Systematic reviews of oral complications from cancer therapies, Oral Care Study Group, MASCC/ISOO: methodology and quality of the literature

Ultrasonic activation of adhesive systems increases bond strength and intratubular penetration of resin cement in root dentin subjected to radiation therapy

OBJECTIVE

This study aimed to evaluate the effect of ultrasonic activation of etch-and-rinse and self-etch adhesive systems on the bond strength of resin cement to irradiated root dentin.

MATERIALS AND METHODS

Eighty human maxillary anterior teeth were distributed into 8 groups (n = 10), according to the type of adhesive system used (etch-and-rinse and self-etch), the ultrasonic activation of the adhesive systems, and the dentin condition (irradiated or non-irradiated - 70 Gy). Endodontic treatment was performed followed by fiberglass post-space preparation. After fiberglass posts' luting, the roots were transversely sectioned on dentin discs and submitted to the push-out bond strength test (0.5 mm/min). The fractured specimens were analyzed under a stereomicroscope and Scanning Electron Microscope (SEM) for failure mode classification. One of the dentin discs was analyzed under SEM to evaluate the characteristics of the adhesive interface.

RESULTS

Irradiated specimens had lower bond strength than non-irradiated specimens (P < 0.0001). Ultrasonic activation of both adhesive systems increased the bond strength of the resin cement to irradiated dentin (P < 0.0001). Radiotherapy significantly affected the failure mode in the middle (P = 0.024) and apical thirds (P = 0.032) (adhesive failure).

CONCLUSION

Non-irradiated specimens had a more homogeneous adhesive interface. When ultrasonically activated, both adhesive systems showed a greater number of resinous tags, regardless of the dentin condition.

CLINICAL RELEVANCE

Ultrasonic activation of adhesive systems is a feasible strategy to enhance fiberglass posts retention in oncological patients.

The effect of hematopoietic stem cell transplantation on patient-reported subjective oral dryness: a systematic review focusing on prevalence, severity and distress

OBJECTIVE

The aim of the present systematic review is to assess the prevalence and severity of and distress caused by xerostomia over time in adult hematopoietic stem cell transplantation (HSCT) recipients.

METHODS

PubMed, Embase, and the Cochrane Library were searched for papers published between January 2000 and May 2022. Clinical studies were included if patient-reported subjective oral dryness was reported in adult autologous or allogeneic HSCT recipients. Risk of bias was assessed according to a quality grading strategy published by the oral care study group of the MASCC/ISOO, resulting in a score between 0 (highest risk of bias) and 10 (lowest risk of bias). Separate analysis focused on autologous HSCT recipients, allogeneic HSCT recipients receiving a myeloablative conditioning (MAC), and those receiving a reduced intensity conditioning (RIC).

RESULTS

Searches yielded 1792 unique records; 22 studies met the inclusion criteria. The quality scores ranged between 1 and 7, with a median score of 4. The prevalence, severity, and distress of xerostomia increased shortly after HSCT. Severity of xerostomia in allogeneic MAC recipients was higher compared to allogeneic RIC recipients 2-5 months post-HSCT (mean difference: 18 points on 0-100 scale, 95% CI: 9-27); after 1-2 years, there was no significant difference anymore.

CONCLUSION

The prevalence of xerostomia in HSCT recipients is high in comparison to the general population. The severity of complaints is raised during the first year post-HSCT. The intensity of the conditioning plays a key role in the short-term development of xerostomia, while factors affecting the recovery in the long term remain largely unknown.

Trismus after partial maxillectomy and radiotherapy: Free flap reconstruction versus prosthetic obturation

OBJECTIVE

Partial maxillectomy and postoperative radiotherapy are both risk factors associated with trismus. This retrospective study aimed to evaluate the incidence and severity of trismus in patients following partial maxillectomy with or without postoperative radiotherapy and to compare free flap reconstruction and prosthetic obturation.

METHODS

A retrospective review of 40 oral cancer patients who underwent partial maxillectomy with or without postoperative radiotherapy was performed. Maximum interincisal distance recorded at least 6 months after surgery was classified according to a revised subjective-objective management-analytical (SOMA) scale and compared between the free flap reconstruction group (n = 12) and the prosthetic obturation group (n = 28).

RESULTS

Trismus was observed in 16/40 (40%) patients, and severe trismus was observed in 4/40 (10%) patients. Although no significant difference in trismus grade was observed between the free flap reconstruction and prosthetic obturation groups, both severe trismus and radiation-induced osteonecrosis were only seen in the prosthetic obturation group with postoperative radiotherapy.

CONCLUSION

Free flap reconstruction was preferable to prosthetic obturation to avoid severe trismus and radiation-induced osteonecrosis in patients who underwent both partial maxillectomy and postoperative radiotherapy.

Oral health in patients scheduled for hematopoietic stem cell transplantation in the Orastem study

Despite advances in transplant medicine, prevalence of complications after hematopoietic stem cell transplantation (HSCT) remains high. The impact of pre-HSCT oral health factors on the incidence and severity of complications post-HSCT is poorly understood. The aim of this prospective, observational study was to analyze oral health in patients planned for HSCT. Patients ≥18 years requiring HSCT were included from five sites between 2011-2018. General health, oral findings and patient-reported symptoms were registered in 272 patients. Oral symptoms around disease onset were reported by 43 patients (15.9%) and 153 patients (58.8%) reported oral complications during previous chemotherapy. One third of patients experienced oral symptoms at the oral examination before conditioning regimen and HSCT. In total, 124 (46.1%) patients had dental caries, 63 (29.0%) had ≥one tooth with deep periodontal pockets, 147 (75.0%) had ≥one tooth with bleeding on probing. Apical periodontitis was observed in almost 1/4 and partially impacted teeth in 17 (6.3%) patients. Oral mucosal lesions were observed in 84 patients (30.9%). A total of 45 (17.4%) of 259 patients had at least one acute issue to be managed prior to HSCT. In conclusion, oral symptoms and manifestations of oral disease were prevalent in patients planned for HSCT. The extent of oral and acute dental diseases calls for general oral screening of patients pre-HSCT.

Salivary Gland Dysfunction Secondary to Cancer Treatment

The number of cancer survivors are increasing and so are the oral toxicities from cancer therapy. Most patients receiving treatment for cancer develop some form of oral adverse events including, but not limited to, mucositis, opportunistic infections, dry mouth, and/or osteonecrosis of the jaw. One of the most common complications from head and neck cancer radiation therapy is salivary gland dysfunction (SGD). SGD is an umbrella term that includes the subjective sensation of dry mouth (xerostomia) and hyposalivation (objective reduction of the salivary flow rate). Dry mouth in cancer patients may lead to functional defects (e.g., eating, speaking, and swallowing), increase the risk of dental caries and oral candidiasis, and can have a negative effect on the nutritional and psychological status of the patients. The aim of this mini review was to summarize the current criteria for diagnosis and management of SGD associated with cancer treatment.

