Oral mucosal injury in oncology patients: perspectives on maturation of a field

Current status and prospect of gut and oral microbiome in pancreatic cancer: Clinical and translational perspectives

Pancreatic cancer is a highly lethal malignancy, and its diagnosis and treatment continue to pose significant challenges. Despite advancements in surgical and comprehensive treatment methods, the five-year survival rate remains below 12 %. With the rapid development of microbiome science, the gut and oral microbiota, which are readily accessible and can be sampled non-invasively, have emerged as a novel area of interest in pancreatic cancer research. Dysbiosis in these microbial communities can induce persistent inflammatory responses and affect the host's immune system, promoting cancer development and impacting the efficacy of treatments like chemotherapy and immunotherapy. This review provides an up-to-date overview of the roles of both gut and oral microbiota in the onset, progression, diagnosis, and treatment of pancreatic cancer. It analyzes the potential of utilizing these microbiomes as biomarkers and therapeutic targets from a clinical application perspective. Furthermore, it discusses future research directions aimed at harnessing these insights to advance the diagnosis and treatment strategies for pancreatic cancer. By focusing on the microbiome's role in clinical and translational medicine, this review offers insights into improving pancreatic cancer diagnosis and treatment outcomes.

Association between oral and fecal microbiome dysbiosis and treatment complications in pediatric patients undergoing allogeneic hematopoietic stem cell transplantation

The oral and gastrointestinal mucosae represent the main targets of the toxic effect of chemo and/or radiotherapy administered during the conditioning regimen before hematopoietic stem cell transplant (HSCT). These harmful consequences and the immunological complications that may occur after the transplant (such as Graft versus Host Disease, GvHD) are responsible for the clinical symptoms associated with mucositis during the aplasia phase, like pain, nausea, vomiting, and diarrhea. These toxicities could play a critical role in the oral and gastrointestinal microbiomes during the post-transplant phase, and the degree of microbial dysbiosis and dysregulation among different bacterial species could also be crucial in intestinal mucosa homeostasis, altering the host's innate and adaptive immune responses and favoring abnormal immune responses responsible for the occurrence of GvHD. This prospective pediatric study aims to analyze longitudinally oral and gut microbiomes in 17 pediatric patients who received allogeneic HSCT for malignant and non-malignant diseases. The oral mucositis was mainly associated with an increased relative abundance of Fusobacteria, and Prevotella species, while Streptococcus descendants showed a negative correlation. The fecal microbiome of subjects affected by cutaneous acute GvHD (aGvHD) correlated with Proteobacteria. Oral mucosal microbiota undergoes changes after HSCT, Fusobacteria, and Prevotella represent bacterial species associated with mucositis and they could be the target for future therapeutic approaches, while fecal microbiome in patients with acute GvHD (aGvHD) revealed an increase of different class of Proteobacteria (Alphaproteobacteria and Deltaproteobacteria) and a negative correlation with the class of Gammaproteobacteria.

The Role of the Innate Immune Response in Oral Mucositis Pathogenesis

Oral mucositis (OM) is a significant complication of cancer therapy with limited management strategies. Whilst inflammation is a central feature of destructive and ultimately ulcerative pathology, to date, attempts to mitigate damage via this mechanism have proven limited. A relatively underexamined aspect of OM development is the contribution of elements of the innate immune system. In particular, the role played by barriers, pattern recognition systems, and microbial composition in early damage signaling requires further investigation. As such, this review highlights the innate immune response as a potential focus for research to better understand OM pathogenesis and development of interventions for patients treated with radiotherapy and chemotherapy. Future areas of evaluation include manipulation of microbial-mucosal interactions to alter cytotoxic sensitivity, use of germ-free models, and translation of innate immune-targeted agents interrogated for mucosal injury in other regions of the alimentary canal into OM-based clinical trials.

Effectiveness of Photobiomodulation and Oral Cryotherapy on Oral Mucositis Among Patients Undergoing Chemotherapy Conditioning Prior to Hematological Stem Cell Transplantation

OBJECTIVES

This review evaluated the best available evidence concerning the effectiveness of photobiomodulation compared to oral cryotherapy in oral-mucositis prevention among patients with hematological stem cell transplantation (HSCT) receiving chemo-conditioning.

DATA SOURCES

An extensive search for published and unpublished studies was conducted in 11 electronic databases and reference lists. Only randomized controlled trials (RCTs) were included. Two reviewers independently screened relevant studies for eligibility, extracted data using a standardized data collection form, and appraised data using the Cochrane Risk of Bias Tool and Grading Recommendations, Assessment, Development and Evaluation (GRADE). Meta-analyses using a random-effect model was performed using Review Manager software. Subgroup analyses were conducted to examine the differential effect of interventions across subgroups and to explore potential sources of heterogeneity. Meta-analyses included 18 RCTs (involving 1,018 patients). Both photobiomodulation and cryotherapy were effective in reducing oral-mucositis severity, severe oral-mucositis incidence, duration, and pain with small to large effect sizes. No significant differences were detected between photobiomodulation and cryotherapy across all outcomes. Subgroup analyses showed significant differences for chemo-conditioning regimens. The overall Grading Recommendations, Assessment, Development and Evaluation quality of evidence was low.

