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Duane B, Yap T, Neelakantan P, Anthonappa R, Bescos R, McGrath C, McCullough M, Brookes Z. Mouthwashes: Alternatives and Future Directions. Int Dent J 2023; 73 Suppl 2:S89-S97. [PMID: 37867066 PMCID: PMC10690551 DOI: 10.1016/j.identj.2023.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 08/21/2023] [Indexed: 10/24/2023] Open
Abstract
This narrative review summarises "alternative" or "natural" over-the-counter (OTC) mouthwashes not covered elsewhere in this supplement and newly emerging products, as potential mouthwashes of the future. The "natural" mouthwashes reviewed include saltwater, baking soda, coconut oil, charcoal, propolis, seaweeds, and probiotics. Other than essential oils, it is apparent that their clinical effectiveness is still under debate, but there is some evidence to suggest that propolis reduces plaque and gingivitis. This review also covers the host immune response, via novel anti-inmmunomodulant mouthwashes, such as erythropoietin to reduce inflammation with oral mucositis (OM) after radiotherapy. The emerging concept of nanoparticle-containing mouthwashes, such as iron oxide, is further discussed for OM, this agent having the potential for more targeted delivery of chemical antimicrobials. Unfortunately, there are impacts on the environment of widening mouthwash use with more new products, including increased use of packaging, antimicrobial resistance, and possible detrimental effects on marine life. Further, there are roadblocks, relating to regularly approvals and side effects, that still need to be overcome for any OTC deivered immunomodulant or nanoformulation mouthwashes. Despite these caveats, there are many new mouthwashes under development, which could help manage major oral diseases such as caries, gingivitis, and periodontal disease.
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Affiliation(s)
- Brett Duane
- Dublin Dental School and Hospital, Trinity College Dublin, Dublin, Ireland
| | - Tami Yap
- Faculty of Medicine, Dentistry & Health Sciences, Melbourne Dental School, University of Melbourne, Carlton, Australia
| | - Prasanna Neelakantan
- Department of Endodontics, University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco, California, USA
| | | | - Raul Bescos
- School of Health Professions, Faculty of Health, University of Plymouth, Plymouth, UK
| | - Colman McGrath
- Applied Oral Sciences & Community Dental Care, Hong Kong
| | - Michael McCullough
- Faculty of Medicine, Dentistry & Health Sciences, Melbourne Dental School, University of Melbourne, Carlton, Australia
| | - Zoë Brookes
- Peninsula Dental School, Plymouth University, Plymouth, UK.
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Colella G, Boschetti CE, Vitagliano R, Colella C, Jiao L, King-Smith N, Li C, Nuoh Lau Y, Lai Z, Mohammed AI, Cirillo N. Interventions for the Prevention of Oral Mucositis in Patients Receiving Cancer Treatment: Evidence from Randomised Controlled Trials. Curr Oncol 2023; 30:967-980. [PMID: 36661723 PMCID: PMC9858113 DOI: 10.3390/curroncol30010074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/04/2023] [Accepted: 01/06/2023] [Indexed: 01/13/2023] Open
Abstract
Oral mucositis is a common and most debilitating complication associated with cancer therapy. Despite the significant clinical and economic impact of this condition, there is little to offer to patients with oral mucositis, and the medications used in its management are generally only palliative. Given that mucositis is ultimately a predictable and, therefore, potentially preventable condition, in this study we appraised the scientific literature to evaluate effective methods of prevention that have been tested in randomised controlled trials (RCTs). Published high-level evidence shows that multiple preventative methods are potentially effective in the prevention of oral mucositis induced by radiotherapy, chemotherapy, or both. Anti-inflammatory medications (including benzydamine), growth factors and cytokines (including palifermin), cryotherapy, laser-and-light therapy, herbal medicines and supplements, and mucoprotective agents (including oral pilocarpine) showed some degree of efficacy in preventing/reducing the severity of mucositis with most anticancer treatments. Allopurinol was potentially effective in the prevention of radiotherapy-induced oral mucositis; antimicrobial mouthwash and erythropoietin mouthwash were associated with a lower risk of development of severe oral mucositis induced by chemotherapy. The results of our review may assist in highlighting the efficacy and testing the effectiveness of low-cost, safe preventative measures for oral mucositis in cancer patients.