The Effect of Radiotherapy on the Marginal Adaptation of Class II Direct Resin Composite Restorations: A Micro-computed Tomography Analysis

This laboratory study was designed to evaluate the marginal adaptation of Class II mesio-occluso-distal (MOD) restorations at the cervical region with micro-computed tomography (micro-CT). Two groups of restorations were compared: 1) those that had been exposed to radiotherapy before restoration was performed using a universal adhesive in etch-and-rinse and self-etch modes; and 2) those that had previously been restored using a universal adhesive in etch-and-rinse and self-etch modes and had subsequently undergone radiotherapy. Sixty intact human molars were randomly divided into groups according to irradiation status: no radiotherapy (control group); radiotherapy followed by restoration (radiotherapy-first group); and restoration followed by radiotherapy (restoration-first group). These three groups were then subdivided into two groups each on the basis of adhesive application type (etch-and-rinse and self-etch modes), for a total of six groups (n=10/group). Standardized Class II MOD cavities were prepared. A universal adhesive (Clearfil Universal Bond Quick, Kuraray, Okayama, Japan) was applied. The teeth were restored with resin composite (Estelite Posterior Quick, Tokuyama, Tokyo, Japan). The radiotherapy protocol was conducted with 60 gray (Gy) at 2 Gy/day, five days a week for six weeks. Adhesive defects were analyzed in distal and mesial views and evaluated with micro-CT (SkyScan 1174v2, Kontich, Antwerp, Belgium) on the basis of the volume of black spaces between the cavity walls and the restorative materials (mm3). The data were analyzed using the Kruskal-Wallis, Mann Whitney U and Wilcoxon tests (p<0.05). The radiotherapy protocol did not affect the marginal adaptation of the universal adhesive at the cervical regions. Regarding the application modes, for the radiotherapy-first group, the self-etch mode caused significantly higher adhesive defects than the etch-and-rinse mode at the dentin margin. For the no-radiotherapy group, the adhesive defects at the dentin margin were significantly higher than at the enamel margin with the application of the etch-and-rinse mode.

Oral Hygiene Practice among Hospitalized Patients: An Assessment by Dental Hygiene Students

AIM

An epidemiological study was carried out, in hospital wards, with the aim of assessing the oral health status of patients subjected to multiple medical treatments.

MATERIAL AND METHODS

The study was conducted at Fondazione IRCCS Policlinico San Matteo (Pavia, Italy). A questionnaire was submitted to patients for the evaluation of oral hygiene devices used; then, a clinical examination was conducted to collect Decayed Missing Filled Teeth (DMFT) index, Plaque Index (PI), and Marginal Gingival Index (MGI) values.

RESULTS

Manual toothbrushes were used by a wide range of the sample study (65-100% among hospital wards), together with mouthwash (20-80%); interproximal aids were used by few patients (the lowest recorded value was 33.3%).

CONCLUSION

dental hygienists could be integrated into hospital wards as oral hygiene procedure instructors, for the improvement of the oral health conditions of hospitalized patients.

Medication-Related Osteonecrosis of the Jaw in Patients Treated Concurrently with Antiresorptive and Antiangiogenic Agents: Systematic Review and Meta-Analysis

Introduction

Medication-related osteonecrosis of the jaws (MRONJ) is a known adverse event related to the use of antiresorptive (AR) drugs. More recently, an association between antiangiogenic (AA) drugs and MRONJ has been suggested. This review aimed to investigate the overall prevalence and relative risk of MRONJ in patients treated concurrently with AA and AR agents in comparison with a single AA or AR drug.

Methods

A review protocol was registered with PROSPERO (ID: CRD42020214244). A systematic literature search, study selection, quality assessment, and data extraction were carried out following PRISMA guidelines. Random-effects meta-analysis models were used to summarize relative estimates for the outcomes, namely prevalence and relative risk of MRONJ. Exposure variable included type of drug, specifically AA and AR agents administered either concurrently or individually.

Results

Eleven studies were included in the final qualitative and quantitative syntheses. The overall pooled weighted prevalence of MRONJ with concurrent AA-AR drugs was 6% (95% CI: 3–8%), compared with 0% (95% CI: 0–0%) for AA only and 5% (95% CI: 0–10%) for AR only. However, high heterogeneity was noted among included studies. Retrospective cohort studies showed a higher pooled prevalence of 13% (95% CI: 10–17%) for concurrent AA-AR therapy. The pooled risk ratio for MRONJ revealed a risk with concurrent AA-AR drugs 2.57 times as high as with AR only (95% CI: 0.84–7.87); however, this difference was not statistically significant. Concurrent AA-AR drugs had a risk for MRONJ 23.74 times as high as with AA only (95% CI: 3.71–151.92).

Conclusions

High-quality, representative studies are needed for accurate estimation of relative risk of MRONJ with concurrent AA and AR therapy.

Effects of irradiation in the mandibular bone loaded with dental implants. An experimental study with a canine model

Radiation therapy may compromise the quality of bone around dental implants, and its ability to regenerate, remodel, and revascularize. This study aimed to describe the irradiation effect on the bone microstructure of the mandible using dental implants in a canine model. Five beagle dogs were exposed to 40 Gy fractionated radiation. In total, 20 dental implants were inserted, two in the irradiated and two in the non-irradiated side. The mandible bone blocks were subjected to 3D micro-computed tomography (µCT) imaging, later evaluated histomorphometrically by light microscopy and scanning electron microscopy. Alterations in irradiated bone were observed under µCT imaging showing an increased anisotropy, porosity, and pore volume. Bone surface-to-bone volume decreased. The bone to implant contact index was significantly reduced in the irradiated bone (75.6% ± 5.8%) as compared to the non-irradiated bone (85.1% ± 6.8%). In the irradiated mandible, osteocytes with their filopodial processes, the bone beneath the periosteum, and subperiosteal veins showed structural differences but were not significant, whereas the diameter of Haversian canals were smaller statistical significant as compared to the control side. The study highlights that radiation dosage of fractioned 40 Gy causes alterations in the alveolar bone microstructure with compatible osseointegration and clinically stable dental implants.

Prevalence of medication related osteonecrosis of the jaw in patients treated with sequential antiresorptive drugs: systematic review and meta-analysis

BACKGROUND

Antiresorptive drugs (ARD) are associated with a known serious adverse event, known as medication-related osteonecrosis of the jaws (MRONJ). Transition from one ARD to another has become common clinical practice with the advent of more potent or safer agents; however, the influence of sequential antiresorptive therapy as a risk factor for MRONJ has not been established.