CONCLUSION

Both photobiomodulation and cryotherapy were effective nonpharmacological oral-mucositis prophylaxis and analgesia, with no significant difference in effectiveness. Chemo-conditioning regimens may influence their effectiveness. Future RCTs may directly compare the effectiveness of photobiomodulation and cryotherapy on the HSCT patients. Rigorous cost-effectiveness studies are also required.

IMPLICATIONS FOR NURSING PRACTICE

Photobiomodulation and cryotherapy can be offered to HSCT patients in clinical settings. A clinical guideline of both interventions can be also developed.

Use of Honey in the Management of Chemotherapy-Associated Oral Mucositis in Paediatric Patients

Background

Oral mucositis (OM) is a critical condition during chemotherapy in both adult and child cancer patients. Paediatric cancer patients have a higher prevalence of OM than adult cancer patients. Honey is a natural product that has been reported to have the best tissue healing properties. The present mini-review focused on the evaluation of the effectiveness of oral care with honey products in the treatment and prophylaxis of chemotherapy-induced OM in child patients.

Methods

A network of electronic English databases including CINAHL, CENTRAL, EMBASE, MEDLINE and PubMed, were used for primary search from April 2010 to April 2020. We have also considered data collected from ClinicalTrials.gov, Web of Science and Google Scholar. PRISMA software was used to build collective data. Controlled trials were included in this review and were critically appraised by Down and Black. The narrative synthesis was performed.

Results

A total number of 346 data of children and adolescents with cancer were considered in this short review. All patients were from three randomized controlled trial articles and two were non-randomised controlled trial articles. Based on the evidence so far revealed, honey may show an effect in the treatment and prophylaxis of OM. The analysis of collected data revealed that the probability value P<0.05. The honey enhanced recovery time and severity of OM were significantly compared with those without honey treatment receiving group of pediatric patients.

Conclusion

Honey not only has been shown to have the capability for healing injured tissues but it is also a more economical treatment, and it has fewer side effects compared to synthetic drugs. Honey or honey products can prevent chemotherapy-induced OM (CIOM) and be the best treatment to grade I, II and III CIOM. However, it is disappointing that studies involving children as patients were few, and limited data available so far.

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Efficacy and Safety of Chinese Patent Medicine for the Prevention and Treatment of Radiotherapy and Chemotherapy-Induced Oral Mucositis: A Systematic Review and Meta-Analysis

Background: Radiotherapy and chemotherapy-induced oral mucositis can affect cancer patients' quality of life, even necessitate cancer therapy and influence prognosis. Chinese patent medicines (CPMs) have been widely used as complementary alternative medicines for the prevention and treatment of oral mucositis, and their efficacy and safety require further evaluation. Therefore, this study was conducted to provide references for clinical practice. Methods: Ten databases were searched electronically and manually to identify randomized controlled trials (RCTs) from their inception to August 2021, concerning the prevention and treatment of radiotherapy and chemotherapy-induced oral mucositis with CPMs. The prevalence, pain level, and the severity of radiotherapy and chemotherapy-induced oral mucositis, as well as the effectiveness rate and adverse effects of CPMs, were set as the outcome criteria. The assessment criteria of the Cochrane Handbook were used to determine study quality and bias, and meta-analysis was conducted using Review Manager 5.4.1 software. Results: A total of 2,312 cases from 27 RCTs were included. Most studies were considered to have a low or unclear risk of bias. More research is available on the use of CPMs in the prevention of radiotherapy and chemotherapy-induced oral mucositis than in its treatment. As for the prevention, it was proved that CPMs could significantly reduce the prevalence of radiotherapy and chemotherapy-induced oral mucositis, especially for the severe types, and decrease pain levels (p < 0.05). For treatment, CPMs could alleviate the symptoms, promote the healing of ulceration in radiotherapy and chemotherapy-induced oral mucositis, and thus improve the efficiency of clinical treatment (p < 0.05). The results of subgroup analyses were mainly consistent with the above results. The adverse effects of CPMs mainly included gastrointestinal reactions and bitter taste, and no serious adverse events were reported. Conclusions: This systematic review and meta-analysis indicated CPMs might be effective for the prevention and treatment of radiotherapy and chemotherapy-induced oral mucositis through reducing the prevalence, decreasing the occurrence of severe types, alleviating the symptoms, and promoting the healing of ulceration. However, due to the limited number of eligible studies and the publication bias, more high-quality, double-blinded, placebo-controlled RCTs are still needed in future research. Systematic Review Registration: [https://inplasy.com/], identifier [INPLASY2021100100].

