Effectiveness of honey on radiation-induced oral mucositis, time to mucositis, weight loss, and treatment interruptions among patients with head and neck malignancies: A meta-analysis and systematic review of literature

Efficacy of nonpharmacological interventions for severe radiation-induced oral mucositis among head and neck cancer patients: A network meta-analysis of randomised controlled trials

AIMS AND OBJECTIVES

To assess the effectiveness of different nonpharmacological treatments for severe radiation-induced oral mucositis in patients with head and neck cancer.

BACKGROUND

Radiation-induced oral mucositis is highly prevalent in patients with head and neck cancer. Current medications for radiation-induced oral mucositis are limited in effectiveness and susceptible to side effects, and while there is an increasing adoption of nonpharmacological interventions, the optimal one remains unclear.

DESIGN

Systematic review and network meta-analysis based on the PRISMA-NMA guidelines.

METHODS

Six databases were searched. Two authors independently performed the literature screening, data extraction and methodological quality assessment of the included studies. Traditional pairwise meta-analysis was performed by R Studio. A network meta-analysis was then conducted to assess the effects of nonpharmacological interventions for severe radiation-induced oral mucositis in patients with head and neck cancer.

RESULTS

Fifty-two studies involving seven types of nonpharmacological interventions were enrolled. The network meta-analysis indicated that natural plant-based therapies might be the most effective, health education interventions might be the second most effective, and honey might be the third most effective interventions for reducing the incidence of severe radiation-induced oral mucositis. For reducing the incidence of severe oral mucositis-related pain, the pairwise meta-analysis showed that only natural plant-based therapies and health education interventions were effective.

CONCLUSIONS

Nonpharmacological interventions are effective in the management of severe radiation-induced oral mucositis among patients with head and neck cancer.

RELEVANCE TO CLINICAL PRACTICE

Nonpharmacological interventions are a category of safe and effective adjunctive therapies that should be encouraged in clinical practice.

TRIAL REGISTRATION DETAILS

CRD42023400745.

Nutritional interventions for the prevention and treatment of cancer therapy-induced oral mucositis: an umbrella review of systematic reviews and meta-analysis

CONTEXT

To date, the efficacy of nutritional interventions on oral mucositis (OM) in patients with cancer, and the quality of this evidence have not been explored.

OBJECTIVE

The goal of this umbrella review was to provide a comprehensive evaluation of nutritional interventions for patients with cancer with OM, as well as to assess the quality of this evidence.

DATA SOURCES

Meta-analyses were searched for using PubMed, Scopus, and ISI Web of Science databases until December 2021, with no time restrictions.

DATA EXTRACTION

Meta-analyses of randomized control trials that evaluated the effects of nutritional interventions on the incidence of OM in patients with cancer had inclusion criteria for this umbrella review. Data extraction, quality assessment of meta-analyses, and primary studies were done independently by 2 authors. The Grading of Recommendations Assessment, Development, and Evaluation technique was used to grade the certainty of evidence.

DATA ANALYSIS

A total of 26 meta-analyses were included in this umbrella review. The results showed that honey, glutamine, and propolis can reduce the incidence of severe OM, based on moderate evidence quality. In addition, zinc supplementation significantly reduced the incidence of OM, regardless of symptom severity; however, low certainty of the evidence was observed. The effects of vitamin E, curcumin, and probiotics on OM were not statistically significant.

CONCLUSION

This umbrella review shows that honey, glutamine, and propolis can significantly reduce the incidence of severe OM. These findings need to be confirmed with well-designed, longitudinal randomized controlled trials.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42022301010.

Assessment of thyme honey oral gel for the prevention of adriamycin and cyclophosphamide chemotherapy-induced oral mucositis in patients with breast cancer

PURPOSE

Oral mucositis (OM) is a common complication of cancer treatment that has an impact on a patient's quality of life and the outcome of cancer therapy. This trial evaluated the effect of thyme honey oral gel for the prevention of chemotherapy-induced OM.

METHODS

One hundred ten breast cancer patients who received their first cycle of chemotherapy with adriamycin (60 mg/m2) and cyclophosphamide (600 mg/m2) were randomly recruited into two groups: group A were patients who followed general oral hygiene recommendations and rinsing saline 3 times a day, and group B were patients with similar protocol but supplied with our formulated oral gel to be applied 2 to 4 times a day. Patients were assessed by the World Health Organization (WHO) oral mucositis grading scales and self-assessment daily questionnaire.

RESULTS

The use of thyme honey was associated with diminishing incidence of OM grade ≥ 2 (95% CI, 0.12 to 0.90; P = 0.030), duration of OM (- 3.36 days; 95% CI, - 5.50 to - 1.22; P = 0.037) and delayed occurrence of OM grade ≥ 2 (95% CI, 0.10 to 0.80; P = 0.017).

CONCLUSION

Thyme honey can be considered as a prophylactic agent for OM and decrease the severity of its symptoms.

