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

Inhibition of compound action potentials in the frog sciatic nerve by inchinkoto, a traditional Japanese medicine used for oral mucositis

OBJECTIVE

This study aimed to determine the effects of traditional Japanese (Kampo) medicines used to treat oral mucositis on nerve conduction.

METHODS

The effects of Kampo medicines, crude drugs, and chemical compounds on compound action potentials (CAPs) were analyzed using extracellular recordings in frog sciatic nerves.

RESULTS

Among the Kampo medicines, inchinkoto demonstrated the most significant reduction in CAP amplitude, with a half-maximal inhibitory concentration (IC50) of 5.4 mg/mL. Hangeshashinto, shosaikoto, hochuekkito, and juzentaihoto also showed a significant reduction. Regarding inchinkoto, Artemisiae Capillari Spica (artemisia) was the most effective crude drug, with an IC50 of 4.2 mg/mL for CAP amplitude reduction, whereas Gardeniae Fructus (gardenia) exerted no significant effect. However, the combined use of artemisia and gardenia reduced the CAP amplitude more effectively than artemisia alone, indicating a synergistic interaction. The chemical ingredient eugenol from artemisia administered at 1 and 3 mmol/L reduced CAP amplitude, whereas other chemical ingredients administered at 0.1 and 1 mmol/L had no significant effects.

CONCLUSIONS

Inchinkoto exhibited the most effective reduction in CAP amplitude in the sciatic nerve of frogs, primarily through the action of artemisia, with potential synergistic interaction between artemisia and gardenia.

Comparisons of successful and failed Phase III trials of drugs and biologicals tested for mitigation of oral mucositis in patients being treated with radiotherapy with or without concomitant chemotherapy for cancers of the head and neck

Oral mucositis (OM) remains a significant toxicity among patients being treated with radiotherapy (RT) alone or with concomitant chemotherapy (CRT) for cancers of the head and neck (HNC). Given its clinical significance as an unmet need and its potential commercial viability, the pharmaceutical industry has been actively pursuing an effective intervention. Despite this interest and activity, only a few agents have been studied in Phase III trials (n = 6). The objective of this study was to identify common features that differentiate successful and failed Phase III OM trials. We used the United States Patent and Trademark Office Patent Public Search database to search patents with "oral mucositis" in the claims. We then searched ClinicalTrials.gov and PubMed to determine if Phase III or Phase II trial data for identified biologics/drugs had been published. We assessed each Phase III and Phase II trial for characteristics that may be associated with trial success or failure. We considered a study as a "success" if the primary endpoint reached statistical significance, and we considered a study as "failure" if the primary endpoint did not reach statistical significance. Of the three successful Phase III trials, one investigated avasopasem manganese (Galera Therapeutics) and two examined palifermin (Amgen). The three failed trials included those evaluating dusquetide (Soligenix), iseganan hydrochloride (IntraBiotics Pharmaceuticals), and clonidine (Monopar Therapeutics). We found that differences in the level of sponsor funding, patient inclusion criteria including radiation source and concomitant chemotherapy regimen, and concordance of primary efficacy outcomes between Phase II and Phase III trials influenced outcomes. To properly design clinical trials for OM in HNC patients, it is important that researchers and sponsors take note of specific study characteristics associated with success or failure, particularly with Phase III trials where the risks and costs are the highest.

Analgesic effect of linalool odor on oral ulcerative mucositis-induced pain in rats

Oral ulcerative mucositis (OUM) induces severe pain, leading to a low quality of life. Linalool odor exposure has recently been reported to suppress inflammatory pain in the hind paws. However, the analgesic effect of linalool odor on orofacial pain remains unclear. In this study, we examined the mechanism underlying the analgesic effect of linalool odor on oral pain caused by OUM using nocifensive behavioral and immunohistochemical analyses in rats. OUM was developed by treating the labial fornix region of the inferior incisors with acetic acid. Linalool at 1% was exposed for 5 min at 30 min before nocifensive behavioral measurements. OUM induced spontaneous pain and mechanical allodynia, which were suppressed by the linalool odor. Mechanical allodynia in the hind paw following the injection of complete Freund's adjuvant was also suppressed by linalool odor. Application of lidocaine to the olfactory bulb attenuated the inhibition of spontaneous pain and hyperactivation of trigeminal spinal nucleus caudalis neurons in OUM model rats. Linalool odor exposure-induced neuronal activation in the locus coeruleus (LC) of OUM model rats was decreased by lidocaine application to the olfactory bulb. The decrease in neuronal activation in the LC was attenuated by the administration of orexin 1 receptor (OX-1) antagonist to the LC. These results suggest that linalool odor stimulation through the olfactory pathway activates LC neurons via OX-1 signaling, leading to the suppression of OUM-induced oral pain.

Management of radiation-induced oral mucositis in head and neck cancer patients: a real-life survey among 25 Italian radiation oncology centers

AIM

Radiation-induced oral mucositis (RIOM) is the most frequent side effect in head and neck cancer (HNC) patients treated with curative radiotherapy (RT). A standardized strategy for preventing and treating RIOM has not been defined. Aim of this study was to perform a real-life survey on RIOM management among Italian RT centers.

METHODS

A 40-question survey was administered to 25 radiation oncologists working in 25 different RT centers across Italy.

RESULTS

A total of 1554 HNC patients have been treated in the participating centers in 2021, the majority (median across the centers 91%) with curative intent. Median treatment time was 41 days, with a mean percentage of interruption due to toxicity of 14.5%. Eighty percent of responders provide written oral cavity hygiene recommendations. Regarding RIOM prevention, sodium bicarbonate mouthwashes, oral mucosa barrier agents, and hyaluronic acid-based mouthwashes were the most frequent topic agents used. Regarding RIOM treatment, 14 (56%) centers relied on literature evidence, while internal guidelines were available in 13 centers (44%). Grade (G)1 mucositis is mostly treated with sodium bicarbonate mouthwashes, oral mucosa barrier agents, and steroids, while hyaluronic acid-based agents, local anesthetics, and benzydamine were the most used in mucositis G2/G3. Steroids, painkillers, and anti-inflammatory drugs were the most frequent systemic agents used independently from the RIOM severity.

CONCLUSION

Great variety of strategies exist among Italian centers in RIOM management for HNC patients. Whether different strategies could impact patients' compliance and overall treatment time of the radiation course is still unclear and needs further investigation.