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Affiliation(s)
- Giuseppe Colella
- Multidisciplinary Department of Medical-Surgical and Dental Specialties, Oral and Maxillofacial Surgery Unit, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
| | - Ciro Emiliano Boschetti
- Multidisciplinary Department of Medical-Surgical and Dental Specialties, Oral and Maxillofacial Surgery Unit, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
| | - Rita Vitagliano
- Multidisciplinary Department of Medical-Surgical and Dental Specialties, Oral and Maxillofacial Surgery Unit, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
| | - Chiara Colella
- Multidisciplinary Department of Medical-Surgical and Dental Specialties, Oral and Maxillofacial Surgery Unit, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
| | - Lebei Jiao
- Melbourne Dental School, The University of Melbourne, Carlton, Melbourne, VIC 3053, Australia
| | - Natalie King-Smith
- Melbourne Dental School, The University of Melbourne, Carlton, Melbourne, VIC 3053, Australia
| | - Chong Li
- Melbourne Dental School, The University of Melbourne, Carlton, Melbourne, VIC 3053, Australia
| | - Yii Nuoh Lau
- Melbourne Dental School, The University of Melbourne, Carlton, Melbourne, VIC 3053, Australia
| | - Zacchaeus Lai
- Melbourne Dental School, The University of Melbourne, Carlton, Melbourne, VIC 3053, Australia
| | - Ali Ibrahim Mohammed
- Melbourne Dental School, The University of Melbourne, Carlton, Melbourne, VIC 3053, Australia
| | - Nicola Cirillo
- Melbourne Dental School, The University of Melbourne, Carlton, Melbourne, VIC 3053, Australia
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Nguyen H, Sangha S, Pan M, Shin DH, Park H, Mohammed AI, Cirillo N. Oxidative Stress and Chemoradiation-Induced Oral Mucositis: A Scoping Review of In Vitro, In Vivo and Clinical Studies. Int J Mol Sci 2022; 23:4863. [PMID: 35563254 PMCID: PMC9101413 DOI: 10.3390/ijms23094863] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/21/2022] [Accepted: 04/24/2022] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | | | | | - Nicola Cirillo
- Melbourne Dental School, The University of Melbourne, Carlton, VIC 3053, Australia; (H.N.); (S.S.); (M.P.); (D.H.S.); (H.P.); (A.I.M.)
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Yaghobee S, Rouzmeh N, Taheri M, Aslroosta H, Mahmoodi S, Mohammadnejad Hardoroodi M, Soleimanzadeh Azar P, Khorsand A. Evaluation of topical erythropoietin application on the healing outcome of gingival graft recipient site; a randomized controlled clinical trial. BMC Oral Health 2021; 21:578. [PMID: 34772399 PMCID: PMC8588661 DOI: 10.1186/s12903-021-01948-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 11/04/2021] [Indexed: 11/28/2022] Open
Abstract
Background Free gingival graft (FGG) is a highly predictable method to increase the width of keratinized gingiva. Various materials have been reported to accelerate the wound healing process. Considering the positive effect of EPO on dermal wound healing this study aimed to investigate the effects of EPO on the rate of healing and degree of inflammation in free gingival grafts. Methods Seventeen patients with bilateral lack of keratinized gingiva in mandible were selected for this clinical trial. The surgical intervention was performed after phase I periodontal therapy. Recipient site was prepared apical to the mucogingival line, and FGG was harvested from the palate. Before graft placement, the test side and control side were treated with 1 ml of EPO 4000 IU/ml and distilled water, respectively, for 2 min. On days 7, 14, 21, 28, 60, and 90 after surgery, the grafted sites were examined by blinded observers to compare the healing and inflammation of the areas. Results All the 17 patients completed the surgeries and follow-up examinations. Direct examination revealed significantly better healing in EPO group only on the 28th day. Assessment of the photographs showed a significant value in favor of the test group at some other time points as well. The EPO group demonstrated less inflammation, which was statistically significant in many time points. The graft area was 80.88 ± 30.21 mm2 and 71.35 ± 15.62 mm2 in the EPO and control groups, respectively. The difference was not significant, though. Conclusions Topical application of erythropoietin can accelerate the healing of gingival grafts and reduce the inflammation during healing period. The final graft outcome, nevertheless, does not seem to be influenced by EPO. Trial registration This was a split-mouth randomized controlled clinical trial (IRCT201201278830N1). The first registration date: 2016-10-22
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Affiliation(s)
- Siamak Yaghobee
- Periodontics Department, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran
| | - Nina Rouzmeh
- Periodontics Department, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran.