TRIAL REGISTRATIONS

This protocol was registered at the Iranian Registry of Clinical Trials: registration number IRCT201506063106N25, on June 12, 2015; approved by the institutional review board at the Deputy of Research, Pharmaceutical Sciences Branch, Islamic Azad University, Tehran, Iran; and approved by the Ethics Committee of Medical Researches of Pharmaceutical Sciences Branch of Islamic Azad University, Tehran, Iran-reference number 5936, on August 17, 2014.

A Comprehensive Review of the Effect of Honey on Human Health

Honey is a nutritious, healthy, and natural food, to which antioxidant, anti-inflammatory, and antimicrobial properties have been attributed, mainly due to its content of phenolic compounds. The aim of this review is to analyze the available evidence of the effect of honey on humans. Forty-eight clinical trials published between 1985 and 2022 were analyzed, with a total of 3655 subjects. More beneficial effects of honey intake than no or negative effects on different cardiovascular and metabolic risk factors, glucose tolerance, mucositis caused by chemo-radiotherapy, cough in children and wound healing, among others have been observed. Although the number of studies conducted to date is limited and the different investigations are not standardized, beneficial effects of honey intake have been observed, especially when its intake replaces the intake of other sweeteners. In addition, honey could be a safe adjuvant to be administered alongside drugs used for certain diseases.

Synbiotics as Supplemental Therapy for the Alleviation of Chemotherapy-Associated Symptoms in Patients with Solid Tumours

Chemotherapy is still the first line of treatment for most cancer patients. Patients receiving chemotherapy are generally prone to infections, which result in complications, such as sepsis, mucositis, colitis, and diarrhoea. Several nutritional approaches have been trialled to counter the chemotherapy-associated side effects in cancer patients, but none have yet been approved for routine clinical use. One of the approaches to reduce or avoid chemotherapy-associated complications is to restore the gut microbiota. Gut microbiota is essential for the healthy functioning of the immune system, metabolism, and the regulation of other molecular responses in the body. Chemotherapy erodes the mucosal layer of the gastrointestinal tract and results in the loss of gut microbiota. One of the ways to restore the gut microbiota is through the use of probiotics. Probiotics are the ‘good’ bacteria that may provide health benefits if consumed in appropriate amounts. Some studies have highlighted that the consumption of probiotics in combination with prebiotics, known as synbiotics, may provide better health benefits when compared to probiotics alone. This review discusses the different nutritional approaches that have been studied in an attempt to combat chemotherapy-associated side effects in cancer patients with a particular focus on the use of pre-, pro- and synbiotics.

Real-world evidence of cisplatin versus carboplatin in patients with locally advanced nasopharyngeal carcinoma receiving concurrent chemoradiotherapy: A multicenter analysis

BACKGROUND

Though concurrent chemoradiotherapy (CCRT) with cisplatin remains a standard of care for patients with locally advanced nasopharyngeal carcinoma (LA-NPC), carboplatin has alternatively been used without sufficient supportive evidences. Thus, we evaluated an efficacy and tolerability of carboplatin CCRT compared with cisplatin in LA-NPC patients.

METHODS

Patients with LA-NPC treated with CCRT were identified through the Thai multicenter head and neck cancer database. Patient tolerability and survival were analyzed and compared between regimens. Survivals were calculated by using the Kaplan-Meier method, and compared by the log-rank test. A p-value of <0.05 was considered statistically significant.

RESULTS

A total of 135 of 980 patients (13.8%) were treated with carboplatin. Patients treated with carboplatin were significantly associated with older age (p < 0.001), smoking (p = 0.003), more comorbidity (p = 0.014), kidney disease (p = 0.016), and lower baseline creatinine clearance (p < 0.001). Intensity-modulated radiation therapy was used significantly more in the cisplatin group than carboplatin group (p < 0.001). Patients who received carboplatin were associated with delay (p = 0.049) and hospitalization (p = 0.006), whereas cisplatin CCRT had more dose reduction (p = 0.001). Patients treated with cisplatin had CCRT interruption from grade 3-4 mucositis (p = 0.019) more than carboplatin, whereas carboplatin had more grade 3-4 thrombocytopenia (p < 0.001). The 5-year overall survival (OS) of patients treated with cisplatin and carboplatin was 59% and 49%, respectively (p = 0.128). Cisplatin or carboplatin CCRT was not a significant predictor for OS and locoregional recurrence-free survival in multivariate analysis.

CONCLUSIONS

Carboplatin CCRT provided acceptable efficacy and tolerability profiles in real-world practice. Carboplatin should be considered as an alternative regimen, particularly in cisplatin-ineligible patients with LA-NPC treated with CCRT.

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.

The protective effects of blueberry honey from Canada against H2O2-induced cytotoxicity in human buccal mucosal cells

OBJECTIVES

Several clinical trials have been conducted worldwide to evaluate the efficacy of honey against stomatitis. However, it is unclear which types of honey are effective at preventing and/or treating stomatitis. This study aimed to evaluate the potencies of several types of honey in preventing and/or curing aphthous stomatitis in in vitro studies.

METHODS

The following experiments were performed: H₂O₂-induced cytotoxicity and mucosal cell migration in a scratch assay using buccal mucosa squamous carcinoma (HO-1-N-1) cells and the cellular expression of heme oxygenase-1 (HO-1) mRNA encoding an enzyme involved in protection against oxidative stress by real-time RT-PCR analysis, and liquid-liquid extraction and UHPLC analysis in order to examine the active components of honey.

