Cancer treatment-induced mucositis pain: strategies for assessment and management

Efficacy of Mucosamin Spray as an Adjunct for Prevention of Oral Mucositis in Children under Chemotherapy: A Two-Center Randomized Clinical Trial

Statement of the Problem

Chemotherapy-induced mucositis is the most common complication during cancer treatment. This complication can lead to pain, increased risk of infection and malnutrition. Therefore, it is important to find a solution to reduce the severity and duration of side effects.

Purpose

This study aimed to assess the efficacy of Mucosamin spray as an adjunct for prevention of oral mucositis in children under chemotherapy.

Materials and Method

This parallel-design clinical trial evaluated 48 patients aged 5 to 15 years with leukemia and lymphoma presenting to the Hematology Department of Mofid and Mahak Hospitals. The patients were randomly divided into two groups (n=24). Before starting chemotherapy, all patients received oral hygiene instructions (toothbrushing without flossing). Patients in both groups were requested to use a mouthwash composed of nystatin, aluminum-magnesium hydroxide suspension (aluminum MgS), and diphenhydramine for 1 min every morning on a daily basis starting the day before treatment. Patients in the intervention group were also requested to spray their entire oral mucosa with Mucosamin spray 3 times a day in addition to using the mouthwash. Patients were requested to refrain from eating and drinking for 1h after spraying. The patients were clinically examined by a senior dental student once every other day for 20 days regarding the occurrence, severity, and duration of oral mucositis. Data were analyzed using the Chi-square and Mann-Whitney tests, Kaplan-Meier survival analysis, and log rank test.

Results

No significant difference was noted between the two groups in the incidence, severity, or time of development of mucositis (p> 0.05). The 7-day non-recovery percentage was 72.7% (SE= 13.4) and 25.0% (SE= 15.3) in the control and test groups, respectively, indicating shorter duration (faster healing) of mucositis in the intervention group (p= 0.01).

Conclusion

Within the limitations of this study, it seems that prophylactic application of Mucosamin spray can shorten the course of oral mucositis, in case of its occurrence.

Safety, Feasibility, and Advantages of Oral Microbiota Transplantation: The First Clinical Case

The pilot clinical study presented demonstrates the possibility, safety, and effectiveness of oral microbiota transplantation from a healthy donor to a patient with neuroblastoma to prevent chemotherapy-induced oral mucositis. A 6-month-old patient with a diagnosis of retroperitoneal neuroblastoma was treated according to the NB 2004 protocol. Due to the development of severe oral mucositis, it was decided to perform oral microbiota transplantation. During the next 3 chemotherapy cycles and conditioning regimen before autologous hematopoietic cell transplantation (auto-HCT), the patient was repeatedly injected per os with donor saliva from her healthy mother. Oral microbiota transplantation was shown to effectively prevent the development of oral mucositis after chemotherapy, and only grade 1 oral mucositis developed after auto-HCT. In all loci of the oral cavity, there was a decreased abundance of bacteria from the Staphylococcaceae, Micrococcaceae, and Xanthomonadaceae families. Conversely, there was an increase in the relative abundance of Streptococcaceae and certain other bacterial taxa. In conclusion, the transplantation of maternal saliva in this patient prevented severe mucositis and was accompanied by a compositional change of the patient's oral microbiota. No adverse events due to the transplantation of maternal saliva were noted.

Advancing Postoperative Pain Management in Oral Cancer Patients: A Systematic Review

The goal of this review is to shed light on the management of orofacial discomfort after a cancer diagnosis in the head and neck region. A search was conducted on PubMed, Scopus, and Web of Science to identify studies on postoperative pain control in oral cancer. The review included open-access research, investigations into pain management, randomized clinical trials, retrospective studies, case-control studies, prospective studies, English-written studies, and full-text publications. Exclusion criteria included animal studies; in vitro studies; off-topic studies; reviews, case reports, letters, or comments; and non-English language. Three reviewers independently accessed databases and assigned a quality rating to the chosen articles. The review explores postoperative pain management in oral cancer patients; highlighting persistent opioid use; the efficacy of adjuvant drugs, such as gabapentin; and a multimodal approach. It emphasizes the need for personalized pain management, recognizing individual pain perception and tailoring interventions. Integrating pharmacological and non-pharmacological strategies is crucial for comprehensive pain management. The review also serves as a guide for future research, emphasizing the need for standardized methodologies and diverse participant populations.

Virtual reality-guided mindfulness for chronic pain in cancer survivors: protocol for the virtual mind study-a single-group feasibility trial

Background

Chronic cancer-related pain (CRP) can have a significant negative impact on quality of life. Mindfulness is hypothesized to mitigate chronic CRP by regulating both physical and emotional resistance to pain. In recent years, there has been interest in the use of virtual reality (VR) to deliver mindfulness meditation. VR provides an immersive and engaging environment, which may enhance one's focused attention to present-moment experiences, potentially making mindfulness less effortful and more efficacious for individuals with chronic pain. There has been little research in this area for people with a history of cancer.

