Radiation-Induced Oral Mucositis

Baseline gut microbiota composition is associated with oral mucositis and tumour recurrence in patients with head and neck cancer: a pilot study

PURPOSE

Mounting evidence suggests that the gut microbiome influences radiotherapy efficacy and toxicity by modulating immune signalling. However, its contribution to radiotherapy outcomes in head and neck cancer (HNC) is yet to be investigated. This study, therefore, aimed to uncover associations between an individual's pre-therapy gut microbiota and (i) severity of radiotherapy-induced oral mucositis (OM), and (ii) recurrence risk in patients with HNC.

METHODS

In this prospective pilot study, 20 patients with HNC scheduled to receive radiotherapy or chemoradiotherapy were recruited. Stool samples were collected before treatment and microbial composition was analysed using 16S rRNA gene sequencing. OM severity was assessed using the NCI-CTCAE scoring system. Patients were also followed for 12 months of treatment completion to assess tumour recurrence.

RESULTS

Overall, 80% of the patients were male with a median age of 65.5 years. Fifty-three percent experienced mild/moderate OM while 47% developed severe OM. Furthermore, 18% experienced tumour relapse within 1 year of treatment completion. A pre-treatment microbiota enriched of Eubacterium, Victivallis, and Ruminococcus was associated with severe OM. Conversely, a higher relative abundance of immunomodulatory microbes Faecalibacterium, Prevotella, and Phascolarctobacterium was associated with a lower risk of tumour recurrence.

CONCLUSION

Our results indicate that a patient's gut microbiota composition at the start of treatment is linked to OM severity and recurrence risk. We now seek to validate these findings to determine their ability to predict treatment outcomes in HNC, with the goal of using this data to inform second-generation microbial therapeutics to optimise treatment outcomes for patients with HNC.

The Microbiome's Influence on Head and Neck Cancers

PURPOSE OF REVIEW

Head and neck tumors (HNC) rank sixth among cancers worldwide. Due to their late diagnosis and poor prognosis, they are a clinical challenge. However, recent years have seen a dynamic development of science on the microbiome. The aim of the study is to discuss the role of the microbiome in HNC, the impact of the microbiome on oncogenesis, the course of the disease, as well as on treatment, and its toxicity.

RECENT FINDINGS

The microbiome's influence on oncogenesis, the course of the disease, and the effectiveness of oncological treatment have been confirmed in cancers of the colon, pancreas, lungs, and prostate. There is no solid literature on HNC. Many studies indicate disruption of the oral microbiome and periodontal disease as potential cancer risk factors. Disruption of the microbiome increases radiotherapy's toxicity, intensifying radiation reactions. The microbiome plays an important role in cancer. It is a new target in research into new therapies. It may also be a prognostic marker of cancer development. Changes in the composition of the microbiome modulate the effectiveness of oncological treatment. More research is needed on the microbiome and its effects on HNC.

Randomized Control Study of the Effects of Turmeric Mouthwash on Oral Health Status, Treatment-Induced Mucositis, and Associated Oral Dysfunctions Among Patients With Head and Neck Cancer

BACKGROUND

Oral mucositis is the most severe and debilitating adverse effect of cancer treatment, resulting in inadequate nutritional intake, treatment disruptions, and dose alteration, leading to increased hospital costs and decreased tumor control.

OBJECTIVE

The aim of this study was to determine the effectiveness of turmeric mouthwash on oral health status and onset and severity of treatment-induced oral mucositis and associated oral dysfunctions among head and neck cancer patients.

METHODS

A randomized controlled design was adopted (CTRI/2018/06/014367). Turmeric mouthwash was administered to the experimental group (n = 46) and benzydamine mouthwash was given to the control group (n = 46). Oral health status and mucositis were graded using the Oral Health Assessment Tool and the World Health Organization oral toxicity criteria, respectively. Oral dysfunctions were measured by a patient-reported oral mucositis symptom scale and xerostomia short-form inventory. All outcome variables were measured weekly during the entire course of radiation therapy.

RESULTS

Both groups were comparable with regard to their demographic and outcome variables ( P > .05). The incidence of intolerable mucositis in the control group was 100% compared with 17.8% in the experimental group. Repeated-measures analysis of variance demonstrated significant differences in the onset and severity of oral mucositis ( P = .001), oral health status ( P = .001), and oral dysfunctions ( P = .001) between the experimental and control groups.

CONCLUSION

Turmeric mouthwash was effective in reducing the severity of oral mucositis and associated oral dysfunctions as compared with benzydamine mouthwash.

IMPLICATIONS

Use of turmeric, a nontoxic and cost-effective intervention, can be an alternative to the traditional management of oral mucositis.

Clock in radiation oncology clinics: cost-free modality to alleviate treatment-related toxicity

A large number of studies have reported that tumor cells are often out of sync with the surrounding healthy tissue. Exploiting this misalignment may be a way to obtain a substantial gain in the therapeutic window. Specifically, based on reports to date, we will assess whether radiotherapy outcomes differ depending on the administration time. Collectively, 24 studies met the inclusion criteria, out of which 12 at least reported that radiation therapy is less toxic when administered at a particular time, probably because there is less collateral damage to healthy cells. However, discrepancies exist across studies and urge further investigation. Mechanistic studies elucidating the relationship between radiotherapy, circadian rhythms, and cell cycle, combined with either our “digital” or “biological” chronodata, would help oncologists successfully chronotype individual patients and strategize treatment plans accordingly.

Identification of Induced Radionuclides Produced from Dental Metals in Proton Beam Therapy for Head and Neck Cancer

Purpose

To identify the induced radionuclides produced from dental metals in proton beam therapy and investigate the accuracy of the Monte Carlo (MC) simulation by comparing the measured radioactivity.

Methods and Materials

Two dental metals of pure titanium and gold-silver-palladium alloy, commonly used in Japan, were used in this study. The dental metal placed at the center of Spread-out Bragg Peak was irradiated by 150-MeV passive scattering proton beam. The gamma rays emitted from the activated dental metals were measured using a high purity germanium (HPGe) detector. The induced radionuclides were identified from the measured gamma-ray energies. Furthermore, the Particle and Heavy Ion Transport code System v.3.24 and DCHAIN were used for the MC simulation. The measured radionuclides and their radioactivity were compared with the simulation results.

Results

In the MC simulation for the activated titanium, vanadium-47, with a half-life of 32.6 minutes had the strongest radioactivity among the induced radionuclides. The energy peaks of gamma rays emitted from titanium-51, scandium-43, scandium-44, and annihilation gamma rays were observed for the activated titanium in the HPGe detector. In the MC simulation for the activated gold-silver-palladium alloy, silver-108, with a half-life of 2.4 minutes had the strongest radioactivity. The energy peaks of gamma rays emitted from silver-104, silver-104 m, silver-108, and annihilation gamma rays were observed for the activated gold-silver-palladium alloy in the HPGe detector. Furthermore, the induced radionuclides and their radioactivity in the MC simulation were consistent with the measurement results for both dental metals, except for a few radionuclides.

Conclusions

We identify the induced radionuclides produced from 2 dental metals and compared their radioactivity between the measurements and the MC simulation. Although the identification of the induced radionuclides using the MC simulation remains uncertain, the MC simulation can be clinically effective for pre-estimating the induced radionuclides in proton beam therapy.

Long-term functional regeneration of radiation-damaged salivary glands through delivery of a neurogenic hydrogel

Salivary gland acinar cells are severely depleted after radiotherapy for head and neck cancer, leading to loss of saliva and extensive oro-digestive complications. With no regenerative therapies available, organ dysfunction is irreversible. Here, using the adult murine system, we demonstrate that radiation-damaged salivary glands can be functionally regenerated via sustained delivery of the neurogenic muscarinic receptor agonist cevimeline. We show that endogenous gland repair coincides with increased nerve activity and acinar cell division that is limited to the first week after radiation, with extensive acinar cell degeneration, dysfunction, and cholinergic denervation occurring thereafter. However, we found that mimicking cholinergic muscarinic input via sustained local delivery of a cevimeline-alginate hydrogel was sufficient to regenerate innervated acini and retain physiological saliva secretion at nonirradiated levels over the long term (>3 months). Thus, we reveal a previously unknown regenerative approach for restoring epithelial organ structure and function that has extensive implications for human patients.