RESULTS

Of the 13 types of honey used, Canadian blueberry honey exhibited the protective effect on H₂O₂-induced cytotoxicity and enhanced cell migration. In addition, blueberry honey increased the expression of HO-1 mRNA with and without cotreatment with H₂O₂. With regard to active components of blueberry honey, the water-soluble components with a mass of >10 kDa showed a cytoprotective effect, but they have not been identified.

CONCLUSION

Canadian blueberry honey, but not the other types of honey, prevents H₂O₂-induced oxidation of cells, probably through activation of the antioxidant and cytoprotective enzyme HO-1. Blueberry honey also enhanced cell migration, which may be relevant to wound healing. The results of this study suggest the possibility of prophylactic and therapeutic effects of Canadian blueberry honey on human stomatitis that could complement existing treatments.

Evaluation of the efficacy of the anti-ulcer oral mucosal protective agent RADoralex® in the prevention and treatment of radiation-induced oral mucosal reactions induced during treatment of nasopharyngeal carcinoma

The aim of this study was to evaluate the efficacy and safety of antiulcer oral mucosal protectant-RADoralex® in the prevention and treatment of radiation-induced oral mucosal reactions elicited during intensity-modulated radiation therapy (IMRT). for locally advanced nasopharyngeal carcinoma (NPC). A total of 90 patients with locally advanced NPC who developed post-treatment grade 1 oral mucositis were selected for this study. They were randomly assigned to the experimental group (n = 44) treated by mouth rinsing with the RADoralex® during radiochemotherapy and the control group (n = 43) treated by mouth rinsing with sodium bicarbonate solution, and the patients’ oral mucosal conditions, quality of life, weight change and oral pain levels were analyzed. The incidence of Common Terminology Criteria for Adverse Events (CTCAE) v4.0 grade 2 and grade 3 oral mucositis were significantly lower in the experimental group than in the control group. Compared to the control group, the time to progression, and the time from the end of treatment to oral mucosa healing in the experimental group was significantly shorter. The experimental group lost 8.66 ± 3.543% of their body weight during treatment period, while the control group lost 12.53 ± 4.284% (p < .001). From the beginning the 3^rd week of treatment to the 2^nd week after the end of treatment, the Oral Mucositis Assessment Scale (OMAS) scores were lower in the experimental group than in the control group (p < .05). RADoralex® significantly reduced the incidence and severity of oral mucositis in patients with locally advanced NPC during radiochemotherapy, delayed the progression of oral mucositis.

Oral mucositis: Current knowledge and future directions

Oral mucositis secondary to head and neck chemoradiation displays a complex molecular pathogenesis involving epithelial and microvascular injury, release of pro-inflammatory cytokines, and host-microbiome communications. These processes lead to oxidative stress and the release of reactive oxygen species that stifle the structural integrity of the oral mucosa, with emergence of erosions and ulcers. The consequences are malnutrition, psychological/psychiatric symptoms, poor quality of life, and occurrence of opportunistic infections. The latter pose a major challenge due to the risk of interruption of anti-neoplastic therapy, tumour recurrence and, ultimately, death. This article aims to present the clinical characteristics, molecular pathogenesis, and an overview of the predisposing factors and current management of oral mucositis. It is anticipated that the future direction of the management of oral mucositis will focus on evidence-based prehabilitation and pre- and per-chemoradiation therapy monitoring.

Role of honey in preventing radiation-induced oral mucositis: a meta-analysis of randomized controlled trials

BACKGROUND

Radiotherapy-induced mucositis easily arouses oral ulceration, pain and xerostomia. Intense pain, difficulty swallowing and speaking greatly affect the quality of life and the treatment process.

OBJECTIVE

This study aimed to examine the effects of honey in preventing and treating radiotherapy-induced mucositis in patients with head and neck cancer using a different analytical strategy.

METHODS

Articles published until July 2020 were searched across PubMed, Embase, and Cochrane Library databases. Randomized controlled trials that evaluated honey were assessed by two reviewers. The number of mucositis incidences was the primary outcome. Weight loss, pain scale and incidence of severe pain were pooled to be calculated as secondary outcomes. Statistical analyses were conducted using RevMan5.3 software. The funnel plot was used to detect publication bias.

RESULTS

Overall, 11/179 records with 715 patients who received radiotherapy were included. Honey significantly reduced the incidence of grade 2 (OR: 0.43, 95%CI: 0.54-0.98, P = 0.03), grade 3 (odds ratio [OR]: 0.24, 95% confidence interval [CI]: 0.16-0.35, P < 0.001) and grade 4 mucositis (OR: 0.17, 95%CI: 0.08-0.36, P < 0.001). In grade 1 (OR: 1.54, 95%CI: 1.15-2.06, P = 0.003), and honey was not significant in preventing radiation-induced mucositis. The incidence of unbearable pain was lower in the honey group at all grades (OR: -0.20, 95%CI: -0.33 to -0.07). The effect of honey on weight loss and pain score was not statistically significant.