Objective

The aim of this mixed methods study is to evaluate the feasibility of a VR-guided mindfulness (VRGM) intervention offered to adult cancer survivors with chronic CRP.

Methods

This mixed methods feasibility study will employ a single-arm, pretest-posttest design with semistructured interviews. In total, 15 cancer survivors will be enrolled in a 6-week home-based intervention that consists of 10-15 min of daily VRGM practice. The primary outcome is feasibility as assessed by accrual rates, retention in the study, intervention adherence, questionnaire completion, and side effect rates. Participants will be assessed on psychosocial outcome measures (i.e., pain, sleep, depressive and anxiety symptoms, fatigue, quality of life, and mindfulness) before and after the intervention, and 6 weeks post intervention (follow-up). Changes in pain will be described in relation to levels of immersion and presence in the virtual environment, trait mindfulness, and amount of VRGM practice. Qualitative information will provide subjective detail on participants' experience with VRGM to complement quantitative data. This study has been approved by the Health Research Ethics Board of Alberta Cancer Committee (HREBA.CC-20-0411).

Conclusions

This novel intervention provides a potential alternative treatment to pharmacological pain management. Results from this study may inform future larger VGRM trials for chronic CRP to help reduce suffering in people with cancer. Study findings will be disseminated through open access publications, traditional conference presentations, professional cancer organizations, and social media platforms.

Pain management for persistent pain post radiotherapy in head and neck cancers: systematic review

OBJECTIVES

To systematically review the existing literature for evidence of efficacy around interventions in the management of persistent pain post radiotherapy for head and neck cancers.

METHODS

A systematic review of the literature was conducted to assess the effectiveness and safety of interventions for the management of persistent post-radiotherapy pain in head and neck cancers. The primary outcome evaluated whether an intervention resulted in a reduction in pain which was determined using validated pain tools.

RESULTS

Two randomised controlled trials involving 196 participants fulfilled the inclusion criteria, one evaluating the effect of hypnotherapy and the other evaluating the effect of pregabalin on radiotherapy related pain in head and neck cancer patients. In one study by Thuma et al. (2016) there was a decrease in pain scores in the hypnotherapy group (p<0.001). In the other study, by Jiang et al. (2018) patients treated with pregabalin had a greater reduction in pain intensity, pain severity and a reduction in pain functional interference (p<0.001).

CONCLUSIONS

The findings of our review suggest that in chronic post-radiotherapy pain for head and neck cancers there is very-low level evidence for the use of hypnotherapy in reducing pain scores and for the use of pregabalin in reducing pain intensity, severity, functional interference and psychological distress with significant improvement in quality of life.

Attempts to Understand Oral Mucositis in Head and Neck Cancer Patients through Omics Studies: A Narrative Review

Oral mucositis (OM) is a common and clinically impactful side effect of cytotoxic cancer treatment, particularly in patients with head and neck squamous cell carcinoma (HNSCC) who undergo radiotherapy with or without concomitant chemotherapy. The etiology and pathogenic mechanisms of OM are complex, multifaceted and elicit both direct and indirect damage to the mucosa. In this narrative review, we describe studies that use various omics methodologies (genomics, transcriptomics, microbiomics and metabolomics) in attempts to elucidate the biological pathways associated with the development or severity of OM. Integrating different omics into multi-omics approaches carries the potential to discover links among host factors (genomics), host responses (transcriptomics, metabolomics), and the local environment (microbiomics).

Cryopreventive temperatures prior to chemotherapy

The superiority of oral cryotherapy (OC) for prevention of chemotherapy-induced oral mucositis (OM) has been demonstrated in several trials. In clinical settings, cooling is usually initiated prior to the chemotherapy infusion. It then continues during the infusion, and for a period after the infusion has been completed. While the cooling period post-infusion depends on the half-life of the chemotherapeutic drug, there is no consensus on when cooling should be initiated prior to the infusion. The lowest achieved temperature in the oral mucosa is believed to provide the best condition for OM prevention. Given this, it was of interest to investigate when along the course of intraoral cooling this temperature is achieved. In total, 20 healthy volunteers participated in this randomized crossover trial. Each subject attended three separate cooling sessions of 30 min each, with ice chips (IC) and the intraoral cooling device (ICD) set to 8 and 15 °C, respectively. At baseline and following 5, 10, 15, 20 and 30 min of cooling, intraoral temperatures were registered using a thermographic camera. The greatest drop in intraoral temperature was seen after 5 min of cooling with IC, ICD^8°C and ICD^15°C, respectively. A statistically significant difference, corresponding to 1.4 °C, was seen between IC and the ICD^15°C (p < 0.05). The intraoral temperature further declined throughout the 30 min of cooling, showing an additional temperature reduction of 3.1, 2.2, and 1.7 °C for IC, ICD^8°C and ICD^15°C, respectively.