| | - Mina Taheri
- Periodontics Department, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran
| | - Hoori Aslroosta
- Periodontics Department, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran
| | - Sanaz Mahmoodi
- Independent Researcher, Novin Formula Consulting Group, Tehran, Iran
| | | | | | - Afshin Khorsand
- Periodontics Department, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran
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Azithromycin oral suspension in prevention and management of oral mucositis in patients undergoing hematopoietic stem cell transplantation: a randomized controlled trial. Support Care Cancer 2021; 30:251-257. [PMID: 34259920 DOI: 10.1007/s00520-021-06409-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 06/28/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES This study aimed to investigate the effects of azithromycin suspension on oral mucositis in patients undergoing hematopoietic stem cell transplantation (HSCT). METHODS AND MATERIAL The study was designed as a single-blind randomized controlled trial in Taleghani medical center affiliated to Shahid Beheshti University of Medical Sciences Tehran Iran. Patients undergoing HSCT were randomly assigned to intervention or control groups. Azithromycin suspension was administered twice daily by gargling for 30 s and swallowing, on the first day of chemotherapy for patients in the intervention group. Graded oral mucositis (OM) occurrence based on National Cancer Institute Common Toxicity Criteria (NCI-CTC) scale (grade 0 to 5) was considered the main outcome, and the Numerical Rating Scale (NRS:0-10) measured the severity of OM symptoms. RESULTS In a duration of 15 months, 88 patients were randomly assigned and finally 70 patients were evaluable for study outcomes (randomized 1:1 to azithromycin versus no-azithromycin). The incidence and duration of the mucositis significantly improved in the intervention group compared to the control. Azithromycin use was consistent with a lower rate of dryness (P < 0.001), dysphagia (P < 0.001), and loss of sense of taste (P < 0.001). Also, in the intervention group, lower intensity of pain due to mucositis (P = 0.01) and lower duration of mucositis were observed (p = 0.045). No significant adverse drug reaction was observed in patients receiving azithromycin. CONCLUSION Based on the result from this study, azithromycin suspension is an effective option in the prevention and treatment of chemotherapy-induced OM. Further study is needed to assess the effect of azithromycin and comparison with other therapeutic options. TRIAL REGISTRATION Iranian Registry of Clinical Trials: IRCT201603093210N13.
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Lima ICGDS, de Fátima Souto Maior L, Gueiros LAM, Leão JC, Higino JS, Carvalho AAT. Clinical applicability of natural products for prevention and treatment of oral mucositis: a systematic review and meta-analysis. Clin Oral Investig 2021; 25:4115-4124. [PMID: 33409696 DOI: 10.1007/s00784-020-03743-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 12/15/2020] [Indexed: 12/28/2022]
Abstract
OBJECTIVE A systematic review and meta-analysis was carried out to verify evidence regarding the efficacy and safety of the clinical applicability of natural products in the prevention and treatment of oral mucositis induced by chemotherapy and/or radiotherapy. METHODOLOGY An electronic research according to the PICOS strategy, using the terms "natural products" and "oral mucositis," was carried out at Pubmed, Cochrane, Embase, and "gray literature." The stages of eligibility, data extraction, and quality assessment of the studies were carried out independently and in duplicate. RESULTS The number of studies identified as eligible was 151, including 47 randomized controlled trials, reporting a total of 3075 participants undergoing some therapy with natural products on oral mucositis. The included clinical trials covered a variety of 31 types of natural products. Considering the risk of bias of the clinical trials, 24 studies (51.1%) were considered to have a low overall risk of bias, nine (19.1%) were at moderate risk, and 14 clinical trials (29.8%) were at high risk of bias. Honey was the most assessed natural agent. Fourteen studies (3.4%) reported that natural agents reduced pain. CONCLUSION The results of the meta-analysis support a positive effect of honey and Aloe vera in reducing mucositis in patients receiving cancer therapy. CLINICAL RELEVANCE The results found add relevant information to the scientific community regarding the prevention and treatment of mucositis. Graphical abstract.