Effect of Honey on Pediatric Radio/Chemotherapy-Induced Oral Mucositis (R/CIOM): A Systematic Review and Meta-Analysis

Background

As a common side effect of radio/chemotherapy, oral mucositis severely affects patients' quality of life. Honey has been recommended for adults with radio/chemotherapy-induced oral mucositis (R/CIOM), but its effect for pediatric patients has not been systematically evaluated. Therefore, the aim of this systematic review and meta-analysis was to illuminate whether honey is effective in treating pediatric R/CIOM.

Methods

Two authors searched electronic databases including PubMed, Embase, the Cochrane Library, Web of Science, and Scopus to identify relevant studies, published in English. Then, the outcomes data was extracted from eligible studies and pooled in the meta-analysis.

Results

Totally, five studies containing 316 patients were included in our systematic review and meta-analysis. The result indicated that honey intervention significantly reduced the recovery time (MD = -5.10, 95% CI [-9.60, -0.61], P < 0.001, I 2 = 98%, random-effect model) in pediatric patients. Honey also reduced the occurrence of all grades of R/CIOM (RR = 0.19, 95% CI [0.12, 0.30], P < 0.001, I2 = 0%, fixed-effect model) and the occurrence of grade III and grade IV R/CIOM (RR = 0.18, 95% CI [0.08, 0.41], P < 0.001, I2 = 7%, fixed-effect model), and the sensitivity analysis showed the results were stable and robust.

Conclusion

Therefore, honey could be a competent candidate for the complementary treatment of pediatric R/CIOM.

Intraprocedural MRI monitoring during percutaneous cryoablation procedures of the head and neck, and spine: a single institution experience

RATIONALE AND OBJECTIVES

Evaluate whether intraprocedural MRI monitoring of percutaneous cryoablation procedures of head and neck, and spine lesions is effective for avoiding iatrogenic neurovascular and mucosal injury.

MATERIALS AND METHODS

We retrospectively reviewed 64 consecutive percutaneous head and neck, and spine cryoablation procedures with intraprocedural MRI monitoring performed on 45 patients (mean age 55 years, range 17-91 years). Ablation goals were either complete local control of primary or metastatic lesions or pain relief.

RESULTS

The technical success rate was 100%. The complication rate was 13% with only 2 complications (3%) requiring further intervention. There were no deaths or persistent neurological or vascular complications. Subsequent cryoablation in the same location was performed in 12 patients (27%). Subsequent surgical intervention in the same location was performed in 7 patients (16%) for progressive disease or worsening symptoms.

CONCLUSIONS

MRI provides excellent visualization of the ice ball margin during percutaneous cryoablation procedures. Accurate intraprocedural visualization of the ice ball allows for adjustment of cryoablation parameters to avoid damage to adjacent vital neurovascular structures or mucosal surfaces. Intraprocedural MRI monitoring is thus a novel and highly effective method that allows a high rate of technical success for cryoablation in the head and neck, and spine while avoiding iatrogenic injury.

Protective Effect of Calcitriol on Organ Damage Induced by 5-Fluorouracil Treatment

Chemotherapy is a major therapeutic strategy for patients with cancer. Owing to the severe inflammatory response of chemotherapy, patients experience extreme discomfort during treatment, and this may interrupt treatment completion. The vitamin D3 has a role in anti-inflammation, but no study has explored whether vitamin D3 has beneficial effects on patients undergoing chemotherapy. In this study, we investigated the effect of calcitriol (Vit-D) on inflammatory responses during 5-fluorouracil (5-FU) treatment. Rats were divided into five groups and treated with 1:1 dilution of 5-FU with equal amount of 0.9% saline, 1:3 dilution of 5-FU with 0.9% saline threefold dilution, 5-FU, Vit-D, or 5-FU + Vit-D. A single dose of 15 mg/kg of 5-FU was intravenously administered for 4 h, and the blood biochemical substances and inflammatory cytokines were assessed after the intervention. The 5-FU group had higher AST, ALT, LDH, and CPK levels than those in the 5-FU + Vit-D group. The 5-FU + Vit-D group had a lower TNF-α value than the 5-FU. The IL-6 levels in the 5-FU + Vit-D group were also significantly lower than those in 5-FU. Calcitriol administration during 5-FU therapy can alleviate the production of inflammatory cytokines and liver damage.

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.

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.

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

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

Ozone Therapy for Oral Palatal Ulcer in a Leukaemic Patient

Chemotherapy usually causes complications affecting several tissues such as oral mucosa. In this case report, a soft palate oral ulcer caused by chemotherapy was treated by ozone gas. This kind of treatment is known for its antimicrobial, regenerative and analgesic proprieties. The results show a complete resolution of the lesion within 2 weeks of treatment. Ozone therapy demonstrates greater effectiveness with respect to this kind of oral lesion compared to traditional therapy. Considering this evidence, ozone therapy should be considered as a useful tool for the adjuvant therapy of oral complications in oncologic patients.