Protective Role of Natural Compounds under Radiation-Induced Injury

In recent years, evidence has shown the potential therapeutic effects of different natural compounds for the prevention and treatment of radiotherapy-induced mucositis (RIOM). RIOM represents one of the most frequent side effects associated with anti-neoplastic treatments affecting patients' quality of life and treatment response due to radiation therapy discontinuation. The innate radio-protective ability of natural products obtained from plants is in part due to the numerous antioxidants possessed as a part of their normal secondary metabolic processes. However, oxygen presence is a key point for radiation efficacy on cancer cells. The aim of this review is to describe the most recent evidence on radiation-induced injury and the emerging protective role of natural compounds in preventing and treating this specific damage without compromising treatment efficacy.

Personalized or unified approach in the prevention and treatment of oral mucositis in patients with malignant neoplasms of the head and neck organs: the choice of the optimal solution

Introduction. The prevalence of oncological diseases of the oropharyngeal region continues to grow steadily, but there is an increase for a number of nosologies in the five-year survival rate of this category of patients, which naturally leads to the actualization of accompanying treatment programs and the desire to improve the quality of life of oncological patients. One of the areas of maintenance therapy in oncology is dental support, the choice of approaches and methods of which is not systematically organized.

Aim. To determine the optimal method of dental support for patients with malignant neoplasms of the head and neck organs for the prevention and treatment of oral mucositis.

Materials and methods. At the Russian Scientific Center of Roentgenoradiology, retrospective analysis of scientific clinical results of oral mycosis treatment in patients with malignant tumors of the head and neck receiving antitumor therapy was performed.

Results. Two main approaches have been identified for the prevention and treatment of oral mucositis in patients with malignant neoplasms of the head and neck organs: personalized and unified approach. using personalized approach, maximal mean value of oral mycosis severity during the whole antitumor treatment period per the Radiation therapy Oncology group (RTOg) classification was 2.19 ± 0.13. The quality of life of patients is reduced by 26.1 %. using unified approach, maximal mean value of oral mycosis severity during the whole antitumor treatment period per the RTOg classification was 2.44 ± 0.05. The quality of life of patients is reduced by 51.5 %, but at the same time, absolutely all patients retain the ability to eat independently and take care of the oral cavity.

Conclusion. Both personalized and unified approaches for the prevention and treatment of oral mucositis are possible for use in clinical practice.

Effects of various treatments for preventing oral mucositis in cancer patients: A network meta-analysis

BACKGROUND

Oral mucositis (OM) is a common side effect of chemotherapy and radiotherapy in patients with cancers. The prevention or treatment of OM in cancer patients is crucial in the treatment of cancer.

METHODS

We searched PubMed, Embase, and Cochrane Library for the randomized control trials (RCTs) of interventions for preventing and treating OM. Network meta-analysis (NMA) was performed to estimate odds ratios (ORs) and 95% confidence intervals (CI) from both direct and indirect evidence. The prespecified primary efficacy outcome was the treatment effect of moderate to severe oral mucositis with 12 interventions. The outcome was moderate to a severe grade of OM.

RESULTS

This study included 55 RCTs with 3,552 participants. The results showed that honey significantly lowered the risk of chemo/radiotherapy-induced moderate to severe oral mucositis than placebo (OR: 0.01, 95%CI 0.00 to 0.45), followed by lignocaine (OR: 0.07, 95%CI 0.00 to 0.95). The surface under cumulative ranking curve (SUCRA) values for honey were 0.95, followed by lignocaine (SUCRA, 0.81) and benzydamine (SUCRA, 0.78).

CONCLUSIONS

The honey is effective for patients with cancer undergoing chemotherapy or radiotherapy-induced oral mucositis.

Effects of probiotic supplementation on related side effects after chemoradiotherapy in cancer patients

OBJECTIVES

Chemotherapy and radiotherapy generally cause serious adverse side effects in cancer patients, thereby affecting subsequent treatment. Numerous studies have shown that taking probiotics is an option for preventing and treating these side effects. In this investigation, a meta-analysis of the effects of oral probiotics on side effects brought on by radiotherapy, chemotherapy, or chemoradiotherapy treatment will be carried out.

METHODS

Two researchers independently and carefully reviewed all pertinent studies that were published before June 30, 2022 and were accessible on PubMed, Embase, Cochrane Library, and the Web of Science. Moreover, the Cochrane Collaboration's Tool was used to evaluate the risk of bias. Utilizing Review Manager software version 5.4, data were retrieved from eligible studies to evaluate their merits and determine odds ratios (OR) and 95% confidence intervals (CIs) (RevMan 5.4).

RESULTS

2 097 patients from 16 randomized controlled trials were extracted, and standard meta-analysis methods were used to examine the data. Compared with the placebo groups, oral probiotics significantly reduced the side effects caused by radiotherapy and chemotherapy on various types of cancer, such as head and neck cancer, pelvic and abdominal cancer, breast cancer, lung cancer, etc. (OR: 0.31, 95% CI: 0.20 - 0.48; P < 0.005). Further analysis found that the incidence of diarrhea in patients with pelvic and abdominal cancers (OR: 0.32, 95% CI: 0.16 - 0.65; P < 0.005) and the frequency of oral mucositis in patients with head and neck tumors were also significantly lower (OR: 0.28, 95% CI: 0.18 - 0.43; P < 0.005) after the oral administration of probiotics. This suggests that probiotics have a positive influence on the treatment of side effects after chemoradiotherapy. Additionally, a funnel plot revealed that there was no significant publication bias in this study.

CONCLUSIONS

Probiotics may help to reduce the occurrence of cancer therapy-related side effects, especially oral mucositis in head and neck tumors and diarrhea in patients with pelvic and abdominal tumors. However, given the small number of clinical trials involved, additional randomized, double-blind, multicentric trials in a larger population are required. This paper may assist researchers in improving trial design in the selection of probiotic strains and selecting appropriate patients who may benefit from probiotic treatments.

Predictive Risk Factors Associated with Severe Radiation-Induced Mucositis in Nasopharyngeal or Oropharyngeal Cancer Patients: A Retrospective Study

Radiation-induced mucositis in head and neck cancer patients generates difficulties in eating and swallowing, and may influence treatment tolerance, compliance, and quality of life. However, predictive factors have not been studied in detail. Thus, the aim of this study was to describe the association between pre-radiotherapy clinical factors and the incidence of severe radiation-induced mucositis in nasopharyngeal or oropharyngeal cancer patients. This retrospective study included all patients with definitive radiotherapy or chemoradiotherapy for nasopharyngeal or oropharyngeal cancer between July 2011 and June 2021 in a single center. The eligibility criteria included patients who received oral management during radiotherapy. Exclusion criteria was patients who received postoperative radiotherapy. The data were acquired from the medical records of patients. One hundred patients were included in this retrospective study. Grade 3 radiation-induced mucositis occurred in 47 patients (47%). Lymphocyte count was significantly associated with grade 3 mucositis (OR = 0.40; 95% CI = 0.19–0.86; p = 0.018). It is suggested that pre-radiation lower lymphocyte counts are a predictive risk factor for severe mucositis in patients who undergo definitive radiotherapy or chemoradiotherapy for nasopharyngeal or oropharyngeal cancer

Factors influencing patient disclosure of cancer diagnosis to the family dentist: online survey in Japan

Oral care during cancer treatment constitutes essential supportive care. We aimed to identify factors associated with cancer patients informing their family dentists about their cancer diagnosis. Using the generated original questionnaire, we conducted a cross-sectional questionnaire study in 500 cancer patients (gastric, colorectal, lung, breast, and prostate cancer) through the Internet from September 10 to 13, 2019. The factors influencing patients' disclosure of their cancer diagnosis to their family dentist were identified by multivariable logistic regression analysis. Nearly half of the respondents (42.2%) informed their family dentist that they had cancer. The disclosing behavior of cancer patients was distinctively associated with their physician's advice (odds ratio [OR] 59.3; 95% confidence interval [CI] 7.7-456.3); 8.6% of all respondents were advised to inform their dentist about their cancer diagnosis. In the group without the physician's advice, good relationship with family dentist was associated with disclosing behavior. This study indicates the need for support for cancer patients to receive appropriate oral care; patients' perceptions of the physician's advice and communication with the family dentist should be motivators for disclosing the cancer diagnosis to dentists. Medical workers involved in cancer care should demonstrate the benefit of medical-dental collaboration in cancer care of patients.

