Antimicrobials, mucosal coating agents, anesthetics, analgesics, and nutritional supplements for alimentary tract mucositis

Oral Health in Children with Chronic Kidney Disease, Hemodialysis, and Renal Transplantation: A Comprehensive Narrative Review of the Oral Manifestations and Dental Implications

Chronic kidney disease (CKD) in children presents multifaceted challenges, impacting various aspects of health, including oral health. This narrative review provides a comprehensive synthesis of literature focusing on the oral health status of pediatric CKD patients, encompassing oral manifestations, dental considerations, and management challenges associated with hemodialysis and kidney transplantation. A comprehensive search strategy was employed, utilizing databases such as PubMed, Scopus, Web of Science, and Google Scholar, to identify relevant literature on oral manifestations in children with CKD, including those undergoing hemodialysis or renal transplantation. Search terms were carefully selected to capture studies examining enamel hypoplasia, dental caries, delayed tooth eruption, gingival diseases, periodontal diseases, radiographic alterations, craniofacial development, dry mouth, and changes in the oral mucosa. Our narrative review meticulously selected articles through a systematic process. Ultimately, 12 studies meeting the inclusion criteria were included in the review. Relevant data from each included study were independently extracted and synthesized, focusing on oral manifestations and their implications in pediatric CKD patients. The synthesized findings were organized and presented in a structured manner within the review article, considering their clinical implications and informing recommendations for dental management of children with CKD. This article highlights the importance of a coordinated effort between nephrologists, dentists, and other healthcare professionals in providing holistic care for pediatric CKD patients. A comprehensive understanding of the oral health status of these children, along with proactive dental management strategies, contributes to improved overall health outcomes and a better quality of life. This review aims to serve as a valuable resource for the oral healthcare providers involved in the care of pediatric CKD patients.

Safety and efficacy of a mucoadhesive phytomedication containing curcuminoids and Bidens pilosa L. extract in the prevention and treatment of radiochemotherapy-induced oral mucositis: Triple-blind, randomized, placebo-controlled, clinical trial

BACKGROUND

Oral mucositis (OM) is the significant complication of radio/chemotherapy treatment. This study evaluated the safety and efficacy of a mucoadhesive phytomedication containing curcuminoids and Bidens pilosa L. (FITOPROT) in the prevention/treatment of OM.

METHODS

Sixty-two patients were randomized into the group's intervention and placebo. Adverse effect assessment, OM grading, pain, and saliva collection were carried at the 1st, 15th, 21st, and final of radiotherapy (RT). Inflammatory salivary mediators were measured.

RESULTS

FITOPROT decreased the severity of OM from the 15th to the final RT, while the placebo showed an increase in the severity (p < 0.05). Intervention group had a lower number of patients with ulcerated OM at the final RT (p < 0.05). Phytomedication prevented increases of IL-8 levels and reduced the salivary nitrite during RT.

CONCLUSIONS

FITOPROT does not promote adverse effects, it appears to be effective at reducing the severity of OM, and it controls the concentration of pro-inflammatory mediators.

Oncological-Therapy Related Oral Mucositis as an Interdisciplinary Problem-Literature Review

Oral mucositis is a toxic side effect of non-surgical cancer treatments: chemotherapy and radiotherapy, which strongly impair quality of life and can not only cause strong pain, but also lead to problems with basic physiological needs as eating and swallowing. Development of oral mucositis is associated with type, dosage, and schedule of radiation or chemotherapy and other factors related to patients. Management of oral mucositis is a valid problem, requiring topical application of anesthetics, coating agents, cryotherapy, low level laser therapy, pharmacological methods as usage of keratinocyte growth factors, supplementation of vitamins, and a proper diet. Another approach to oral mucositis measurement includesphotobiomodulation, which brings analgesic and anti-inflammatory effects.Although oral mucositis is a general health issues, the role of proper dental care is essential. It should include elimination of all potential sources of mucosal injury and microorganisms inhabiting theoral cavity through oral hygiene education,professional management ofdental plaque,and treatment of the caries and periodontium, which are necessary to reduce the risk of inflammation in the oral cavity. This paper describes the possibilities of monitoring oral mucositis,taking into account the latest therapeutic achievements.

Systematic review of anti-inflammatory agents for the management of oral mucositis in cancer patients and clinical practice guidelines

PURPOSE

The aim of this systematic review was to update the clinical practice guidelines for the use of anti-inflammatory agents in the prevention and/or treatment of oral mucositis.

METHODS

A systematic review was conducted by the Multinational Association of Supportive Care in Cancer/ International Society of Oral Oncology (MASCC/ISOO) subcommittee on mucositis guideline update. 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 clinical practice guidelines published in 2014. Based on the evidence level, one of the following three guideline determinations was possible: recommendation, suggestion, and no guidelines.

RESULTS

A total of 11 new papers across five interventions were examined. The recommendation for the use of benzydamine mouthwash for the prevention of radiotherapy-induced mucositis remained unchanged. New suggestion for the use of the same for prevention of mucositis associated with chemoradiotherapy was made. No guideline was possible for any other anti-inflammatory agents due to inadequate and/or conflicting evidence.

CONCLUSIONS

Of the anti-inflammatory agents studied for oral mucositis, the evidence supports the use of benzydamine mouthwash in the specific populations listed above. Additional well-designed research is needed on other (class of agents) interventions and in other cancer treatment settings.