Oral Mucositis in Pediatric Oncology Patients: A Nested Case-Control to a Prospective Cohort

Abstract This study aimed to evaluate the factors associated with the occurrence of severe oral mucositis (SOM) in pediatric oncology patients during the chemotherapeutic treatment. This is a nested case-control to a prospective cohort that monitored 105 patients for 10 consecutive weeks after the beginning of the chemotherapy treatment. Logistic regression was used to identify the factors associated with SOM, by group of malignancy (hematologic or solid tumors) (Sig.=5%). To patients with hematologic tumors were found factors associated with SOM in two weeks of treatment: in the 6th week (increase in frequency of chemotherapy doses (OR=3.02)) and in the 7th week (female sex (OR=21.28); and increase in frequency of chemotherapy doses (OR=2.51)); and to patients with solid tumors were found factors associated with SOM in five weeks of treatment: in the 1st week (female sex (OR=14.43); age increase (OR=1.24)); in the 2nd week (Miscellany (OR=6.39)); in the 5th week (Antimetabolites (OR=17.44); Miscellany (OR=45.42); and platelets reduction (OR=1.12)); in the 6th week (creatinine increase (OR=1.63)); and in the 7th week (creatinine increase (OR=2.39)). For patients with hematologic tumors, to be female, and the increase in the frequency of chemotherapy doses increased the risk for SOM and for patients with solid tumors, to be female, the increase in age and in level blood concentration of creatinine, the reduction in number of platelets and the use of chemotherapy with miscellany and antimetabolites agents were associated with an increase in risk for occurrence of SOM.

Local Formula with Mucoadhesive Property: A Randomized Clinical Trial of a Therapeutic Agent for the Treatment of Oral Aphthous Ulcers

BACKGROUND

Recurrent or occasional aphthous lesions represent a painful oral condition with high prevalence. Since the etiology is still unclear and most likely related to a dysfunction in the local immune system, several treatment strategies have been proposed, including systemic agents, local agents, and laser therapy, to reduce the pain and discomfort for the patient without acting on the causes.

MATERIALS AND METHODS

The purpose of the present randomized study was to assess the clinical efficacy of a new topical gel with mucoadhesive property to reduce the pain and the dimension of the aphthosis lesions. Fifty patients presenting at least one minor ulcer were randomized to a control group (placebo prescription), a first test group (topical agent with laser), and a second test group (topical agent only). The healing rate, the visual analog scale (VAS) score for pain, and the diameter reduction were monitored for 10 days.

RESULTS

Both test groups showed better results than control group, significant clinical efficacy, and a median total reduction time of 4 days with no significant adjunctive benefit from the use of laser.

CONCLUSION

The clinical results are encouraging; nevertheless other studies are needed to valid this kind of treatment.

CLINICAL SIGNIFICANCE

The present randomized clinical study suggested that the use of topical mucoadhesive agents could represent a valid therapy for minor aphthous lesions. How to cite this article: Giammarinaro E, Cosola S, Oldoini G, et al. Local Formula with Mucoadhesive Property: A Randomized Clinical Trial of a Therapeutic Agent for the Treatment of Oral Aphthous Ulcers. J Contemp Dent Pract 2019;20(11):1249-1253.

Chemotherapy-induced oral mucositis is associated with detrimental bacterial dysbiosis

BACKGROUND

Gastrointestinal mucosal injury (mucositis), commonly affecting the oral cavity, is a clinically significant yet incompletely understood complication of cancer chemotherapy. Although antineoplastic cytotoxicity constitutes the primary injury trigger, the interaction of oral microbial commensals with mucosal tissues could modify the response. It is not clear, however, whether chemotherapy and its associated treatments affect oral microbial communities disrupting the homeostatic balance between resident microorganisms and the adjacent mucosa and if such alterations are associated with mucositis. To gain knowledge on the pathophysiology of oral mucositis, 49 subjects receiving 5-fluorouracil (5-FU) or doxorubicin-based chemotherapy were evaluated longitudinally during one cycle, assessing clinical outcomes, bacterial and fungal oral microbiome changes, and epithelial transcriptome responses. As a control for microbiome stability, 30 non-cancer subjects were longitudinally assessed. Through complementary in vitro assays, we also evaluated the antibacterial potential of 5-FU on oral microorganisms and the interaction of commensals with oral epithelial tissues.

RESULTS

Oral mucositis severity was associated with 5-FU, increased salivary flow, and higher oral granulocyte counts. The oral bacteriome was disrupted during chemotherapy and while antibiotic and acid inhibitor intake contributed to these changes, bacteriome disruptions were also correlated with antineoplastics and independently and strongly associated with oral mucositis severity. Mucositis-associated bacteriome shifts included depletion of common health-associated commensals from the genera Streptococcus, Actinomyces, Gemella, Granulicatella, and Veillonella and enrichment of Gram-negative bacteria such as Fusobacterium nucleatum and Prevotella oris. Shifts could not be explained by a direct antibacterial effect of 5-FU, but rather resembled the inflammation-associated dysbiotic shifts seen in other oral conditions. Epithelial transcriptional responses during chemotherapy included upregulation of genes involved in innate immunity and apoptosis. Using a multilayer epithelial construct, we show mucositis-associated dysbiotic shifts may contribute to aggravate mucosal damage since the mucositis-depleted Streptococcus salivarius was tolerated as a commensal, while the mucositis-enriched F. nucleatum displayed pro-inflammatory and pro-apoptotic capacity.