Omega-3 nanoemulgel in prevention of radiation-induced oral mucositis and its associated effect on microbiome: a randomized clinical trial

BACKGROUND

Oral mucositis (OM) is recognized as one of the most frequent debilitating sequelae encountered by head and neck cancer (HNC) patients treated by radiotherapy. This results in severe mucosal tissue inflammation and oral ulcerations that interfere with patient's nutrition, quality of life (QoL) and survival. Omega-3 (ω-3) polyunsaturated fatty acids (PUFAs) have recently gained special interest in dealing with oral diseases owing to its anti-inflammatory, anti-oxidant and wound healing properties. Thus, this study aims to assess topical Omega-3 nanoemulgel efficacy in prevention of radiation-induced oral mucositis and regulation of oral microbial dysbiosis.

MATERIALS AND METHODS

Thirty-four head and neck cancer patients planned to receive radiotherapy were randomly allocated into two groups: Group I: conventional preventive treatment and Group II: topical Omega-3 nanoemulgel. Patients were evaluated at baseline, three and six weeks after treatment using the World Health Organization (WHO) grading system for oral mucositis severity, Visual Analogue Scale (VAS) for perceived pain severity, and MD-Anderson Symptom Inventory for Head and Neck cancer (MDASI-HN) for QoL. Oral swabs were collected to assess oral microbiome changes.

RESULTS

VAS scores and WHO mucositis grades were significantly lower after six weeks of treatment with topical Omega-3 nanoemulgel when compared to the conventional treatment. The total MDASI score was significantly higher in the control group after three weeks of treatment, and the head and neck subscale differed significantly at both three and six weeks. A significant reduction in Firmicutes/Bacteroidetes ratio was observed after six weeks in the test group indicating less microbial dysbiosis.

CONCLUSIONS

Topical Omega-3 nanoemulgel demonstrated a beneficial effect in prevention of radiation-induced oral mucositis with a possibility of regulating oral microbial dysbiosis.

Preparation and pharmaceutical properties of Hangeshashinto oral ointment and its safety and efficacy in Syrian hamsters with 5-fluorouracil-induced oral mucositis

Chemotherapy-induced oral mucositis (COM) is a common adverse effect of cancer chemotherapy. Several clinical studies reported that repetitive use of mouthwashes containing 2.5-6.25% Hangeshashinto (HST), a Kampo formula, relieves COM, but the effect is insufficient. To solve this problem, we produced an oral ointment of 12% HST extract (considered quantitatively equivalent to 20% commercially available HST), which will increase the local concentrations of its active ingredients and prolong the contact time with COM. In this study, we evaluated the pharmaceutical properties (spreadability and stability) of HST oral ointment. In addition, its safety (oral mucosal irritation) and therapeutic effects on 5-fluorouracil-induced oral mucositis were evaluated in male Syrian hamsters. The HST ointment showed good spreadability and stability for more than 8 weeks at 4 °C. In the oral mucosal irritation test, topical application of HST ointment (0.2 g) three times per day for 14 days had no adverse effect on the oral mucosa of hamsters. In hamsters treated with 5-fluorouracil (60 mg/kg) twice, COM was induced by a submucosal injection of 5% acetic acid into the cheek pouch. When HST ointment (50 µg) was topically applied to the mucositis area once per day for 12 days, the area and macroscopic score of mucositis were significantly decreased, and the depth of the wound tended to be reduced compared with the lactose ointment-treated control animals. These findings suggest that HST oral ointment shows good properties in spreadability, stability, and safety, and elicits a therapeutic effect in an animal model of COM.

Protease-activated receptors in health and disease

Proteases are signaling molecules that specifically control cellular functions by cleaving protease-activated receptors (PARs). The four known PARs are members of the large family of G protein-coupled receptors. These transmembrane receptors control most physiological and pathological processes and are the target of a large proportion of therapeutic drugs. Signaling proteases include enzymes from the circulation; from immune, inflammatory epithelial, and cancer cells; as well as from commensal and pathogenic bacteria. Advances in our understanding of the structure and function of PARs provide insights into how diverse proteases activate these receptors to regulate physiological and pathological processes in most tissues and organ systems. The realization that proteases and PARs are key mediators of disease, coupled with advances in understanding the atomic level structure of PARs and their mechanisms of signaling in subcellular microdomains, has spurred the development of antagonists, some of which have advanced to the clinic. Herein we review the discovery, structure, and function of this receptor system, highlight the contribution of PARs to homeostatic control, and discuss the potential of PAR antagonists for the treatment of major diseases.

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

PURPOSE

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

METHODS AND MATERIALS

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

RESULTS

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

CONCLUSIONS

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

Natural Products for the Prevention and Treatment of Oral Mucositis-A Review

Cancer, a major world public health problem, is associated with chemotherapy treatments whose administration leads to secondary concerns, such as oral mucositis (OM). The OM disorder is characterized by the presence of ulcers in the oral mucosa that cause pain, bleeding, and difficulty in ingesting fluids and solids, or speaking. Bioactive compounds from natural sources have arisen as an effective approach for OM. This review aims to summarize the new potential application of different natural products in the prevention and treatment of OM in comparison to conventional ones, also providing a deep insight into the most recent clinical studies. Natural products, such as Aloe vera, Glycyrrhiza glabra, Camellia sinensis, Calendula officinalis, or honeybee crops, constitute examples of sources of bioactive compounds with pharmacological interest due to their well-reported activities (e.g., antimicrobial, antiviral, anti-inflammatory, analgesic, or wound healing). These activities are associated with the bioactive compounds present in their matrix (such as flavonoids), which are associated with in vivo biological activities and minimal or absent toxicity. Finally, encapsulation has arisen as a future opportunity to preserve the chemical stability and the drug bioa vailability of bioactive compounds and, most importantly, to improve the buccal retention period and the therapeutic effects.

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

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

Action of Matricaria recutita (chamomile) in the management of radiochemotherapy oral mucositis: A systematic review

The objective of this study was to evaluate the effect of topical chamomile in the prevention and/or treatment of oral mucositis (OM) in cancer patients. It was a systematic review, which sought articles of the randomized clinical trial according to the PRISMA parameters, registered in the PROSPERO. The databases used were PubMed, Cochrane Library, and Bireme. Descriptors were selected from DeCs/MeSH and the PICO strategy was applied. The search found 148 publications. After all the steps, six articles were selected. The total sample included 492 patients and all studies used the same OM measurement scale. The results showed that the application of topical chamomile was effective in the prevention and/or treatment of OM in four of the six studies, with a dose ranging from 1% to 2.5% and duration that ranged from single to 4 times a day. Some limitations were observed: the minimum age of the patients was not informed, and there was no specification of the sites involved or the chemotherapies used. The application of topical chamomile in the preventive/therapeutic of chemo-induced OM seems to be recommended. In addition, scientific production should be encouraged, as it aims to determine useful protocols for this phytotherapy for the oncology population.