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Affiliation(s)
- Ingrid Carla Guedes da Silva Lima
- Department of Preventive and Clinical Odontology, Post-graduate Program in Odontology, Universidade Federal de Pernambuco, Prof. Moraes Rego, 1235, Cidade Universitária, Recife, Pernambuco, 50670-901, Brazil.
| | - Laura de Fátima Souto Maior
- Department of Preventive and Clinical Odontology, Post-graduate Program in Odontology, Universidade Federal de Pernambuco, Prof. Moraes Rego, 1235, Cidade Universitária, Recife, Pernambuco, 50670-901, Brazil
| | - Luiz Alcino Monteiro Gueiros
- Department of Preventive and Clinical Odontology, Post-graduate Program in Odontology, Universidade Federal de Pernambuco, Prof. Moraes Rego, 1235, Cidade Universitária, Recife, Pernambuco, 50670-901, Brazil
| | - Jair Carneiro Leão
- Department of Preventive and Clinical Odontology, Post-graduate Program in Odontology, Universidade Federal de Pernambuco, Prof. Moraes Rego, 1235, Cidade Universitária, Recife, Pernambuco, 50670-901, Brazil
| | - Jane Sheila Higino
- Pharmacy Department, Health Sciences Center, Universidade Federal de Pernambuco, Recife, Brazil
| | - Alessandra Albuquerque Tavares Carvalho
- Department of Preventive and Clinical Odontology, Post-graduate Program in Odontology, Universidade Federal de Pernambuco, Prof. Moraes Rego, 1235, Cidade Universitária, Recife, Pernambuco, 50670-901, Brazil
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Kitagawa J, Kobayashi R, Nagata Y, Kasahara S, Ono T, Sawada M, Ohata K, Kato-Hayashi H, Hayashi H, Shimizu M, Itoh Y, Tsurumi H, Suzuki A. Polaprezinc for prevention of oral mucositis in patients receiving chemotherapy followed by hematopoietic stem cell transplantation: A multi-institutional randomized controlled trial. Int J Cancer 2020; 148:1462-1469. [PMID: 32984946 DOI: 10.1002/ijc.33316] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/06/2020] [Accepted: 09/18/2020] [Indexed: 01/22/2023]
Abstract
Oral mucositis is a common and distressing complication in patients receiving high-dose chemotherapy followed by hematopoietic stem cell transplantation (HSCT). We reported previously in a single-center retrospective analysis that zinc-L-carnosine (polaprezinc [PZ]) reduced the incidence of oral mucositis associated with HSCT. To verify the accuracy of the prophylactic effect of PZ against oral mucositis, we carried out a multi-institutional prospective randomized controlled study. Patients were randomly allocated to either the prevention group, in which PZ lozenge treatment was started before chemotherapy, or the control group, in which administration of PZ lozenges was initiated immediately after the onset of Grade 2 oral mucositis. Oral mucositis was evaluated daily from the start of chemotherapy to 35 days after transplantation. A total of 91 patients were enrolled, and 88 patients (47 in the control group and 41 in the prevention group) were eligible for data analysis. The incidence of Grade ≥2 but not Grade ≥3 oral mucositis was significantly reduced in the prevention group compared to the control group (44.7% in control group vs 22.0% in the prevention group, P = .025). There were no significant differences in the incidence rates of other adverse events or the rate of engraftment (95.6% vs 97.2%, P = .693) between the two groups. These findings suggest that PZ lozenge is effective for prophylaxis against Grade ≥2 oral mucositis associated with chemotherapy in patients undergoing HSCT without any influence on the HSCT outcome.
