Oral graft vs host disease: An immune system disorder in hematopoietic cell transplantation

Table 1 Histological grading of oral mucosa and salivary glands according to Horn et al[14]

Grade	Definition
Grade I	Mucosa: Vacuolization of basal cells, moderate lymphocytic infiltrate, moderate epithelial exocytosis Salivary glands: Mild interstitial inflammation
Grade II	Mucosa: Epithelial cells with basal vacuolization and dyskeratotic, necrotic keratinocytes with satellitosis, moderate to heavy lymphocytic infiltrate in the submucosa and moderate epithelial exocytosis Salivary glands: Mild acinar destruction, ductal dilation, squamous metaplasia, mucous pooling, mild fibrosis, duct cell proliferation, periductal lymphocytic infiltrate
Grade III	Mucosa: Focal cleavage between the epithelium and connective tissue, intense lymphocytic infiltrate in the connective tissue, dyskeratotic epithelial cells, lymphocyte exocytosis Salivary glands: Marked interstitial lymphocytic infiltrate. Diffuse destruction of ducts and acini
Grade IV	Mucosa: Separation of epithelium and the connective tissue Salivary glands: Nearly complete loss of acini, dilated ducts, interstitial fibrosis with or without inflammation

Table 2 Minimal criteria for diagnosis of oral chronic graft vs host disease and categories

Category	Definition
Not GVHD	No evidence for GVHD
Possible GVHD	Evidence of GVHD but other possible explanations (e.g., Clinical features that suggest or favor a drug reaction)
Consistent with GVHD	Clear evidence of GVHD with mitigating factors (e.g., Unequivocal evidence of CMV yet abundant apoptotic epithelial changes that are not associated with CMV- infected cells by immunostaining)
GVHD	Unequivocal evidence of GVHD and no further comment necessary (e.g., Inflammation may be minimal despite extensive destruction of the targeted epithelia)

Adapt from Shulman et al[12]. GVHD: Graft vs host disease: CMV: Cytomegalovirus.

Table 3 Shulman et al[12] chronic graft-vs-host disease histologic classification of oral mucosa and salivary glands, according to National Institutes of Health Consensus

Epithelium	Epithelial thickness (normal, atrophic, hyperkeratosis and acanthosis), presence of vacuolization, apoptosis, spongiosis, atypical keratinocytes, exocytosis of lymphocytes, presence of other inflammatory cells and thickening of basal lamina
Lamina propria	Predominant cell type in the inflammatory infiltrate and their distribution in relation to the salivary duct and epithelium
Salivary glands	Lymphocytes within the duct, periductal mixed infiltrate, presence of lymphocytes within the acini, apoptosis in the ducts and acini, periductal fibrosis, acinar cell degeneration, interstitial fibrosis, duct ectasia and loss of polarity of epithelial cells of the duct