CONCLUSIONS

Altogether, our work reveals that chemotherapy-induced oral mucositis is associated with bacterial dysbiosis and demonstrates the potential for dysbiotic shifts to aggravate antineoplastic-induced epithelial injury. These findings suggest that control of oral bacterial dysbiosis could represent a novel preventive approach to ameliorate oral mucositis.

Utility of polaprezinc in reducing toxicities during radiotherapy: a literature review

Chemoradiotherapy is important for treating malignancies. However, radiation-induced toxicities develop as chemoradiotherapy-related complications. Various agents reduce or prevent toxicities, but there are no standard treatments. Polaprezinc (PZ), a chelating compound used for gastric ulcers, has antioxidant and free radical scavenging effects. Although few studies have evaluated PZ and radiation-induced normal tissue damage, several clinical studies have shown the efficacy of PZ for oral mucositis, esophagitis, proctitis and taste alterations during and after radiotherapy. Moreover, preclinical data support the clinical data, indicating good potential of testing PZ in future trials. However, as there are only few well-documented review articles on PZ use in cancer treatment, we conducted this literature review. PZ reduced several radiation-induced toxicities and improved the quality of life.

Pharmacological modulation of radiation-induced oral mucosal complications

Radiation-induced mucositis is a common toxicity, especially in patients with head and neck cancers. Despite recent technological advances in radiation therapy, such as intensity-modulated radiotherapy, radiation-induced mucositis is still causing treatment disruptions, negatively affecting patients' long and short term quality of life, and impacting medical resources use with economic consequences. The objective of this article was to review the latest updates in the management of radiation-induced mucositis, with a focus on pharmaceutical strategies for the prevention or treatment of mucositis. Although numerous studies analysing the prevention and management of oral radiation-induced mucositis have been conducted, there are still few reliable data to guide daily clinical practice. Furthermore, most of the tested drugs have shown no (anti-inflammatory cytokine, growth factors) or limited (palifermin) effect. Therapies for acute oral mucositis are predominantly focused on improving oral hygiene and providing symptoms control. Although low-level laser therapy proved efficient in preventing radiation-induced oral mucositis in patients with head and neck cancer, this intervention requires equipment and trained medical staff, and is therefore insufficiently developed in clinical routine. New effective pharmacological agents able to prevent or reverse radio-induced mucositis are required.

CE: Oral Care for Head and Neck Cancer Symptom Management

: An evidence-based practice change at a radiation oncology center in a large academic medical center was designed to reduce the severity of oral mucositis in adults receiving radiation treatment for head and neck cancer. In the intervention described, patients were given newly created oral care kits and educational materials to improve their oral hygiene. Evaluations were conducted at three points during the project (before radiation treatment, during week 4 to 5 of treatment, and one month after treatment). At week 4 to 5-when the severity of oral mucositis is expected to peak-patients reported improved oral hygiene practices and reduced oral mucositis severity. The authors conclude that the use of these oral care kits and educational materials lessened the effects of oral mucositis during and after radiation treatment.

Interventions for preventing oral mucositis in patients with cancer receiving treatment: cytokines and growth factors

BACKGROUND

Oral mucositis is a side effect of chemotherapy, head and neck radiotherapy, and targeted therapy, affecting over 75% of high-risk patients. Ulceration can lead to severe pain and difficulty with eating and drinking, which may necessitate opioid analgesics, hospitalisation and supplemental nutrition. These complications may disrupt cancer therapy, which may reduce survival. There is also a risk of death from sepsis if pathogens enter the ulcers of immunocompromised patients. Ulcerative oral mucositis can be costly to healthcare systems, yet there are few preventive interventions proven to be beneficial. Cytokines and growth factors may help the regeneration of cells lining of the mouth, thus preventing or reducing oral mucositis and its negative effects.

OBJECTIVES

To assess the effects of cytokines and growth factors for preventing oral mucositis in patients with cancer who are receiving treatment.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (searched 10 May 2017); the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 4) in the Cochrane Library (searched 10 May 2017); MEDLINE Ovid (1946 to 10 May 2017); Embase Ovid (7 December 2015 to 10 May 2017); CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to 10 May 2017); and CANCERLIT PubMed (1950 to 10 May 2017). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials.