OBJECTIVES

To investigate the prevalence of MRONJ in oncology or osteoporosis patients treated with two or more sequential ARDs as opposed to a single antiresorptive drug.

MATERIAL AND METHODS

Systematic electronic literature searches were conducted using Ovid MEDLINE, Ovid EMBASE, and Cochrane Central Register of Controlled Trials. Two review authors retrieved studies using pre-determined eligibility criteria and conducted quality assessment and data extraction. Fixed or random-effects meta-analysis models were used to summarize relative estimates for prevalence of MRONJ.

RESULTS

A total of 483 titles and abstracts were screened, and 18 full texts were retrieved for review. Twelve studies were included in the final qualitative and quantitative synthesis. Random effects meta-analysis models revealed a weighted pooled MRONJ prevalence of 19% (95% CI 10-27%) for sequential pamidronate-zoledronate therapy, 10% (95% CI 3-22%) for sequential ibandronate-zoledronate therapy. Pooled weighted prevalence of MRONJ was 13% (95% CI 3-22%) for sequential bisphosphonate-denosumab therapy while bisphosphonates only was 5% (95% CI 0-9%) and denosumab only was 4% (95% CI 3-5%).

CONCLUSIONS

The present systematic review suggests an increased prevalence of MRONJ associated with sequential ARD therapy for pamidronate-zoledronate and bisphosphonate-denosumab administration when compared to single ARD therapy.

Salivary Gland Hypofunction and Xerostomia in Head and Neck Radiation Patients

BACKGROUND

The most manifest long-term consequences of radiation therapy in the head and neck cancer patient are salivary gland hypofunction and a sensation of oral dryness (xerostomia).

METHODS

This critical review addresses the consequences of radiation injury to salivary gland tissue, the clinical management of salivary gland hypofunction and xerostomia, and current and potential strategies to prevent or reduce radiation injury to salivary gland tissue or restore the function of radiation-injured salivary gland tissue.

RESULTS

Salivary gland hypofunction and xerostomia have severe implications for oral functioning, maintenance of oral and general health, and quality of life. Significant progress has been made to spare salivary gland function chiefly due to advances in radiation techniques. Other strategies have also been developed, e.g., radioprotectors, identification and preservation/expansion of salivary stem cells by stimulation with cholinergic muscarinic agonists, and application of new lubricating or stimulatory agents, surgical transfer of submandibular glands, and acupuncture.

CONCLUSION

Many advances to manage salivary gland hypofunction and xerostomia induced by radiation therapy still only offer partial protection since they are often of short duration, lack the protective effects of saliva, or potentially have significant adverse effects. Intensity-modulated radiation therapy (IMRT), and its next step, proton therapy, have the greatest potential as a management strategy for permanently preserving salivary gland function in head and neck cancer patients.Presently, gene transfer to supplement fluid formation and stem cell transfer to increase the regenerative potential in radiation-damaged salivary glands are promising approaches for regaining function and/or regeneration of radiation-damaged salivary gland tissue.

Should oral foci of infection be removed before the onset of radiotherapy or chemotherapy?

Pretreatment dental screening aims to locate and eliminate oral foci of infection in order to eliminate local, loco-regional, or systemic complications during and after oncologic treatment. An oral focus of infection is a pathologic process in the oral cavity that does not cause major infectious problems in healthy individuals, but may lead to severe local or systemic inflammation in patients subjected to oncologic treatment. As head and neck radiotherapy patients bear a lifelong risk on oral sequelae resulting from this therapy, the effects of chemotherapy on healthy oral tissues are essentially temporary and reversible. This has a large impact on what to consider as an oral focus of infection when patients are subjected to, for example, head and neck radiotherapy for cancer or intensive chemotherapy for hematological disorders. While in patients subjected to head and neck radiotherapy oral foci of infection have to be removed before therapy that may cause problems ultimately, in patients that will receive chemotherapy such, so-called chronic, foci of infection are not in need of removal of teeth but can be treated during a remission phase. Acute foci of infection always have to be removed before or early after the onset of any oncologic treatment.

Photobiomodulation Therapy in the Treatment of Oral Mucositis, Dysphagia, Oral Dryness, Taste Alteration, and Burning Mouth Sensation Due to Cancer Therapy: A Case Series

Oral complications of cancer therapy, such as oral dryness, dysphagia, and taste alteration, are associated with a negative impact in the quality of life of the patients. Few supportive care measures are available for such complications. This case series reveals the effectiveness of the photobiomodulation (PBM) therapy when used in a specific protocol and parameters, in the management of oral complications related to cancer therapy. Dysphagia was measured using the functional outcome swallowing scale for staging oropharyngeal dysphagia (FOSS). Oral mucositis was measured according to the National Cancer Institute scale. The quantity of the whole resting and stimulated saliva was measured in order to assess the oral dryness. In addition, the taste alteration was measured according to a protocol suggested by the International Standards organization (ISO). Sensation of burning mouth was measured using a visual analogue scale. These measurements were made before treatment, during, and at the end of the treatment. Diode laser 635 nm was used in 3 J/cm2. Five sessions interleaved with 24 h breaks were conducted for the dysphagia and oral dryness, and 10 sessions were conducted for the taste alteration and burning mouth sensation. Regardless of the limitations of this case series, PBM can be considered safe, time saving, and a promising approach for the management of the oral complications due to cancer therapy and the quality of life of cancer patients.

Dentin-pulp complex reactions in conventional and radiation-related caries: A comparative study

Background

Radiation-related caries (RRC) is one of the most significant oral toxicities of head and neck radiotherapy (HNRT); however, the potential of radiation to directly cause harmful dentin and pulpal effects and impair response to caries progression is controversial.

Material and Methods

Therefore, the aim of this study was to characterize the reactions of the dentin-pulp complex in teeth affected by RRC. Patients and methods: Twenty-two carious teeth extracted from 22 head and neck cancer (HNC) patients were divided into control (conventional caries; n=11) and irradiated (RRC; n=11) groups and paired matched by dental homology, clinical patterns of caries progression following the Post-Radiation Dental Index (PRDI) and microscopic depth of carious invasion. Histopathological characteristics based on morphological hierarchy, cell populations of dental pulp, blood vessels, neural elements, extracellular matrix components, inflammation, patterns of carious invasion and reactionary dentin presence were evaluated by optical light microscopy and histomorphometry.

Results

Mean PRDI scores were 3.2 for the control group and 3.8 for the irradiated group. Dentin demineralization patterns were also similar between the groups and the mean depths of demineralization were 1,158.58µm and 1,056.89µm for the control and irradiated groups, respectively.