Mammals' humoral immune proteins and peptides targeting the bacterial envelope: from natural protection to therapeutic applications against multidrug‐resistant Gram ‐negatives

Mammalian innate immunity employs several humoral ‘weapons’ that target the bacterial envelope. The threats posed by the multidrug‐resistant ‘ESKAPE’ Gram‐negative pathogens (Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp.) are forcing researchers to explore new therapeutic options, including the use of these immune elements. Here we review bacterial envelope‐targeting (peptidoglycan and/or membrane‐targeting) proteins/peptides of the mammalian immune system that are most likely to have therapeutic applications. Firstly we discuss their general features and protective activity against ESKAPE Gram‐negatives in the host. We then gather, integrate, and discuss recent research on experimental therapeutics harnessing their bactericidal power, based on their exogenous administration and also on the discovery of bacterial and/or host targets that improve the performance of this endogenous immunity, as a novel therapeutic concept. We identify weak points and knowledge gaps in current research in this field and suggest areas for future work to obtain successful envelope‐targeting therapeutic options to tackle the challenge of antimicrobial resistance.

In situ mucoadhesive hydrogel capturing tripeptide KPV: the anti-inflammatory, antibacterial and repairing effect on chemotherapy-induced oral mucositis

The self-healing of chemotherapy-induced oral mucositis is difficult in practice because of both local bacterial infection and severe inflammation. Herein, in situ mucoadhesive hydrogels (PPP_E) were successfully prepared by using temperature-sensitive PLGA-PEG-PLGA (PPP) as a matrix and epigallocatechin-3-gallate (EGCG) with inherent antibacterial activity as an adhesion enhancer. A series of PPP_E precursor solutions with various EGCG concentrations (1%, 2% and 5%) were prepared by fixing the PPP concentration at 25%. EGCG slightly decreased the sol-gel transition temperature and shortened the sol-gel transition time of the PPP hydrogel. Moreover, the incorporation of EGCG could significantly increase the tissue adhesion properties of the PPP hydrogel at 37 °C. PPP_2%E displayed a suitable gelation temperature (36.2 °C), gelation time (100 s) and storage modulus (48 Pa). Tripeptide KPV as a model drug was easily dissolved in cold PPP_2%E precursor solution to prepare KPV@PPP_2%E hydrogel. The anti-inflammatory activity and promotion of cell migration potential by KPV in PPP-2% E hydrogel were well maintained. Moreover, KPV@PPP_2%E exhibited strong antibacterial efficacy against S. aureus. PPP_2%E precursor solution rapidly transformed to a hydrogel and adhered to the wound surface for 7 hours when administrated to the gingival mucosa of rats. Treatment with KPV@PPP_2%E hydrogel greatly improved the food intake and body weight recovery of rats with chemotherapy-induced oral mucositis. Moreover, the tissue morphology of the ulcerated gingiva after application of KPV@PPP_E hydrogel was also well repaired by promoting CK10 and PCNA expression. In addition, the inflammatory cytokines including IL-1β and TNF-α were significantly inhibited by KPV@PPP_2%E hydrogel while IL-10 was up-regulated. KPV@PPP_2%E hydrogel also had an anti-bacterial effect on MRSA-infected gingival ulcer wounds, which resulted in the obvious inhibition of infiltration by inflammatory cells into submucosal tissues. Conclusively, KPV@PPP_E may be a promising practical application for cancer patients with chemotherapy-induced oral mucositis.

Evaluation of topical morphine for treatment of oral mucositis in cancer patients

Introduction

Oral mucositis is a painful side effect to chemotherapy. Orally applied opioids may offer analgesia with fewer side effects than systemic opioids.

Methods

A randomized trial comparing the analgesic effect of a morphine oromucosal solution (OM) to placebo and a positive control group receiving intravenous (IV) morphine as an add-on treatment to morphine patient-controlled analgesia (PCA) in a mixed population of paediatric and adult haematology patients. All patients in the study were equipped with a morphine PCA pump and the participating patients were instructed to use this pump as an escape. Primary outcome was morphine consumption (mg/kg/hour) on the PCA pump. Secondary outcomes included pain intensity difference at rest and when performing oral hygiene, time to first PCA bolus, nutrition intake and adverse events.

Findings

A total of 60 patients (38 children <18 years) were randomized. Thirty patients were allocated to morphine OM/placebo IV (group MO), 15 patients to placebo OM/morphine IV (group MI) and 15 patients to placebo OM/placebo IV (group P). The median morphine consumption in the MO group (22.7 mcg/kg/hour 95% confidence interval (CI) 19.4-29.4 mcg/kg/hour, p = 0.38) was not significantly different from the placebo group (24.6 mcg/kg/hour 95% CI 16.8-34.4 mcg/kg/hour, p = 0.44) or the MI group (13.7 mcg/kg/hour 95% CI 9.7-37.8 mcg/kg/hour). For the secondary outcomes, the analysis of summed pain intensity difference after the first, third and fourth administrations of study medication indicated a reduction in pain for the MI group compared to the P and MO groups. No serious adverse events were reported.

Conclusion

The findings indicate that the analgesic effect of peripherally applied morphine is not significantly different from placebo, and parenteral opioids should continue to be the standard of care.

Effect of omeprazole and sucralfate on gastrointestinal injury in a fasting/NSAID model

BACKGROUND

Equine gastric ulcer syndrome (EGUS) is a common and significant cause of morbidity in horses, with a range of clinical signs, including inappetence, colic and poor performance. Hospitalised horses are exposed to factors that may induce EGUS, including fasting and nonsteroidal anti-inflammatory drug (NSAID) administration, and may be at risk for development of squamous (ESGD) and glandular gastric disease (EGGD). Prophylactic anti-ulcer medication is often prescribed for these patients, but drug selection is complicated by different aetiology and response to treatment of ESGD and EGGD.

OBJECTIVES

To establish the efficacy of sucralfate or omeprazole used prophylactically in horses exposed to a combined feed-fast and NSAID administration EGUS induction protocol. We hypothesised that these drugs would be equally effective for prevention of gastric lesions in the experimental cohort.

STUDY DESIGN

Randomised crossover experimental design.

METHODS

Horses (n = 14) received either omeprazole (1 mg/kg PO q24h) or sucralfate (20 mg/kg PO q8h) while undergoing the feed-fast/NSAID protocol, allowed an 8-week washout period, and then administered the alternate treatment. Serial gastroscopy, ultrasound and haematology documented treatment effects.

RESULTS

ESGD and EGGD score increased over time under both treatments. There was a significant effect of treatment on EGGD scores (P < .001), with post-treatment EGGD scores higher for horses receiving sucralfate (median 3; IQR 2.25,3) than omeprazole (1; 1,1). The effect of treatment on ESGD scores just achieved significance (P = .05), with post-treatment ESGD scores higher for sucralfate (4; 3,4) than omeprazole (2; 2,3).