CONCLUSION

Honey can prevent and alleviate grade 2-4 mucositis, especially in high grade mucositis. Honey also provides some relief from severe pain. But, more evidence is required to prove that honey is an effective substance for relieving pain or minimizing weight loss.

Nutritional supplements in the management of oral mucositis in patients with head and neck cancer: Narrative literary review

BACKGROUND AND AIMS

Oral mucositis is the most common side effect in response to anticancer therapies in the head and neck region. It has a debilitating potential for the health of affected individuals, negatively interfering with nutritional status and quality of life. Due to the great complexity of its pathogenicity, different forms of interventions for prevention and treatment are being studied, including nutritional supplements with vitamin E, zinc and glutamine. This study aimed to review the literature on the influence of nutrients, in supplement form, for prevention and/or treatment of mucositis in patients with head and neck cancer.

METHODS

A survey of studies related to the definition, treatment and prevention of mucositis with nutrients was carried out between January 2018 and July 2019, using the Pubmed, Cochrane Library and Scielo databases. In the end, 61 relevant scientific publications were selected between the years 2004 and 2019.

RESULTS

Nutrients such as vitamin E, glutamine and zinc are forms of supplementation that have positive effects on the manifestation and severity of oral mucositis due to their antioxidant and immunomodulatory properties. However, some studies reveal that antioxidant properties may reduce the effectiveness of antineoplastic therapy.

CONCLUSIONS

This study suggests the effectiveness of vitamin E, zinc and glutamine in preventing and treating oral mucositis. However, the importance of new clinical researches to clarify possible doubts is highlighted, as well as the creation of a protocol that includes the dose, route and time of administration, for greater safety in use.

A systematic review of interventions to mitigate radiotherapy-induced oral mucositis in head and neck cancer patients

BACKGROUND

Oral mucositis is a debilitating consequence of radiotherapy in patients with head and neck cancers. Radiation-induced oral mucositis (RIOM) can cause pain and weight loss, reduce quality of life and affect treatment outcomes.

METHODS

A systematic review was undertaken to identify and examine the efficacy of low-cost interventions to mitigate RIOM and to develop clinical guidelines based on the evidence.

RESULTS

The author identified three interventions: benzydamine hydrochloride mouth rinse (BHM), honey and oral glutamine (OG). The search identified twenty-four studies in total. Four studies examined BHM; all findings were favourable, although only one had moderate methodological quality, and the rest were low. The product was poorly tolerated by some participants in one study. Twelve studies examined honey. Eleven of these had favourable results; two studies had moderate methodological quality, and the rest were low. Eight studies examined OG. Six of these had favourable results; two studies had moderate methodological quality, and the rest were low.

CONCLUSION

The author cannot recommend BHM to mitigate RIOM due to the overall low quality of the studies and poor tolerance to the product. The author cannot recommend honey to mitigate RIOM due to weak evidence supporting the intervention. The author can recommend OG to mitigate RIOM. There is a need for high-quality studies with a consensus of the methodology to reduce heterogeneity and examination of the cost-effectiveness of the interventions.

Research progress on radioprotective effects of bee products

Radiation exposure is an on going and serious threat in military and public health concern. There is an unmet need for effective preventative or mitigative treatments against radiation-induced injuries. The handful of Food and Drug Administration in the US approved radiation protection agents cannot be widely used due to their side effects. Some natural nontoxic compounds such as bee products have been reported to prevent and treat radiation-induced injuries (e.g. scavenging free radicals, inhibiting cell apoptosis and reducing DNA damage), indicating that they may be a potential option as a safe radioprotective agent. Bee products are nontoxic and have no known side effects on the human body, and are effective in the field of radiation protection. They are expected to be interesting drug candidates for preventing and treating radiation-induced injuries. This article reviews the prevention and treatment of bee products on radiation-induced injuries.

Usefulness of Honey as an Adjunct in the Radiation Treatment for Head and Neck Cancer: Emphasis on Pharmacological and Mechanism/s of Actions

BACKGROUND

In the treatment of head and neck cancer (HNC), ionizing radiation is an important modality in achieving curative objectives. However, the effective use of radiation is compromised by the side effects resulting from the damage to the adjacent normal tissue. Preclinical studies carried out in the recent past have shown that the age old dietary agent honey, which also possess myriad medicinal use is beneficial in mitigating diverse radiation-induced side effects like mucositis, xerostomia, fatigue, weight loss and to promote healing of refractory wounds.

OBJECTIVE

The objective of this memoir is to review the beneficial effects of honey in mitigating radiation-induced side effects in HNC and to emphasize on the underlying mechanism of action for the beneficial effects Methods: Two authors searched Google Scholar, PubMed, Embase, and the Cochrane Library for publications up to December 2019 to assess the ability of honey in reducing the severity of radiation-induced ill effects in the treatment of HNC. Subsequently, the adjunct pharmacological effects and mechanism/s responsible were also searched for and appropriately used to substantiate the underlying mechanism/s of action for the beneficial effects.