Effect of the hospital-community-family (HCF) nutritional management on patients with esophageal and head and neck cancers undergoing radiotherapy: a randomized control trial

Background

Malnutrition is particularly common in patients undergoing radiotherapy for head and neck cancers (HNC) and esophageal cancers (EC). Proper nutritional management plays an important role in improving the nutritional status and reducing complications in patients undergoing radiotherapy for malignancy. With most nutrition studies limited to the nutritional management of patients during hospitalization or after discharge, there is a lack of research evidence on the nutritional management of patients in combination with out-of-hospital. The aim of this study was to evaluate the effect of the hospital-community-family (HCF) nutritional management model on nutritional status and radiotherapy complications in EC and HNC radiotherapy patients.

Methods

Between October 2019 and October 2021, a total of 116 EC and HNC radiotherapy patients were randomized into control group (conventional nutritional support) and experimental group (HCF-model nutritional management), and assessed weekly for 3 months. The primary endpoint was the patient's Nutrition Risk Screening 2002 (NRS2002) score, Scored Patient-Generated Subjective Global Assessment (PG-SGA), weight change, and Eastern Cooperative Oncology Group (ECOG) score from baseline level to 3 months after the end of treatment. The secondary endpoints were the incidence of albumin, hemoglobin, hematological parameters, and radiotherapy complications.

Results

A total of 95 patients (47 in the control group and 48 in the experimental group) completed the study. At 3 months after treatment, NRS2002 (P=0.028) and PG-SGA (P=0.022) decreased, and albumin was higher (P=0.001) than at the beginning of treatment in HCF group. Weight decreased (P<0.001) and PG-SGA was higher after 3 months of treatment (P=0.012) in the control group. PG-SGA (P<0.001), NRS2002 (P<0.001), and ECOG (P=0.006) in the HCF group at the end of the 3-month treatment period were lower in the conventional group (P<0.05). The incidence of radiation mucositis (P=0.018)and radiation dermatitis (P=0.028) in the HCF nutrition management group was significantly reduced (P<0.05).

Conclusions

HCF-model nutritional management significantly improved the nutritional status and reduced the incidence and severity of radiation mucositis and dermatitis for EC and HNC radiotherapy patients. These findings suggest that HCF-model nutritional management is a promising nutritional management model.

Trial Registration

Chinese Clinical Trial Registry identifier: ChiCTR2300068399.

Patient-reported oral mucositis in solid tumour patients undergoing chemotherapy: a Ugandan experience

Purpose

The mitotic rate of the gastrointestinal tract (GIT) mucosa predisposes the entire system to chemotherapeutic-induced mucositis but the oral cavity due to its accessibility provides an opening to evaluate the extent of the problem much more easily. In addition, the oral cavity being the gateway to the GIT affects the feeding ability of the patient when the ulcers set in.It is therefore from this perspective that we embarked on a study to evaluate the extent of mucositis among patients being treated for solid tumours at our centre.

Methods

Using the mouth and throat soreness (OMDQ MTS) questionnaire, we prospectively evaluated mucositis among 100 patients undergoing chemotherapy for solid tumours at the Uganda Cancer Institute. In addition to patient reported outcomes, we also had clinician assessed mucositis measurements.

Results

Approximately, 50% of the participants were breast cancer patients. The results demonstrated that patient assessment of mucositis is possible in our setting at a 76% full compliance rate. Up to 30% of our patients reported moderate-to-severe mucositis, though the figure was lower as assessed by the clinicians.

Conclusions

The self-reported OMDQ MTS can be useful in our setting for daily mucositis evaluation, hence leading to timely hospital visits before the manifestation of severe complications.

A comparative study to assess the effectiveness of curcumin, mucosamin, and chlorhexidine in chemotherapy-induced oral mucositis

BACKGROUND

Oral mucositis is one of the most frequent and challenging side effects of chemotherapy. At present, none of the guidelines recommend the use of various mouthwashes available for the treatment of oral mucositis.

METHODS

This study was designed to evaluate the efficacy of curcumin, mucosamin, and chlorhexidine in the treatment of chemotherapy-induced oral mucositis. In this randomized and double-blind study, 71 patients over 18 years, who received chemotherapy and suffered from chemotherapy-induced oral mucositis, were randomized into curcumin, mucosamin, and chlorhexidine groups. The World Health Organization (WHO) Oral Toxicity Scale, the Oral Mucositis Assessment Scale (OMAS), and the Numerical Rating Scale (NRS) were used to evaluate oral mucositis. The main endpoint included the onset of complete recovery after starting the treatment.

FINDINGS

Based on the WHO, OMAS for erythema, and NRS criteria, complete recovery was achieved from the third day in the curcumin group, which was significantly earlier compared to the other two groups (P < 0.05). The OMAS score for ulceration represented an improvement from day 5 in the curcumin group, which was significantly faster compared to the other two groups (P = 0.04).

CONCLUSIONS

Our results indicated that all three approaches were effective in improving oral mucositis; however, curcumin could result in faster recovery in comparison with mucosamin and chlorhexidine. The use of curcumin in the treatment of oral mucositis appears to be a viable intervention for reducing potential compromise to treatment and improving the quality of life.