MAIN LIMITATIONS

This study was performed in healthy horses, and response to treatment may differ in horses with clinical illness. Additional investigation in a larger population may be required to detect significant differences in other clinical parameters.

CONCLUSIONS

Omeprazole was superior to sucralfate for mitigating gastric lesion severity in healthy horses exposed to a feed-fast/NSAID model.

Clinical practice guideline for the prevention of oral and oropharyngeal mucositis in pediatric cancer and hematopoietic stem cell transplant patients: 2021 update

PURPOSE

To update the 2015 clinical practice guideline for the prevention of oral mucositis in pediatric cancer or hematopoietic stem cell transplant (HSCT) patients.

METHODS

We performed seven systematic reviews of mucositis prevention. Three reviews included randomized controlled trials (RCTs) conducted in pediatric and adult patients evaluating cryotherapy, keratinocyte growth factor (KGF) or photobiomodulation therapy with a focus on efficacy. Three reviews included studies of any design conducted in pediatric patients evaluating these same interventions with a focus on adverse events and feasibility. One review included all RCTs of any intervention for mucositis prevention in pediatric patients. Primary outcome was severe oral mucositis.

RESULTS

We included 107 unique studies of cryotherapy (22 RCTs and 4 pediatric studies); KGF (15 RCTs and 12 pediatric studies); photobiomodulation therapy (29 RCTs and 8 pediatric studies) and any intervention (31 pediatric RCTs). Effects on severe mucositis reduction from RCTs were cryotherapy risk ratio (RR) 0.49 and 95% confidence interval (CI) 0.31-0.76; palifermin RR 0.81 and 95% CI 0.69-0.95 and photobiomodulation therapy RR 0.40 and 95% CI 0.27-0.60. Cryotherapy was not feasible in young children while photobiomodulation therapy was feasible across age groups. Palifermin was associated with adverse effects.

CONCLUSIONS

Cryotherapy should be used for older cooperative pediatric patients who will receive short infusions of melphalan or 5-fluorouracil. Intraoral photobiomodulation therapy (620-750 nm spectrum) should be used in pediatric patients undergoing autologous or allogeneic HSCT and for pediatric head and neck carcinoma patients undergoing radiotherapy. Palifermin should not be used routinely in pediatric cancer or HSCT patients.

[Chemo-induced mucositis in pediatric oncology: Perspectives?]

Mucositis is defined as inflammatory and/or ulcerative lesions of the oral and/or gastrointestinal tract. It occurs in approximately 40% to 50% of adults patients receiving conventional chemotherapy and up to 75% of patients receiving high dose chemotherapy as conditioning for hematopoietic stem cell transplantation. It is a toxic side effect, which strongly impairs quality of life and leads to refractory pain, increasing risk of infection and even therapeutic modifications. Despite improvements made, the management of mucositis remains a challenge and is still not consensual. A multicentric survey of practices concerning the preventive and curative management of chemo-induced mucositis in pediatric oncology department in France was carried out using a standardized questionnaire. Results confirm heterogeneous practices and the small progress made during the last decade. This national survey and an analysis of the recent literature leads to propose guidelines for the prevention and treatment of oral mucositis in children receiving treatment for cancer.

Radiotherapy-Specific Chronic Pain Syndromes in the Cancer Population: An Evidence-Based Narrative Review

While radiation therapy is increasingly utilized in the treatment paradigm of many solid cancers, the chronic effects of radiation therapies are poorly characterized. Notably, understanding radiation-specific chronic pain syndromes is paramount given that the diagnosis and management of these conditions can serve to prevent long-standing functional impairments, optimize quality of life, and even allow for continued radiotherapy candidacy. These radiation-specific chronic pain phenomena include dermatitis, mucositis, enteritis, connective tissue fibrosis, lymphedema, and neuropathic pain syndromes. It is necessary to maintain a low threshold of suspicion for appropriately diagnosing these conditions as there exists a variance in when these symptoms arise after radiation. However, we present key epidemiological data delineating vulnerable cancer populations for each pain syndrome along with the available evidence for the management for each specific condition.

Oromucosal precursors of in loco hydrogels for wound-dressing and drug delivery in oral mucositis: Retain, resist, and release

Oromucosal films and tablets were developed as multifunctional biomaterials for the treatment of oral mucositis. These are intended to function as a hybrid, performing as a controlled drug delivery system and as a wound-dressing device. The dosage forms are precursors for in loco hydrogels that are activated by the saliva. An anti-inflammatory and anesthetic activity is attained from budesonide tripartite polymeric nanoparticles and lidocaine, while the polymeric network allows the protection and cicatrization of the wound. Different biomaterials and blends were investigated, focusing on the capacity to retain and resist on-site, as well as achieve a long-lasting controlled release. As the limiting factor, the choice was made according to the films' results. A polymer mix of Methocel™ K100M and Carbopol® (974P, EDT 2020, or Ultrez 10) blends were used. Overall, regrading critical factors, Carbopol® increased films' elasticity and flexibility, mucoadhesion, and the strength of the hydrogels, while higher concentrations led to thicker, more opaque, and lower strain resistance products. Whereas 974P and Ultrez 10 performed similarly, EDT 2020 led to uniformity problems and weaker films, hydrogels and bioadhesion. The optimized products were enhanced with sodium hyaluronate and drug-loaded for further characterization. Concerning the dosage form, the films' hydrogels were more resilient, while the tablets had higher mucoadhesiveness and longer swelling. Although through different networks and mechanisms, both dosage forms and grades revealed similar release profiles. A Case II time-evolving stereoselectivity for the 22R and 22S budesonide epimers was found, and Fickian-diffusion for lidocaine. Ultimately, the developed formulations show great potential to be used in OM management. Both of the selected grades at 0.6% displayed excellent performance, while Ultrez 10 can be preferable for the films' production due to its lower viscosity before neutralization and higher after activation. Where the tablets are easier to produce and offer better adhesion, the films are more customizable post-production and have higher rheological performance for wound-dressing.

MASCC/ISOO clinical practice guidelines for the management of mucositis: sub-analysis of current interventions for the management of oral mucositis in pediatric cancer patients

OBJECTIVE

The aim of this sub-analysis was to highlight the MASCC/ISOO clinical practice guidelines for the management of oral mucositis (OM) in pediatric patients and to present unique considerations in this patient population.

METHODS

This sub-analysis of the pediatric patient population is based on the systematic review conducted by the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISSO) published in 2019/2020. Studies were scored and assigned a level of evidence based on previously published criteria. Data regarding adverse effects and compliance was collected from the original publications.

RESULTS

A total of 45 papers were included and assessed in this sub-analysis, including 21 randomized controlled trials (RCTs). Chewing gum was demonstrated to be not effective in preventing OM in pediatric cancer patients in 2 RCTs. The efficacy of all other interventions could not be determined based on the available literature.