Efficacy of a glycopolymer-based oral rinse upon pain associated with ulcerative and erosive lesions of the oral mucosa: A within-subject pilot study

OBJECTIVES

The purpose of this pilot study was to assess the magnitude of effect for a new topical rinse that may impact oral soreness and function in ulcerative oral mucosal lesions.

STUDY DESIGN

Twenty-five consecutive patients with ulcerative/erosion lesion and moderate pain visual analogue pain score (≥4) rated their mouth and throat soreness and oral symptoms at baseline and at 24, 48, and 72 hours after open-label use of a chitosan-based, nonanesthetic oral rinse (Synvaza) at least twice a day. No changes in prior therapy, including analgesics, were allowed during the trial.

RESULTS

All measures of oral soreness decreased in severity from baseline to 72 hours, and overall oral soreness decreased by 28% (P < .01). Oral soreness associated with talking decreased by 67% (P < .01), drinking by 62% (P < .01), swallowing by 56% (P = .04), sleeping by 51% (P = .02) and eating by 50% (P < .01). The product was rated favorably for texture, flavor, soothing relief, mouth feel, and burning/stinging with use.

CONCLUSIONS

Oral rinsing with the study product reduced mucosal pain without anesthetic effect and improved oral function.

US oncology-wide incidence, duration, costs and deaths from chemoradiation mucositis and antimucositis therapy benefits

Approximate oncology-wide incidence, duration, costs and deaths associated with mucositis and identify health economic benefits of antimucositis therapies. Review the literature relevant to the clinical experience of mucositis by pathophysiology, incidence, duration, costs and deaths. Use US insurance actuarial and epidemiology on cancer to generalize an oncology-wide impact of toxic mucositis. Toxic mucositis causes oropharyngoesophageal ulcerations, chemo-induced nausea, vomiting and diarrhea. Acutely, it lasts 102 days/six cycles of chemotherapy, 60 days in human stem-cell transplantation patients and 70-84 days in head and neck cancer patients at annual costs of US$13.23 billion/522,166 treated patients (US$20,892/erosive-type mucositis patient, US$25,337/physiologic mucositis patient) and 46,699 deaths. Using antimucositis therapies prior to 2013 provided fractional benefits at high costs. By completely preventing and rapidly reversing mucositis, high-potency polymerized cross-linked sucralfate promises superior health economic benefits.

Milk diets influence doxorubicin-induced intestinal toxicity in piglets

Chemotherapy-induced gastrointestinal (GI) toxicity is a common adverse effect of cancer treatment. We used preweaned piglets as models to test our hypothesis that the immunomodulatory and GI trophic effects of bovine colostrum would reduce the severity of GI complications associated with doxorubicin (DOX) treatment. Five-day-old pigs were administered DOX (1 × 100 mg/m(2)) or an equivalent volume of saline (SAL) and either fed formula (DOX-Form, n = 9, or SAL-Form, n = 7) or bovine colostrum (DOX-Colos, n = 9, or SAL-Colos, n = 7). Pigs were euthanized 5 days after initiation of chemotherapy to assess markers of small intestinal function and inflammation. All DOX-treated animals developed diarrhea, growth deficits, and leukopenia. However, the intestines of DOX-Colos pigs had lower intestinal permeability, longer intestinal villi with higher activities of brush border enzymes, and lower tissue IL-8 levels compared with DOX-Form (all P < 0.05). DOX-Form pigs, but not DOX-Colos pigs, had significantly higher plasma C-reactive protein, compared with SAL-Form. Plasma citrulline was not affected by DOX treatment or diet. Thus a single dose of DOX induces intestinal toxicity in preweaned pigs and may lead to a systemic inflammatory response. The toxicity is affected by type of enteral nutrition with more pronounced GI toxicity when formula is fed compared with bovine colostrum. The results indicate that bovine colostrum may be a beneficial supplementary diet for children subjected to chemotherapy and subsequent intestinal toxicity.

Differential Effectiveness of Clinically-Relevant Analgesics in a Rat Model of Chemotherapy-Induced Mucositis

Chemotherapy-induced intestinal mucositis is characterized by pain and a pro-inflammatory tissue response. Rat models are frequently used in mucositis disease investigations yet little is known about the presence of pain in these animals, the ability of analgesics to ameliorate the condition, or the effect that analgesic administration may have on study outcomes. This study investigated different classes of analgesics with the aim of determining their analgesic effects and impact on research outcomes of interest in a rat model of mucositis. Female DA rats were allocated to 8 groups to include saline and chemotherapy controls (n = 8). Analgesics included opioid derivatives (buprenorphine; 0.05mg/kg and tramadol 12.5mg/kg) and NSAID (carprofen; 15mg/kg) in combination with either saline or 5-Fluorouracil (5-FU; 150mg/kg). Research outcome measures included daily clinical parameters, pain score and gut histology. Myeloperoxidase assay was performed to determine gut inflammation. At the dosages employed, all agents had an analgesic effect based on behavioural pain scores. Jejunal myeloperoxidase activity was significantly reduced by buprenorphine and tramadol in comparison to 5-FU control animals (53%, p = 0.0004 and 58%, p = 0.0001). Carprofen had no ameliorating effect on myeloperoxidase levels. None of the agents reduced the histological damage caused by 5-FU administration although tramadol tended to increase villus length even when administered to healthy animals. These data provide evidence that carprofen offers potential as an analgesic in this animal model due to its pain-relieving efficacy and minimal effect on measured parameters. This study also supports further investigation into the mechanism and utility of opioid agents in the treatment of chemotherapy-induced mucositis.