Immune infiltration could predict the efficacy of short-term radiotherapy in patients with cervical cancer

Radiotherapy is the main treatment for cervical cancer. It is usually applied alone or in combination with surgery and/or chemotherapy. To explore the association between immune microenvironment of cervical cancer and radiotherapy response, we collected 20 paired cervical cancer tumor samples before and after radiotherapy and partial clinical information. With paired-end RNA-seq, we quantified the immune infiltration and tumor purity of these samples, and obtained 6350 differentially expressed genes before and after radiotherapy. With the help of R language, the function enrichment analysis and 22 immune cells infiltration analysis were carried out. Moreover, we built a random forest model based on the immune microenvironment to predict the short-term efficacy of radiotherapy. We found that the effect of radiotherapy on the immune microenvironment of stage III and IV cervical cancer patients was weaker than that of stage I and II cervical cancer patients. Radiotherapy can significantly reduce the tumor purity and increase immune infiltration. The proportions of the immune infiltrating cells are predictive of the radiotherapy efficacy. In addition, the local mucositis caused by radiotherapy can improve the curative effect of radiotherapy.

Prophylactic management of radiation-induced mucositis using herbal mouthwash in patients with head and neck cancer: an assessor-blinded randomized controlled trial

OBJECTIVES

Radiation-induced mucositis (RIOM) is one of the most common side effects from head and neck radiotherapy. Several reagents have been introduced to manage the symptom; however, there is still a limited number of effective reagents. Herbal mouthwashes with payayor (Clinacanthus nutans Lindau) and fingerroot (Boesenbergia rotunda) were tested their efficacies in preventing and reducing severity of RIOM in comparison with normal saline with sodium bicarbonate.

METHODS

One hundred twenty patients with head and neck cancer undergoing radiotherapy participated in the study and were randomly assigned into three treatment groups using block randomization method. The participants were assigned one of the three mouthwashes for use throughout their radiotherapy course and were assessed for their mucositis scores from week one to six into their radiotherapy course as well as at one-month follow-up. Body mass index was also measured for comparison of nutritional status.

RESULTS

The two mouthwashes were similarly effective in prophylaxis of RIOM in term of severity. The averaged mucositis scores were less than two for all groups. For the onset of RIOM, both herbal mouthwashes could slightly delay the symptom but not statistically significant. Patients' body mass index across the three treatment groups was also comparable. The patients were largely satisfied with all the mouthwashes with no clear preference on any of them.

CONCLUSIONS

Prophylactic treatment of RIOM using herbal mouthwashes could substitute the current standard of normal saline with bicarbonate. A different formulation of the two herbs could potentially improve the prophylactic outcome.

TRIAL REGISTRATION NO

NCT03359187.

Evaluation of the antiapoptotic and anti-inflammatory properties of chitosan in methotrexate-induced oral mucositis in rats

BACKGROUND

Methotrexate (MTX), a chemotherapeutic agent, is known to cause oral mucositis. Chitosan has been shown to have a protective effect in inflammatory animal models. This research aimed to examine the protective effect of chitosan against oral mucositis caused by MTX.

METHODS AND RESULTS

Wistar albino rats were randomly divided into three groups. Control (n = 8), (saline via oral gavage for 5 days), MTX (n = 8), (60 mg/kg single dose MTX intraperitoneally on the 1st day and for the following 4 days saline via oral gavage), and MTX + chitosan (n = 8), (1st day single dose 60 mg/kg MTX intraperitoneally and followed with 200 mg/kg chitosan via oral gavage for 4 days). After 24 h of the last dose, the animals were euthanised. Blood, tongue, buccal and palatal mucosa tissues were collected. Serum interleukin 1-beta (IL1-β), tumour necrosis factor-alpha (TNF-α), matrix metalloproteinase (MMP-1, and MMP-2) activities, tissue bcl-2/bax ratio and the expression of caspase-3 (casp-3), and casp-9 were detected. The tissues were also examined histologically. Serum TNF-α, IL1-β, MMP-1 and MMP-2 activities and tissue casp-3 and casp-9 activities significantly increased but the bcl-2/bax ratio significantly decreased in the MTX group compared those of the control group. Histologically, diffuse inflammatory cells were observed in MTX group. However, In the MTX + chitosan group, all the values were close to those of the control group.

CONCLUSION

It was demonstrated that chitosan has a protective effect against oral mucosal damage caused by MTX. Thus, it may be a candidate agent against MTX induced oral mucositis.

The effect of topical chamomile in the prevention of chemotherapy-induced oral mucositis: A randomized clinical trial

OBJECTIVE

To clinically assess the effectiveness of topical chamomile oral gel in the prevention of chemotherapy-induced oral mucositis.

MATERIAL AND METHODS

A parallel single-blind randomized clinical trial conducted on 45 patients who were undergoing chemotherapy. Patients were assigned to three equal groups. Group I received conventional symptomatic treatment that included antifungal agents (Miconaz oral gel, Medical Union Pharmaceuticals), topical anesthetics, and anti-inflammatory agent (BBC oral spray, Amoun Pharmaceutical Company) three times per day for three weeks, group II received 3% chamomile topical oral gel, whereas group III patients were given both conventional symptomatic treatment and chamomile topical oral gel. All patients were clinically assessed for pain and oral mucositis severity at three separate time intervals: 1 week, 2 weeks, and 3 weeks.

