Although any site of the alimentary tract may be affected from the adverse effects, OM has drawn most of the interest in this topic. It is well known that OM is associated with significant morbidity and may have a role in increased mortality (1). However, evidence-based treatment options for OM are limited, thus primary prevention is more important (1, 11). Prediction of duration and severity of OM and determination of important risk factors in every patient may facilitate providing of individualized preventive precautions and management for OM. Although certain parameters have been suggested as risk factors for mucositis, including poor oral health, low body mass index, extremes of age, and female sex, none has been consistent or accurate (12).
While recent data underscore the importance of certain genetic factors in the pathogenesis of OM (12), the association of HLA phenotype and OM has drawn little attention. To the best of our knowledge, only one recent study reported that low levels of HLA-DRB1 and HLA-DRB5 expression were associated with a more severe OM in patients with multiple myeloma who underwent high-dose melphalan treatment (13). The authors concluded that expression levels of HLA-DRB1 and HLA-DRB5 may serve as potential predictive biomarkers for mucositis severity. Thus, we aimed to evaluate the association of HLA phenotype and OM risk in patients undergoing allogeneic HSCT.
Inflammatory bowel diseases are chronic immunologically mediated diseases of the gut mucosa. Some clinical features of Crohn's disease and ulcerative colitis may be influenced by specific HLA-DR alleles. Behçet's disease is a chronic multisystem inflammatory disorder characterized mainly by recurrent oral ulcers, ocular involvement, genital ulcers, and skin lesions, presenting with remissions and exacerbations. It is thought that both environmental and genetic factors contribute to its onset and development. Apart of positive association with HLA-B*51, additional independent associations with HLA-B*15, -B*27, -B*57, and -A*26 have been shown as risk factors for Behçet's disease, while HLA-B*49 and -A*03 may be protective from Behçet's disease (14). In IBDs and Behçet’s disease mucositis is a manifestation of the disease and it responds to immunosuppressive therapy. Contrarily, OM develops in association with immunosuppressive therapy in patients undergoing HSCT. Although the pathogenesis of mucositis may be different in inflammatory disease and after HSCT, it may be speculated that development of mucosal inflammation in HSCT may also have an association with certain HLA phenotypes. Our study suggested some possible associations between HLA phenotypes and duration and severity of OM. In patients having HLA alleles A23, B44, DR15, and DR11, OM was milder and OM duration was shorter. In contrast, in patients with HLA alleles A26 and B52, OM was more severe and OM duration was longer. Regression analysis suggests that HLA-B44, HLA-DR11, and HLA-A23 may be independently associated with milder OM.
Data regarding influence of age and gender on the OM development is conflicting (3, 5, 15, 16). Our study population was in general young and the age range was relatively narrow. Thus it is not possible to make clear conclusions about the age effect on OM risk. We did not found any association of OM and sex.
The CR in our study was primarily myeloablative, which was associated with a significantly longer OM duration and a non-significant increase in the severity of OM. Therefore, CR could be a confounding factor in our study. Most of HSCT indications were acute leukemia (57.7%). So it is not possible to make an interpretation about the risk of OM and underlying diagnosis.
Frequency of febrile neutopenia was similar in patients with mild or severe OM. Duration and severity of OM did not show any correlation with GVHD. There are studies having similar results with our study (17–19) whereas there are also studies showing correlation (18–20).
OM duration and severity correlated with neutrophil engraftment. This finding is in accordance with the fact that neutrophil quantity and quality may be important in mucosal defense and recovery. Our findings regarding association of myeloablative regimen and prolonged neutropenia with longer duration of OM were consistent with previous reports (1, 3–5, 21).
Source of HSCT (PB or BM) was not found associated with OM duration or severity. Although neutrophil engraftment occurred earlier in patients with PB-derived HSCT, OM duration was not shorter. This finding indicates that solely earlier recovery from neutropenia may not result in a better course of OM and other factors also influence the course of OM. Some studies suggest more severe OM after BM-derived HSCT compared to PB-derived HSCT (22). However, in this study, NET was significantly faster in the PB-derived HSCT group which may account for the difference between the rates of severe OM in both groups.
To our knowledge, WTMS was not used previously in the literature and provided some important information in our study. Utilization of WTMS in more detailed and larger studies are needed to assess its validity and importance better.
The limitations of our study were the small sample size which might result in underestimation of some potentially important risk factors for OM. The lack of reference studies in the literature also shadows our findings’ importance. It is not possible to reach strict conclusions about the association between mucositis and HLA alleles and there is need for larger scale studies in which more homogenous patients and treatment modalities are investigated. In this regard, the small numbers of patients in HLA allele groups may be associated with type II error. We could not determine the effect of MTX on OM or HLA alleles because all but one patient received MTX treatment for GVHD prophylaxis. We think that dental hygiene was not a significant confounder in our study because all patients had dental health management by the same dentist team. However, we did not check if the patients complied with oral self-care measures and this may still be a confounding factor.
All patients were recommended to cease smoking two months before HSCT. However we do not have data about smoking status of the study population. Thus, we could not assess the influence of smoking on OM in our study.
Furthermore, influence of individual pain threshold, concomitant infections and experience of the observer on assessment of OM grade and lack of features like xerostomia, tastelessness and dysphagia in the WHO scale may have affected accurate assessment of OM. Thus it is hard to make further interpretations.