PREVENTION AND TREATMENT OF MUCOSITIS AT AN ONCOLOGY OUTPATIENT CLINIC: A COLLECTIVE CONSTRUCTION

The aim was to develop a nursing care protocol for the prevention and treatment of chemotherapy-induced mucositis at an outpatient clinic of a High Complexity Center in Oncology. A qualitative convergent-care research was undertaken. The construction of the protocol was driven by the criteria of Evidence-Based Practice. Data were collected from January to June 2013 in two steps. Firstly, we collected data on medical charts of customers to obtain sociodemographic and therapeutic data and nursing interventions performed for prevention, detection and treatment of mucositis. After this first step, workshops were held with the nurses to validate the available material and human resources, besides the feasible care to compose the protocol. Care was related to oral hygiene, mouth rinse, cryotherapy, laser therapy and interventions related to the nutritional scope. The implementation of this care protocol has standardized the care strategies.

Use of Curcumin Mouthrinse in Radio-Chemotherapy Induced Oral Mucositis Patients: A Pilot Study

INTRODUCTION

Oral Mucositis is a complex and distinct pathobiologic entity resulting in injuries in mucosa that is a common complication in cancer patients undergoing chemotherapy (CT) and radiation therapy (RT). Phytochemicals, such as Curcumin, turmeric extract, has attracted great attention for its therapeutic benefits in clinical oncology due to its chemopreventive, antitumoral, chemosensibilizing and radiosensibilizing activities against various types of cancers and the complications associated with their management.

AIM

To evaluate the efficacy and safety of curcumin mouthwash in the management of Oral Mucositis in cancer patients undergoing radio-chemotherapy.

MATERIALS AND METHODS

The research group consisted of 20 adult cancer patients undergoing radio-chemotherapy at the Regional Oncology Centre, who were evaluated for signs and symptoms of oral mucositis and then randomly divided into two groups. Standard preventive oral care i.e. chlorhexidine mouthwash 0.2% was given to one group while the other group was provided with freshly prepared curcumin mouthwash; each to be used thrice daily. Oral mucositis was assessed at days 0, 10 and 20. The World Health Organization (WHO) scale, the Oral Mucositis Assessment Scale (OMAS), and a Numerical Rating Scale (NRS; patient reporting scale of 0-10) were used. Adverse events were tracked.

STATISTICAL ANALYSIS

Descriptive statistics, Independent sample t-test and repeated measure ANOVA test were performed.

RESULTS

Statistically significant difference was found in the NRS (p=0.000), Erythema (p=0.050), ulceration (p=0.000) and WHO scores (p=0.003) between the two groups.

CONCLUSION

Curcumin was found to be better than chlorhexidine mouth wash in terms of rapid wound healing and better patient compliance in management of radio-chemotherapy induced oral mucositis. No oral or systemic complications were reported.

Cost-effective analysis of topical chlorhexidine in hematologic patients at risk for oral mucositis

OBJECTIVE

The aim of this study was to explore whether management of mucositis with Chlorhexidine (CHX) mouthwash could be a cost-effective method to decrease the risk of mortality and economic burden in hemato-oncologic or hematopoietic stem cell transplantation (HSCT) patients.

METHODS

A cost-effectiveness analysis model of prophylactic CHX mouthwash use versus no-CHX mouthwash use for the prevention of oral mucositis was developed for patients undergoing cytotoxic therapy or HSCT. The outcome variable was survival. The primary variables were CHX mouthwash use, probability of mucositis, probability of increased hospital stay, and length of hospital stay. Probability and cost data were obtained from the literature.

RESULTS

Our analysis selected CHX mouthwash use during anticancer treatment as the preferred strategy for the base-case analysis as compared to no CHX mouthwash (marginal value 0.032). There was a $14,391 cost difference per patient between the two strategies.

CONCLUSION

The results of this study suggest that CHX mouthwash use during anticancer treatment results in an increased survival and decreased cost for the population studied. Using our base-case data, an additional 32 of every 1,000 hemato-oncologic or HSCT patients will survive when employing the preferred strategy of prophylactic CHX mouthwash.

CLINICAL RELEVANCE

CHX mouthwash should be offered for hematologic patients undergoing HSCT or administered with chemotherapy.

Morphine mouthwash for the management of oral mucositis in patients with head and neck cancer

Background:

Oral mucositis is a debilitating side effect of cancer treatment for which there is not much successful treatments at yet. We evaluated the effectiveness of topical morphine compared with a routine mouthwash in managing cancer treatment-induced mucositis.

Materials and Methods:

Thirty head and neck cancer patients with severe mucositis (World Health Organization Grade III or IV) were randomized into the morphine and magic mouthwash groups. Patients received morphine sulfate 2% or magic solution (contained magnesium aluminum hydroxide, viscous lidocaine, and diphenhydramine), 10 ml for every 3 h, six times a day, for 6 days. Both groups received same dietary and oral hygiene instructions and care. Mucositis was graded at baseline and every 3 days after treatment. Patients’ satisfaction and drug effect maintenance were also evaluated.

Results:

Twenty-eight patients (mean age of 49.5 ± 13.2 years, 63.3% female) completed the trial; 15 in the morphine group and 13 in the magic group. There was a decrease in mucositis severity in both of the morphine (P < 0.001) and magic (P = 0.049) groups. However, at the 6^th day, more reduction was observed in mucositis severity in the morphine compared with magic group (P = 0.045). Drug effect maintenance was similar between the two groups, but patients in the morphine group were more satisfied by their treatments than those in the magic group (P = 0.008).