RESULTS

The existing data is suggestive that honey is beneficial in mitigating the radiation-induced mucositis, xerostomia, healing of recalcitrant wounds in radiation exposed regions and multiple pathways mediate the beneficial effects especially, free radical scavenging, antioxidant, wound healing, anticancer, analgesic, anti-inflammatory, anabolic, anti-fatigue and anti-anaemic effects that add additional value to the use of honey as an adjunct in cancer therapy.

CONCLUSION

For the first time this review addresses the underlying pharmacological effects related to the beneficial effects of honey in radiation-induced damage, and attempts at emphasizes the lacunae that need further studies for optimizing the use of honey as an adjunct in radiotherapy of HNC. The authors suggest that future studies should be directed at understanding the detail molecular mechanisms responsible for the beneficial effects using validated cell culture and animal models of study. Large multi centric clinical trials with standardised honey is also needed to understand the clinical use of honey.

Radiation-Induced Oral Mucositis in Head and Neck Cancer Patients. Five Years Literature Review

Backround: Radiation-induced oral mucositis consists of a series of relatively frequent side effects after head and neck cancer radiotherapy and has an adverse impact on both regular treatment process and the quality of life of patients.

OBJECTIVE

The purpose of the present review is to optimize the current management of radiation-induced oral mucositis in head and neck cancer patients.

METHODS

PubMed database research was performed on articles published since 2015 that demonstrated efficacy in the management of radiation-induced oral mucositis in head and neck cancer patients. The study selection included observational, prospective, comparative, randomized, double- blind, placebo-controlled or uncontrolled, and retrospective studies, as well as systematic reviews and metanalyses.

RESULTS

From the 931 citations obtained from the search, only 94 articles met the inclusion criteria, including mucosal protectants, anti-inflammatory agents, growth factors, and various miscellaneous and natural agents. Several methods, including both pharmacological and natural agents, have been proposed for the management of oral mucositis. In addition to the already known interventions with strong evidence, according to the Multinational Association of Supportive Care in Cancer and he International Society of Oral Oncology guidelines, further agents have been used. However, a great number of them lack clear evidence, which surely requires the design of more controlled clinical trials for a better assessment of the ideal methods.

CONCLUSION

The management of oral mucositis constitutes an active area of research. In light of these results, it is aimed to illustrate those treatment strategies that are most effective regarding the treatment approach of oral mucositis.

Honey Against Radiation-induced Oral Mucositis in Head and Neck Cancer Patients. An Umbrella Review of Systematic Reviews and Meta- Analyses of the Literature

Backround: Oral mucositis (OM) consists of a major side effect of radiotherapy (RT) in head and neck (H-N) cancer patients and natural honey is gaining more and more scientific interest due to its beneficial effects in tissue repair.

OBJECTIVE

The aim of this review is to better clarify the preventive/therapeutic role of honey in the management of OM in patients with H-N cancer undergoing RT with or without chemotherapy (CT).

METHODS

We used the PubMed database to retrieve journal articles and the inclusion criteria were only reviews and meta-analyses that illustrated the effective use of honey for either the prevention or treatment of OM in H-N cancer patients receiving either RT alone or in combination with CT.

RESULTS

Our search resulted in 92 citations, of which 12 eventually fulfilled the inclusion criteria of our study. Decreased incidence and severity of OM, extended time of occurrence of mucositis, less weight loss and less treatment interruptions were occasionally documented with conventional honey use in the included reviews and meta-analyses. In contrast to conventional honey, manuka honey proved to be weak in improving OM management in the small number of included reviews in our search.

CONCLUSION

Conventional honey might constitute a highly promising natural product against OM attracting much scientific interest due to its easy accessibility and low financial cost. Hence, the lack of studies with high evidence requires further advanced research to enhance the existing knowledge about the potential value of honey in radiation-induced OM in H-N cancer patients.

Methodological Quality of Systematic Reviews and Meta-analyses Published in High-Impact Otolaryngology Journals

OBJECTIVE

To assess the methodological quality of intervention-focused systematic reviews (SRs) and meta-analyses (MAs) published in high-impact otolaryngology journals.

DATA SOURCES

Ovid Medline, Embase, and Cochrane Library.

REVIEW METHODS

A comprehensive search was performed for SR and MA citations from 2012 to 2017 in the 10 highest impact factor otolaryngology journals. Abstracts were screened to identify published manuscripts in which the authors indicated clearly that they were performing an SR or MA. Applying a modified typology of reviews, 4 reviewers characterized the review type as SR, MA, or another review type. A simplified version of the AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews 2) tool was used to assess the reporting and methodological quality of the SRs and MAs that were focused on interventions.

RESULTS

Search and abstract screening generated 499 manuscripts that identified themselves as performing an SR or MA. A substantial number (85/499, 17%) were review types other than SRs or MAs, including 34 (7%) that were literature reviews. In total, 236 SRs and MAs focused on interventions. Over 50% of these SRs and MAs had weaknesses in at least 3 of the 16 items in the AMSTAR 2, and over 40% had weaknesses in at least 2 of the 7 critical domains. Ninety-nine percent of SRs and MAs provided critically low confidence in the results of the reviews.