CONCLUSION

There is limited or conflicting evidence about interventions for the management of OM in pediatric cancer patients, except for chewing gum which was ineffective for prevention. Therefore, currently, data from adult studies may need to be extrapolated for the management of pediatric patients. Honey and photobiomodulation therapy in this patient population had encouraging potential. Implementation of a basic oral care protocol is advised amid lack of high level of evidence studies.

Lactobacillus reuteri DSM 17938 and ATCC PTA 5289 ameliorates chemotherapy-induced oral mucositis

Oral mucositis (OM) is a common complication of cancer therapy, however OM management remains unsatisfactory. There is a growing interest in the therapeutic potential of probiotics in OM due to positive findings of its use in intestinal mucositis. This study aimed to determine the efficacy and safety of the probiotic combination Lactobacillus reuteri DSM 17938 and ATCC PTA 5289 strains in chemotherapy-induced OM. Mice were divided into 4 groups. PBS/water and PBS/LR groups comprised of mice injected with PBS intraperitoneally (i.p.), and were given water or the mixture of L. reuteri (LR) DSM 17938 and ATCC PTA 5289 in water respectively. The 5-FU/water and 5-FU/LR groups comprised of mice injected with 5-FU i.p., and were given water or L. reuteri DSM 17938 and ATCC PTA 5289 in water respectively. Histopathological analysis revealed that the oral epithelia of the 5-FU/water and 5-FU/LR groups were thinner compared to PBS/water and PBS/LR groups. However, epithelial damage was significantly reduced in the 5-FU/LR compared to 5-FU/water group. Additionally, the 5-FU/LR group showed reduced oxidative stress and inflammation in the oral mucosa. We further showed that L. reuteri reduced oxidative stress through the nuclear factor E2-related factor-2 (Nrf-2) signalling. There was no evidence of translocation of L. reuteri systemically. This study demonstrated for the first time that L. reuteri protected oral mucosa against damage induced by chemotherapy.

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Glutamine for Amelioration of Radiation and Chemotherapy Associated Mucositis during Cancer Therapy

Glutamine is a major dietary amino acid that is both a fuel and nitrogen donor for healing tissues damaged by chemotherapy and radiation. Evidence supports the benefit of oral (enteral) glutamine to reduce symptoms and improve and/or maintain quality of life of cancer patients. Benefits include not only better nutrition, but also decreased mucosal damage (mucositis, stomatitis, pharyngitis, esophagitis, and enteritis). Glutamine supplementation in a high protein diet (10 grams/day) + disaccharides, such as sucrose and/or trehalose, is a combination that increases glutamine uptake by mucosal cells. This increased topical effect can reduce painful mucosal symptoms and ulceration associated with chemotherapy and radiation in the head and neck region, esophagus, stomach and small intestine. Topical and oral glutamine seem to be the preferred routes for this amino acid to promote mucosal healing during and after cancer treatment.

Mucoadhesive Electrospun Fibre-Based Technologies for Oral Medicine

Oral disease greatly affects quality of life, as the mouth is required for a wide range of activities including speech, food and liquid consumption. Treatment of oral disease is greatly limited by the dose forms that are currently available, which suffer from short contact times, poor site specificity, and sensitivity to mechanical stimulation. Mucoadhesive devices prepared using electrospinning offer the potential to address these challenges by allowing unidirectional site-specific drug delivery through intimate contact with the mucosa and with high surface areas to facilitate drug release. This review will discuss the range of electrospun mucoadhesive devices that have recently been reported to address oral inflammatory diseases, pain relief, and infections, as well as new treatments that are likely to be enabled by this technology in the future.

Lasting Gammaproteobacteria profile changes characterized hematological cancer patients who developed oral mucositis following conditioning therapy

Background: Oral mucositis (OM) is a common side effect of conditioning therapy implemented before hematopoietic stem cell transplantation (HSCT). The role of oral microbiome in OM is not fully elucidated. Objective: To determine oral microbiome profile changes post-conditioning in HSCT patients who developed moderate OM, or mild to no OM. Design: Patient groups were: Muc0-1 with OM-score = 0-1 (43 paired samples) and Muc2 with WHO OM-score = 2 (36 paired samples). Bacterial DNA was isolated from oral samples (saliva, swabs of buccal mucosa, tongue, and supragingival plaque) at pre-conditioning (T 0 ), post-conditioning mucositis onset (T Muc ), and one-year post-conditioning (T Year ). 16S-rRNA gene next-generation sequencing was used to determine the relative abundance (RA) of >700 oral species. Alpha-diversity, beta-diversity and linear discriminant analyses (LDA) were performed Muc2 versus Muc0-1. Results: Muc2 oral microbiome alpha- and beta-diversity differed between T 0 and T Muc . Muc2 alpha-diversity and Muc0-1 beta-diversity did not differ between T 0 and T Year . T 0 to T Muc LDA scores were significant in Muc2 for Gammaproteobacteria. For Muc2 patients, the average RA decreased for Haemophilus parainfluenza, a species known as mucosal surfaces protector, but increased for Escherichia-Shigella genera. Conclusions: Post-conditioning OM might contribute to long-term oral microbiome changes affecting Gammaproteobacteria, in HSCT patients.

Current topical trends and novel therapeutic approaches and delivery systems for oral mucositis management

Oral mucositis (OM) is an extremely serious and challenging complication of chemoradiotherapy, which may limit the efficacy of cancer treatment. Complications related to OM include potential nutrition impairment, high economic burden, and negative impacts on patients' quality of life. Current therapeutic options with local traditional pharmaceutical formulations are largely focused on controlling symptoms, and only few agents are available for treatment. Several local supportive and palliative agents are used for the prevention of OM; however, a standard treatment for the disease has not been confirmed yet. The efficacy of treatment could be improved through the introduction of new medical agents with updated dosage forms that can enhance and optimize local drug delivery and create greater therapeutic effects with fewer side effects. The focus of this review was to provide clear and direct information about the currently available topical therapeutic agents in clinical practice used to cure and/or reduce the incidence of ulcerative symptoms of OM, excluding the associated pain and other coexisting complications such as bacterial and fungal infections. The review also provides recent evidences regarding agents that could be used as promising novel therapies in updated local delivering systems. This will support further encouraging options and approaches for the management of OM and will improve compliance that could be translated in better disease control and survival.

Oral biosciences: The annual review 2019

BACKGROUND

Journal of Oral Biosciences is devoted to the advancement and dissemination of fundamental knowledge concerning every aspect of oral biosciences.

