performed for five periods: from Day 0 to D+5, from D+6 to D+10, from D+11 to D+15, from D+16 to D+20, and from D+21 to D+30. RESULTS: A total of 97 patients (56% male and 44% female) who underwent hematopoietic stem cell transplantation at the Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo between January 2008 and July 2009 were prospectively examined. The incidence of ulcerative mucositis was highest from days +6 to +10 and from days +11 to +15 in the patients who underwent autologous and allogeneic hematopoietic stem cell transplantation, respectively. CONCLUSION: The data, including the dental plaque and periodontal status data, showed that these oral health factors were predictive of the incidence and severity of oral mucositis in a cohort of patients with similar conditioning regimens before hematopoietic stem cell transplantation. .

Busulfan and melphalan as conditioning regimen for allogeneic hematopoietic stem cell transplantation in acute myeloid leukemia in first complete remission

BACKGROUND: Allogeneic hematopoietic stem cell transplantation with HLA-identical donors has been established for the treatment of acute myeloid leukemia patients for over 30 years with a cure rate of 50 percent to 60 percent. OBJECTIVES: To analyze the overall survival of patients and identify factors that influence the outcomes of this type of transplant in patients in 1st complete remission who received a busulfan and melphalan combination as conditioning regimen. METHODS: Twenty-five consecutive patients with acute myeloid leukemia were enrolled between 2003 and 2008. The median age was 34 years old (Range: 16 - 57 years). All patients received cyclosporine and methotrexate for prophylaxis against graft-versus-host disease. Median neutrophil engraftment time was 16 days (Range: 7 - 22 days) and 17 days (Range: 7 - 46 days) for platelets. Sinusoidal obstructive syndrome was observed in three patients, seven had grade II acute graft-versus-host disease and one extensive chronic graft-versus-host disease. RESULTS: The overall survival by the Kaplan-Meier method was 48 percent after 36 months with a plateau at 36 months after transplantation. Intensive consolidation with high-dose arabinoside resulted in an improved survival (p-value = 0.0001), as did grade II acute graft-versus-host disease (p-value = 0.0377) and mild chronic graft-versus-host disease (p-value < 0.0001). Thirteen patients died, five due to infection within 100 days of transplant, two due to hemorrhages, one to infection and graftversus-host disease and three relapses followed by renal failure (one) and infection (two). The cause of death could not be determined for two patients. CONCLUSION: The busulfan and melphalan conditioning regimen is as good as other conditioning regimens providing an excellent survival rate.

Autologous hematopoietic stem cell transplantation in classical Hodgkin's lymphoma

BACKGROUND: Hodgkin's lymphoma has high rates of cure, but in 15 percent to 20 percent of general patients and between 35 percent and 40 percent of those in advanced stages, the disease will progress or will relapse after initial treatment. For this group, hematopoietic stem cell transplantation is considered one option of salvage therapy. OBJECTIVES: To evaluate a group of 106 patients with Hodgkin's lymphoma, who suffered relapse or who were refractory to treatment, submitted to autologous hematopoietic stem cell transplantation in a single transplant center. METHODS: A retrospective study was performed with data collected from patient charts. The analysis involved 106 classical Hodgkin's lymphoma patients who were consecutively submitted to high-dose chemotherapy followed by autologous transplants in a single institution from April 1993 to December 2006. RESULTS: The overall survival rates of this population at five and ten years were 86 percent and 70 percent, respectively. The disease-free survival was approximately 60 percent at five years. Four patients died of procedure-related causes but relapse of classical Hodgkin's lymphoma after transplant was the most frequent cause of death. Univariate analysis shows that sensitivity to pre-transplant treatment and hemoglobin < 10 g/dL at diagnosis had an impact on patient survival. Unlike other studies, B-type symptoms did not seem to affect overall survival. Lactic dehydrogenase and serum albumin concentrations analyzed at diagnosis did not influence patient survival either. CONCLUSION: Autologous hematopoietic stem cell transplantation is an effective treatment strategy for early and late relapse in classical Hodgkin's lymphoma for cases that were responsive to pre-transplant chemotherapy. Refractory to treatment is a sign of worse prognosis. Additionally, a hemoglobin concentration below 10 g/dL at diagnosis of Hodgkin's lymphoma has a negative impact on the survival of patients after transplant. As far as we know this relationship has not been previously reported.