CONCLUSION

Intervention-focused SRs and MAs published in high-impact otolaryngology journals have important methodological limitations that diminish confidence in the results of these reviews.

Comparative prevention potential of 10 mouthwashes on intolerable oral mucositis in cancer patients: A Bayesian network analysis

BACKGROUND

There is a wide variety of mouthwashes currently available for the prevention of intolerable oral mucositis (OM) onset. Because of a lack of evidence from head-to-head randomized controlled trials (RCTs), the relative effects of these mouthwashes in intolerable OM patients remain unclear. This study compared the preventive effect of ten mouthwashes in intolerable OM.

METHODS

A literature search was performed of the Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, and MEDLINE (PubMed) databases. Reports published from 1990 to 2019 focusing on mouthwashes for preventing OM were identified. Authors assessed the studies' risk of bias in accordance with the Cochrane Handbook for Systematic Reviews of Interventions, and followed the PRISMA for Network Meta-Analyses Statement. Authors estimated summary odds ratios (ORs) using pairwise and Bayesian network meta-analysis with random effects.

RESULTS

Thirty-six RCTs, with a total of 2594 patients, were included in the present study. Bayesian network analysis showed that honey (Odd Ratio [OR] 0.17, 95%CI 0.09 to 0.30), chamomile (OR 0.09, 95% CI 0.01 to 0.52), curcumin (OR 0.23, 95% CI 0.08 to 0.67) and benzydamine (OR 0.26, 95% CI 0.12 to 0.54) mouthwashes were superior to placebo. Honey mouthwashes were more efficacious than chlorhexidine (OR 0.34, 95% CI 0.12 to 0.92), sucralfate (OR 0.26, 95% CI 0.06 to 0.96) and povidone-iodine (OR 0.30, 95% CI 0.11 to 0.82) mouthwashes. Other mouthwashes showed no significant differences.

CONCLUSIONS

According to the analysis of rank probabilities, chamomile, honey, curcumin and benzydamine mouthwashes may be the most advantageous in terms of the prevention of intolerable OM.

Antimicrobial activity of honey in periodontal disease: a systematic review

BACKGROUND

Honey has shown positive antimicrobial and anti-inflammatory actions in several dermatological studies; however, it is unclear if it could be effective in the treatment of periodontal disease.

OBJECTIVES

To answer the question: Does honey have antimicrobial activity against periodontopathogens?

METHODS

Six electronic databases were screened from initiation to 31 January 2019 for randomized clinical trials (RCTs) and controlled in vitro studies exploring the antimicrobial effect of honey against periodontopathogens. Honey's botanical origin, periopathogens that showed microbial susceptibility to honey, MICs, microbial growth conditions, control product and clinical follow-up were the main investigated outcomes. The risk of bias (RoB) of included RCTs was assessed using the Cochrane Collaboration RoB tool. The RoB of in vitro studies was evaluated based on the Sarkis-Onofre judgement model adapted to the context of honey.

RESULTS

A total of 1448 publications were found as search results in the screened databases. Sixteen eligible papers were included based on predetermined inclusion criteria. Retained studies included 5 RCTs and 11 in vitro controlled trials. Manuka and multifloral honeys were the most studied varieties. The tested honeys showed a significant antimicrobial action, with different MICs, against eight periopathogens. Four of the five RCTs showed a high RoB, while 4 of the 11 retained in vitro studies showed a medium RoB.

CONCLUSIONS

Honey showed a significant antimicrobial activity against all targeted periopathogens. Additional experiments are required to explore the entire antimicrobial spectrum of honey towards all pathogens involved in periodontal disease.

Effects of 9 oral care solutions on the prevention of oral mucositis: a network meta-analysis of randomized controlled trials

BACKGROUND

Oral mucositis (OM) is a common, disabling, and severe early effect of chemotherapy and radiotherapy that limits the effectiveness of anticancer therapy. The prevention and treatment of OM in patients with malignant tumors is an urgent problem in the field of anticancer therapy.

METHODS

Databases including PubMed, Embase, Scopus, The Cochrane Library, and Google Scholar were searched to collect published randomized control trials (RCTs) about the effects of different oral care solutions on the prevention of OM from inception to January 2019. We used the Cochrane Handbook to assess the methodological quality of the RCTs. Two of the authors independently extracted the articles and predefined data. Network meta-analysis was then performed using Stata 15.0 software.

RESULTS

A total of 28 RCTs involving 1861 patients were included. The results of network meta-analysis showed that chlorhexidine, benzydamine, honey, and curcumin were more effective than placebo (P < .05) and that honey and curcumin were more effective than povidone-iodine (P < .05). Probability ranking according to the Surface Under the Cumulative Ranking curve showed the following treatments: curcumin, honey, benzydamine, chlorhexidine, allopurinol, sucralfate, granulocyte-macrophage colony-stimulating factor, povidone-iodine, and aloe.

CONCLUSION

Our preliminary results indicate that curcumin and honey may serve as the preferred options for patients to prevent OM. The findings may offer an important theoretical basis for clinical prevention and treatment. However, this conclusion still requires an RCT with a larger sample size for further verification.