Conclusions

Pulp histopathological changes and dentin reaction patterns were similar between groups and varied according to the PRDI scores and carious lesions depth. Dentin and pulp reactions are highly preserved in RRC teeth. Key words:Cancer, radiotherapy, radiation-related caries, teeth, pulp.

Radiation-related superficial oral mucoceles: An under-recognized acute toxicity in head and neck cancer patients

Background

Acute toxicity is usually defined as adverse changes occurring immediately or a short time after the start of oncological treatment.

Material and Methods

Cross-sectional retrospective study performed with head and neck cancer patients who underwent radiotherapy from 2013 to 2016.

Results

Ten (1.2%) patients developed SOMs during radiotherapy, most (80%) of which were men with a mean age of 59.5 years at diagnosis. SOMs mainly affected the floor of the mouth (60%) between the fourth and the sixth weeks of radiation therapy. All lesions were asymptomatic and spontaneously ruptured approximately 9 days after diagnosis.

Conclusions

Although rare, SOMs may be regarded as an acute oral toxicity of head and neck radiotherapy.

Key words:Superficial oral mucoceles; head and neck cancer; radiation toxicity, acute toxicity.

Impact of Oral Side Effects from Conditioning Therapy Before Hematopoietic Stem Cell Transplantation: Protocol for a Multicenter Study

Background

The oral cavity is a common site of complications related to the cytotoxic effect of high-dose chemotherapy and radiation therapy. Considering our limited understanding of the burden of illness in the oral cavity from various cytotoxic therapies, it is difficult to produce evidence-based, preventive and management protocols. A prospective multicenter study is necessary to collect data on the burden of illness from various cytotoxic regimens.

Objective

The objectives of this prospective international observational multicenter study in hematopoietic stem cell transplant (HSCT) patients are to establish the nature, incidence and temporal relationship of oral complications related to conditioning regimens (chemotherapy with or without total body irradiation), stem cell transplantation and the immunologic reactions (mainly graft-vs-host-disease) that may follow, and to determine what subjective and objective oral complications related to treatment can predict negative clinical and economic outcomes and reduced quality of life.

Methods

Adult patients at six study sites receiving full intensity conditioning, reduced intensity conditioning or nonmyeloablative conditioning, followed by autologous or allogeneic hematopoietic stem cell infusion, are included. A pre-treatment assessment includes medical conditions, planned chemo- and radiation therapy regimen, medications, allergies, social history, patient report of oral problems, dental history, subjective oral complaints, objective measures of oral conditions, current laboratory values, dental treatment recommended and untreated dental disease. Starting 1-3 days after hematopoietic stem cell infusion, a bedside assessment is completed 3 days per week until resolution of neutropenia. A patient questionnaire is also completed during hospitalization. Beyond this time, patients with continued oral mucositis or other oral problems are followed 1 day per week in an inpatient or outpatient setting. Additional visits for urgent care for acute oral problems after hospitalization are documented. Autologous transplant patients are being followed up at 100 days (SD 30 days) and at 1 year (SD 30 days) post-transplantation to identify any long-term side effects. Patients treated with allogeneic transplantation are being followed at 100 days (SD 30 days), 6 months (SD 30 days), and 12 months (SD 30 days). The follow-up assessments include cancer response to therapy, current medical conditions, medications, subjective and objective oral findings, quality of life measures and laboratory values. The targeted enrollment is 254 patients who have received HSCT.

Results

A total of 260 participants have been enrolled, with 233 (91%) who have received HSCT. We anticipate enrollment of 20-30 additional participants to obtain the sample size of 254 enrolled participants who have received HSCT.

Conclusions

The results of the ongoing prospective study will provide a unique dataset to understand the impact of oral complications on patients undergoing HSCT and provide needed evidence for guidelines regarding the management of this patient cohort.

First-in-man mesenchymal stem cells for radiation-induced xerostomia (MESRIX): study protocol for a randomized controlled trial

Background

Salivary gland hypofunction and xerostomia are major complications following radiotherapy for head and neck cancer and may lead to debilitating oral disorders and impaired quality of life. Currently, only symptomatic treatment is available. However, mesenchymal stem cell (MSC) therapy has shown promising results in preclinical studies. Objectives are to assess safety and efficacy in a first-in-man trial on adipose-derived MSC therapy (ASC) for radiation-induced xerostomia.

Methods

This is a single-center, phase I/II, randomized, placebo-controlled, double-blinded clinical trial. A total of 30 patients are randomized in a 1:1 ratio to receive ultrasound-guided, administered ASC or placebo to the submandibular glands. The primary outcome is change in unstimulated whole salivary flow rate. The secondary outcomes are safety, efficacy, change in quality of life, qualitative and quantitative measurements of saliva, as well as submandibular gland size, vascularization, fibrosis, and secretory tissue evaluation based on contrast-induced magnetic resonance imaging (MRI) and core-needle samples. The assessments are performed at baseline (1 month prior to treatment) and 1 and 4 months following investigational intervention.

Discussion

The trial is the first attempt to evaluate the safety and efficacy of adipose-derived MSCs (ASCs) in patients with radiation-induced xerostomia. The results may provide evidence for the effectiveness of ASC in patients with salivary gland hypofunction and xerostomia and deliver valuable information for the design of subsequent trials.

Trial registration

EudraCT, Identifier: 2014-004349-29. Registered on 1 April 2015.

ClinicalTrials.gov, Identifier: NCT02513238. First received on 2 July 2015.

The trial is prospectively registered.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-1856-0) contains supplementary material, which is available to authorized users.

[Salivation in children during anticancer chemotherapy]

The study aimed to assess the needs and options for salivation management in children treated with antileukemic chemotherapy. In a preliminary cross-sectional study the saliva flow rate and viscosity were evaluated in 75 leukemic children that received chemotherapy with methotrexate in low dose (44 people, 44 episode, group 1), or in high-dose (31 people, 42 episode, group 2), and in 25 healthy children (group 3). Then, 26 children were randomly divided into two groups in the 70 episodes course of high-dosed chemotherapy, and received acetylcysteine (A) or only standard oral management (S) for 1-10 day of treatment. Parameters of salivation and children performance (Lansky et al.) were evaluated. Mann-Whitney U-test was used for analysis. In group 1, 2 and 3 the flow rate (Me [LQ/HQ]) was 0.5 [0.3; 0.8]; 0.9 [0.6; 1.2] and 0.5 [0.3; 0.6] ml/min respectively (p1-3>0.05; p<0.01; p1-2<0.05). Viscosity levels in group 1, 2 and 3 were 2.75 [3.67; 3.67], 10.05 [5.3; 26.0] and 3.9 [2.7; 6.5] unites respectively (p1-3>0.05; p2, 3<0.01; p1, 2<0.01). In group A and S the flow rate was 2.7 [0.5; 4.1] and 0.4 [0.1; 2.2] ml/min (р<0.05); viscosity was 1.5 [1.2; 4.1] and 6.4 [5.3; 8.1] unites (р<0.001), performance Lansky index was 80 [65; 90] and 70 [60; 80] (р<0.01) respectively. Salivation dysfunction complicates the chemotherapy with high-dosed methotrexate in children: it is indicated by high viscosity combined with elevated flow rate. Acetylcysteine normalizes saliva viscosity and improves children's performance.