HIGHLIGHT

This review features review articles in the fields of "Bone Cell Biology," "Microbiology," "Oral Heath," "Biocompatible Materials," "Mouth Neoplasm," and "Biological Evolution" in addition to the review articles by winners of the Lion Dental Research Award ("Role of nicotinic acetylcholine receptors for modulation of microcircuits in the agranular insular cortex" and "Phospholipase C-related catalytically inactive protein: A novel signaling molecule for modulating fat metabolism and energy expenditure") and the Rising Members Award ("Pain mechanism of oral ulcerative mucositis and the therapeutic traditional herbal medicine hangeshashinto," "Mechanisms underlying the induction of regulatory T cells by sublingual immunotherapy," and "Regulation of osteoclast function via Rho-Pkn3-c-Src pathways"), presented by the Japanese Association for Oral Biology.

CONCLUSION

These reviews in the Journal of Oral Biosciences have inspired the readers of the journal to broaden their knowledge regarding various aspects of oral biosciences. The current editorial review introduces these exciting review articles.

Senolytics (DQ) Mitigates Radiation Ulcers by Removing Senescent Cells

Radiation ulcers are a prevalent toxic side effect in patients receiving radiation therapy. At present, there is still no effective treatment for the complication. Senescent cells accumulate after radiation exposure, which can induce cell and tissue dysfunction. Here we demonstrate increased expression of p16 (a senescence biomarker) in human radiation ulcers after radiotherapy and radiation-induced persistent cell senescence in animal ulcer models. Furthermore, senescent cells secreted the senescence-associated secretory phenotype (SASP) and induced cell senescence in adjacent cells, which was alleviated by JAK inhibition. In addition, the clearance of senescent cells following treatment with a senolytics cocktail, Dasatinib plus Quercetin (DQ), mitigated radiation ulcers. Finally, DQ induced tumor cell apoptosis and enhanced radiosensitivity in representative CAL-27 and MCF-7 cell lines. Our results demonstrate that cell senescence is involved in the development of radiation ulcers and that elimination of senescent cells might be a viable strategy for patients with this condition.

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

PURPOSE

To update the clinical practice guidelines for the use of antimicrobials, mucosal coating agents, anesthetics, and analgesics for the prevention and/or treatment of oral mucositis (OM).

METHODS

A systematic review was conducted by the Mucositis Study Group of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO). The body of evidence for each intervention, in each cancer treatment setting, was assigned an evidence level. The findings were added to the database used to develop the 2014 MASCC/ISOO clinical practice guidelines. Based on the evidence level, the following guidelines were determined: Recommendation, Suggestion, and No Guideline Possible.

RESULTS

A total of 9 new papers were identified within the scope of this section, adding to the 62 papers reviewed in this section previously. A new Suggestion was made for topical 0.2% morphine for the treatment of OM-associated pain in head and neck (H&N) cancer patients treated with RT-CT (modification of previous guideline). A previous Recommendation against the use of sucralfate-combined systemic and topical formulation in the prevention of OM in solid cancer treatment with CT was changed from Recommendation Against to No Guideline Possible. Suggestion for doxepin and fentanyl for the treatment of mucositis-associated pain in H&N cancer patients was changed to No Guideline Possible.

CONCLUSIONS

Of the agents studied for the management of OM in this paper, the evidence supports a Suggestion in favor of topical morphine 0.2% in H&N cancer patients treated with RT-CT for the treatment of OM-associated pain.

World Workshop on Oral Medicine VII: Non-opioid pain management of head and neck chemo/radiation-induced mucositis: A systematic review

OBJECTIVE

To evaluate the current evidence regarding the effectiveness of non-opioid interventions for the therapeutic management of pain in head and neck cancer patients with oral mucositis resulting from radiotherapy only or chemoradiotherapy.

MATERIALS AND METHODS

A literature search was conducted which included randomised controlled trials that assessed patient-related outcome of pain in patients with oral mucositis associated with radiation therapy only or chemoradiotherapy. Literature searches were conducted in MEDLINE via Pubmed, Embase, Scopus and CINAHL.

RESULTS

The electronic searches identified 846 articles. Screening revealed that six articles met all eligibility inclusion criteria. Interventions showing statistically significant benefits to reduce oral mucositis associated pain compared to placebo included doxepin (p < 0.001, 95% CI -6.7 to -2.1), amitriptyline (p = 0.04), diclofenac (p < 0.01) and benzydamine (p = 0.014).

CONCLUSIONS

Non-opioid interventions, including topical doxepin, amitriptyline, diclofenac and benzydamine, were found to provide relief of pain due to mucositis, and when effective may allow for reduction in the use of opioids in pain management.

The Management of Pediatric Oncology Inpatients With Oral Mucositis

The purpose of the study was to investigate the management of chemotherapy-induced oral mucositis (OM) in pediatric patients. A total of 68 separate episodes of OM were assessed in 47 children who had received chemotherapy. The severity of the child's OM was assessed using 2 scales, and relevant clinical information was collected. The mean onset time of OM was 8.4 days (±4.0), with a median duration of 7.0 days (4.0, 10.5), with median admission of 7.0 days (4.5, 13.5). The overall adherence to an oral health protocol was 59%, which decreased with more severe OM. A third of patients used chlorhexidine mouthwash only, which was used in preference in cases of severe OM. Almost all patients had some systemic analgesia administered, with a significant increase in patient-controlled analgesia/nurse-controlled analgesia and intravenous ketamine in severe cases. Various types of prophylaxis/treatment of secondary infections and supportive care were associated with the severity of OM. The management of OM in children is important to limit its burden. An oral care protocol was recommended. Chlorhexidine mouthwash can maintain some form of oral care when brushing becomes too uncomfortable in severe OM. Pain management is important for the management of OM, and its intensity increases with increasing severity of OM.

Randomized Phase 2 Trial of a Novel Clonidine Mucoadhesive Buccal Tablet for the Amelioration of Oral Mucositis in Patients Treated With Concomitant Chemoradiation Therapy for Head and Neck Cancer

PURPOSE

Oral mucositis (OM) is a frequent and painful sequela of concomitant chemoradiation (CRT) used for the treatment of head and neck cancer (HNC) for which there is no effective intervention. This randomized, placebo-controlled study evaluated the efficacy of a novel, mucoadhesive topical tablet formulation of clonidine in mitigating CRT-induced OM in patients with HNC.

METHODS AND MATERIALS

Patients with HNC undergoing adjuvant radiation therapy (60-66 Gy; 5 × 1.8-2.2 Gy/wk) with concomitant platinum-based chemotherapy received daily local clonidine at 50 μg (n = 56), 100 μg (n = 65), or placebo (n = 62) via a topical mucobuccal tablet starting 1 to 3 days before and continuing during treatment. The primary endpoint was the incidence of severe OM (severe OM [SOM], World Health Organization grade 3/4).