What is wrong with the meta-analyses on honey and oral mucositis due to cancer therapies?

OBJECTIVES

The results of meta-analyses currently represent the highest level of evidence in modern medicine. Taking the example of radiotherapy and radiochemotherapy-induced oral mucositis and the effects of honey, we analysed six meta-analyses on the topic to assess the quality of the meta-analyses.

DESIGN

We analysed the various meta-analyses in detail and compared whether the authors have correctly included the various trials or not.

RESULTS

We found that the quality of these meta-analyses was low. Especially the more recent meta-analyses included trials in which radiotherapy was not part of the medical intervention or where substances other than pure honey were used.

CONCLUSIONS

It is impossible to determine the underlying reasons why these meta-analyses were able to pass the peer-review system without the request for adequate improvements prior to publication. According to the literature at least 7% of the included meta-analyses revealed false results, but it was assumed that due to limitations of external validity and to the decreased likelihood of updating positive meta-analyses, the true proportion of false positives in the meta-analysis was likely to be higher. However, it is crucial that when severe flaws in meta-analyses are detected that they be reported or the meta-analyses are withdrawn, otherwise the normal reader will take the results as given.

Using Bee Products for the Prevention and Treatment of Oral Mucositis Induced by Cancer Treatment

Oral mucositis is one of the most frequent complications after chemotherapy or radiotherapy or a combination of both. There is no standard therapy for its prevention or treatment. Considering that some bee products have been found to be of value in this situation, we decided to analyze the scientific literature on the subject. Scientific publications on bee products were identified by a literature search on Pubmed, Scopus and Google Scholar. There is a lot of evidence regarding the use of honey for oral mucositis due to chemotherapy or radiotherapy or a combination of both. Unfortunately, the quality of several meta-analyses on the topic is very low. There is some evidence on propolis, a little on royal jelly and none whatsoever on pollen and other bee products like apilarnil or bee venom. Bee products such as honey, propolis and royal jelly may be well suited to be integrated into a general concept for the prevention and treatment of oral mucositis which should also include other established concepts like oral care, oral cryotherapy, topical vitamin E and low-level-laser therapy. Bee products could become an integral part in the treatment of chemotherapy, radiotherapy and radio chemotherapy. High-quality meta-analyses and further studies, especially on the combinations of various strategies, are needed.

Effect of Topical Application of Pure Honey in Chemo-radiation-Induced Mucositis and Its Clinical Benefits in Improving Quality of Life in Patients of Oral Squamous Cell Carcinoma

Oral cancer is a major health problem in India, and in certain parts, it represents more than 50% of all cancers. Since almost all of these patients receive chemo-radiotherapy with or without surgery for treatment, a vast majority of them also develop oral mucositis, a debilitating adverse effect of chemo-radiation. There have been various reports in the literature regarding the beneficial role of honey in the management of oral mucositis. The objective of this study was to investigate whether the application of honey in mucositis confers any significant improvement in lesions of mucositis and more specifically whether application of honey brings about any improvement in the quality of life of patients suffering from chemo-radiation-induced oral mucositis. If found to be beneficial, honey could provide a simple, elegant and cost-effective solution to a troublesome health problem, thus benefiting a large number of patients.

Honey in oral health and care: A mini review

BACKGROUND

Honey is a natural product made from the nectar of flowers by honey bees and has over 200 compounds in it, including sugars, water, organic acids, minerals and polyphenols - the exact structure and composition of honey often determined by which plant source(s) the honey bee took the nectar from. Honey has been used in diets and medicines for thousands of years; however, this review, for the first time, aims to look at its place in modern medicine concerning oral health.

HIGHLIGHT

The present review for the first time attempted to address the protective effect of honey in the oral care.

CONCLUSION

For the first time this review addresses the usefulness of honey against Streptococcus mutans infections, dental plaque and caries, gingivitis and halitosis. Honey was also useful in preventing side effects associated with treatment of cancers of the head and neck, namely, radiation induced mucositis, xerostomia and poor wound healing. This is well supported by evidence in literature and was examined in this review.

Honey as a Treatment in Otorhinolaryngology: A Review by Subspecialty

OBJECTIVES

To provide an up-to-date review of honey's effectiveness and potential applications in otorhinolaryngology.

METHODS

A literature search of the online databases PubMed, EMBASE, and Cochrane Central Register of Controlled Trials was conducted.

RESULTS

Sixty-three studies were identified within head and neck surgery (n = 23, 36%); pediatric otolaryngology (n = 18, 29%); rhinology, sinus, and skull base surgery (n = 11, 17%); otology (n = 6, 10%), facial plastic and reconstructive surgery (n = 3, 5%); and laryngology (n = 2, 3%). Studies included 6 meta-analyses, 44 randomized control trials, 5 case reports, and 8 animal models or in vitro studies. Of 55 clinical studies, 50 reported Level 1 evidence (prospective randomized control trials), and 5 reported Level 4 evidence (case series). The evidence level by subspecialty was: head and neck surgery (Level 1 n = 23), pediatrics (Level 1 n = 18), rhinology (Level 1 n = 7, level 4 n = 1), otology (Level 1 n = 1, Level 4 n = 3), facial plastics and reconstructive surgery (Level 4 n = 1), and laryngology (Level 1 n = 2).