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Affiliation(s)
- Junichi Kitagawa
- First Department of Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Ryo Kobayashi
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
| | - Yasuyuki Nagata
- Division of Hematology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Senji Kasahara
- Department of Hematology, Gifu Municipal Hospital, Gifu, Japan
| | - Takaaki Ono
- Division of Hematology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Michio Sawada
- Department of Hematology, Japanese Red Cross Gifu Hospital, Gifu, Japan
| | - Koichi Ohata
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
| | | | - Hideki Hayashi
- Laboratory of Pharmaceutical Engineering, Gifu Pharmaceutical University, Gifu, Japan
| | - Masahito Shimizu
- First Department of Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Yoshinori Itoh
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
| | - Hisashi Tsurumi
- First Department of Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Akio Suzuki
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
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Gebri E, Kiss A, Tóth F, Hortobágyi T. Female sex as an independent prognostic factor in the development of oral mucositis during autologous peripheral stem cell transplantation. Sci Rep 2020; 10:15898. [PMID: 32985512 PMCID: PMC7522228 DOI: 10.1038/s41598-020-72592-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 08/28/2020] [Indexed: 11/11/2022] Open
Abstract
Oral mucositis (OM) is a frequent complication of stem cell transplantation-associated toxicity in haematological malignancies, contributing to mortality. Therapy still remains mainly supportive. We assessed risk factors in retrospective analysis of 192 autologous peripheral stem cell transplantation patients with lymphoma and multiple myeloma (MM), respectively. Futhermore, we examined the hormone levels both in serum and saliva during transplantation in 7 postmenopausal female patients with lymphoma compared to healthy controls using electrochemiluminescence immunoassay (ECLIA). Multivariable analysis revealed neutrophil engraftment (p < 0.001; p = 0.021) and female sex (p = 0.023; p = 0.038) as independent predictive factors in the combined patient group and in the lymphoma group, and neutrophil engraftment (p = 0.008) in the MM group. Of the 85 female participants 19 were pre- and 66 postmenopausal. Fifteen of the pre-, and 49 of the postmenopausal women developed ulcerative mucositis (p = 0.769), more often with lymphoma than MM (p = 0.009). Serum estrogen decreased significantly both in postmenopausal controls and transplantated patients compared to premenopausals, with no difference in saliva. Serum progesterone level was significantly (p = 0.026) elevated at day + 7 of transplantation, while salivary progesterone increased at day + 7 and + 14. Our results indicate a predominantly negative effect of female sex hormones on oral immunity with role in the aetiopathogenesis of OM.
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Affiliation(s)
- Enikő Gebri
- Department of Dentoalveolar Surgery and Dental Outpatient Care, Faculty of Dentistry, University of Debrecen, Debrecen, Hungary
| | - Attila Kiss
- Department of Haematopoietic Transplantation Centre, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Ferenc Tóth
- Department of Biomaterials and Prosthetic Dentistry, Faculty of Dentistry, University of Debrecen, Debrecen, Hungary
| | - Tibor Hortobágyi
- MTA-DE Cerebrovascular and Neurodegenerative Research Group, Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.
- Faculty of Medicine, Institute of Pathology, University of Szeged, Állomás utca 2, Szeged, 6725, Hungary.
- Department of Old Age Psychiatry, Institute of Psychiatry Psychology and Neuroscience, King's College London, London, UK.
- Centre for Age-Related Medicine, SESAM, Stavanger University Hospital, Stavanger, Norway.
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Logan RM, Al-Azri AR, Bossi P, Stringer AM, Joy JK, Soga Y, Ranna V, Vaddi A, Raber-Durlacher JE, Lalla RV, Cheng KKF, Elad S. Systematic review of growth factors and cytokines for the management of oral mucositis in cancer patients and clinical practice guidelines. Support Care Cancer 2020; 28:2485-2498. [PMID: 32080767 DOI: 10.1007/s00520-019-05170-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 11/05/2019] [Indexed: 01/05/2023]
Abstract
PURPOSE To update the clinical practice guidelines for the use of growth factors and cytokines for the prevention and/or treatment of oral mucositis (OM). METHODS A systematic review was conducted by the Mucositis Study Group of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO). The body of evidence for each intervention, in each cancer treatment setting, was assigned an evidence level. The findings were added to the database used to develop the 2014 MASCC/ISOO clinical practice guidelines. Based on the evidence level, the following guidelines were determined: recommendation, suggestion, and no guideline possible. RESULTS A total of 15 new papers were identified within the scope of this section and were merged with 51 papers that were reviewed in the previous guidelines update. Of these, 14, 5, 13, 2, and 1 were randomized controlled trials about KGF-1, G-CSF, GM-CSF, EGF, and erythropoietin, respectively. For the remaining agents there were no new RCTs. The previous recommendation for intravenous KGF-1 in patients undergoing autologous hematopoietic stem cell transplantation (HSCT) conditioned with high-dose chemotherapy and TBI-based regimens is confirmed. The previous suggestion against the use of topical GM-CSF for the prevention of OM in the setting of high-dose chemotherapy followed by autologous or allogeneic stem cell transplantation remains unchanged. CONCLUSIONS Of the growth factors and cytokines studied for the management of OM, the evidence supports a recommendation in favor of KGF-1 and a suggestion against GM-CSF in certain clinical settings.