Mitigating acute chemotherapy-associated adverse events in patients with cancer

Despite the enthusiasm surrounding novel targeted agents and immunotherapies, chemotherapy remains the mainstay treatment for most human malignancies, either alone or in combination. Yet, the burden of chemotherapy-associated adverse events (CAAEs) remains high and, importantly, is associated with considerable morbidity, mortality and costs that affect patients across multiple dimensions, including physical, emotional and social functioning. CAAEs can directly affect patient outcomes and indirectly increase the risk of cancer recurrence by compromising treatment intensity and continuity. Systematic efforts to identify and critically summarize the evidence on management approaches for CAAEs remain limited. Herein, we review the most common acute CAAEs having a major effect on survival, quality of life, function and/or continuation of optimal therapy. We focus on selected acute toxicities that occur during treatment, summarizing their underlying pathophysiology, multifactorial aetiologies, evidenced-based treatments, prevention strategies and management recommendations. We also summarize the available evidence on risk factors, validated risk assessment tools and other efforts to optimize symptom control in patients most likely to benefit in order to personalize the prevention and treatment of acute CAAEs. Finally, we discuss innovative symptom monitoring and supportive care interventions that are under development to further improve the outcomes of patients with cancer.

AMPK phosphorylates NAMPT to regulate NAD+ homeostasis under ionizing radiation

Radiation-induced oral mucositis is the most common complication for patients who receive head/neck radiotherapy. Nicotinamide adenine dinucleotide (NAD⁺) is vital for DNA damage repair under ionizing radiation, through functioning as either the substrate for protein poly(ADP-ribosyl)ation at DNA break sites or the cofactor for multiple DNA repair-related enzymes, which therefore can result in a significant consumption of cellular NAD⁺ during DNA repair. Mammalian cells produce NAD⁺ mainly by recycling nicotinamide via the salvage pathway, in which the rate-limiting step is governed by nicotinamide phosphoribosyltransferase (NAMPT). However, whether NAMPT is co-opted under ionizing radiation to timely fine-tune NAD⁺ homeostasis remains elusive. Here we show that ionizing radiation evokes NAMPT activation within 30 min without apparent changes in its protein expression. AMPK rapidly phosphorylates NAMPT at S314 under ionizing radiation, which reinforces the enzymatic activity of NAMPT by increasing NAMPT binding with its substrate phosphoribosyl pyrophosphate (PRPP). AMPK-mediated NAMPT S314 phosphorylation substantially restores NAD⁺ level in the irradiated cells and facilitates DNA repair and cell viability. Our findings demonstrate a new post-translational modification-based signalling route, by which cells can rapidly orchestrate NAD⁺ metabolism to support DNA repair, thereby highlighting NAMPT as a potential target for the prevention of ionizing radiation-induced injuries.

Impact of the COVID-19 and Socioeconomic Status on Access to Care for Otorhinolaryngology Patients

Since December 2019, COVID-19 has greatly influenced public healthcare systems around the globe in various aspects, including limitation of healthcare accessibility due to lack of both human and financial resources, suspension of clinics, and fear of infection causing healthcare avoidance. The aim of this study was to investigate the impact of COVID-19 on access to healthcare for otorhinolaryngology patients from different socioeconomic status (SES) groups. Otorhinolaryngology patients' disease severity status, diagnosed at the first hospital visit, was investigated during the pre -and post-COVID-19 pandemic era in a single medical center located in Seoul, Korea. An ordinal regression model was used to assess the impact of both SES and the COVID-19 pandemic on otorhinolaryngology diseases. Within the chronic rhinosinusitis group, lower SES was associated with a higher disease severity at the first visit compared to higher SES (OR = 3.25). During the COVID-19 pandemic, while the total number of outpatients was reduced, the severity of these ENT diseases seemed to increase compared to the pre-pandemic severity in every SES group. Our study demonstrates the negative impact a worldwide pandemic can have on healthcare inequity and disease severity, and highlights the importance of re-allocating fundamental resources for those in need during periods of public health crisis.

Fabrication of Mucoadhesive Films Containing Pharmaceutical Ionic Liquid and Eudragit Polymer Using Pressure-Assisted Microsyringe-Type 3D Printer for Treating Oral Mucositis

Oral mucositis in the oral cavity, caused by radiation therapy and chemotherapy, requires personalized care and therapy due to variations in the lesions of patients. In the present study, we fabricated a model of personalized oral film containing an ibuprofen/lidocaine ionic liquid (IL) for patients with oral mucositis using a pressure-assisted microsyringe-type 3D printer at room temperature. The film contained a Eudragit polymer (L100, EPO, or RSPO) to make the film solid, and the printer ink was composed of organo ink (organic solvent to dissolve both drugs and the Eudragit polymer). The viscosity of the printer ink was assessed to investigate its extrudability. The contact angle and the surface tension at the interface between each liquid printer ink and a solid polypropylene sheet were measured to determine the retention of the ink in 3D printing. The physical properties of IL-loaded Eudragit-based dry films were examined by X-ray diffraction and differential scanning calorimetry. Dissolution tests indicated that IL-loaded films containing a Eudragit polymer exhibited different drug release rates in phosphate buffer (pH 6.8; Eudragit L100 > IL alone > Eudragit EPO > Eudragit RSPO). These results provide useful information for the specific fabrication of IL-loaded polymer-based films using organo inks and pressure-assisted microsyringe-type 3D printers.

Prophylactic management of radiation-induced mucositis using herbal mouthwash in patients with head and neck cancer: an assessor-blinded randomized controlled trial

OBJECTIVES

Radiation-induced mucositis (RIOM) is one of the most common side effects from head and neck radiotherapy. Several reagents have been introduced to manage the symptom; however, there is still a limited number of effective reagents. Herbal mouthwashes with payayor (Clinacanthus nutans Lindau) and fingerroot (Boesenbergia rotunda) were tested their efficacies in preventing and reducing severity of RIOM in comparison with normal saline with sodium bicarbonate.

METHODS

One hundred twenty patients with head and neck cancer undergoing radiotherapy participated in the study and were randomly assigned into three treatment groups using block randomization method. The participants were assigned one of the three mouthwashes for use throughout their radiotherapy course and were assessed for their mucositis scores from week one to six into their radiotherapy course as well as at one-month follow-up. Body mass index was also measured for comparison of nutritional status.

RESULTS

The two mouthwashes were similarly effective in prophylaxis of RIOM in term of severity. The averaged mucositis scores were less than two for all groups. For the onset of RIOM, both herbal mouthwashes could slightly delay the symptom but not statistically significant. Patients' body mass index across the three treatment groups was also comparable. The patients were largely satisfied with all the mouthwashes with no clear preference on any of them.

CONCLUSIONS

Prophylactic treatment of RIOM using herbal mouthwashes could substitute the current standard of normal saline with bicarbonate. A different formulation of the two herbs could potentially improve the prophylactic outcome.

TRIAL REGISTRATION NO

NCT03359187.

Metabolomics Combined with Network Pharmacology-Based Strategy to Reveal the Underlying Mechanism of Zhenhuang Submicron Emulsion in Treating Oropharyngeal Mucositis Complications of Radiation Therapy for Head and Neck Cancer

Introduction

Head and neck tumors account for more than 6% of all cancers. The primary treatment for tumors of the head and neck is radiation therapy, which can induce oropharyngeal mucositis as a side effect. At present, there is no widely available therapeutic for the treatment of oropharyngeal mucositis in clinical practice. Based on the traditional prescription Liushen Wan, the pathogenesis and pathology, we developed a new Chinese medicine prescription and made Zhenhuang submicron emulsion (ZHSE) spray, which has an efficacious therapeutic effect for oropharyngeal mucositis. However, its mechanism is unclear.

Methods

This research explored the mechanism behind the modulatory effects of ZHSE by a strategy of metabolomics and network pharmacology. Multivariate data analyses, including unsupervised principal component analysis (PCA) and supervised orthogonal partial least squares discriminant analysis (OPLS-DA), were performed. Potential biomarkers were identified depending on the mass-charge ratio of the selected compound. Statistical and pathway enrichment analysis was performed in the KEGG pathway database. Network pharmacology combining metabolomic analyses was conducted to illustrate the key targets and pathways.