RESULTS

SOM developed in 45% versus 60% (P = .06) of patients treated with clonidine compared with placebo and occurred for the first time at 60 Gy as opposed to 48 Gy (median; hazard ratio, 0.75 [95% confidence interval, 0.484-1.175], P = .21); median time to onset was 45 versus 36 days. Opioid analgesic use, mean patient-reported mouth and throat soreness, and CRT compliance were not significantly different between treatment arms. Adverse events were reported in 90.8% versus 98.4%, nausea in 49.6% versus 71.0%, dysphagia in 32.8% versus 48.4%, and reversible hypotension in 6.7% versus 1.6% of patients on clonidine versus placebo, respectively.

CONCLUSIONS

Although the primary endpoint was not met, the positive trends of OM-associated outcomes suggest that the novel mucoadhesive tablet delivery of clonidine might favorably affect the course and severity of CRT-induced SOM and support further evaluation.

Oral mucositis and microbial colonization in oral cancer patients undergoing radiotherapy and chemotherapy: A prospective analysis in a tertiary care dental hospital

AIM

The ulcerative phase of oral mucositis following radiotherapy/chemotherapy for oral cancer colonizes bacteria, fungi and viruses. The role of a microbiota, specifically bacterial colonization in oral mucositis, is still unclear, and there is no existing data that correlates the shift in the bacterial colonization with mucositis severity. The aim of this study was to assess the bacterial colonization and study the MCR-1 (mobilized colistin resistance), VIM2 (β-lactam resistance), TET(K) (tetracycline resistance) and bla_KPC (carbapenem resistance) genes' expression in isolated facultative anaerobes at 3 time points in oral mucositis patients undergoing radiotherapy and concomitant radiochemotherapy.

METHODS

A total of 24 oral cancer patients were divided into 2 groups: A (N = 12) undergoing radiotherapy; and B (N = 12) undergoing radiochemotherapy. Saliva was collected from all patients at 3 time intervals during the treatment. The isolated bacterial colonies were subjected to gene expression and analysis.

RESULTS

Staphylococcus aureus (22%), Staphylococcus epidermidis (29%), Pseudomonas aeruginosa (28%), Escherichia coli (25%) and Klebsiella pneumoniae (26%) are the facultative anaerobes isolated from saliva. The bacterial isolates obtained during and at the end of therapy appeared to express a higher level of antibiotic-resistance genes (VIM2, MCR-1, TET[K], bla_KPC ) than those isolated at the onset of therapy.

CONCLUSION

Bacterial colonization and gene expression varied during different stages of mucositis.

Oral Pain in the Cancer Patient

Oral pain due to cancer and associated treatments is common. The prevalence and severity of oral cancer is high. Painful oral mucositis develops in head and neck cancer patients following surgery and associated radiation therapy and/or chemotherapy. In addition, oral pain, including pain from mucositis, occurs in patients receiving chemotherapy for cancers of the hematopoietic system and cancers at other anatomic sites. Despite pain management practices that include high-dose opioid analgesics, patients rarely obtain relief from either head and neck cancer pain or mucositis pain. Because oral pain in cancer patients is likely due to both nociceptive and neuropathic mechanisms, effective management of pain requires treatments for both processes. As knowledge of the pathophysiology of oral pain in cancer patients increases, new approaches for the prevention and management are anticipated. This article focuses on the emerging evidence that supports the molecular mechanisms and the unique oral micro-neuroanatomy that in combination produce the severe oral pain experienced by cancer patients. In addition, this article summarizes the current state of clinical management of oral mucositis pain.

Gut microbiota: implications for radiotherapy response and radiotherapy-induced mucositis

Radiotherapy is a mainstay of solid tumor management but can be associated with unacceptable levels of off-target tissue toxicity which impact treatment outcomes and patients' quality of life. Tumour response to radiotherapy and the frequency and severity of radiotherapy-induced toxicities, especially mucositis, varies among patients. Gut microbiota has been found to modulate both the efficacy and toxicity of some types of cancer chemotherapies and immunotherapies but has yet to be investigated thoroughly in the setting of radiotherapy. Area covered: In this review, we discuss the potential role of gut microbiota on modulating radiotherapy-induced oral and gastrointestinal mucositis and the anti-tumor response to radiotherapy through modulation of immune responses. Expert opinion: The gut microbiota plays a major role in the modulation of systemic immune responses, which influence both radiotherapy response and gastrointestinal toxicities such as mucositis. Hence, investigating the gut microbiota link to the variation in radiotherapy responses and toxicities among patients is warranted. Future targeting of these responses with a patient-tailored restoration of optimal microbial composition could lead to a new era of mucositis prevention and enhanced tumor responses.

Merit-based Claim Adjudication for Cancer Treatment Toxicities - Policy Trends that Lower Downstream Costs

BACKGROUND

-Due largely to the lack of effective therapeutic options, between 1973-2013, chemoradiation toxic mucositis (CRTM) has remained an uncapped expenditure for 40 years, with incremental costs of $17,000-$40,000 per patient per episode. Costs in patient morbidity and mortality have continued as well. A recent therapeutic option associated with complete prevention and/or rapid sustained elimination (high potency polymerized cross-linked sucralfate, HPPCLS) delivers value by eliminating downstream costs CRTM experienced in the first 12 months. While many insurers carry the therapy as a specialty pharmacy support drug, few are familiar with the associated health economic benefits and the statutory requirements driving its coverage.

PURPOSE

-To present the rationale behind early policy trends that frame CRTM as an emergent/urgent medical condition mandated coverage as an essential health benefit. Rather than problematic for costs, this coverage trend appears to be value-based.

METHODS

-Discuss early adverse claim experience of HPPCLS. Present the costs, tenets and statutes driving policy trend toward obligatory coverage of CRTM. Review the ethical (fiduciary) and statutory requirements for CRTM coverage.

RESULTS

-CRTM coverage is ethically responsible since it is a direct consequence of authorized cancer treatment. The symptom/signs complex of CRTM meets the 'prudent layperson' statutory definition of emergency medical condition. All previously uncapped downstream costs of CRTM can be reduced to the cost of therapy, saving $15-$30K per patient per CRTM episode.

CONCLUSIONS

-Policy trend of CRTM coverage as an emergent/urgent medical condition is a value-based approach of toxicity management, conserving resources, cutting costs and eliminating patient morbidity and mortality.

Efficacy of controlled-release oxycodone for reducing pain due to oral mucositis in nasopharyngeal carcinoma patients treated with concurrent chemoradiotherapy: a prospective clinical trial

Background

Pain due to oral mucositis (OM) is a major problem during concurrent chemoradiotherapy (CCRT) in nasopharyngeal carcinoma (NPC) patients.