RESULTS

Most patients experienced oral mucositis with more severity reported in the conventional group (grade III = 6.7%) compared to the other two groups, neither of which developed more than grade II. Mean pain scores showed no significant difference between the groups, but intragroup analysis showed that pain score increased in the conventional treatment group more than the other two groups.

CONCLUSION

Topical chamomile 3% gel has demonstrated in this study to lower the severity of the mucositis with lower pain scores compared to the other two groups.

Protective effects of resveratrol against 5-fluorouracil-induced oxidative stress and inflammatory responses in human keratinocytes

Although 5-fluorouracil (5-FU) is currently used as an anti-cancer chemotherapy, adverse effects such as oral mucositis potentially limit its clinical application. Additionally, the prevention of 5-FU-induced side effects are scarce. Resveratrol is known to decrease oxidative damage and inflammation. In this study, we examined the protective effects of resveratrol on 5-FU-induced oxidative stress and inflammatory responses in normal human keratinocytes (HaCaT cell) as in vitro oral mucositis model. HaCaT cells were exposed to 5-FU and simultaneously treated with resveratrol. The effects of resveratrol on 5-FU-induced cytotoxicity were evaluated using cell viability assay. The production of reactive oxygen species (ROS) was measured using a fluorescence spectrophotometer. The effects of resveratrol on nuclear factor erythroid 2-related factor 2 (Nrf2), silent information regulator transcript-1 (SIRT-1), and nuclear factor kappa B (NF-κB) signaling and inflammatory cytokine expression were examined. Resveratrol suppressed 5-FU-induced overproduction of ROS by upregulating anti-oxidant defense genes through Nrf2 activation and SIRT-1 expression. Concerning inflammatory responses, resveratrol suppressed the 5-FU-induced expression of pro-inflammatory cytokines via NF-κB nuclear translocation. Conversely, N-acetylcysteine reduced ROS levels without affecting the expression of pro-inflammatory cytokines. Resveratrol might be useful for preventing 5-FU-induced adverse effects by activating anti-oxidant and anti-inflammatory responses.

Antarctic Strain of Rhodotorula mucilaginosa UFMGCB 18,377 Attenuates Mucositis Induced by 5-Fluorouracil in Mice

Mucositis is one of the most strenuous side effects caused by chemotherapy drugs, such as 5-fluorouracil (5-FU), during the treatment of several types of cancers. The disease is so prevalent and aggressive that many patients cannot resist such symptoms. However, despite its frequency and clinical significance, there is no effective treatment to prevent or treat mucositis. Thus, the use of probiotics as an adjuvant for the treatment has gained prominence. In the present study, we evaluated the effectiveness of oral administration of the Antarctic strain of Rhodotorula mucilaginosa UFMGCB 18,377 as an alternative to minimize side effects of 5-FU-induced mucositis in mice. Body weight, food consumption, stool consistency, and presence of blood in the feces were assessed daily in mice orally treated or not with the yeast and submitted or not to experimental mucositis. Blood, bones, and intestinal tissues and fluid were used to determine intestinal permeability and immunological, microbiological, and histopathological parameters. Treatment with R. mucilaginosa UFMGCB 18,377 was able to decrease clinical signs of the disease, such as reduction of food intake and body weight loss, and also decreased the number of intestinal enterobacteria and intestinal length shortening. Additionally, treatment was able to decrease the levels of MPO and EPO activities and inflammatory infiltrates, as well as the histopathological lesions characteristic of mucositis in the jejunum and ileum. Results of the present study showed that the oral administration of R. mucilaginosa UFMGCB 18,377 protected mice against mucositis induced by 5-FU.

A randomized controlled trial of manual versus powered tooth brushing during haematopoietic stem cell transplantation

Aim

To compare manual and powered tooth brushing (MT and PT) with respect to patient compliance to brushing frequency advice, plaque removal and severity of oral mucositis (OM) in patients undergoing hematopoietic stem cell transplantation (HSCT) after high‐dose chemotherapy.

Materials & methods

A randomized controlled trial was conducted. Forty‐six patients scheduled to receive myeloablative conditioning regimen before autologous HSCT were included and randomly assigned to control (MT, n = 23) or test (PT, n = 23) groups. Starting at day 1 (day of hospital admission for HSCT), brushing frequency (patient recorded diary), plaque scores (Plaque Control Index) and oral mucositis (Oral Mucositis Nursing Index) were recorded daily. Data for days 1 to 17 were analysed using regression analysis and general linear models.

Results

Few patients maintained 4 times per day brushing, but most brushed at least 2 times per day throughout the study. In PT, overall plaque scores were lower by 6.98% (p = .006) as compared to MT. No differences were seen in OM scores between the groups (p = .968). A small but significant positive correlation was found between plaque scores and OM severity: R²=0.15 (p < .01).