Results

Critical metabolic pathways were investigated, 56f biomarkers were enriched and key metabolites such as linoleic acid, 9,10-epoxyoctadecenoic acid, acetoacetic acid and citric acid were identified. A complex network of “compound-target-potential metabolite” interactions was drawn to illuminate the regulation of chemical constituents on key metabolites. These findings manifest that ZHSE regulates endogenous metabolite disorders during the treatment of oropharyngeal mucositis by various constituents, interacting with multiple targets associated with inflammation and pain.

Conclusion

In this work, we determined several critical biomarkers and metabolic pathways and identified the possible regulatory mechanism by which ZHSE functions in the treatment of oropharyngeal mucositis. This study provides a new perspective on integrating metabolomics and network pharmacology for exploring improved therapy for head and neck tumors based on the traditional classic prescription of LSW.

Clinical evaluation of toll-like receptor-5 agonist for radiation-induced oral mucositis in beagle dogs

This study aimed to evaluate the clinical safety and validate the radiomitigative effect of KMRC011, against radiation-induced oral mucositis in beagle dogs. Clinical safety was evaluated by assessing tolerability, complete blood tests, and plasma biochemistry after drug administration. The radiomitigative effect of KMRC011 was evaluated macropathologically and histopathologically after inducing oral mucositis iatrogenically using 20 Gy irradiation. The plasma concentration of interleukin-6 was measured via enzyme-linked immunosorbent assay, as a biomarker of KMRC011 bioreactivity. Decreased tolerability, increased neutrophil count, hepatic enzyme concentration, C-reactive protein concentration, and interleukin-6 concentration after the administration was observed and ceased within 24 h without additional treatment. Although all animals included in the present study developed severe mucositis in the late course of the study, animals administered KMRC011 showed less erythema, ulcer, inflammatory infiltration. These results suggest that KMRC011 may be used as an adjuvant for radiotherapy without severe adverse effects, especially during short-term radiotherapy, such as hypofractionated radiotherapy or stereotactic radiotherapy.

A prospective interventional study of recombinant human interleukin-11 mouthwash in chemotherapy-induced oral mucositis

BACKGROUND

This prospective interventional study aimed to evaluate and analyse the efficacy of rhIL-11 mouthwash compared to Kangfuxin fluid in treatment and blank control in prevention of oral mucositis (OM) in patients receiving chemotherapy.

MATERIALS AND METHODS

In total, 50 patients in the treatment group and 62 patients in the prevention group were included. Subsequently, each group was divided into an experimental group and a control group. In the treatment group, the experimental patients received recombinant human interleukin-11 (rhIL-11) mouthwash, whereas the control group received Kangfuxin fluid. In the prevention group, experimental patients still received rhIL-11 mouthwash based on routine oral care, whereas the control group only received routine oral care. Meanwhile, we observed and recorded the efficacy in the treatment group, and the occurrence and grades of OM in the prevention group.

RESULTS

Through statistical analysis, the results showed that on the seventh day of treatment, the experimental group showed more improvement compared to the control group, and it was statistically significant (p = 0.032). The average healing time in the experimental group (3.59 ± 1.927 days) was shorter than that in the control group (4.96 ± 2.421 days; p = 0.031). In the prevention group, we observed the incidence of oral mucositis. No significant differences were found in the occurrence and grades of OM in the experimental and control groups (p = 0.175).

CONCLUSION

Our preliminary results indicate that rhIL-11 mouthwash may be a superior option to treat OM, especially in severe cases, compared to Kangfuxin fluid. However, there is no advantage in prevention.

Antibiotic-Induced Gut Microbiota Depletion Accelerates the Recovery of Radiation-Induced Oral Mucositis in Rats

PURPOSE

Due to its pivotal role in the modulation of immune and inflammatory responses, the gut microbiota has emerged as a key modulator of cancer treatment-induced gastrointestinal mucositis. However, it is not clear yet how it affects radiation therapy-induced oral mucositis (OM). As such, this study aimed to explore the gut microbiota's role in the pathogenesis of radiation-induced OM in rats.

METHODS AND MATERIALS

Male Sprague Dawley rats were treated with 20 Gy x-ray radiation (Rx) delivered to the snout, with or without antibiotic-induced microbiota depletion (AIMD). OM severity was assessed, and tongue tissues were collected on day 9 and 15 postradiation for tissue injury and inflammatory markers assessment.

RESULTS

AIMD+Rx had a significantly shorter duration of severe OM compared with Rx alone group. Macroscopically, the tongue ulcer-like area was smaller in AIMD+Rx compared with the Rx group. Microscopically, a smaller percentage of the mucosal ulcer was observed in the dorsal tongue of AIMD+Rx compared with the Rx group. AIMD+Rx also had significantly lower levels of interleukin 6, interleukin 1 beta, and toll like receptor 4 in the tongue tissues than the Rx group.

CONCLUSIONS

The gut microbiota plays a role in OM pathogenesis, mainly in the recovery phase, through the modulation of proinflammatory pathways. Future microbiota-targeted interventions may improve OM in clinical settings.

Paraprobiotics and Postbiotics of Lactobacillus delbrueckii CIDCA 133 Mitigate 5-FU-Induced Intestinal Inflammation

Intestinal mucositis is a commonly reported side effect in oncology practice. Probiotics are considered an excellent alternative therapeutic approach to this debilitating condition; however, there are safety questions regarding the viable consumption of probiotics in clinical practice due to the risks of systemic infections, especially in immune-compromised patients. The use of heat-killed or cell-free supernatants derived from probiotic strains has been evaluated to minimize these adverse effects. Thus, this work evaluated the anti-inflammatory properties of paraprobiotics (heat-killed) and postbiotics (cell-free supernatant) of the probiotic Lactobacillus delbrueckii CIDCA 133 strain in a mouse model of 5-Fluorouracil drug-induced mucositis. Administration of paraprobiotics and postbiotics reduced the neutrophil cells infiltrating into the small intestinal mucosa and ameliorated the intestinal epithelium architecture damaged by 5-FU. These ameliorative effects were associated with a downregulation of inflammatory markers (Tlr2, Nfkb1, Il12, Il17a, Il1b, Tnf), and upregulation of immunoregulatory Il10 cytokine and the epithelial barrier markers Ocln, Cldn1, 2, 5, Hp and Muc2. Thus, heat-killed L. delbrueckii CIDCA 133 and supernatants derived from this strain were shown to be effective in reducing 5-FU-induced inflammatory damage, demonstrating them to be an alternative approach to the problems arising from the use of live beneficial microorganisms in clinical practice.

Sildenafil improves radiation-induced oral mucositis by attenuating oxidative stress, NF-κB, ERK and JNK signalling pathways

Radiation-induced oral mucositis is a common and dose-limiting complication of head and neck radiotherapy with no effective treatment. Previous studies revealed that sildenafil, a phosphodiesterase 5 inhibitor, has anti-inflammatory and anti-cancer effects. In this study, we investigated the effect of sildenafil on radiation-induced mucositis in rats. Two doses of radiation (8 and 26 Gy X-ray) were used to induce low-grade and high-grade oral mucositis, separately. A control group and three groups of sildenafil citrate-treated rats (5, 10, and 40 mg/kg/day) were used for each dose of radiation. Radiation increased MDA and activated NF-κB, ERK and JNK signalling pathways. Sildenafil significantly decreased MDA level, nitric oxide (NO) level, IL1β, IL6 and TNF-α. The most effective dose of sildenafil was 40 mg/kg/day in this study. Sildenafil also significantly inhibited NF-κB, ERK and JNK signalling pathways and increased bcl2/bax ratio. In addition, high-dose radiation severely destructed the mucosal layer in histopathology and led to mucosal cell apoptosis in the TUNEL assay. Sildenafil significantly improved mucosal structure and decreased inflammatory cell infiltration after exposure to high-dose radiation and reduced apoptosis in the TUNEL assay. These findings show that sildenafil can improve radiation-induced oral mucositis and decrease the apoptosis of mucosal cells via attenuation of inflammation and oxidative stress.

Role of the microbiome in oral cancer occurrence, progression and therapy

The oral cavity, like other digestive or mucosal sites, contains a site-specific microbiome that plays a significant role in maintaining health and homeostasis. Strictly speaking, the gastrointestinal tract starts from the oral cavity, with special attention paid to the specific flora of the oral cavity. In healthy people, the microbiome of the oral microenvironment is governed by beneficial bacteria, that benefit the host by symbiosis. When a microecological imbalance occurs, changes in immune and metabolic signals affect the characteristics of cancer, as well as chronic inflammation, disruption of the epithelial barrier, changes in cell proliferation and cell apoptosis, genomic instability, angiogenesis, and epithelial barrier destruction and metabolic regulation. These pathophysiological changes could result in oral cancer. Rising evidence suggests that oral dysbacteriosis and particular microbes may play a positive role in the evolution, development, progression, and metastasis of oral cancer, for instance, oral squamous cell carcinoma (OSCC) through direct or indirect action.