Methods

We enrolled 56 NPC patients receiving CCRT and allocated them into two groups: moderate pain group (n = 27) and a severe pain group (n = 29) according to the degree of pain reported (moderate = numerical rating scale (NRS) score 4–6 or severe = NRS score 7–10) at initiation of controlled-release oxycodone (CRO) treatment.

Results

Total dose of CRO was significantly higher in severe pain patients than in moderate pain patients (791.60 ± 332.449 mg vs. 587.27 ± 194.940 mg; P = 0.015). Moderate pain patients had significantly better quality of life (P = 0.037), lower weight loss (P = 0.030) and more active CCRT response (90.9% vs. 64.0%; P = 0.041). Although 24-h pain control rate was comparable in the two groups (85.2% vs. 86.2%; P = 0.508), the moderate pain group score eventually stabilized at ~ 2 vs. 3 in the severe pain group (P < 0.001); the titration time to reach bearable pain (NRS ≤ 3) was also significantly shorter in moderate pain patients (2.45 ± 0.60 days vs. 3.60 ± 1.98 days; P = 0.012). Incidence of adverse events was comparable in both groups.

Conclusions

The study findings suggest that early introduction of low-dose CRO at the moderate pain stage could help reduce the total dose required, provide better pain control, improve quality of life, and enhance CCRT response.

Pain mechanism of oral ulcerative mucositis and the therapeutic traditional herbal medicine hangeshashinto

BACKGROUND

Oral ulcerative mucositis causes severe pain during eating and speaking, resulting in poor quality of life for patients with cancer undergoing chemoradiotherapy. Recently, some basic and clinical studies demonstrated that hangeshashinto, a traditional Japanese herbal medicine, alleviated oral ulcerative mucositis-induced pain. Here, we review a recently revealed pain mechanism underlying oral ulcerative mucositis in a preclinical rat model and the pharmacological analgesic effect of hangeshashinto.

HIGHLIGHT

In a rat model of experimentally induced oral ulcerative mucositis, the mucosal surface of the ulcerative region is damaged, which increases oral bacterial loading in the mucosa and prostanoid production. Chemotherapeutic drugs exaggerate the pathological condition and cause severe pain. The pain-related TRP channels, TRPV1, TRPA1, and/or TRPV4, mediate spontaneous and mechanical pain in oral ulcerative mucositis models. Swab application of hangeshashinto had a prolonged localized analgesic effect on oral ulcerative mucositis, even in a chemotherapy-treated oral ulcer model. Two ingredients of hangeshashinto, gingerol and shogaol, strongly inhibit voltage-activated sodium channels (though they have agonistic effects on TRPV1 and TRPA1), which confers hyposensitivity to the oral mucosa. Their analgesic effects on oral ulcerative mucositis are accompanied by accelerated delivery of drugs (other saponin-containing herbal extracts) into the ulcerative region.

CONCLUSION

Elucidation of the pain mechanism of oral ulcerative mucositis and analgesic mechanism of hangeshashinto will allow identification of novel therapeutic approaches against oral ulcerative mucositis-induced pain in patients. The traditional Japanese herbal medicine hangeshashinto is a reliable drug with supporting scientific evidence.

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.

Oral microbiota reduce wound healing capacity of epithelial monolayers, irrespective of the presence of 5-fluorouracil

Oral mucositis is still one of the most painful side effects of chemotherapeutic treatment and a mounting body of evidence suggests a key role for the oral microbiome in mucositis development. However, the underlying mechanisms remain elusive. In this work, we have investigated the interactions between the host, the microbiome, and chemotherapeutic treatments in more detail. The effect of 5-fluorouracil, commonly inducing mucositis, was assessed on a co-culture model that consists of an epithelial cell layer and a biofilm derived from oral microbiota from different types of samples (saliva, buccal swabs and tongue swabs) and donors (healthy individuals and patients suffering from mucositis). After 24 h co-incubation, all oral microbial samples were found to reduce wound healing capacity with 26 ± 15% as compared with untreated condition. Compared with saliva and tongue samples, buccal samples were characterized by lower bacterial cell counts and hence higher wound healing capacity. For samples from healthy individuals, an inverse correlation was observed between bacterial cell counts and wound healing capacity, whereas for patients suffering from mucositis no correlation was observed. Moreover, patient-derived samples had a less diverse microbial community and higher abundances of pathogenic genera. No major impact of 5-fluorouracil on wound healing capacity or the composition of the microbiome was seen at physiologically relevant concentrations in the mouth. In conclusion, bacterial cell count is inversely correlated with wound healing capacity, which emphasizes the importance of oral hygiene during oral wound healing in healthy individuals. However, future research on extra measures besides oral hygiene is needed to assure a good wound healing during mucositis, as for patients the bacterial composition seems also crucial. The direct effect of 5-fluorouracil on both the microbiome and wound healing is minimal, pointing to the importance of the host and its immune system in chemotherapy-induced microbial shifts. Impact statement Chemotherapy-induced oral mucositis has a major impact on the quality of life of patients. The additional costs and treatment time associated with this pathology are significant. Although the pathology of the disease is well understood, the role and importance of oral microbiota currently are less clear. In this study, we focused on the effect of oral microbiota on wound healing, the final phase of oral mucositis, during 5-FU exposure. We show that the bacterial load and composition have a major impact on the healing process in contrast to 5-FU which only marginally slows down healing. This emphasizes the importance of good oral health care during oral mucositis to minimize bacterial load around the oral lesions. However, since we show that also the composition of the oral microbiome plays a role in wound recovery, the identification of specific pathogenic species or their metabolites might be worthwhile to allow proper treatment.

Oral and Dental Health in Head and Neck Cancer Patients

A diagnosis of head and neck cancer (HNC) is typically followed by therapy that is associated with immediate and long-lasting toxic consequences. HNC patients' oral health needs may be complex and are best addressed in multidisciplinary collaborative teams including surgical, medical, and radiation oncologists, dental providers, nutrition, speech/swallow specialists, and physical therapists. Oral health maintenance also requires patient compliance and caregiver support. The role of dental providers begins prior to cancer diagnosis and continues through survivorship. This includes oral screening and health maintenance, management of common oral complications such as mucositis, pain, infection, salivary dysfunction, altered taste, and dental decay, as well as complex issues that include soft tissue fibrosis, osteoradionecrosis of the jaw, dysphagia, and recurrent/new primary malignancies. As the number of potential therapeutic interventions for HNC increase, so do the spectrum of side effects affecting the oral cavity, oropharynx, and dentition. Specific approaches to oral care must be tailored to the idiosyncrasies of the patient and his/her therapy and condition. Oral and dental care is impacted by the patient's oral and dental status prior to cancer therapy, as well as the specific cancer type, location, stage, and its treatment and potential comorbid conditions. Communication between the dental professional and the oncology team is required for appropriate therapy and is best accomplished by integrated healthcare teams.