SELECTION CRITERIA

We included parallel-design randomised controlled trials (RCTs) assessing the effects of cytokines and growth factors in patients with cancer receiving treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the results of electronic searches, extracted data and assessed risk of bias. For dichotomous outcomes, we reported risk ratios (RR) and 95% confidence intervals (CI). For continuous outcomes, we reported mean differences (MD) and 95% CIs. We pooled similar studies in random-effects meta-analyses. We reported adverse effects in a narrative format.

MAIN RESULTS

We included 35 RCTs analysing 3102 participants. Thirteen studies were at low risk of bias, 12 studies were at unclear risk of bias, and 10 studies were at high risk of bias.Our main findings were regarding keratinocyte growth factor (KGF) and are summarised as follows.There might be a reduction in the risk of moderate to severe oral mucositis in adults receiving bone marrow/stem cell transplantation after conditioning therapy for haematological cancers (RR 0.89, 95% CI 0.80 to 0.99; 6 studies; 852 participants; low-quality evidence). We would need to treat 11 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 6 to 112). There might be a reduction in the risk of severe oral mucositis in this population, but there is also some possibility of an increase in risk (RR 0.85, 95% CI 0.65 to 1.11; 6 studies; 852 participants; low-quality evidence). We would need to treat 10 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 5 to prevent the outcome to 14 to cause the outcome).There is probably a reduction in the risk of moderate to severe oral mucositis in adults receiving radiotherapy to the head and neck with cisplatin or fluorouracil (RR 0.91, 95% CI 0.83 to 1.00; 3 studies; 471 participants; moderate-quality evidence). We would need to treat 12 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 7 to infinity). It is very likely that there is a reduction in the risk of severe oral mucositis in this population (RR 0.79, 95% CI 0.69 to 0.90; 3 studies; 471 participants; high-quality evidence). We would need to treat 7 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 5 to 15).It is likely that there is a reduction in the risk of moderate to severe oral mucositis in adults receiving chemotherapy alone for mixed solid and haematological cancers (RR 0.56, 95% CI 0.45 to 0.70; 4 studies; 344 participants; moderate-quality evidence). We would need to treat 4 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 3 to 6). There might be a reduction in the risk of severe oral mucositis in this population (RR 0.30, 95% CI 0.14 to 0.65; 3 studies; 263 participants; low -quality evidence). We would need to treat 10 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 8 to 19).Due to the low volume of evidence, single-study comparisons and insufficient sample sizes, we found no compelling evidence of a benefit for any other cytokines or growth factors and there was no evidence on children. There did not appear to be any serious adverse effects of any of the interventions assessed in this review.

AUTHORS' CONCLUSIONS

We are confident that KGF is beneficial in the prevention of oral mucositis in adults who are receiving: a) radiotherapy to the head and neck with cisplatin or fluorouracil; or b) chemotherapy alone for mixed solid and haematological cancers. We are less confident about a benefit for KGF in adults receiving bone marrow/stem cell transplant after conditioning therapy for haematological cancers because of multiple factors involved in that population, such as whether or not they received total body irradiation (TBI) and whether the transplant was autologous (the patients' own cells) or allogeneic (cells from a donor). KGF appears to be a relatively safe intervention.Due to limited research, we are not confident that there are any beneficial effects of other cytokines and growth factors. There is currently insufficient evidence to draw any conclusions about the use of cytokines and growth factors in children.

Double-blind placebo-controlled randomized clinical trial evaluating doxycycline effects on chemotherapy-induced oral mucositis

WHAT IS KNOWN AND OBJECTIVE

Chemotherapy (CT)-associated oral mucositis (OM) is one of the most debilitating and painful side effects in oncology patients, with limited effective management options. During CT, matrix metalloproteinases (MMPs) are upregulated, causing damage in mucosal and submucosal tissues, and playing a key role in OM; therefore, the use of subantimicrobial doxycycline as a MMP inhibitor may represent a potential approach for OM management. The aim of this clinical trial was to evaluate the efficacy and safety of low doses of doxycycline in OM development in individuals with acute leukaemia (AL) during CT.

METHODS

Randomized controlled clinical trial (Registration No. NCT01087476) performed in adult AL patients scheduled to receive CT (September 2010-October 2014). Individuals were stratified by leukaemia type and assigned randomly to receive doxycycline hyclate (50 mg/d) (doxycycline group: DG) or placebo (placebo group: PG) before and during CT. Included subjects had a baseline oral examination and thereafter 3 times a week during 21 days. The primary outcome was OM development.

RESULTS AND DISCUSSION

One hundred and forty-seven AL subjects were enrolled: 74 in DG and 73 in PG; baseline characteristics between groups were comparable. During follow-up, 15 (10.2%) individuals developed OM; no differences between treatment groups were found (DG:8.1%, PG:12.3%; P = .59). The mean OM Assessment Scale score was 2.51, without differences between groups (DG:2.7, PG:2.4; P = .65). Low baseline blood albumin levels in the OM-affected individuals were identified, revealing the effect of systemic deterioration as a predisposing factor for OM development. No adverse effects were observed.