Effect of leaving chronic oral foci untreated on infectious complications during intensive chemotherapy

BACKGROUND

Leukaemic patients receiving intensive chemotherapy and patients undergoing autologous stem-cell transplantation (ASCT) are routinely screened for oral foci of infection to reduce infectious complications that could occur during therapy. In this prospective study we assessed the effect of leaving chronic oral foci of infection untreated on the development of infectious complications in intensively treated haematological patients.

METHODS

We included and prospectively evaluated all intensively treated leukaemic patients and patients undergoing ASCT who were referred to our medical centre between September 2012 and May 2014, and who matched the inclusion/exclusion criteria. Acute oral foci of infection were removed before chemotherapy or ASCT, whereas chronic oral foci were left untreated.

RESULTS

In total 28 leukaemic and 35 ASCT patients were included. Acute oral foci of infection were found in 2 leukaemic (7%) and 2 ASCT patients (6%), and chronic oral foci of infection in 24 leukaemic (86%) and 22 ASCT patients (63%). Positive blood cultures with microorganisms potentially originating from the oral cavity occurred in 7 patients during treatment, but were uneventful on development of infectious complications.

CONCLUSIONS

Our prospective study supports the hypothesis that chronic oral foci of infection can be left untreated as this does not increase infectious complications during intensive chemotherapy.

Practical use of povidone-iodine antiseptic in the maintenance of oral health and in the prevention and treatment of common oropharyngeal infections

AIMS

To better inform medical practitioners on the role of antiseptics in oropharyngeal health and disease, this article focuses on povidone-iodine (PVP-I), an established and widely-available antiseptic agent.

METHODOLOGY

Review of the anti-infective profile, efficacy and safety of PVP-I in managing common upper respiratory tract infections such as the common cold, influenza and tonsillo-pharyngitis, as well as oral complications resulting from cancer treatment (oral mucositis), and dental conditions (periodontitis, caries).

RESULTS

Antiseptics with broad-spectrum anti-infective activity and low resistance potential offer an attractive option in both infection control and prevention. While there is some evidence of benefit of antiseptics in a variety of clinical settings that include dental and oral hygiene, dermatology, oncology, and pulmonology, there appears to be discordance between the evidence-base and practice. This is especially apparent in the management and prevention of oropharyngeal infections, for which the use of antiseptics varies considerably between clinical practices, and is in marked contrast to their dermal application, where they are extensively used as both a prophylaxis and a treatment of skin and wound infections, thus minimising the use of antibiotics.

CONCLUSION

The link between oral and oropharyngeal health status and susceptibility to infection has long been recognised. The high rates of antibiotic misuse and subsequent development of bacterial resistance (e.g. increasing vancomycin-resistant enterococci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA)) in large parts of the world, especially across Asia Pacific, highlight the need for identifying alternative antimicrobials that would minimise the use of these medications. This, together with recent large-scale outbreaks of, for example, avian and swine influenza virus, further underline the importance of an increasing armamentarium for infection prevention and control.

Various forms of tissue damage and danger signals following hematopoietic stem-cell transplantation

Hematopoietic stem-cell transplantation (HSCT) is the most potent curative therapy for many malignant and non-malignant disorders. Unfortunately, a major complication of HSCT is graft-versus-host disease (GVHD), which is mediated by tissue damage resulting from the conditioning regimens before the transplantation and the alloreaction of dual immune components (activated donor T-cells and recipient’s antigen-presenting cells). This tissue damage leads to the release of alarmins and the triggering of pathogen-recognition receptors that activate the innate immune system and subsequently the adaptive immune system. Alarmins, which are of endogenous origin, together with the exogenous pathogen-associated molecular patterns (PAMPs) elicit similar responses of danger signals and represent the group of damage-associated molecular patterns (DAMPs). Effector cells of innate and adaptive immunity that are activated by PAMPs or alarmins can secrete other alarmins and amplify the immune responses. These complex interactions and loops between alarmins and PAMPs are particularly potent at inducing and then aggravating the GVHD reaction. In this review, we highlight the role of these tissue damaging molecules and their signaling pathways. Interestingly, some DAMPs and PAMPs are organ specific and GVHD-induced and have been shown to be interesting biomarkers. Some of these molecules may represent potential targets for novel therapeutic approaches.

PATIENT'S PERSPECTIVE ON HYPERBARIC OXYGEN TREATMENT OF OSTEORADIONECROSIS

Osteoradionecrosis (ORN) is a known complication to radiation therapy for head and neck cancer with a prevalence of 5–7% among radiated patients. Treatment might include dental surgery and reconstruction of the jawbone as well as hyperbaric oxygen treatment (HBOT). HBOT takes place in a closed compartment where patients are breathing 100% oxygen under pressure for 90 minutes once a day every weekday for 6 weeks. In Denmark, HBOT is available at two facilities with very different organizational set-ups.

Oral complications in hematopoietic stem cell recipients: the role of inflammation

Hematopoietic stem cell transplantation (HSCT) is widely used as a potentially curative treatment for patients with various hematological malignancies, bone marrow failure syndromes, and congenital immune deficiencies. The prevalence of oral complications in both autologous and allogeneic HSCT recipients remains high, despite advances in transplant medicine and in supportive care. Frequently encountered oral complications include mucositis, infections, oral dryness, taste changes, and graft versus host disease in allogeneic HSCT. Oral complications are associated with substantial morbidity and in some cases with increased mortality and may significantly affect quality of life, even many years after HSCT. Inflammatory processes are key in the pathobiology of most oral complications in HSCT recipients. This review article will discuss frequently encountered oral complications associated with HSCT focusing on the inflammatory pathways and inflammatory mediators involved in their pathogenesis.

Appropriate and necessary oral care for people with cancer: guidance to obtain the right oral and dental care at the right time

PURPOSE

The identification of experienced and knowledgeable dental specialists to provide appropriate oral care for cancer patients, as well as the integration of this care within general oncology management, may be a challenge. This paper discusses the general and additional requirements for dental care providers to support the cancer patient and provide prevention and/or treatment for oral complications of cancer therapy.

METHODS

We performed a literature review of specific issues regarding the oral cavity and adjacent structures in the cancer patient, including detection and early diagnosis of oral malignancy. We incorporated the systemic effects of cancer and its therapy that affect oral disease and treatment. We present a summary of how to seek expert dental care for cancer patients and for referral from the dental and medical community.