Conclusions:

Topical morphine is more effective and more satisfactory to patients than the magic mouthwash in reducing severity of cancer treatment-induced oral mucositis. More studies with larger sample size and longer follow-up are required in this regard.

Doxepin for Radiation Therapy-Induced Mucositis Pain in the Treatment of Oral Cancers

Radiotherapy (RT), an integral part of the oncologic treatment for patients with head and neck cancer, can cause adverse side effects such as oral mucositis (OM). Pain from OM can impact a patient’s quality of life and interrupt RT treatment schedules, which decreases the probability for achieving cancer cure. Conventionally, RT-induced OM pain is treated with analgesics and/or mouthwash rinses. Doxepin, a traditional tricyclic antidepressant with analgesic and anesthetic properties when applied topically to the mucosa, has been shown to lower OM pain in multiple single-arm trials (Epstein et al.) and more recently, in a placebo-controlled crossover study (Leenstra and Miller et al.). Currently, a placebo-controlled study (Sio and Miller et al.) using doxepin for esophagitis pain caused by RT to the thorax is underway. Doxepin will also be further compared with magic mouthwash and a placebo solution in a three-arm trial (Miller and Sio et al.) with head and neck cancer patients with OM pain caused by RT. Doxepin may represent a new standard for treating RT-induced OM pain in the future.

Basic oral care for hematology-oncology patients and hematopoietic stem cell transplantation recipients: a position paper from the joint task force of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) and the European Society for Blood and Marrow Transplantation (EBMT)

PURPOSE

Hematology-oncology patients undergoing chemotherapy and hematopoietic stem cell transplantation (HSCT) recipients are at risk for oral complications which may cause significant morbidity and a potential risk of mortality. This emphasizes the importance of basic oral care prior to, during and following chemotherapy/HSCT. While scientific evidence is available to support some of the clinical practices used to manage the oral complications, expert opinion is needed to shape the current optimal protocols.

METHODS

This position paper was developed by members of the Oral Care Study Group, Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) and the European Society for Blood and Marrow Transplantation (EBMT) in attempt to provide guidance to the health care providers managing these patient populations.

RESULTS

The protocol on basic oral care outlined in this position paper is presented based on the following principles: prevention of infections, pain control, maintaining oral function, the interplay with managing oral complications of cancer treatment and improving quality of life.

CONCLUSION

Using these fundamental elements, we developed a protocol to assist the health care provider and present a practical approach for basic oral care. Research is warranted to provide robust scientific evidence and to enhance this clinical protocol.

Computer evaluation of hidden potential of phytochemicals of medicinal plants of the traditional indian ayurvedic medicine

Applicability of our computer programs PASS and PharmaExpert to prediction of biological activity spectra of rather complex and structurally diverse phytocomponents of medicinal plants, both separately and in combinations has been evaluated. The web-resource on phytochemicals of 50 medicinal plants used in Ayurveda was created for the study of hidden therapeutic potential of Traditional Indian Medicine (TIM) (http://ayurveda.pharmaexpert.ru). It contains information on 50 medicinal plants, their using in TIM and their pharmacology activities, also as 1906 phytocomponents. PASS training set was updated by addition of information about 946 natural compounds; then the training procedure and validation were performed, to estimate the quality of PASS prediction. It was shown that the difference between the average accuracy of prediction obtained in leave-5%-out cross-validation (94,467%) and in leave-one-out cross-validation (94,605%) is very small. These results showed high predictive ability of the program. Results of biological activity spectra prediction for all phytocomponents included in our database are in good correspondence with the experimental data. Additional kinds of biological activity predicted with high probability provide the information about most promising directions of further studies. The analysis of prediction results of sets of phytocomponents in each of 50 medicinal plants was made by PharmaExpert software. Based on this analysis, we found that the combination of phytocomponents from Passiflora incarnata may exhibit nootropic, anticonvulsant and antidepressant effects. Experiments carried out in mice models confirmed the predicted effects of Passiflora incarnata extracts.

Adverse event management of oral mucositis in patients with breast cancer

Oral mucositis (OM) is a clinically important and frequent adverse event (AE) associated with cancer treatment with conventional chemotherapy as well as new targeted agents. Incidence and severity of OM vary from treatment to treatment and from patient to patient. The pathogenesis of chemotherapy-induced OM can be divided into 5 phases. OM induced by targeted therapies differs among other things in appearance, course, concomitant AEs and toxicity, and thus could be perceived as an entity distinct from chemotherapy-induced OM with an innate pathogenic mechanism. OM has a severe impact on a patient's quality of life (QoL) by causing complications such as pain and discomfort. Even more important are associated restrictions in nutrition and hydration. Thus, the efficacy of cancer therapy might be impaired due to the necessity of dose delays and dose reductions. Numerous preventive and therapeutic approaches have been evaluated, but currently no single agent has changed the standard of care in preventing and treating OM. Thus, the current management has evolved from clinical experience rather than clinical evidence. This article will review the AE 'OM' induced by breast cancer treatment with chemotherapy and targeted agents in order to provide practical guidance for management and prevention.

Doxepin rinse versus placebo in the treatment of acute oral mucositis pain in patients receiving head and neck radiotherapy with or without chemotherapy: a phase III, randomized, double-blind trial (NCCTG-N09C6 [Alliance])

PURPOSE

Painful oral mucositis (OM) is a significant toxicity during radiotherapy for head and neck cancers. The aim of this randomized, double-blind, placebo-controlled trial was to test the efficacy of doxepin hydrochloride in the reduction of radiotherapy-induced OM pain.