CONCLUSIONS

Honey can be used for a variety of otolaryngology conditions. The highest quality meta-analyses support oral honey for prevention and treatment of oral mucositis in cancer patients, cough associated with upper respiratory infection in children, and pain control after tonsillectomy. Further research will likely justify broader applications.

The effect of an oral care protocol and honey mouthwash on mucositis in acute myeloid leukemia patients undergoing chemotherapy: a single-blind clinical trial

OBJECTIVES

The purpose of the study is to evaluate and compare the effectiveness of honey mouthwash and an oral care protocol on mucositis and weight loss in patients with acute myeloid leukemia receiving chemotherapy.

MATERIALS AND METHODS

In this single-blind clinical trial, 53 acute myeloid leukemia (AML) patients receiving chemotherapy were randomly assigned into three groups: honey mouthwash (n = 17), oral care (n = 17), and control (n = 19). The severity of mucositis and weights was examined blindly at the baseline and 4-week follow-up.

RESULTS

The prevalence of grades of mucositis in the study groups was significant at the end of the third (p = 0.002) and fourth (p < 0.001) weeks. The mucositis severity decreased at the end of the third and fourth weeks in the honey mouthwash group (p < 0.05), whereas it increased in the control group (p < 0.001). The difference in the weight was significant between the honey mouthwash and the control groups (p < 0.05, MD = 1.95) at the end of the third week, and between the honey mouthwash group with the control (p < 0.01, MD = 2.92) and oral care groups (p < 0.05, MD = 1.95) at the end of the fourth week.

CONCLUSIONS

Honey mouthwash is effective in preventing and reducing the severity of mucositis, and weight loss and can be recommended for patients undergoing chemotherapy.

CLINICAL RELEVANCE

The results of this study suggest that honey mouthwash can reduce the incidence and severity of mucositis in patients, reduce or eliminate the possibility of weight loss in them, as well as encourage some weight gain. Compared to routine oral care, honey mouthwash is also easier to use and handle.

TRIAL REGISTRATION

IRCT2015121419919N7.

Adjunctive Treatments for the Prevention of Chemotherapy- and Radiotherapy-Induced Mucositis

Background: Chemoradiotherapy-associated mucositis can manifest as pain, inflammation, dysphagia, diarrhea, weight loss, rectal bleeding, and infection. Mucositis is a major dose-limiting side effect of chemotherapy, affecting nutritional intake and oral and intestinal function. Despite several interventions being available, there is a need for safe and effective preventative and treatment options for treatment-induced mucositis. The goals of this review are to discuss interventions based on foods and natural products and present the research to date. Methods: A narrative literature review identified 60 clinical studies examining various nutritional compounds and 20 examining probiotics. 9 studies on probiotics for the prevention of diarrhea were also assessed on methodological quality and limitations identified. Results: Several compounds have been posited as useful adjuvants for cancer treatment–related mucositis. Probiotics demonstrate efficacy for the prevention and treatment of chemoradiotherapy-induced gastrointestinal toxicity without significant side effects. Glutamine and activated charcoal were reported to reduce chemotherapy-induced diarrhea but not radiation-induced intestinal mucositis. Honey has been reported to decrease treatment interruptions, weight loss, and delays the onset of oral mucositis. Zinc, glutamine, and topical vitamin E were demonstrated efficacy for oral mucositis. Conclusion: There is plausible clinical evidence for the administration of several adjunctive treatments for the prevention and treatment of mucositis. Probiotics were reported to reduce the burden of intestinal mucositis and treatment-induced diarrhea. Activated charcoal and glutamine are beneficial for chemotherapy-induced diarrhea, whereas the administration of honey, zinc, and glutamine reduce the risk of developing oral mucositis during chemotherapy or radiotherapy.

Honey Mitigates Radiation-Induced Oral Mucositis in Head and Neck Cancer Patients without Affecting the Tumor Response

Radiation-induced mucositis is a dose-limiting factor in the effective treatment of head and neck (H & N) cancers. The objective of this study was to understand the efficacy of honey in mitigating radiation-induced mucositis and whether it would interfere with tumor control. This was a single-blinded, randomized, controlled study and was carried out in patients with H & N cancer requiring curative radiotherapy (>62 Gy (Gray)). The patients meeting the inclusion criteria were randomly assigned to receive either honey (n = 25) or povidone-iodine (active comparator) (n = 25) during radiotherapy. Oral mucositis was assessed using the RTOG (Radiation Therapy Oncology Group) grading system before the start, during, and at the end of the treatment by an investigator unaware of the treatment. The results indicate that when compared with the active comparator, honey reduced the radiation-induced oral mucositis, decreased the incidence of intolerable mucositis, treatment breaks, loss of treatment days (p < 0.0001 and < 0.0003) and did not affect the radiation-induced tumor response. The clinical observations indicate that honey mitigates the radiation-induced mucositis and does not interfere with tumor cell killing.