RESULTS

Due to the complexity conferred by the disease and its treatment, cancer patients require educated, experienced dentists for treatment and/or prevention of oral-related morbidity. Correct diagnosis and evidence-based prophylactic and therapeutic oral care can significantly improve patient quality of life and reduce morbidity and healthcare costs.

CONCLUSIONS

The knowledge and expertise of dental professionals regarding prevention/treatment of complications and secondary malignant lesions in cancer patients are critical. Integration of oral care with the oncology care and in survivors requires effective communication between dental and medical providers beginning ideally at diagnosis. These clinicians may be identified at the cancer center, nearby hospital dental programs, and, less commonly, in the community.

Prevention and treatment of oral mucositis in patients with head and neck cancer treated with (chemo) radiation: report of an Italian survey

PURPOSE

There is a limited number of therapies with a high level of recommendations for mucositis, while several strategies are currently employed with a limited evidence for efficacy. A national survey among Italian oncologists who treat head and neck cancer (HNC) was conducted in order to assess the most common preventive and therapeutic protocols (including nutritional support and pain control) for oral mucositis (OM) in patients undergoing chemoradiotherapy.

METHODS

From September to November 2012, a nationwide electronic survey with 21 focused items was proposed to chemotherapy and radiotherapy centers.

RESULTS

We collected 111 answers. Common Terminology Criteria for Adverse Events (CTCAE) scale is employed by 55% of the physicians in assessing mucosal toxicity. The most relevant predictive factors for OM development are considered smoke, alcohol use, planned radiotherapy, and concurrent use of radiosensitizing chemotherapy. Prophylactic gastrostomy is adopted in <10% of the patients. Preventive antibiotics or antimycotics are prescribed by 46% of the responders (mainly local or systemic antimycotic drugs). Alkalinizing mouthwashes or coating agents are frequently adopted (70% of the cases). Among therapeutic interventions, systemic fluconazole is administered by 80% of the physicians. Pain is mainly treated by weak followed by strong opioids.

CONCLUSIONS

A variety of preventive and therapeutic protocols for OM exists among the participating Italian centers, with some uniformity in respect to nutritional support, use of antimycotic and painkillers. There is an urgent need for well-conducted clinical trials aimed at assessing the best choices for OM prevention and treatment in HNC.

The psychosomatic disorders pertaining to dental practice with revised working type classification

Psychosomatic disorders are defined as disorders characterized by physiological changes that originate partially from emotional factors. This article aims to discuss the psychosomatic disorders of the oral cavity with a revised working type classification. The author has added one more subset to the existing classification, i.e., disorders caused by altered perception of dentofacial form and function, which include body dysmorphic disorder. The author has also inserted delusional halitosis under the miscellaneous disorders classification of psychosomatic disorders and revised the already existing classification proposed for the psychosomatic disorders pertaining to dental practice. After the inclusion of the subset (disorders caused by altered perception of dentofacial form and function), the terminology "psychosomatic disorders of the oral cavity" is modified to "psychosomatic disorders pertaining to dental practice".

The oral management of oncology patients requiring radiotherapy, chemotherapy and/or bone marrow transplantation

Patients undergoing cancer therapy may experience unwanted side-effects involving the oral cavity and more evidence is emerging regarding the management of these complications. These oral effects have both short and long-term implications. Dentists need to be aware of these implications and liaise closely with the oncology teams to establish pathways of oral care. This enables patients to have appropriate dental support in place before, during and after cancer therapy. This article is an executive summary of a review undertaken for a national clinical guideline, The Oral Management of Oncology Patients following Radiotherapy, Chemotherapy and/or Bone Marrow Transplanation. The full text is available on the FDS website: www.rcseng.ac.uk/fds/publications-clinical-guidelines/clinical_guidelines/

Application of chlorhexidine, fluoride and artificial saliva during radiotherapy: an in vitro study of microleakage in Class V restorations

BACKGROUND

The aim of this study was to evaluate the effect on microleakage in Class V restorations of daily applications of artificial saliva, fluoride mouthrinses and chlorhexidine to irradiated bovine teeth.

METHODS

Class V cavities were created in 60 bovine teeth. The teeth were divided randomly into two groups: the first group (n = 30) was subjected to radiotherapy until the teeth had received a total accumulated dose of 60 Gy; the second group (n = 30) was used as a control group. Both groups were divided into three subgroups (n = 10): in Group A teeth were submerged in Xeros Dentaid(®) artificial saliva; Group B teeth were submerged in a solution of 1% amine fluoride; Group C teeth were submerged in 0.12% chlorhexidine. All treatments were applied three times a day for six weeks. Afterwards microleakage into the composite restorations was measured using MIP4 image software.

RESULTS

It was seen that radiation caused increases in microleakage in composite restorations. Statistically significant differences were found in the artificial saliva group (p = 0.013) and the chlorhexidine group (p = 0.023).

CONCLUSIONS

Microleakage in composite restorations was greater among radiated teeth.

Dental students' knowledge of characteristics and management of oral complications of cancer therapy

OBJECTIVE

The aim of this study is to investigate the level of Turkish senior dental students' knowledge regarding the orodental complications and their treatment methods of cancer patients.

STUDY DESIGN

A 15-item questionnaire which was obtained from National Institute of Dental and Craniofacial Research that contained information about the orodental complications of the cancer therapy and the dentists' role to provide their treatment protocols was used. Seventy-seven senior dental students answered the questionnaire and the replies were analyzed with stratified and logistic data analyses.

RESULTS

Overall, correct replies ranged from 5.2 to 98.7 %. The students knew the basic knowledge of the complications of cancer therapy; however, they failed to answer to the questions (ranging between 1.3 and 94.8 %) about the required clinical practices. The respondents preferred not to answer the questions about the prophylactic measures dentist shall take during a precancer treatment oral evaluation (9.1 %), management of pain in cancer treatment (6.5 %), and necessary considerations before a dental procedure in a chemotherapy patient (3.9 %). The multiple logistic regression analysis revealed that gender had no statistically significant effect on the correct or false answers to the questions (p > 0.05).

CONCLUSION

Our results disclosed that dental students' knowledge about oral complications of cancer therapy and the modalities to manage these complications vary. Reevaluation of current undergraduate curricula and continuing education for graduates might address the gaps identified and an educational program about oral and dental management of patients who are to receive/receiving/have received cancer therapy can be prepared and augmented into dental curriculum.