Impact of different fixed dental prostheses on radiation dose in helical tomotherapy as measured with metal oxide semiconductor field-effect transistor dosimetry

OBJECTIVE

This ex vivo study evaluated the effects of different fixed dental prostheses and protective materials on scattered radiation during radiation therapy (RT).

STUDY DESIGN

Natural teeth (group NT) and 4 types of prostheses (group BL: bilayer lithium disilicate glass-ceramic; group MZ: monolithic zirconia ceramic; group BZ: bilayer zirconia-based all ceramic; and group BM: bilayer metal-ceramic restorations) were examined in maxillary and mandibular arch phantoms. All groups were divided into 3 subgroups: (1) without protective material over the prostheses; (2) protected with a soft acrylic night guard; and (3) protected with polyvinylsiloxane putty. All groups were irradiated with helical RT at 2 Gy and 6 MV photon energy. Doses were measured internally and externally 3 times on each phantom. Results were significant at P < .05.

RESULTS

No statistically significant differences in doses were found between groups NT and BL in either phantom, but these groups were different from the others. The differences between groups BZ and MZ were insignificant. Doses in group BM were significantly larger than all other groups. No significant differences existed between doses with and without protective material.

CONCLUSIONS

Doses increased significantly due to scattered radiation from the prostheses with increasing material density. Protective materials had no significant effect on dose.

Predicting acute severe toxicity for head and neck squamous cell carcinomas by combining dosimetry with a radiosensitivity biomarker: a pilot study

OBJECTIVE

Radiotherapy (RT) against head and neck squamous cell carcinomas (HNSCC) may lead to severe toxicity in 30-40% of patients. The normal tissue complication probability (NTCP) models, based on dosimetric data refined the normal tissue dose/volume tolerance guidelines. In parallel, the radiation-induced nucleoshuttling (RIANS) of the Ataxia-Telangiectasia Mutated protein (pATM) is a predictive approach of individual intrinsic radiosensitivity. Here, we combined NTCP with RADIODTECT©, a blood assay derived from the RIANS model, to predict RT toxicity in HNSCC patients.

METHODS

RADIODTECT© cutoff values (i.e. 57.8 ng/mL for grade⩾2 toxicity and 46 ng/mL for grade⩾3 toxicity) have been previously assessed. Validation was performed on a prospective cohort of 36 HNSCC patients treated with postoperative RT. Toxicity was graded with the Common Terminology Criteria for Adverse Events (CTCAE) scale and two criteria were considered: grade⩾2 oral mucositis (OM2), grade⩾3 mucositis (OM3) and grade⩾2 dysphagia (DY2), grade⩾3 dysphagia (DY3). pATM quantification was assessed in lymphocytes of HNSCC patients. The discrimination power of the pATM assay was evaluated through the Area Under the Receiver Operator Characteristics Curve (AUC-ROC). Two previously described NTCP models were considered, including the dose to the oral cavity and the mean dose to the parotid glands (OM2 and OM3) and the dose to the oral cavity, to the larynx and the volume of pharyngeal constrictor muscles (DY2 and DY3).

RESULTS

Combining NTCP models with RADIODTECT© blood test improved the AUC-ROC. Considering the prediction of mucositis, AUC-ROC^{NTCP+RADIODTECT©}=0.80 was for OM2, and AUC-ROC^{NTCP+RADIODTECT©}=0.78 for OM3. Considering the prediction of acute dysphagia, AUC-ROC^{NTCP+RADIODTECT©}=0.71 for DY2 and for DY3.

CONCLUSIONS

Combining NTCP models with a radiosensitivity biomarker might significantly improve the prediction of toxicities for HNSCC patients.

Radiation Exposure Perturbs IL-17RA-Mediated Immunity Leading to Changes in Neutrophil Responses That Increase Susceptibility to Oropharyngeal Candidiasis

Fungal infections caused by Candida albicans are a serious problem for immunocompromised individuals, including those undergoing radiotherapy for head and neck cancers. Targeted irradiation causes inflammatory dysregulation and damage to the oral mucosa that can be exacerbated by candidiasis. Post-irradiation the cytokine interleukin-17 (IL-17) protects the oral mucosae by promoting oral epithelial regeneration and balancing the oral immune cell populations, which leads to the eventual healing of the tissue. IL-17 signaling is also critical for the antifungal response during oropharyngeal candidiasis (OPC). Yet, the benefit of IL-17 during other forms of candidiasis, such as vulvovaginal candidiasis, is not straightforward. Therefore, it was important to determine the role of IL-17 during OPC associated with radiation-induced inflammatory damage. To answer this question, we exposed Il17ra^−/− and wild-type mice to head-neck irradiation (HNI) and OPC to determine if the IL-17 signaling pathway was still protective against C. albicans. HNI increased susceptibility to OPC, and in Il17ra^−/− mice, the mucosal damage and fungal burden were elevated compared to control mice. Intriguingly, neutrophil influx was increased in Il17ra^−/− mice, yet these cells had reduced capacity to phagocytose C. albicans and failed to clear OPC compared to immunocompetent mice. These findings suggest that radiotherapy not only causes physical damage to the oral cavity but also skews immune mediators, leading to increased susceptibility to oropharyngeal candidiasis.

Surgical Risk Prediction for Nasolacrimal Duct Obstruction in Radioactive Iodine-Treated Thyroid Cancer: A Nationwide Cohort Study

Background: To estimate the incident risk of surgical intervention for nasolacrimal duct obstruction after radioactive iodine (RAI) treatment and elucidate the high-risk group of patients with thyroid cancer (TC). Methods: This is a nationwide, population-based cohort study using data from the Korean National Health Claims database. Among the entire South Korean population aged between 20 and 80 years from 2007 to 2019, all patients with TC were included. Among all TC patients, a cohort was established by classifying it into the RAI and non-RAI groups according to whether RAI treatment was performed during the recruitment period. A log-rank analysis was used to evaluate the risk of nasolacrimal duct obstruction surgery in the RAI group compared with that in the non-RAI group. The Cox proportional hazards regression analysis was performed to calculate the adjusted hazard ratio (HR). The analysis was performed stratified by the age group, sex, frequency of RAI treatment, and cumulative dose of ¹³¹I. Results: Among 55,371 TC patients, who received RAI treatment, 515 (0.93%) underwent nasolacrimal duct obstruction surgeries, and among 56,950 TC patients, who did not receive RAI treatment, 72 (0.13%) underwent the surgeries. The average timing of incident nasolacrimal duct obstruction surgery was 3.8 ± 2.1 years after the first exposure to RAI. The incidence rate of nasolacrimal duct obstruction surgery was 104.04/100,000 person-years in the RAI group. There was a significantly higher risk of nasolacrimal duct obstruction surgery (HR 7.50 [confidence interval, CI: 5.86-9.60], p < 0.001) in the RAI group than in the non-RAI group. The risks significantly increased in the high-dose group (HR 14.15 [CI: 10.88-18.39]) and those younger than 50 years (HR 15.54 [CI: 9.76-24.72]). Conclusion: We quantified the risk of RAI-induced nasolacrimal duct obstruction surgery through a long-term follow-up of 9 years, which may contribute to estimating the general health care burden related to RAI treatment for TC patients in a practical setting. Great attention should be paid to its risk in patients younger than 50 years, especially in those treated with high doses.

Effect of ruxolitinib on the oral mucosa of patients with steroid-refractory chronic Graft-versus-Host disease and oral involvement

BACKGROUND

Chronic Graft-versus-Host Disease (cGVHD) can impact quality of life, especially in patients with oral involvement. Half of the patients with cGVHD do not respond to first-line therapy with corticosteroids and calcineurin inhibitors. Ruxolitinib is effective in steroid-refractory (SR)-cGVHD cases, but the long-term effects of ruxolitinib on the oral mucosa are unknown.

OBJECTIVE(S)

This study aims to assess the effect of ruxolitinib on the oral mucosa of SR-cGVHD patients with oral involvement.