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Affiliation(s)
- Richard M Logan
- Adelaide Dental School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, 5005, South Australia, Australia
| | - Abdul Rahman Al-Azri
- Adelaide Dental School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, 5005, South Australia, Australia. .,Dental and OMFS Department, Oral Pathology and Medicine, Al-Nahdha Hospital, Ministry of Health, Muscat, Oman.
| | - Paolo Bossi
- Medical Oncology, University of Brescia, ASST-Spedali Civili, Brescia, Italy
| | - Andrea M Stringer
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia.,Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, 5005, South Australia, Australia
| | - Jamie K Joy
- Clinical Pharmacy, Cancer Treatment Centers of America, Boca Raton, FL, USA
| | - Yoshihiko Soga
- Okayama University Hospital, 2-5-1, Shikata-cho, Kita-ku, Okayama, Japan
| | - Vinisha Ranna
- Department of Oral and Maxillofacial Surgery, The Mount Sinai Hospital, New York, NY, USA
| | - Anusha Vaddi
- Oral Medicine, Eastman Institute for Oral Health, University of Rochester Medical Center, Rochester, NY, USA.,Division of Oral and Maxillofacial Diagnostic Sciences, University of Connecticut School of Dental Medicine, Farmington, CT, USA
| | - Judith E Raber-Durlacher
- Department of Oral Medicine, Academic Centre for Dentistry Amsterdam, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, Netherlands.,Department of Oral and Maxillofacial Surgery, Amsterdam UMC, University of Amsterdam , Amsterdam, Netherlands
| | - Rajesh V Lalla
- Division of Oral and Maxillofacial Diagnostic Sciences, University of Connecticut School of Dental Medicine, Farmington, CT, USA
| | - Karis Kin Fong Cheng
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Sharon Elad
- Oral Medicine, Eastman Institute for Oral Health, University of Rochester Medical Center, Rochester, NY, USA
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Çakmak S, Nural N. Incidence of and risk factors for development of oral mucositis in outpatients undergoing cancer chemotherapy. Int J Nurs Pract 2018; 25:e12710. [DOI: 10.1111/ijn.12710] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 10/12/2018] [Accepted: 10/17/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Seher Çakmak
- Department of Internal Medicine Nursing; Karadeniz Technical University; Trabzon Turkey
| | - Nesrin Nural
- Department of Internal Medicine Nursing; Karadeniz Technical University; Trabzon Turkey
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11
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A mucoadhesive thermosensitive hydrogel containing erythropoietin as a potential treatment in oral mucositis: in vitro and in vivo studies. Drug Deliv Transl Res 2018; 8:1226-1237. [DOI: 10.1007/s13346-018-0566-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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12
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Trophic factors in the treatment and prevention of alimentary tract mucositis. Curr Opin Support Palliat Care 2018. [DOI: 10.1097/spc.0000000000000340] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Akbari V, Rezazadeh M, Minayian M, Amirian M, Moghadas A, Talebi A. Effect of freeze drying on stability, thermo-responsive characteristics, and in vivo wound healing of erythropoietin-loaded trimethyl chitosan/glycerophosphate hydrogel. Res Pharm Sci 2018; 13:476-483. [PMID: 30607145 PMCID: PMC6288991 DOI: 10.4103/1735-5362.245959] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Erythropoietin (EPO) was successfully incorporated into a bioadhesive thermosensitive hydrogel based on trimethyl chitosan (TMC)/β-glycerophosphate (GP) for prevention and treatment of oral mucositis in cancerous patients. The aim of the present study was to evaluate the effect of freeze drying on thermo-responsive property of the hydrogel and structural stability of the loaded protein. The freeze-dried EPO-loaded hydrogel were characterized using various methods. Gelation property by rheological analysis, EPO aggregation in formulations by sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE), protein secondary structure by far ultraviolet-circular dichroism (CD), and the antigenic activity of EPO with ELISA techniques. The healing effects of the freeze-dried formulation was also investigated in Sprague-Dawley rats with chemotherapy-induced mucositis and compared with freshly prepared mixture. Finally, the retention time of the gel in the oral cavity was assessed in healthy volunteers. SDS-PAGE, CD, and ELISA confirmed the stability of conformational structure of loaded and released EPO. Severity of mucositis was markedly reduced in animals treated with freeze-dried EPO hydrogel; whereas the group received normal saline did not show any significant healing. EPO salvia level was decreased rapidly following EPO solution compared to the gel application. Approximately, 40% of EPO was maintained on the buccal areas in patients receiving the hydrogel system after 30 min. Therefore, the TMC/GP could preserve EPO stability after freeze drying and has the potential in the treatment of oral mucositis and other oral or subcutaneous wounds.