Therapeutic approaches to myeloma bone disease: an evolving story

Bone disease is a major morbidity factor in patients with multiple myeloma and significantly affects their overall survival. A complex interplay between malignant plasma cells and other marrow cells results in the generation of a microenvironment capable of enhancing both tumor growth and bone destruction. Bisphosphonates have consistently reduced the incidence of skeletal-related events in patients with multiple myeloma and other osteotropic tumors as well. However, their use is burdened with side-effects, including the risks of osteonecrosis of the jaw and kidney failure, suggesting that they should be discontinued after prolonged administration. New molecular targets of cell cross-talk in myeloma bone marrow are therefore under intensive investigation and new drugs are being explored in preclinical and clinical studies of myeloma bone disease. Compounds targeting osteoclast activation pathways, such as receptor activator of nuclear factor-κB/receptor activator of nuclear factor-κB ligand/osteoprotegerin, B-cell activating factor, mitogen-activated protein kinase and macrophage inflammatory protein-1α/chemokine receptor for macrophage inflammatory protein-1α axes, or soluble agents that improve osteoblast differentiation by modulating specific inhibitors such as Dickkopf-1 and transforming growth factor-β, as well as novel approaches of cytotherapy represent a new generation of promising drugs for the treatment of myeloma bone disease.

Clinical management of salivary gland hypofunction and xerostomia in head-and-neck cancer patients: successes and barriers

The most significant long-term complication of radiotherapy in the head-and-neck region is hyposalivation and its related complaints, particularily xerostomia. This review addresses the pathophysiology underlying irradiation damage to salivary gland tissue, the consequences of radiation injury, and issues contributing to the clinical management of salivary gland hypofunction and xerostomia. These include ways to (1) prevent or minimize radiation injury of salivary gland tissue, (2) manage radiation-induced hyposalivation and xerostomia, and (3) restore the function of salivary gland tissue damaged by radiotherapy.

Morphometric analysis - Cone beam computed tomography to predict bone quality and quantity

AIM

Modified quantitative computed tomography is a method used to predict bone quality and quantify the bone mass of the jaw. The aim of this study was to determine whether bone quantity or quality was detected by cone beam computed tomography (CBCT) combined with image analysis. MATERIALS AND PROCEDURES: Different measurements recorded on two phantoms (Siemens phantom, Comac phantom) were evaluated on images taken with the Somatom VolumeZoom (Siemens Medical Solutions, Erlangen, Germany) and the NewTom 9000 (NIM s.r.l., Verona, Italy) in order to calculate a calibration curve. The spatial relationships of six sample cylinders and the repositioning from four pig skull halves relative to adjacent defined anatomical structures were assessed by means of three-dimensional visualization software.

RESULTS

The calibration curves for computer tomography (CT) and cone beam computer tomography (CBCT) using the Siemens phantom showed linear correlation in both modalities between the Hounsfield Units (HU) and bone morphology. A correction factor for CBCT was calculated. Exact information about the micromorphology of the bone cylinders was only available using of micro computer tomography.

CONCLUSION

Cone-beam computer tomography is a suitable choice for analysing bone mass, but, it does not give any information about bone quality.

A systematic review of dental disease in patients undergoing cancer therapy

INTRODUCTION

This purpose of this systematic review was to evaluate the literature and update our current understanding of the impact of present cancer therapies on the dental apparatus (teeth and periodontium) since the 1989 NIH Development Consensus Conference on the Oral Complications of Cancer Therapies.

REVIEW METHOD

A systematic literature search was conducted with assistance from a research librarian in the databases MEDLINE/PubMed and EMBASE for articles published between 1 January 1990 and 31 December 2008. Each study was independently assessed by two reviewers. Taking into account predetermined quality measures, a weighted prevalence was calculated for the prevalence of dental caries, severe gingival disease, and dental infection. Data on DMFT/dmft, DMFS/dmfs, plaque, and gingival indexes were also gathered. The level of evidence, recommendation, and guideline (if possible) were given for published preventive and management strategies.

RESULTS

Sixty-four published papers between 1990 and 2008 were reviewed. The weighted overall prevalence of dental caries was 28.1%. The overall DMFT for patients who were post-antineoplastic therapy was 9.19 (SD, 7.98; n = 457). The overall plaque index for patients who were post-antineoplastic therapy was 1.38 (SD, 0.25; n = 189). The GI for patients who were post-chemotherapy was 1.02 (SD, 0.15; n = 162). The weighted prevalence of dental infections/abscess during chemotherapy was reported in three studies and was 5.8%.

CONCLUSIONS

Patients who were post-radiotherapy had the highest DMFT. The use of fluoride products and chlorhexidine rinses are beneficial in patients who are post-radiotherapy. There continues to be lack of clinical studies on the extent and severity of dental disease that are associated with infectious complications during cancer therapy.

A systematic review of viral infections associated with oral involvement in cancer patients: a spotlight on Herpesviridea

PURPOSE

Our aim was to evaluate the literature for the prevalence of and interventions for oral viral infections and, based on scientific evidence, point to effective treatment protocols. Quality of life (QOL) and economic impact were assessed if available in the articles reviewed.

METHODS

Our search of the English literature focused on oral viral infections in cancer patients within the timeframe of 1989-2007. Review methods were standardized. Cohort studies were used to determine the weighted prevalence of oral viral infection in cancer patients. The quality of selected articles were assessed and scored with respect to sources of bias, representativeness, scale validity, and sample size. Interventional studies were utilized to determine management guidelines. Literature search included measures of QOL and economic variables.

RESULTS

Prevalence of oral herpes simplex virus (HSV) infection in neutropenic patients was higher than in patients treated with radiotherapy for head and neck cancer (49.8% vs. 0%, respectively). In patients treated with radiochemotherapy for head and neck cancer, the prevalence of oral HSV infection increases up to 43.2% (CI, 0-100%). Prevalence of HSV infection was higher when oral ulcers existed. Information about other oral viral infections is sparse. There was a significant benefit of using acyclovir to prevent HSV oral infection (at 800 mg/day). Various dosing protocols of valacyclovir achieved prevention of HSV reactivation (500 or 1,000 mg/day). The prevalence of HSV reactivation was similar for acyclovir and valacyclovir. No information about impact on QOL and economic burden was available.

CONCLUSIONS

Acyclovir and valacyclovir are equally effective in preventing oral HSV infection. Neutropenic patients, who were primarily treated for hematological malignancies in the studies reviewed, are at a greater risk for viral infection.

A systematic review of orofacial pain in patients receiving cancer therapy

PURPOSE

We present the findings of a structured systematic review of the literature assessing orofacial pain induced by malignant disease and/or its therapy (excluding mucositis). This evaluation of the literature published after the 1989 NIH Development Consensus conference on the oral complications of cancer therapies is an effort to assess the prevalence of pain, quality of life and economic impact, and management strategies for cancer therapy-induced orofacial pain.