PATIENTS AND METHODS

In all, 155 patients were randomly allocated to a doxepin oral rinse or a placebo for the treatment of radiotherapy-related OM pain. Patients received a single dose of doxepin or placebo on day 1 and then crossed over to receive the opposite agent on a subsequent day. Pain questionnaires were administered at baseline and at 5, 15, 30, 60, 120, and 240 minutes. Patients were then given the option to continue doxepin. The primary end point was pain reduction as measured by the area under the curve (AUC) of the pain scale using data from day 1.

RESULTS

Primary end point analysis revealed that the AUC for mouth and throat pain reduction was greater for doxepin (-9.1) than for placebo (-4.7; P < .001). Crossover analysis of patients completing both phases confirmed that patients experienced greater mouth and throat pain reduction with doxepin (intrapatient changes of 4.1 for doxepin-placebo arm and -2.8 for placebo-doxepin arm; P < .001). Doxepin was associated with more stinging or burning, unpleasant taste, and greater drowsiness than the placebo rinse. More patients receiving doxepin expressed a desire to continue treatment than did patients with placebo after completion of each of the randomized phases of the study.

CONCLUSION

A doxepin rinse diminishes OM pain. Further studies are warranted to determine its role in the management of OM.

Risk management strategies for reducing oral adverse drug events

Oral adverse drug effects negatively impact oral health, comfort and function.

BACKGROUND

Patients treated in the oral health care environment take multiple medications, many of which cause oral complications. Dental professionals are challenged with making recommendations to prevent or minimize drug-induced oral disease risks, while reducing symptoms to improve oral health quality of life.

METHODS

This paper presents a critical analysis of current evidence regarding common oral adverse drug events, and reviews existing clinical practice guidelines based upon findings from published systematic reviews.

RESULTS

There is a lack of sufficient, high quality evidence to support most recommendations for interventions to relieve signs and symptoms of drug-induced oral adverse events. Existing recommendations are largely based on data obtained from observational studies and case reports, and from randomized controlled clinical trials with significant design flaws and potential reporting bias. Outcome measures, especially those related to symptom relief and long-range benefits, are either insufficient or lacking.

CONCLUSIONS

Oral adverse drug effects are a common problem, and additional data is needed to support best practices for product recommendations to improve oral health in medicated patients.

Local and systemic pathogenesis and consequences of regimen-induced inflammatory responses in patients with head and neck cancer receiving chemoradiation

Treatment-related toxicities are common among patients with head and neck cancer, leading to poor clinical outcomes, reduced quality of life, and increased use of healthcare resources. Over the last decade, much has been learned about the pathogenesis of cancer regimen-related toxicities. Historically, toxicities were separated into those associated with tissue injury and those with behavioural or systemic changes. However, it is now clear that tissue-specific damage such as mucositis, dermatitis, or fibrosis is no longer the sole consequence of direct clonogenic cell death, and a relationship between toxicities that results in their presentation as symptom clusters has been documented and attributed to a common underlying pathobiology. In addition, the finding that patients commonly develop toxicities representing tissue injury outside radiation fields and side effects such as fatigue or cognitive dysfunction suggests the generation of systemic as well as local mediators. As a consequence, it might be appropriate to consider toxicity syndromes, rather than the traditional approach, in which each side effect was considered as an autonomous entity. In this paper, we propose a biologically based explanation which forms the basis for the diverse constellation of toxicities seen in response to current regimens used to treat cancers of the head and neck.

Emerging evidence on the pathobiology of mucositis

BACKGROUND

Considerable progress has been made in our understanding of the biological basis for cancer therapy-induced mucosal barrier injury (mucositis). The last formal review of the subject by MASCC/ISOO was published in 2007; consequently, an update is timely.

METHODS

Panel members reviewed the biomedical literature on mucositis pathobiology published between January 2005 and December 2011.

RESULTS

Recent research has provided data on the contribution of tissue structure changes, inflammation and microbiome changes to the development of mucositis. Additional research has focused on targeted therapy-induced toxicity, toxicity clustering and the investigation of genetic polymorphisms in toxicity prediction. This review paper summarizes the recent evidence on these aspects of mucositis pathobiology.

CONCLUSION

The ultimate goal of mucositis researchers is to identify the most appropriate targets for therapeutic interventions and to be able to predict toxicity risk and personalize interventions to genetically suitable patients. Continuing research efforts are needed to further our understanding of mucositis pathobiology and the pharmacogenomics of toxicity.

Systematic review of antimicrobials, mucosal coating agents, anesthetics, and analgesics for the management of oral mucositis in cancer patients

PURPOSE

The aim of this project was to develop clinical practice guidelines on the use of antimicrobials, mucosal coating agents, anesthetics, and analgesics for the prevention and management of oral mucositis (OM) in cancer patients.

METHODS

A systematic review of the available literature was conducted. The body of evidence for the use of each agent, in each setting, was assigned a level of evidence. Based on the evidence level, one of the following three guideline determinations was possible: recommendation, suggestion, or no guideline possible.