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Affiliation(s)
- Vajihe Akbari
- Department of Pharmaceutical Biotechnology and Isfahan Pharmaceutical Research Center, School of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, I.R. Iran
| | - Mahboubeh Rezazadeh
- Department of Pharmaceutics and Novel Drug Delivery System Research Center, School of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, I.R. Iran
| | - Mohsen Minayian
- Department of Pharmacology, School of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, I.R. Iran
| | - Marjan Amirian
- Department of Pharmaceutics and Novel Drug Delivery System Research Center, School of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, I.R. Iran
| | - Azadeh Moghadas
- Department of Clinical pharmacy, School of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, I.R. Iran
| | - Ardeshir Talebi
- Pathology Department, School of Medicine, Isfahan University of Medical Sciences, Isfahan, I. R. Iran
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Riley P, Glenny A, Worthington HV, Littlewood A, Fernandez Mauleffinch LM, Clarkson JE, McCabe MG. Interventions for preventing oral mucositis in patients with cancer receiving treatment: cytokines and growth factors. Cochrane Database Syst Rev 2017; 11:CD011990. [PMID: 29181845 PMCID: PMC6486203 DOI: 10.1002/14651858.cd011990.pub2] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Oral mucositis is a side effect of chemotherapy, head and neck radiotherapy, and targeted therapy, affecting over 75% of high-risk patients. Ulceration can lead to severe pain and difficulty with eating and drinking, which may necessitate opioid analgesics, hospitalisation and supplemental nutrition. These complications may disrupt cancer therapy, which may reduce survival. There is also a risk of death from sepsis if pathogens enter the ulcers of immunocompromised patients. Ulcerative oral mucositis can be costly to healthcare systems, yet there are few preventive interventions proven to be beneficial. Cytokines and growth factors may help the regeneration of cells lining of the mouth, thus preventing or reducing oral mucositis and its negative effects. OBJECTIVES To assess the effects of cytokines and growth factors for preventing oral mucositis in patients with cancer who are receiving treatment. SEARCH METHODS Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (searched 10 May 2017); the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 4) in the Cochrane Library (searched 10 May 2017); MEDLINE Ovid (1946 to 10 May 2017); Embase Ovid (7 December 2015 to 10 May 2017); CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to 10 May 2017); and CANCERLIT PubMed (1950 to 10 May 2017). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. SELECTION CRITERIA We included parallel-design randomised controlled trials (RCTs) assessing the effects of cytokines and growth factors in patients with cancer receiving treatment. DATA COLLECTION AND ANALYSIS Two review authors independently screened the results of electronic searches, extracted data and assessed risk of bias. For dichotomous outcomes, we reported risk ratios (RR) and 95% confidence intervals (CI). For continuous outcomes, we reported mean differences (MD) and 95% CIs. We pooled similar studies in random-effects meta-analyses. We reported adverse effects in a narrative format. MAIN RESULTS We included 35 RCTs analysing 3102 participants. Thirteen studies were at low risk of bias, 12 studies were at unclear risk of bias, and 10 studies were at high risk of bias.Our main findings were regarding keratinocyte growth factor (KGF) and are summarised as follows.There might be a reduction in the risk of moderate to severe oral mucositis in adults receiving bone marrow/stem cell transplantation after conditioning therapy for haematological cancers (RR 0.89, 95% CI 0.80 to 0.99; 6 studies; 852 participants; low-quality evidence). We would need to treat 11 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 6 to 112). There might be a reduction in the risk of severe oral mucositis in this population, but there is also some possibility of an increase in risk (RR 0.85, 95% CI 0.65 to 1.11; 6 studies; 852 participants; low-quality evidence). We would need to treat 10 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 5 to prevent the outcome to 14 to cause the outcome).There is probably a reduction in the risk of moderate to severe oral mucositis in adults receiving radiotherapy to the head and neck with cisplatin or fluorouracil (RR 0.91, 95% CI 0.83 to 1.00; 3 studies; 471 participants; moderate-quality evidence). We would need to treat 12 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 7 to infinity). It is very likely that there is a reduction in the risk of severe oral mucositis in this population (RR 0.79, 95% CI 0.69 to 0.90; 3 studies; 471 participants; high-quality evidence). We would