Conclusions

Powered tooth brushing resulted in lower plaque scores, but was not associated with reduced OM severity. Individual plaque scores were positively related to OM severity.

Drug Delivery (Nano)Platforms for Oral and Dental Applications: Tissue Regeneration, Infection Control, and Cancer Management

The oral cavity and oropharynx are complex environments that are susceptible to physical, chemical, and microbiological insults. They are also common sites for pathological and cancerous changes. The effectiveness of conventional locally-administered medications against diseases affecting these oral milieus may be compromised by constant salivary flow. For systemically-administered medications, drug resistance and adverse side-effects are issues that need to be resolved. New strategies for drug delivery have been investigated over the last decade to overcome these obstacles. Synthesis of nanoparticle-containing agents that promote healing represents a quantum leap in ensuring safe, efficient drug delivery to the affected tissues. Micro/nanoencapsulants with unique structures and properties function as more favorable drug-release platforms than conventional treatment approaches. The present review provides an overview of newly-developed nanocarriers and discusses their potential applications and limitations in various fields of dentistry and oral medicine.

An Evidence-Based Research on Botanical Sources for Oral Mucositis Treatment in Traditional Persian Medicine

BACKGROUND

Cancer is one of the most prevalent diseases associated with heavy complications in treatment. Mucotoxic cancer therapies such as head and neck radiotherapy and some of the chemotherapy agents may lead to oral mucositis. In addition to its economic consequences, mucositis also affects patients' quality of life. In Traditional Persian Medicine (TPM) manuscripts, several medicaments have been suggested for the treatment of mucositis.

OBJECTIVE

Considering the public welcome for herbal medicine, the current evidence-based review study is conducted to investigate the herbal remedies which have been proposed for oral mucositis in TPM.

METHODS

At first, a comprehensive survey was done on Qanon fi al-Teb, which is the most important textbook of TPM; then the scientific name of the herbs was authenticated according to the botanical textbooks. At last, data banks including Scopus, Pubmed, Web of science and Science direct were investigated for possible relevant properties of each medicinal plant in the literature.

RESULTS

In total, 30 herbs are introduced in this study. According to the registered documents, 18 herbs are reported to have antioxidant, anti-inflammatory, antimicrobial, anti-nociceptive and wound healing properties of which the therapeutic effect of only a few herbs including Glycyrrhiza glabra, Malva sylvestris, Morus nigra, Punica granatum, and Solanum nigrum were directly evaluated against oral mucositis on the literature.

CONCLUSION

Despite the lack of human studies on mucositis for the other discussed herbs, their related pharmacological properties can be considered for new natural drug discovery supported by medieval and traditional experiments.

Cutaneous reactions to pediatric cancer treatment: Part I. Conventional chemotherapy

Chemotherapies often cause side effects of the skin, nails, and mucosal surfaces. These mucocutaneous toxicities contribute to morbidity and affect quality of life. Identification and management of these drug-induced eruptions is vital to allow for continuation of essential therapies. This review demonstrates the wide range of chemotherapy-induced cutaneous toxicities in children and includes clues for diagnosis as well as tips for counseling and management.

Palliative oral care in patients undergoing radiotherapy: Integrated review

Maintaining a patient's quality of life is main the aim while treating cancer patients. Patients getting treated for oral cancer encountered with numerous symptoms at the time of radiotherapy and most of these are side effect which can persist even after few months to year after the treatment gets over. Radiotherapy is a vital aspect of both curative and palliative cancer care. Understanding the basics complications of radiotherapy along with its primary management of oral symptoms can assist family physicians in providing complete primary care for their cancer patients. Palliative oral care helps to ease symptoms from the cancer treatment. Oral care negligence is still a major cause of worsening of posttreatment quality of life of an individual. The article mainly empathies on the oral health care need to be taken care by primary care physicians in the cancer patients during and after the radiotherapy. Consequences associated with radiotherapy in oral cavity and its systematic overview of preventing and managing acute and chronic condition. It enlightens the importance of dentist role on improving quality of life of these patients.

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.

Pathogenesis and Treatment of Pancreatic Cancer Related Pain

Pancreatic cancer is often diagnosed due to the patient seeking medical attention for abdominal pain. It is among the most painful cancers, with pain severity strongly correlating with prognosis. Perineural invasion is a prominent feature of pancreatic cancer and often the first route of metastasis resulting in neuropathic pain. While surgical pain is present, it is generally short-lived; chemo- and radio-therapy associated side effect pain is often longer lasting and more difficult to manage. Treatment-induced mucositis in response to chemotherapy occurs throughout the GI tract resulting in infection-prone ulcers on the lip, buccal mucosa, palate or tongue. Cisplatin treatment is associated with axonal neuropathy in the dorsal root ganglion, although other large sensory fibers can be affected. Opioid-induced hyperalgesia can also emerge in patients. Along with traditional means to address pain, neurolytic celiac plexus block of afferent nociceptive fibers has been reported to be effective in 74% of patients. Moreover, as cancer treatments become more effective and result in improved survival, treatment-related side effects become more prevalent. Here, pancreatic cancer and treatment associated pain are reviewed along with current treatment strategies. Potential future therapeutic strategies to target the pathophysiology underlying pancreatic cancer and pain induction are also presented.