RESULTS

A recommendation was developed in favor of patient-controlled analgesia with morphine in hematopoietic stem cell transplant (HSCT) patients. Suggestions were developed in favor of transdermal fentanyl in standard dose chemotherapy and HSCT patients and morphine mouth rinse and doxepin rinse in head and neck radiation therapy (H&N RT) patients. Recommendations were developed against the use of topical antimicrobial agents for the prevention of mucositis. These included recommendations against the use of iseganan for mucositis prevention in HSCT and H&N RT and against the use of antimicrobial lozenges (polymyxin-tobramycin-amphotericin B lozenges/paste and bacitracin-clotrimazole-gentamicin lozenges) for mucositis prevention in H&N RT. Recommendations were developed against the use of the mucosal coating agent sucralfate for the prevention or treatment of chemotherapy-induced or radiation-induced OM. No guidelines were possible for any other agent due to insufficient and/or conflicting evidence.

CONCLUSION

Additional well-designed research is needed on prevention and management approaches for OM.

Emerging evidence on the pathobiology of mucositis

BACKGROUND

Considerable progress has been made in our understanding of the biological basis for cancer therapy-induced mucosal barrier injury (mucositis). The last formal review of the subject by MASCC/ISOO was published in 2007; consequently, an update is timely.

METHODS

Panel members reviewed the biomedical literature on mucositis pathobiology published between January 2005 and December 2011.

RESULTS

Recent research has provided data on the contribution of tissue structure changes, inflammation and microbiome changes to the development of mucositis. Additional research has focused on targeted therapy-induced toxicity, toxicity clustering and the investigation of genetic polymorphisms in toxicity prediction. This review paper summarizes the recent evidence on these aspects of mucositis pathobiology.

CONCLUSION

The ultimate goal of mucositis researchers is to identify the most appropriate targets for therapeutic interventions and to be able to predict toxicity risk and personalize interventions to genetically suitable patients. Continuing research efforts are needed to further our understanding of mucositis pathobiology and the pharmacogenomics of toxicity.

Early supplementation of parenteral nutrition is capable of improving quality of life, chemotherapy-related toxicity and body composition in patients with advanced colorectal carcinoma undergoing palliative treatment: results from a prospective, randomized clinical trial

AIM

Patients suffering from advanced colorectal cancer can experience unintended weight loss and/or treatment-induced gastrointestinal toxicity. Based on current evidence, the routine use of parenteral nutrition (PN) for patients with colorectal cancer is not recommended. This study evaluates the effect of PN supplementation on body composition, quality of life (QoL), chemotherapy-associated side effects and survival in patients with advanced colorectal cancer.

METHOD

Eighty-two patients with advanced colorectal cancer receiving a palliative chemotherapy were prospectively randomized to either oral enteral nutrition supplement (PN-) or oral enteral nutrition supplement plus supplemental PN (PN+). Every 6 weeks body weight, body mass index (BMI), chemotherapy-associated side effects and caloric intake were assessed, haemoglobin and serum albumin were measured. Body composition was assessed by body impedance analysis, and QoL was evaluated by European Organization for Research and Treatment of Cancer (EORTC) QLQC30 questionnaire.

RESULTS

No differences were evident at baseline between the groups for age, sex, diagnosis, weight, BMI or QoL. A difference in BMI was observed by week 36, whereas differences of the mean body cell mass could be observed from week 6, albumin dropped significantly in the PN- group in week 36 and QoL showed significant differences from week 18. Chemotherapy-associated side effects were higher in PN-. The survival rate was significantly greater in the PN+ group.

CONCLUSION

A supplementation with PN slows weight loss, stabilizes body-composition and improves QoL in patients with advanced colorectal cancer. Furthermore, it can reduce chemotherapy-related side effects.

Severity of oral mucositis in patients undergoing hematopoietic cell transplantation and an oral laser phototherapy protocol: a survey of 30 patients

BACKGROUND DATA AND OBJECTIVE

Oral mucositis (OM) is one of the worst cytotoxic effects of chemotherapy and radiotherapy in patients undergoing hematopoietic cell transplantation (HCT), and it causes severe morbidity. Laser phototherapy has been considered as an alternative therapy for prevention and treatment of OM. The aim of this study was to describe the incidence and severity of OM in HCT patients subjected to laser phototherapy, and to discuss its effect on the oral mucosa.

PATIENTS AND METHODS

Information concerning patient age and gender, type of basic disease, conditioning regimen, type of transplant, absence or presence of pain related to the oral cavity, OM grade, and adverse reactions or unusual events were collected from 30 patients undergoing HCT (allogeneic or autologous). These patients were given oral laser phototherapy with a InGaAIP laser (660 nm and 40 mW) daily. The data were tabulated and their frequency expressed as percentages.

RESULTS

In the analysis of those with OM, it was observed that 33.4% exhibited grade I, 40% grade II, 23.3% grade III, and 3.3% grade IV disease. On the most critical post-HCT days (D+5 and D+8), it was observed that 63.3% of patients had grade I and 33.3% had grade II disease; no patients had grade III or IV disease in this period. This severity of OM was similar to that seen in other studies of laser phototherapy and OM.

CONCLUSION

The low grades of OM observed in this survey show the beneficial effects of laser phototherapy, but randomized clinical trials are necessary to confirm these findings.

Double-blind, placebo-controlled, randomized study of chlorhexidine prophylaxis for 5-fluorouracil-based chemotherapy-induced oral mucositis with nonblinded randomized comparison to oral cooling (cryotherapy) in gastrointestinal malignancies

BACKGROUND

The purpose was to evaluate prevention of oral mucositis (OM) using chlorhexidine compared with placebo and with oral cooling (cryotherapy) during fluorouracil (5-FU)-based chemotherapy in gastrointestinal (GI) cancer.