MATERIALS AND METHODS

An observational longitudinal patient study was conducted in 53 patients with SR-cGVHD and oral involvement who were treated with ruxolitinib. The baseline condition of the oral mucosa was compared to its condition at 4 and 12 weeks after starting ruxolitinib.

RESULTS

The overall response was 81% (43/53), with a complete response in 53% (28/53) and partial response in 28% (15/53) after 12 weeks (p < 0.001). Men and patients concurrently using immunosuppressive therapy responded better than women (p = 0.005) and patients with ruxolitinib monotherapy (p = 0.02), respectively. At a longer follow-up (median 20 months), oral symptoms were comparable to the 12-week symptoms (p = 0.78), regardless of ruxolitinib use (p = 0.83).

CONCLUSION

Ruxolitinib treatment of SR-cGVHD patients with oral involvement was associated with a significant response of the oral manifestations at 12 weeks.

CLINICAL RELEVANCE

The oral mucosa of SR-cGVHD patients is likely to improve after 4 and 12 weeks of ruxolitinib treatment. Symptom severity at baseline does not affect the response of the oral mucosa.

Oxidative Stress and Chemoradiation-Induced Oral Mucositis: A Scoping Review of In Vitro, In Vivo and Clinical Studies

Chemoradiation-induced mucositis is a debilitating condition of the gastrointestinal tract eventuating from antineoplastic treatment. It is believed to occur primarily due to oxidative stress mechanisms, which generate Reactive Oxygen Species (ROS). The aim of this scoping review was to assess the role of oxidative stress in the development of Oral Mucositis (OM). Studies from the literature, published in MEDLINE and SCOPUS, that evaluated the oxidative stress pathways or antioxidant interventions for OM, were retrieved to elucidate the current understanding of their relationship. Studies failing inclusion criteria were excluded, and those suitable underwent data extraction, using a predefined data extraction table. Eighty-nine articles fulfilled criteria, and these were sub-stratified into models of study (in vitro, in vivo, or clinical) for evaluation. Thirty-five clinical studies evaluated antioxidant interventions on OM's severity, duration, and pain, amongst other attributes. A number of clinical studies sought to elucidate the protective or therapeutic effects of compounds that had been pre-determined to have antioxidant properties, without directly assessing oxidative stress parameters (these were deemed "indirect evidence"). Forty-seven in vivo studies assessed the capacity of various compounds to prevent OM. Findings were mostly consistent, reporting reduced OM severity associated with a reduction in ROS, malondialdehyde (MDA), myeloperoxidase (MPO), but higher glutathione (GSH) and superoxide dismutase (SOD) activity or expression. Twenty-one in vitro studies assessed potential OM therapeutic interventions. The majority demonstrated successful a reduction in ROS, and in select studies, secondary molecules were assessed to identify the mechanism. In summary, this review highlighted numerous oxidative stress pathways involved in OM pathogenesis, which may inform the development of novel therapeutic targets.

Efficacy of the Nourishing Yin and Clearing Heat Therapy Based on Traditional Chinese Medicine in the Prevention and Treatment of Radiotherapy-Induced Oral Mucositis in Nasopharyngeal Carcinomas: A Systematic Review and Meta-Analysis of Thirty Randomized Controlled Trials

This study aimed to evaluate the efficacy of nourishing Yin and clearing heat therapy (NYCH therapy) based on traditional Chinese medicine (TCM) in the treatment of radiotherapy-induced oral mucositis (RTOM) in nasopharyngeal carcinomas (NPCs). A total of eight online databases were searched from inception to September 2021 for randomized controlled trials (RCTs). The control group was treated with Western medicine (WM) alone, whereas the experimental group was treated with a combined NYCH and WM therapy. A total of 30 RCTs involving 2562 participants were ultimately included. NYCH therapy combined with conventional WM delayed the onset time (days) of RTOM (MD = 10.80, p < 0.001), and at that time, a higher cumulative radiotherapy dose (Gy) (MD = 5.72, p < 0.001) was completed in the experimental group. The combination regimen also reduced the incidence of severe oral mucositis (Grade III–IV) (RR = 0.25, p < 0.001). In addition, the treatment efficacy of the experimental group was significantly better than that of the control group (RR = 1.31, p < 0.001). Compared with the patients in the control group, the experimental group had lower xerostomia scores (MD = -1.07, p < 0.001) and more saliva (MD = 0.36, p < 0.001). NYCH combined with WM improved the efficacy of treating RTOM in NPC. This study provides a sufficient basis for conducting further large RCTs to prove the efficacy of NYCH.

Efficacy and Safety of Chinese Patent Medicine for the Prevention and Treatment of Radiotherapy and Chemotherapy-Induced Oral Mucositis: A Systematic Review and Meta-Analysis

Background: Radiotherapy and chemotherapy-induced oral mucositis can affect cancer patients' quality of life, even necessitate cancer therapy and influence prognosis. Chinese patent medicines (CPMs) have been widely used as complementary alternative medicines for the prevention and treatment of oral mucositis, and their efficacy and safety require further evaluation. Therefore, this study was conducted to provide references for clinical practice. Methods: Ten databases were searched electronically and manually to identify randomized controlled trials (RCTs) from their inception to August 2021, concerning the prevention and treatment of radiotherapy and chemotherapy-induced oral mucositis with CPMs. The prevalence, pain level, and the severity of radiotherapy and chemotherapy-induced oral mucositis, as well as the effectiveness rate and adverse effects of CPMs, were set as the outcome criteria. The assessment criteria of the Cochrane Handbook were used to determine study quality and bias, and meta-analysis was conducted using Review Manager 5.4.1 software. Results: A total of 2,312 cases from 27 RCTs were included. Most studies were considered to have a low or unclear risk of bias. More research is available on the use of CPMs in the prevention of radiotherapy and chemotherapy-induced oral mucositis than in its treatment. As for the prevention, it was proved that CPMs could significantly reduce the prevalence of radiotherapy and chemotherapy-induced oral mucositis, especially for the severe types, and decrease pain levels (p < 0.05). For treatment, CPMs could alleviate the symptoms, promote the healing of ulceration in radiotherapy and chemotherapy-induced oral mucositis, and thus improve the efficiency of clinical treatment (p < 0.05). The results of subgroup analyses were mainly consistent with the above results. The adverse effects of CPMs mainly included gastrointestinal reactions and bitter taste, and no serious adverse events were reported. Conclusions: This systematic review and meta-analysis indicated CPMs might be effective for the prevention and treatment of radiotherapy and chemotherapy-induced oral mucositis through reducing the prevalence, decreasing the occurrence of severe types, alleviating the symptoms, and promoting the healing of ulceration. However, due to the limited number of eligible studies and the publication bias, more high-quality, double-blinded, placebo-controlled RCTs are still needed in future research. Systematic Review Registration: [https://inplasy.com/], identifier [INPLASY2021100100].

Salivary Gland Function, Development and Regeneration

Salivary glands produce and secrete saliva, which is essential for maintaining oral health and overall health. Understanding both the unique structure and physiological function of salivary glands, as well as how they are affected by disease and injury will direct the development of therapy to repair and regenerate them. Significant recent advances, particularly in the OMICS field, increase our understanding of how salivary glands develop at the cellular, molecular and genetic levels; the signaling pathways involved, the dynamics of progenitor cell lineages in development, homeostasis and regeneration and the role of the extracellular matrix microenvironment. These provide a template for cell and gene therapies as well as bioengineering approaches to repair or regenerate salivary function.

Oral-Gut Microbiome Axis in the Pathogenesis of Cancer Treatment-Induced Oral Mucositis

Oral mucositis (OM) is one of the most common and debilitating oral complications of cancer treatments including chemotherapy, radiotherapy, and hematopoietic stem cell transplantation. It is associated with severe pain and difficulties in chewing, swallowing, and speech. This leads to impairment of basic oral functions and could result in unplanned treatment interruption or modification. As such, OM negatively impacts both patients' quality of life as well as tumor prognostic outcomes. Understanding pathways underlying OM pathogenesis help identify new targets for intervention or prevention. The pathophysiology of OM has been widely studied over past decades with several pathways related to oxidative stress, inflammation, and molecular and cellular signaling being implicated. In this mini-review, we will discuss the emerging role of the oral-gut microbiome axis in the development of OM. Particularly, we will elaborate on how the alterations in the oral and gut microbiota as well as intestinal dysfunction caused by cancer treatments could contribute to the pathogenesis of OM. Further, we will briefly discuss the potential methods for targeting the oral-gut microbiome axis to improve OM outcomes.