WHAT IS NEW AND CONCLUSION

Subantimicrobial doses of doxycycline did not reduce the incidence, onset, duration or severity of OM.

Oral mucosal injury caused by mammalian target of rapamycin inhibitors: emerging perspectives on pathobiology and impact on clinical practice

In recent years oral mucosal injury has been increasingly recognized as an important toxicity associated with mammalian target of rapamycin (mTOR) inhibitors, including in patients with breast cancer who are receiving everolimus. This review addresses the state-of-the-science regarding mTOR inhibitor-associated stomatitis (mIAS), and delineates its clinical characteristics and management. Given the clinically impactful pain associated with mIAS, this review also specifically highlights new research focusing on the study of the molecular basis of pain. The incidence of mIAS varies widely (2-78%). As reported across multiple mTOR inhibitor clinical trials, grade 3/4 toxicity occurs in up to 9% of patients. Managing mTOR-associated oral lesions with topical oral, intralesional, and/or systemic steroids can be beneficial, in contrast to the lack of evidence supporting steroid treatment of oral mucositis caused by high-dose chemotherapy or radiation. However, steroid management is not uniformly efficacious in all patients receiving mTOR inhibitors. Furthermore, technology does not presently exist to permit clinicians to predict a priori which of their patients will develop these lesions. There thus remains a strategic need to define the pathobiology of mIAS, the molecular basis of pain, and risk prediction relative to development of the clinical lesion. This knowledge could lead to novel future interventions designed to more effectively prevent mIAS and improve pain management if clinically significant mIAS lesions develop.

Interventions for preventing oral mucositis in patients with cancer receiving treatment: oral cryotherapy

BACKGROUND

Oral mucositis is a side effect of chemotherapy, head and neck radiotherapy, and targeted therapy, affecting over 75% of high risk patients. Ulceration can lead to severe pain and difficulty eating and drinking, which may necessitate opioid analgesics, hospitalisation and nasogastric or intravenous nutrition. These complications may lead to interruptions or alterations to cancer therapy, which may reduce survival. There is also a risk of death from sepsis if pathogens enter the ulcers of immunocompromised patients. Ulcerative oral mucositis can be costly to healthcare systems, yet there are few preventive interventions proven to be beneficial. Oral cryotherapy is a low-cost, simple intervention which is unlikely to cause side-effects. It has shown promise in clinical trials and warrants an up-to-date Cochrane review to assess and summarise the international evidence.

OBJECTIVES

To assess the effects of oral cryotherapy for preventing oral mucositis in patients with cancer who are receiving treatment.

SEARCH METHODS

We searched the following databases: the Cochrane Oral Health Group Trials Register (to 17 June 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library 2015, Issue 5), MEDLINE via Ovid (1946 to 17 June 2015), EMBASE via Ovid (1980 to 17 June 2015), CANCERLIT via PubMed (1950 to 17 June 2015) and CINAHL via EBSCO (1937 to 17 June 2015). We searched the US National Institutes of Health Trials Registry, and the WHO Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching databases.

SELECTION CRITERIA

We included parallel-design randomised controlled trials (RCTs) assessing the effects of oral cryotherapy in patients with cancer receiving treatment. We used outcomes from a published core outcome set registered on the COMET website.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the results of electronic searches, extracted data and assessed risk of bias. We contacted study authors for information where feasible. For dichotomous outcomes, we reported risk ratios (RR) and 95% confidence intervals (CI). For continuous outcomes, we reported mean differences (MD) and 95% CIs. We pooled similar studies in random-effects meta-analyses. We reported adverse effects in a narrative format.