METHODS

A systematic medical literature search was conducted with assistance from a research librarian in MEDLINE/PubMed and EMBASE databases for articles published between January 1, 1990 and December 31, 2008. Each study was independently assessed by two reviewers with expertise in the field of oral oncology.

RESULTS

Thirty-nine studies assessed pain in the head and neck region. The measure was commonly embedded in quality of life studies. Most of these studies described pain in head and neck cancer (HNC) patients, which therefore became the focus of the report. Pain is common in patients with HNC and is reported by approximately half of patients prior to cancer therapy, 81% during therapy, 70% at the end of therapy, and by 36% at 6 months after treatment. Pain is experienced beyond the 6-month period by approximately one third of patients and is typically more severe than pre-treatment cancer-induced pain.

CONCLUSIONS

This systematic review identified the presence of pain before cancer therapy, likely attributable to the cancer; an increase in pain during therapy and the common persistence of pain following cancer treatment. Continuing research should use validated tools to prospectively assess orofacial pain, its causes and pathophysiology, and its effect on quality of life and economic impact. Clinical trials of pain management in this setting are also warranted.

A systematic review of dysgeusia induced by cancer therapies

PURPOSE

The purpose was to review relevant scientific papers written since 1989 which focused on the prevalence and management of dysgeusia as an oral side effect of cancer treatment.

METHODS

Our literature search was limited to English language papers published between 1990 and 2008. A total of 30 papers were reviewed; the results of 26 of these papers were included in the present systematic review. A structured assessment form was used by two reviewers for each paper. Studies were weighted as to the quality of the study design, and treatment recommendations were based on the relative strength of each paper.

RESULTS

A wide range in reported prevalence of dysgeusia was identified with the weighted prevalence from 56-76%, depending on the type of cancer treatment. Attempts to prevent dysgeusia through the prophylactic use of zinc sulfate or amifostine have been of limited benefit. Nutritional counseling may be helpful to some patients in minimizing the symptoms of dysgeusia.

CONCLUSIONS

Dysgeusia is a common oral side effect of cancer therapy (radiotherapy, chemotherapy, or combined modality therapy) and often impacts negatively on quality of life. From the current literature, there does not appear to be a predictable way of preventing or treating dysgeusia.

A systematic review of oral fungal infections in patients receiving cancer therapy

PURPOSE

The aims of this systematic review were to determine, in patients receiving cancer therapy, the prevalence of clinical oral fungal infection and fungal colonization, to determine the impact on quality of life and cost of care, and to review current management strategies for oral fungal infections.

METHODS

Thirty-nine articles that met the inclusion/exclusion criteria were independently reviewed by two calibrated reviewers, each using a standard form. Information was extracted on a number of variables, including study design, study population, sample size, interventions, blinding, outcome measures, methods, results, and conclusions for each article. Areas of discrepancy between the two reviews were resolved by consensus. Studies were weighted as to the quality of the study design, and recommendations were based on the relative strength of each paper. Statistical analyses were performed to determine the weighted prevalence of clinical oral fungal infection and fungal colonization.

RESULTS

For all cancer treatments, the weighted prevalence of clinical oral fungal infection was found to be 7.5% pre-treatment, 39.1% during treatment, and 32.6% after the end of cancer therapy. Head and neck radiotherapy and chemotherapy were each independently associated with a significantly increased risk for oral fungal infection. For all cancer treatments, the prevalence of oral colonization with fungal organisms was 48.2% before treatment, 72.2% during treatment, and 70.1% after treatment. The prophylactic use of fluconazole during cancer therapy resulted in a prevalence of clinical fungal infection of 1.9%. No information specific to oral fungal infections was found on quality of life or cost of care.

CONCLUSIONS

There is an increased risk of clinically significant oral fungal infection during cancer therapy. Systemic antifungals are effective in the prevention of clinical oral fungal infection in patients receiving cancer therapy. Currently available topical antifungal agents are less efficacious, suggesting a need for better topical agents.

A systematic review of bisphosphonate osteonecrosis (BON) in cancer

PURPOSE

This systematic review aims to examine the prevalence of bisphosphonate osteonecrosis (BON) in the cancer population, prevention and treatment protocols, and quality of life issues.

METHODS

A search of MEDLINE/PubMed and EMBASE form October 2003 to December 31, 2008 was conducted with the objective of identifying publications that contained original data regarding BON.

RESULTS

A total of 28 publications fulfilled inclusion criteria, but only 22 were used for prevalence analysis. No randomized controlled clinical trials, meta-analysis, or quality of life papers were found that contained information regarding either prevalence or treatment protocols for the management of BON. The overall weighted prevalence of BON included a sample of 39,124 patients with a mean weighted prevalence of 6.1%. The weighted prevalence was 13.3% for studies with documented follow-up with a sample size of 927 individuals. The weighted prevalence in studies with undocumented follow-up was 0.7% in a sample of 8,829 chart reviews. Epidemiological studies evaluated a total of 29,368 individual records, and the weighted BON prevalence was 1.2%.

CONCLUSIONS

High-quality studies are needed to accurately characterize the prevalence of BON, and to determine effective treatment protocols.

A systematic review of salivary gland hypofunction and xerostomia induced by cancer therapies: prevalence, severity and impact on quality of life

PURPOSE

This systematic review aimed to assess the literature for prevalence, severity, and impact on quality of life of salivary gland hypofunction and xerostomia induced by cancer therapies.

METHODS

The electronic databases of MEDLINE/PubMed and EMBASE were searched for articles published in English since the 1989 NIH Development Consensus Conference on the Oral Complications of Cancer Therapies until 2008 inclusive. Two independent reviewers extracted information regarding study design, study population, interventions, outcome measures, results and conclusions for each article.

RESULTS

The inclusion criteria were met by 184 articles covering salivary gland hypofunction and xerostomia induced by conventional, 3D conformal radiotherapy or intensity-modulated radiotherapy in head and neck cancer patients, cancer chemotherapy, total body irradiation/hematopoietic stem cell transplantation, radioactive iodine treatment, and immunotherapy.

CONCLUSIONS

Salivary gland hypofunction and xerostomia are induced by radiotherapy in the head and neck region depending on the cumulative radiation dose to the gland tissue. Treatment focus should be on optimized/new approaches to further reduce the dose to the parotids, and particularly submandibular and minor salivary glands, as these glands are major contributors to moistening of oral tissues. Other cancer treatments also induce salivary gland hypofunction, although to a lesser severity, and in the case of chemotherapy and immunotherapy, the adverse effect is temporary. Fields of sparse literature included pediatric cancer populations, cancer chemotherapy, radioactive iodine treatment, total body irradiation/hematopoietic stem cell transplantation, and immunotherapy.