The Interplay among Radiation Therapy, Antibiotics and the Microbiota: Impact on Cancer Treatment Outcomes

Radiation therapy has been used for more than a century, either alone or in combination with other therapeutic modalities, to treat most types of cancer. On average, radiation therapy is included in the treatment plans for over 50% of all cancer patients, and it is estimated to contribute to about 40% of curative protocols, a success rate that may reach 90%, or higher, for certain tumor types, particularly on patients diagnosed at early disease stages. A growing body of research provides solid support for the existence of bidirectional interaction between radiation exposure and the human microbiota. Radiation treatment causes quantitative and qualitative changes in the gut microbiota composition, often leading to an increased abundance of potentially hazardous or pathogenic microbes and a concomitant decrease in commensal bacteria. In turn, the resulting dysbiotic microbiota becomes an important contributor to worsen the adverse events caused in patients by the inflammatory process triggered by the radiation treatment and a significant determinant of the radiation therapy anti-tumor effectiveness. Antibiotics, which are frequently included as prophylactic agents in cancer treatment protocols to prevent patient infections, may affect the radiation/microbiota interaction through mechanisms involving both their antimicrobial activity, as a mediator of microbiota imbalances, and their dual capacity to act as pro- or anti-tumorigenic effectors and, consequently, as critical determinants of radiation therapy outcomes. In this scenario, it becomes important to introduce the use of probiotics and/or other agents that may stabilize the healthy microbiota before patients are exposed to radiation. Ultimately, newly developed methodologies may facilitate performing personalized microbiota screenings on patients before radiation therapy as an accurate way to identify which antibiotics may be used, if needed, and to inform the overall treatment planning. This review examines currently available data on these issues from the perspective of improving radiation therapy outcomes.

Preventive effect and safety of Chinese herbal medicine for oral mucositis during radiotherapy in patients with head and neck cancer: Study protocol for a randomized trial

Background

Oral mucositis (OM) is a common side effect of radiotherapy (RT) that can have severe implications in patients with head and neck cancer (HNC). Traditional Chinese medicine (TCM) formula is widely applied in treating OM, but little substantial evidence exists to clarify it effects. The study intends to determine whether the TCM-based prescription in treating HNC with RT can improve the OM when compared with RT alone.

Methods

A single-center, randomized, two-arm parallel-group, open-label controlled clinical trial will be conducted to determine whether the Zi-Yin-Liang-Ge-San (ZYLGS), which contains Rx. Scutellariae, Rx. Glycyrrhizae, Hb. Dendrobii, Rx. Ophiopogonis, and Hb. Menthae Haplocalycis, combined with RT can improve the incidence and severity of OM. Two hundred participants will randomly 1:1 to receive at least 6 weeks of RT plus ZYLGS powder or control. The primary outcome measures are onset, gradation of OM (Common Terminology Criteria for Adverse Events v5.0), and oral pain (visual analogue scale). The secondary outcome measures include nutritional status, the EORTC Quality of Life Core Questionnaire and head and neck module. The Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events, serious adverse events, and blood and biochemical analysis will be recorded to evaluate the safety. Visits will be performed for each week during the RT treatment period and then 2 weeks in the follow-up period.

Discussion

The study's result will provide a high-level evidence for TCM-based formulation for HNC patients with RT on the effect of OM prevention and management.

Pathogenesis and Amelioration of Radiation-Induced Oral Mucositis

OPINION STATEMENT

Oral mucositis (OM) causes significant detriment to patient quality of life. Despite advances in RT, chemotherapy, and surgery for HNC which have led to improved local control and survival, management of certain toxicities such as OM have not kept pace. Numerous strategies have emerged with demonstrable benefit in preventing severe OM. However, ones which are not only effective, but practical and affordable to implement are rare. For example, infusion of growth factors or free radical scavengers, and daily treatment of intra-oral sites with lasers are supported by high-quality evidence but have not become widely adopted. It falls to familiarity of the physician with the available preventative measures and ultimately, patient preference in accepting which strategies for OM amelioration are used. In this review, we present a pathophysiological-based review of prevention techniques available for reducing the incidence and duration of severe OM.

Impact of Parenteral Glutamine Supplement on Oncologic Outcomes in Patients with Nasopharyngeal Cancer Treated with Concurrent Chemoradiotherapy

Background: Oral mucositis (OM) is a common toxic side effect in nasopharyngeal carcinoma (NPC) patients receiving concurrent chemoradiotherapy (CCRT) that has a negative impact on treatment outcomes and patients’ survival. Our study aimed to evaluate the impact of parenteral glutamine supplement (dipeptiven) on oncologic outcomes in patients with NPC treated with CCRT. Methods: Patients who were diagnosed with pathologically proved NPC and treated with CCRT were enrolled into our study. Patients were classified as dipeptiven (+) and dipeptiven (−). Oncologic outcomes were measured, and multivariate regression analysis was performed. Grade 3−4 treatment related toxicities were also documented. Results: A total of 144 patients with NPC were recruited in this study to evaluate oncologic outcomes, with 41 dipeptiven (+) and 103 dipeptiven (−). CCRT interruption rate and severe adverse effect (SAE) rate were significant lower in the dipeptiven (+) group than in the dipeptiven (−) group. The median overall survival (OS) was not mature yet in the dipeptiven (+) group and 30 months in the dipeptiven (−) group (p < 0.01). Multivariate analysis demonstrated that dipeptiven supplementation and CCRT interruption were independent predictors associated with better survival. The OS was longest in patients with a dipeptiven supplement and patients who had CCRT interruption had significantly worst OS. As for safety profiles, grade 3 to 4 adverse effects were fewer in dipeptiven (+) than in dipeptiven (−). Conclusion: Dipeptiven supplementation is crucial in NPC patients treated with CCRT, which can ameliorate treatment-related toxicity and augment treatment efficacy. Further prospective clinical trials are warranted to validate our results.

Efficacy of Kanglaite against radiotherapy-induced mucositis in head and neck cancer, a phase II trial

PURPOSE

To explore the potential protective effect of Kanglaite injection against radiotherapy-induced mucositis in patients with head and neck cancer.

PATIENTS AND METHODS

This was an open-label, single-arm, and phase II trial. The primary endpoint was the incidence of grade 3-4 radiation-induced mucositis. The secondary endpoints were hematological toxicity, non-hematological toxicity, nutritional status, and quality of life. All patients received 20g Kanglaite daily concurrently with radiotherapy.

RESULTS

The data of 46 patients were available for analysis. The incidence rates of grade 3 mucositis, pain, dysphagia, and neutropenia were 10.9%, 2.2%, 10.9%, and 6.5%, respectively, while the incidence of grade 4 acute toxicities was zero. The rate of opioid use was 2.2%. Radiotherapy dose reduction was 2.2% and no irradiation field was modified. The nutritional supports were oro-enteral nutritional supplements (13.0%), TPN (10.9%), and feeding tubes (0%) during radiotherapy. After radiotherapy, 52.2% of patients lost weight, and the weight loss was <10%. The mean pain score in the QLQ-H&N35 and QLQ-C30 was <50. Patients had nearly normal physical, emotional, and cognitive functions.

CONCLUSIONS

A low incidence of grade 3-4 radiation-induced mucositis and no severe acute toxic events, with favorable nutritional status and quality of life, were observed in cancer patients after Kanglaite injection. Our findings highlight the need for a prospective, multicenter, and randomized study to investigate the effect of Kanglaite injection on the reduction of radiation-induced mucositis in patients with head and neck cancer.

Efficacy of Bacillus clausii UBBC - 07 spores in the amelioration of oral mucositis in head and neck cancer patients undergoing radiation therapy

BACKGROUND

The natural flora of healthy mucosa offer protection to the host. The loss of this barrier during radiotherapy enhances insults from physical, chemical and microbial agents.

METHODOLOGY

A randomized, double blind, placebo-controlled, parallel study on forty-six patients who underwent radiotherapy for head and neck cancers was undertaken. Patients were randomized either to standard treatment plus Bacillus clausii UBBC07 or standard treatment plus placebo. Bacillus clausii UBBC07 was given as an oral suspension of 2 billion spores twice every day for 30 days or until completion of total fractions of radiation. Grading of the mucositis was performed using CTCAE v.4.03 severity scale. The time taken for the appearance, resolution and severity of mucositis was evaluated.