A new recombinant MS-superoxide dismutase alleviates 5-fluorouracil-induced intestinal mucositis in mice

Intestinal mucositis is a common side effect of anticancer regimens that exerts a negative impact on chemotherapy. Superoxide dismutase (SOD) is a potential therapy for mucositis but efficient product is not available because the enzyme is degraded following oral administration or induces an immune reaction after intravascular infusion. Multi-modified Stable Anti-Oxidant Enzymes^® (MS-AOE^®) is a new recombinant SOD with better resistance to pepsin and trypsin. We referred it as MS-SOD to distinguish from other SODs. In this study we investigated its potential to alleviate 5-FU-induced intestinal injury and the mechanisms. An intestinal mucositis model was established in C57/BL6 mice by 5-day administration of 5-FU (50 mg/kg every day, ip). MS-SOD (800 IU/10 g, ig) was given once daily for 9 days. 5-FU caused severe mucositis with intestinal morphological damage, bodyweight loss and diarrhea; MS-SOD significantly decreased the severity. 5-FU markedly increased reactive oxygen species (ROS) and inflammatory cytokines in the intestine which were ameliorated by MS-SOD. Furthermore, MS-SOD modified intestinal microbes, particularly reduced Verrucomicrobia, compared with the 5-FU group. In Caco2 cells, MS-SOD (250–1000 U/mL) dose-dependently decreased tBHP-induced ROS generation. In RAW264.7 cells, MS-SOD (500 U/mL) had no effect on LPS-induced inflammatory cytokines, but inhibited iNOS expression. These results demonstrate that MS-SOD can scavenge ROS at the initial stage of injury, thus play an indirect role in anti-inflammatory and barrier protein protection. In conclusion, MS-SOD attenuates 5-FU-induced intestinal mucositis by suppressing oxidative stress and inflammation, and influencing microbes. MS-SOD may exert beneficial effect in prevention of intestinal mucositis during chemotherapy in clinic.

Efficacy of Melatonin in prevention of radiation-induced oral mucositis: A randomized clinical trial

OBJECTIVES

Evaluating the effectiveness of melatonin in prevention of radiation-induced oral mucositis.

MATERIAL AND METHODS

A randomized controlled clinical study was conducted on forty head and neck cancer (HNC) patients undergoing radiotherapy at the Department of Clinical Oncology, Alexandria University, Egypt. Patients were assigned equally to either control group who received conventional treatment or test group who received 20 mg of melatonin along with the conventional treatment. All patients were clinically evaluated for oral mucositis severity and pain at three and six weeks after the start of radiotherapy. Additionally, the total antioxidant capacity (TAC) in patients' saliva samples was assessed at the start of radiotherapy and six weeks later.

RESULTS

92.5% of all patients have experienced oral mucositis with more severity reported in the control group (30%) compared with the test group (5%). Mean pain scores decreased significantly, in the second assessment, in test group rather than the controls. TAC values showed a significant difference between the test and controls with a significant decrease in TAC in the control group.

CONCLUSION

The administration of melatonin with conventional treatment has reduced severe oral mucositis development. It aided in decreasing pain and hindering the reduction of TAC resulting from radiotherapy among the test group compared with controls.

Young head and neck cancer patients are at increased risk of developing oral mucositis and trismus

OBJECTIVES

To evaluate cancer treatment-related toxicities in young head and neck cancer (HNC) patients.

MATERIAL AND METHODS

A total of 44 patients were included in the present retrospective cohort study, which was designed to access oral toxicities of cancer treatment in young (< 45 years of age, Group I, n = 22) and old (> 58 years of age, Group II, n = 22) HNC patients with similar tumor stage and treatment protocols. Oral mucositis (OM), xerostomia, dysphagia, dysgeusia, trismus, and radiodermatitis were assessed during days 7th, 21st, and 35th of head and neck radiotherapy (HNRT) according to previously validated scales (World Health Organization criteria and the National Cancer Institute and Common Terminology Criteria for Adverse Events version 4.0).

RESULTS

Patients from both groups showed high incidence and severity of oral toxicities by the end of the HNRT with OM (81.9% (Group I); 63.6% (Group II)) and xerostomia (72.6% (Group I); 77.2% (Group II)) being the most prevalent toxicities. No differences regarding xerostomia, dysphagia, dysgeusia, and radiodermatitis incidences or severity could be observed between groups. However, higher incidences and severity of OM at 21st and 35th fractions (odds ratio = 2.22 and 5.71, respectively) and trismus at 21st and 35th fractions (odds ratio = 6.17 and 14.5, respectively) were observed throughout the treatment in young patients when compared to older patients (p < 0.01 and p < 0.05, respectively).