need to treat 7 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 5 to 15).It is likely that there is a reduction in the risk of moderate to severe oral mucositis in adults receiving chemotherapy alone for mixed solid and haematological cancers (RR 0.56, 95% CI 0.45 to 0.70; 4 studies; 344 participants; moderate-quality evidence). We would need to treat 4 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 3 to 6). There might be a reduction in the risk of severe oral mucositis in this population (RR 0.30, 95% CI 0.14 to 0.65; 3 studies; 263 participants; low -quality evidence). We would need to treat 10 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 8 to 19).Due to the low volume of evidence, single-study comparisons and insufficient sample sizes, we found no compelling evidence of a benefit for any other cytokines or growth factors and there was no evidence on children. There did not appear to be any serious adverse effects of any of the interventions assessed in this review. AUTHORS' CONCLUSIONS We are confident that KGF is beneficial in the prevention of oral mucositis in adults who are receiving: a) radiotherapy to the head and neck with cisplatin or fluorouracil; or b) chemotherapy alone for mixed solid and haematological cancers. We are less confident about a benefit for KGF in adults receiving bone marrow/stem cell transplant after conditioning therapy for haematological cancers because of multiple factors involved in that population, such as whether or not they received total body irradiation (TBI) and whether the transplant was autologous (the patients' own cells) or allogeneic (cells from a donor). KGF appears to be a relatively safe intervention.Due to limited research, we are not confident that there are any beneficial effects of other cytokines and growth factors. There is currently insufficient evidence to draw any conclusions about the use of cytokines and growth factors in children.
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Affiliation(s)
- Philip Riley
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of ManchesterCochrane Oral HealthJR Moore BuildingOxford RoadManchesterUKM13 9PL
| | - Anne‐Marie Glenny
- The University of ManchesterDivision of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and HealthJR Moore BuildingOxford RoadManchesterUKM13 9PL
| | - Helen V Worthington
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of ManchesterCochrane Oral HealthJR Moore BuildingOxford RoadManchesterUKM13 9PL
| | - Anne Littlewood
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of ManchesterCochrane Oral HealthJR Moore BuildingOxford RoadManchesterUKM13 9PL
| | - Luisa M Fernandez Mauleffinch
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of ManchesterCochrane Oral HealthJR Moore BuildingOxford RoadManchesterUKM13 9PL
| | - Jan E Clarkson
- University of DundeeDivision of Oral Health SciencesDental Hospital & SchoolPark PlaceDundeeScotlandUKDD1 4HR
| | - Martin G McCabe
- The University of ManchesterDivision of Cancer SciencesManchester Academic Health Science CentreManchesterUK
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Silva FC, Marto JM, Salgado A, Machado P, Silva AN, Almeida AJ. Nystatin and lidocaine pastilles for the local treatment of oral mucositis. Pharm Dev Technol 2016; 22:266-274. [DOI: 10.1080/10837450.2016.1221424] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Filipa Cosme Silva
- Hospital de Santa Maria, Serviço de Gestão Técnico-Farmacêutica, Centro Hospitalar Lisboa Norte, EPE, Lisbon, Portugal
- Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal
| | - Joana M. Marto
- Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal
| | - Ana Salgado
- Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal
| | - Paula Machado
- Laboratório de Controlo Microbiológico, ADEIM, Faculty of Pharmacy, Universidade de Lisboa, Lisboa, Portugal
| | - Alexandra N. Silva
- Laboratório de Controlo Microbiológico, ADEIM, Faculty of Pharmacy, Universidade de Lisboa, Lisboa, Portugal
| | - António J. Almeida
- Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal
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Fleury M, Shabafrouz K, Deplanque G. Questions about the formulation of erythropoietin mouthwash for the prevention of oral mucositis. Hematol Oncol 2016; 35:931. [DOI: 10.1002/hon.2296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 03/03/2016] [Indexed: 11/06/2022]
Affiliation(s)
- Mapi Fleury
- Service of Pharmacy; Centre Hospitalier Universitaire Vaudois (CHUV); Lausanne Switzerland
- School of Pharmaceutical Science (EPGL); Genève-Lausanne Switzerland
| | - Keyvan Shabafrouz
- Department of Medical Oncology; Centre Hospitalier Universitaire Vaudois (CHUV); Lausanne Switzerland
| | - Gael Deplanque
- Department of Medical Oncology; Centre Hospitalier Universitaire Vaudois (CHUV); Lausanne Switzerland
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