RESULTS

There was a significant increase (p < 0.01) in median time for the onset of mucositis i.e., 10 days in test and 8 days in control groups respectively. The median time for remission was found to be 12 days in test and 14 days in the control group (p < 0.05). Grade IV mucositis was observed in no patients in test group and 2 patients in the control group (p < 0.05). No adverse events attributed to the Bacillus clausii were seen. Bacillus clausii UBBC07 therapy delayed the onset, decreased the time to remission and displayed strong impact on suppressing the occurrence of high-grade mucositis amongst the test group.

CONCLUSIONS

This study provides a positive trend that probiotics like Bacillus clausii UBBC07 spores could act as a tool to ameliorate oral mucositis.

A randomized clinical trial of granulocyte macrophage colony stimulating factor mouthwash for oral mucositis in head and neck cancer

PURPOSE

Oral mucositis (OM) is a significant problem for patients with head and neck cancer (HNC). The purpose of this double-blind, randomized clinical trial (RCT) was to evaluate the effectiveness of the granulocyte macrophage colony stimulating factor (GM-CSF) mouthwash compared to Salt and Soda mouthwash for both the prevention (prior to onset of OM) and treatment (beginning at the onset of OM to its healing) of radiation therapy (RT)-induced OM.

METHODS

A total of 91 patients with HNC were randomized to receive: GM-CSF throughout both the prevention and treatment phases (GG group); Salt and Soda throughout both phases (SS group) or Salt and Soda during the prevention phase followed by GM-CSF at the onset of OM (SG group). Three groups were compared on the occurrence and grades of OM, functional status, pain, chewing, and swallowing during and after RT.

RESULTS

No significant differences were found in the occurrence and grades of OM in the patients who used GM-CSF vs. Salt and Soda in the prevention phase. In addition, no differences were seen among the three groups in functional status, pain, chewing, and swallowing during and after RT.

CONCLUSION

Given that GM-CSF was no more effective than Salt and Soda mouthwash for the prevention or treatment of OM, the readily available and cheaper mouthwash can be used at considerable cost savings.

TOPICAL AGENTS FOR THE PREVENTION AND TREATMENT OF ORAL MUCOSITIS

OBJECTIVE

The aim: To make a narrative assessment of the agents currently in use, with a particular emphasis on the topical agents that we frequently utilize in our practice.

PATIENTS AND METHODS

Materials and methods: The main method of this work is a review of literary sources. We reviewed the literature (PubMed, Google Scholar, Web of Science, Scopus) to support and explain the interventions we use in different cases of oral mucositis patients. We decided to combine our experience with evidence-based data.

CONCLUSION

Conclusions: Topical treatments alleviate and prevent oral mucositis. Topical medicines can assist maintain oral balance and moistness by modulating oral bacteria and replacing saliva.

The Effect of Radiation and Chemoradiation Therapy on the Head and Neck Mucosal Microbiome: A Review

Radiation (RT) and chemoradiation therapy (CRT) play an essential role in head and neck cancer treatment. However, both cause numerous side effects in the oral cavity, paranasal sinuses, and pharynx, having deleterious consequences on patients’ quality of life. Concomitant with significant advances in radiation oncology, much attention has turned to understanding the role of the microbiome in the pathogenesis of treatment-induced tissue toxicity, to ultimately explore microbiome manipulation as a therapeutic intervention. This review sought to discuss current publications investigating the impact of RT and CRT-induced changes on the head and neck microbiome, using culture-independent molecular methods, and propose opportunities for future directions. Based on 13 studies derived from a MEDLINE, EMBASE, and Web of Science search on November 7, 2021, use of molecular methods has uncovered various phyla and genera in the head and neck microbiome, particularly the oral microbiome, not previously known using culture-based methods. However, limited research has investigated the impact of RT/CRT on subsites other than the oral cavity and none of the studies aimed to examine the relationship between the head and neck microbiome and treatment effectiveness. Findings from this review provide helpful insights on our current understanding of treatment-induced oral mucositis, dental plaque, and caries formation and highlight the need for future research to examine the effect of RT/CRT on the sinonasal and oropharyngeal microbiome. In addition, future research should use larger cohorts, examine the impact of the microbiome on treatment response, and study the effect of manipulating the microbiome to overcome therapy resistance.

How can biophotonics help dentistry to avoid or minimize cross infection by SARS-CoV-2?

Biophotonics is defined as the combination of biology and photonics (the physical science of the light). It is a general term for all techniques that deal with the interaction between biological tissues/cells and photons (light). Biophotonics offers a great variety of techniques that can facilitate the early detection of diseases and promote innovative theragnostic approaches. As the COVID-19 infection can be transmitted due to the face-to-face communication, droplets and aerosol inhalation and the exposure to saliva, blood, and other body fluids, as well as the handling of sharp instruments, dental practices are at increased risk of infection. In this paper, a literature review was performed to explore the application of Biophotonics approaches in Dentistry focusing on the COVID-19 pandemic and how they can contribute to avoid or minimize the risks of infection in a dental setting. For this, search-related papers were retrieved from PubMED, Scielo, Google Schoolar, and American Dental Association and Centers for Disease Control and Prevention databases. The body of evidence currently available showed that Biophotonics approaches can reduce microorganism load, decontaminate surfaces, air, tissues, and minimize the generation of aerosol and virus spreading by minimally invasive, time-saving, and alternative techniques in general. However, each clinical situation must be individually evaluated regarding the benefits and drawbacks of these approaches, but always pursuing less-invasive and less aerosol-generating procedures, especially during the COVID-19 pandemic.

Effects of dose-dependent response to gamma radiation on circumvallate papilla by expression of caspase-3 in vivo

BACKGROUND

Radiotherapy is one of the most significant treatment modality of head and neck cancers. However, it has various hazards on the normal tissues in the radiation field. One of these affected tissues is the lingual mucosa with their papillae such as circumvallate papilla. The effects of radiation on the lingual specialized mucosa may be represented by radiation-induced mucositis and taste alteration including partial or complete loss of taste.

OBJECTIVES

The aim of the study was to evaluate the dose-dependent response of circumvallate papillae to gamma radiation by immunohistochemical expression of caspase-3.

MATERIAL AND METHODS

Twenty-four adult male albino rats were divided into 3 equal groups irradiated at 2.0, 4.0 and 6.0 Gy whole-body gamma radiation doses. Six non-irradiated rats were used as the control group. The radiation effects on circumvallate papillae were evaluated three days after irradiation via histomorphometric investigation of the papillary size and taste buds' distortion in addition to an immunohistochemical assessment of the apoptotic activity using Caspase-3 marker.

RESULTS

Dose-related changes were observed in the circumvallate papillae size and morphology and taste buds affection. The changes were obviously detected in rats irradiated at 4 Gy and 6 Gy doses. The detection of caspase-3 marker was evident in a dose-dependent manner in all the irradiated groups, more noticeably in the taste bud cells.

CONCLUSIONS

It could be concluded that circumvallate papillae are adversely affected in a dose-dependent manner by gamma radiation particularly in 4 Gy and 6 Gy doses.

Effectiveness of Oral Cryotherapy for Oral Mucositis on Cancer Patient Undergoing Cancer Therapy: A Systematic Review

BACKGROUND: Oral mucositis is one of the complications in patients undergoing cancer therapy. Oral cryotherapy (OC) is an intervention to reduce the severity of oral mucositis. AIM: To identify, analyze, and evaluate articles regarding the effectiveness of cryotherapy for oral mucositis in cancer patients undergoing cancer therapy. METHODS: We performed searching on seven databases (PubMed, CENTRAL, Wiley, CANCERLIT, Science Direct, EBSCO, and SpringerLink). The investigation focused on English-language articles, intervention, or observational study reporting on the effectiveness of OC against oral mucositis in patients undergoing chemotherapy, and published between October 2015 and October 2020. RESULTS: Eleven articles met the eligibility criteria for inclusion consisting of 5 RCTs, 3 Quasi-Experiment studies, 2 Cohort studies, and one pre-experimental study. The majority of the studies show that OC is an effective intervention to reduce the degree and severity of oral mucositis in patients undergoing cancer therapy (Hematopoietic Stem Cell Transplantation and chemotherapy). CONCLUSION: OC is practical, low-cost, and relatively safe and can be an alternative therapy in reducing oral mucositis as a side effect of cancer therapy.