METHODS

Patients with previously untreated GI cancer receiving bolus 5-FU/leucovorin chemotherapy were randomized to chlorhexidine mouthrinse 3 times a day for 3 weeks (Arm A), double-blind placebo (normal saline) with the same dose and frequency (Arm B), or cryotherapy with crushed ice 45 minutes during chemotherapy (Arm C). Patients self-reported on severity (CTC-grading) and duration of OM.

RESULTS

Among 225 patients randomized, 206 answered the questionnaire (70, 64, and 63 patients in Arms A, B, and C, respectively) and were well balanced with respect to diagnoses, stage, age, sex, smoking habits, and performance status. Mucositis grade 3-4 occurred more frequently in Arm B (33%) than in A (13%, P< .01) and C (11%, P< .005). Duration was significantly longer in B than in both A (P= .035) and C (P= .003).

CONCLUSIONS

The frequency and duration of OM are significantly improved by prophylactic chlorhexidine and by cryotherapy. The latter is easy and inexpensive but has limited use, as it is drug- and schedule-dependent. The current study is the first double-blind randomized evaluation of prophylactic chlorhexidine in a large adult patient population with solid tumors receiving highly OM-inducing chemotherapy. A role for chlorhexidine in the prevention of OM is suggested, which should be evaluated further.

Management of oral mucositis in patients who have cancer

Oral mucositis is a clinically important and sometimes dose-limiting complication of cancer therapy. Mucositis lesions can be painful, affect nutrition and quality of life, and have a significant economic impact. The pathogenesis of oral mucositis is multifactorial and complex. This review discusses the morbidity, economic impact, pathogenesis and clinical course of mucositis. Current clinical management of oral mucositis is largely focused on palliative measures such as pain management, nutritional support and maintenance of good oral hygiene. However, several promising therapeutic agents are in various stages of clinical development for the management of oral mucositis. These agents are discussed in the context of recently updated evidence-based clinical management guidelines.

Considerations in the pediatric population with cancer

This article is divided into three time periods according to the different phases of cancer treatment: pre, inter, and postcancer therapy. The purpose of dental protocols prior to cancer therapy and the incidence and management of acute and long term oral complications from cancer therapy in the pediatric population are discussed.

Intestinal mucositis: mechanisms and management

PURPOSE OF REVIEW

To describe the advances in the rapidly evolving field of intestinal (or alimentary) mucositis during the past year.

RECENT FINDINGS

Major advances have been made in both the clinical and preclinical setting, with the publication of a suite of articles regarding the pathobiology and management of mucositis, as well as several articles on important basic research in the area. The mechanism of mucositis development is now understood to be much more complex than previously thought, with an interplay of host and drug factors leading to overt damage, and variation in manifestation of that damage depending on the specific region of the gut. The MASCC/ISOO management guidelines for mucositis have been updated: a recommendation for the use of palifermin in the hematology transplant setting has been added, and a couple of previous recommendations have been revoked. This marks an important milestone in mucositis, as it is the first time a drug has been available that substantially reduces the occurrence and severity of mucositis.

SUMMARY

There is still much to be done to abolish the severe toxicity of chemotherapy and radiotherapy; however, progress is accelerating, and new targeted drugs are becoming available.

Severe mucositis: how can nutrition help?

PURPOSE OF REVIEW

To review the recent evidence on the effect of nutrition on the incidence and severity of mucositis following anticancer treatment.

RECENT FINDINGS

There have been many recent publications on mucositis and on nutrition in cancer, but very few on nutrition and mucositis in cancer. It is difficult to establish a definite link between nutritional status, nutritional interventions and mucositis. Malnutrition is probably a risk factor for mucositis, however, and some of the interventions that improve nutrition in cancer patients and reduce the risk of cancer in the general population work via mechanisms that might positively affect the development and course of mucositis. Whilst it can be tempting to extrapolate these findings to suggest that nutritional support can reduce the incidence and severity of mucositis, this would be premature.

SUMMARY

There may well be a link between nutritional status, nutritional supplementation, anticancer treatment and mucositis, but it is not yet proven; and mechanism-based, prospective, randomized studies are required to answer the question. This is likely to be an area of increased study in the future.

Mucositis: biology and management

PURPOSE OF REVIEW

Oral mucositis is a common regimen-limiting toxicity of radiation therapy and concomitant radiosensitizing chemotherapy for treatment of head and neck cancers. In addition to its symptomatic impact, oral mucositis increases the likelihood of unplanned breaks or delays in treatment, reduction in chemotherapy dose, use of feeding tube placement or total parenteral nutrition, the need for an intravenous line, opioid use and hospitalization.

RECENT FINDINGS

Recent research has demonstrated that chemoradiation-induced mucosal injury is the result of a complex series of biological and cellular events that take place predominantly in the submucosa, with the epithelium being the target tissue. From these findings, novel biologically based preventive treatments are being developed, with a number of agents currently in clinical trials. The implications of recent advancements in radiation therapy treatment planning and delivery are also considered.

SUMMARY

Mucositis is a common and serious complication secondary to chemoradiotherapy for head and neck cancer that has a profound effect on morbidity, compliance and treatment outcomes. Currently available interventions are directed at minimizing local radiation exposure and providing symptomatic relief. In the near future, a number of new treatment modalities can be expected to be introduced for reduction of severity and duration of mucositis.