MAIN RESULTS

We included 14 RCTs analysing 1280 participants. The vast majority of participants did not receive radiotherapy to the head and neck, so this review primarily assesses prevention of chemotherapy-induced oral mucositis. All studies were at high risk of bias. The following results are for the main comparison: oral cryotherapy versus control (standard care or no treatment). Adults receiving fluorouracil-based (5FU) chemotherapy for solid cancersOral cryotherapy probably reduces oral mucositis of any severity (RR 0.61, 95% CI 0.52 to 0.72, 5 studies, 444 analysed, moderate quality evidence). In a population where 728 per 1000 would develop oral mucositis, oral cryotherapy would reduce this to 444 (95% CI 379 to 524). The number needed to treat to benefit one additional person (NNTB), i.e. to prevent them from developing oral mucositis, is 4 people (95% CI 3 to 5).The results were similar for moderate to severe oral mucositis (RR 0.52, 95% CI 0.41 to 0.65, 5 studies, 444 analysed, moderate quality evidence). NNTB 4 (95% CI 4 to 6).Severe oral mucositis is probably reduced (RR 0.40, 95% CI 0.27 to 0.61, 5 studies, 444 analysed, moderate quality evidence). Where 300 per 1000 would develop severe oral mucositis, oral cryotherapy would reduce this to 120 (95% CI 81 to 183), NNTB 6 (95% CI 5 to 9). Adults receiving high-dose melphalan-based chemotherapy before haematopoietic stem cell transplantation (HSCT)Oral cryotherapy may reduce oral mucositis of any severity (RR 0.59, 95% CI 0.35 to 1.01, 5 studies, 270 analysed, low quality evidence). Where 824 per 1000 would develop oral mucositis, oral cryotherapy would reduce this to 486 (95% CI reduced to 289 to increased to 833). The NNTB is 3, although the uncertainty surrounding the effect estimate means that the 95% CI ranges from 2 NNTB, to 111 NNTH (number needed to treat in order to harm one additional person, i.e. for one additional person to develop oral mucositis).The results were similar for moderate to severe oral mucositis (RR 0.43, 95% CI 0.17 to 1.09, 5 studies, 270 analysed, low quality evidence). NNTB 3 (95% CI 2 NNTB to 17 NNTH).Severe oral mucositis is probably reduced (RR 0.38, 95% CI 0.20 to 0.72, 5 studies, 270 analysed, moderate quality evidence). Where 427 per 1000 would develop severe oral mucositis, oral cryotherapy would reduce this to 162 (95% CI 85 to 308), NNTB 4 (95% CI 3 to 9).Oral cryotherapy was shown to be safe, with very low rates of minor adverse effects, such as headaches, chills, numbness/taste disturbance, and tooth pain. This appears to contribute to the high rates of compliance seen in the included studies.There was limited or no evidence on the secondary outcomes of this review, or on patients undergoing other chemotherapies, radiotherapy, targeted therapy, or on comparisons of oral cryotherapy with other interventions or different oral cryotherapy regimens. Therefore no further robust conclusions can be made. There was also no evidence on the effects of oral cryotherapy in children undergoing cancer treatment.

AUTHORS' CONCLUSIONS

We are confident that oral cryotherapy leads to large reductions in oral mucositis of all severities in adults receiving 5FU for solid cancers. We are less confident in the ability of oral cryotherapy to reduce oral mucositis in adults receiving high-dose melphalan before HSCT. Evidence suggests that it does reduce oral mucositis in these adults, but we are less certain about the size of the reduction, which could be large or small. However, we are confident that there is an appreciable reduction in severe oral mucositis in these adults.This Cochrane review includes some very recent and currently unpublished data, and strengthens international guideline statements for adults receiving the above cancer treatments.

Ultrasensitive microfluidic array for serum pro-inflammatory cytokines and C-reactive protein to assess oral mucositis risk in cancer patients

In addition to disease diagnostics, there is a need for biomarkers to predict severity of cancer therapy side effects such as oral mucositis. Oral mucositis is an inflammatory lesion of oral mucosa caused by high-dose chemotherapy and/or radiation that is especially prevalent during oral cancer treatment. We describe here a semi-automated, modular microfluidic immunoarray optimized for ultrasensitive detection of pro-inflammatory cytokines involved in pathobiology of oral mucositis. Our goal is to methodologically identify risk of mucositis early in oral cancer treatment, before the onset of lesions. Biomarkers include tumor necrosis factor alpha (TNF-α), interleukin-6 (IL-6), interleukin-1β (IL-1β), and C-reactive protein (CRP). Protein analytes were captured from serum in a capture chamber by 1-μm magnetic beads coated with antibodies and enzyme labels. Beads are then transported downstream to a detection chamber containing an eight-sensor array coated with glutathione-coated gold nanoparticles (GSH-AuNP) and a second set of antibodies to capture the beads with analyte proteins. In this first application of the immunoarray to four-protein multiplexed measurements, ultralow detection limits of 10-40 fg mL(-1) in 5 μL serum were achieved for simultaneous detection in 30 min. Mass detection limits were 2.5-10 zmol, as few as 1500 molecules. Accuracy and diagnostic utility of the arrays were demonstrated by correlation of levels of the four biomarker proteins in serum from head and neck cancer patients with results from standard ELISA. This approach may lead to rapid, low-cost estimates of projected risk for severity of oral mucositis in cancer patients to enable improved therapeutic management.

Alleviating mucositis: are we on track for a novel therapeutic?

Oral and gastrointestinal mucositis has emerged as an important toxicity of cancer therapy. In addition to supportive care measures, agents for the prevention or treatment of mucositis in specific patient populations are described in the evidence-based clinical practice guidelines published by the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology. However, there still remains an unmet clinical need for preventive and therapeutic agents in several patient populations. The successful development of such agents will rely on our improved understanding of the pathogenic mechanisms underlying mucositis. Studies are also underway on novel delivery mechanisms and risk prediction models that can facilitate the selective use of interventions for mucositis in a targeted and cost-effective manner. A large number of agents are at various stages in the clinical development pipeline. Enhanced management of this dose-limiting toxicity will allow the delivery of optimal cancer therapy and improve patient prognosis.