Estudo do polimorfismo C677T do gene da metilenotetrahidrofolatoredutase (MTHFR) em pacientes com mucosite do trato gastrointestinal apóstransplante alogênico de medula óssea / Analysis of single nucleotide polymorphisms C677T of methylenetetrahidrofolate reductase (MTHFR) on the development of oral mucositis in allogeneic hematopoietic stem cell transplantation

A mucosite oral, também chamada recentemente de mucosite do tratogastrointestinal, continua sendo um importante efeito colateral que podecomprometer o resultado do transplante de células tronco hematopoéticas. Elapode ocorrer em 100% dos pacientes submetidos ao transplante alogênico decélulas-tronco e a maior incidência neste pode ser atribuída à administração demetotrexate. A ocorrência de mucosite ulcerativa está relacionada ao aumentodos custos hospitalares, a redução da sobrevida em 100 dias e infecçãosistêmica aumentando o risco de sepse. A última década foi muito importantepara a compreensão da mucosite oral, incluindo a predisposição genética dosindivíduos e alterações nas enzimas responsáveis a metabolização dequimioterápicos. Recentemente, o polimorfismo C677T no genemetilenotetrahidrofolato redutase (MTHFR) têm ganhado enfoque na relaçãocom a incidência da mucosite. Esta enzima metaboliza o metotrexate e a ela éatribuída maior ou menor atividade levando a modificações na metabolizaçãodo fármaco. Poucos trabalhos prospectivos e caso-controle são encontrados naliteratura corrente com relação ao polimorfismo C677T e a incidência damucosite. O objetivo deste estudo foi uma análise prospectiva caso-controle darelação do polimorfismo MTHFR C677T com a incidência da mucosite. Alémdisso, a influência da condição de saúde bucal (presença de placa dental einflamação gengival) com a incidência de mucosite oral foi analisada. Foraminseridos 97 pacientes divididos em 2 grupos: 35 pacientes submetidos aotransplante alogênico e 62 pacientes submetidos ao transplante autólogo.

Oral mucositis remains an important side-effect and life-threateningcomplication of hematopoietic stem cell transplantation. It can occurs in 100%of patients underwenting allogeneic stem cell transplantation. The differences inincidence between allogeneic and autologous transplantation may be due tomethotrexate administration in the first. Ulcerative mucositis is related toincrease hospitalar costs, reduced 100-days survival and systemic infectionsleading to sepsis risk. The last decade was very important to the understandingof oral mucositis, including genetics changes in enzymes responsible to drugmetabolization, as the C677T polymorphism in the methylenetethrahidrofolatereductase gene (MTHFR). A prospective evaluation of oral mucositis in relationto the C677T MTHFR polymorphism was done. Also, the influence of oral healthcondition (presence of dental plaque and gingival inflammation) with theincidence of oral mucositis was analyzed. A cohort of 97 patients (35allogeneic-study group and 62 autologous-control group) with median age of41.5 years was evaluated. Conditioning regimen comprised busulfan andmelphalan or becenum based conditioning regimen (BEAM – becenum,etoposide, cytarabin and melphalan. GVHD prophylaxis comprised cyclosporineA plus short course of methotrexate in allogeneic transplantation. No rescuewith folinic acid was done in the methotrexate administration. Results showedthat C677T polymorphism was not significant in the study group compared withcontrol group in predicting incidence and severity of oral mucositis. However,the incidence and severity of oral mucositis was influenced by oral healthcondition. In conclusion, C677T MTHFR polymorphism was not related to oralmucositis, but oral health status was an important factor in developingmucositis. These findings reinforce the importance of a dentist in the...