The role of pro-inflammatory cytokines in cancer treatment-induced alimentary tract mucositis: pathobiology, animal models and cytotoxic drugs

Alimentary tract (AT) mucositis can be a major problem for patients undergoing cancer treatment. It has significant clinical and economic consequences and is a major factor that can compromise the provision of optimal treatment for patients. The pathobiology of AT mucositis is complex and the exact mechanisms that underlie its development still need to be fully elucidated. Current opinion considers that there is a prominent interplay between all of the compartments of the mucosa involving, at a molecular level, the activation of transcription factors, particularly nuclear factor-kappaB, and the subsequent upregulation of pro-inflammatory cytokines and inflammatory mediators. The purpose of this review is to examine the literature relating to what is currently known about the pathobiology of AT mucositis, particularly with respect to the involvement of pro-inflammatory cytokines, as well as currently used animal models and the role of specific cytotoxic chemotherapy agents in the development of AT mucositis.

Updated clinical practice guidelines for the prevention and treatment of mucositis

Considerable progress in research and clinical application has been made since the original guidelines for managing mucositis in cancer patients were published in 2004, and the first active drug for the prevention and treatment of this condition has been approved by the United States Food and Drug Administration and other regulatory agencies in Europe and Australia. These changes necessitate an updated review of the literature and guidelines. Panel members reviewed the biomedical literature on mucositis published in English between January 2002 and May 2005 and reached a consensus based on the criteria of the American Society of Clinical Oncology. Changes in the guidelines included recommendations for the use of palifermin for oral mucositis associated with stem cell transplantation, amifostine for radiation proctitis, and cryotherapy for mucositis associated with high-dose melphalan. Recommendations against specific practices were introduced: Systemic glutamine was not recommended for the prevention of gastrointestinal mucositis, and sucralfate and antimicrobial lozenges were not recommended for radiation-induced oral mucositis. Furthermore, new guidelines suggested that granulocyte-macrophage-colony stimulating factor mouthwashes not be used for oral mucositis prevention in the transplantation population. Advances in mucositis treatment and research have been complemented by an increased rate of publication on mucosal injury in cancer. However, additional and sustained efforts will be required to gain a fuller understanding of the pathobiology, impact on overall patient status, optimal therapeutic strategies, and improved educational programs for health professionals, patients, and caregivers. These efforts are likely to have significant clinical and economic impact on the treatment of cancer patients. Cancer 2007;109:820-31. (c) 2007 American Cancer Society.

Treatment of Mucositis, Including New Medications

Mucositis is a clinically important and sometimes dose-limiting complication of cancer therapy. Mucositis lesions can be painful, affect nutrition and quality of life, lead to sepsis, and have significant economic impact. Recent modeling of the toxicity has been based on the continuum of clinical signs and symptoms of mucositis involving the alimentary tract, including both oral and gastrointestinal sites. The pathogenesis of oral and gastrointestinal mucositis is multifactorial and complex. In recent years, there has been a substantial increase in both basic and clinical research related to mucosal injury in cancer patients. Since most of this research has been directed to oral mucositis, the present review principally addresses this component of the toxicity. Morbidity, economic impact, pathogenesis and clinical course of mucositis are discussed. In addition, several agents in clinical development for mucositis are discussed in the context of the current pathobiologic model as well as the recently updated evidence-based clinical management guidelines.

Developing evidence-based guidelines for management of alimentary mucositis: process and pitfalls

INTRODUCTION

It is important yet difficult to maintain currency in clinical oncology practice. The emergence of new diagnostic technologies and new paradigms for cancer treatment combine to produce a rapidly changing clinical approach to patients aided by the increasing use of multidisciplinary care teams and development of evidence-based protocols.

METHODS

Teams of experts review the literature in a given area and produce management guidelines and protocols for use by practicing clinicians. Traditionally within Hematology/Oncology, these guidelines have been directed to management of a given tumor type. However, in recent years, attention has increasingly turned to supportive oncology; for example, there are now management guidelines for conditions such as neutropenic fever [Hughes et al. Clinical Infectious Diseases 34(6):730-751, 2002], antiemetic (The Antiemetic Subcommittee of the Multinational Association of Supportive Care in Cancer Annals of Oncology 17:20-28, 2006) and most recently, mucositis [Rubenstein et al. Cancer 100(9 Suppl):2026-2046, 2004]. It is critical that any guideline process should include education, evaluation, and timely update in its remit, because guidelines become highly compromised if their existence is not widely known, if they do not facilitate clinical practice, or if they are not reflective of contemporary medical literature.

RESULTS

The Mucositis Study Group (MSG) of the Multinational Association for Supportive Care in Cancer/International Society for Oral Oncology was created in 1998 to specifically address the multiprofessional approach to clinical care, research, and education associated with mucosal injury in cancer patients. A specific outcome has been the development of evidence-based guidelines for the management of mucositis [Rubenstein et al. Cancer 100(9 Suppl):2026-2046, 2004; The Mucositis Study Group of MASCC/ISSO 2005]. The original guidelines [Rubenstein et al. Cancer 100(9 Suppl):2026-2046, 2004] and a companion paper discussing the science behind mucositis [Sonis et al. Cancer 100(9):1995-2025, 2004], were published in 2004. The MSG has recently updated the guidelines [The Mucositis Study Group of MASCC/ISSO 2005].

DISCUSSION

This paper discusses the process involved and the lessons learned that might help other groups planning to undertake a similar project.