CONCLUSION

Young HNC patients are more affected by cancer treatment-related OM and trismus despite the similarities in clinical staging and treatment protocols with elderly patients.

Use of the Rat Grimace Scale to Evaluate Visceral Pain in a Model of Chemotherapy-Induced Mucositis

Simple Summary

Mucositis is a painful and often debilitating condition associated with cancer treatment. Management of associated symptoms is an important clinical consideration. Animal models are used in mucositis research to model the condition in humans in order to develop novel therapeutic agents to relieve symptoms. Previous animal studies have focused on disease severity and outcomes, but often failed to measure pain. The rat grimace scale (RGS) is a validated observational measure used to gauge pain levels experienced by rats. The aim of this study was to assess the rat grimace scale in a rat model of mucositis, and to examine whether changes in clinical signs and anxiety reflected the grimace responses recorded. We also aimed to determine whether the responses were pain-specific by administering potent opioid painkilling agents. In the present study rat grimace scores did not change significantly between treatments. Development of reliable pain assessment methods in animal models is urgently required to improve model relevance to human clinical practice, in addition to safeguarding animal welfare.

Abstract

The rat grimace scale (RGS) is a measure of spontaneous pain that evaluates pain response. The ability to characterize pain through a non-invasive method has considerable utility for numerous animal models of disease, including mucositis, a painful, self-limiting side-effect of chemotherapy treatment. Preclinical studies investigating novel therapeutics for mucositis often focus on pathological outcomes and disease severity. These investigations fail to measure pain, in spite of reduction of pain being a key clinical therapeutic goal. This study assessed the utility of the RGS for pain assessment in a rat model of mucositis, and whether changes in disease activity index (DAI) and open field test (OFT) reflected the grimace responses recorded. Sixty tumor-bearing female Dark Agouti rats were injected with either saline or 5-Fluourouracil alone, or with co-administration of opioid analgesics. Whilst differences in DAI were observed between treatment groups, no difference in RGS scores or OFT were demonstrated. Significant increases in grimace scores were observed across time. However, whilst a statistically significant change may have been noted, the biological relevance is questionable in terms of practical usage, since an observer is only able to score whole numbers. Development of effective pain assessment methods in animal models is required to improve welfare, satisfy regulatory requirements, and increase translational validity of the model to human patients.

Regulation of HMGB1 release protects chemoradiotherapy-associated mucositis

Oral mucositis (OM) is a common complication in cancer patients undergoing anticancer treatment. Despite the clinical and economic consequences of OM, there are no drugs available for its fundamental control. Here we show that high-mobility group box 1 (HMGB1), a "danger signal" that acts as a potent innate immune mediator, plays a critical role in the pathogenesis of OM. In addition, we investigated treatment of OM through HMGB1 blockade using NecroX-7 (tetrahydropyran-4-yl)-[2-phenyl-5-(1,1-dioxo-thiomorpholin-4-yl)methyl-1Hindole-7-yl]amine). NecroX-7 ameliorated basal layer epithelial cell death and ulcer size in OM induced by chemotherapy or radiotherapy. This protective effect of NecroX-7 was mediated by inhibition of HMGB1 release and downregulation of mitochondrial oxidative stress. Additionally, NecroX-7 inhibited the HMGB1-induced release of tumor necrosis factor-alpha (TNF-α), interleukin (IL)-1β, and macrophage inflammatory protein (MIP)-1β, as well as the expression of p53-upregulated modulator of apoptosis (PUMA) and the excessive inflammatory microenvironment, including nuclear factor-kB (NF-kB) pathways. In conclusion, our findings suggest that HMGB1 plays a key role in the pathogenesis of OM; therefore, blockade of HMGB1 by NecroX-7 may be a novel therapeutic strategy for OM.

Meta-analysis of oral cryotherapy in preventing oral mucositis associated with cancer therapy

AIMS

To review scientific evidence related to oral cryotherapy to prevent oral mucositis after cancer therapy.

BACKGROUND

Oral mucositis is a common complication of cancer therapy. In the most severe form of oral mucositis, patients cannot eat or drink at all and must receive nutrition and fluid replacement through parenteral support. Topical cooling of the oral mucosa may be an option for the prevention of oral mucositis.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

The literature search was performed using the Ovid MEDLINE, Embase, Cochrane Library, and CINAHL Complete electronic databases for articles published up to 2017. The reference lists of all retrieved articles were manually reviewed to identify additional relevant studies.

RESULTS

Of 353 publications, 15 randomized controlled trials, involving 919 cancer patients, conducted between 1994 and 2017 were included in the present meta-analysis. Oral cryotherapy, applied during treatment of solid cancers, led to a statistically lower level (P < .05) of oral mucositis overall, and of the more severe grades (3-4 and 2-4).

CONCLUSIONS

Results of this study provide a scientific basis for oral cryotherapy as a viable nursing intervention that can significantly reduce the occurrence of severe oral mucositis.

Effects of Glycine on Collagen, PDGF, and EGF Expression in Model of Oral Mucositis

Oral mucositis is frequently a toxic effect of chemotherapeutic and/or radiotherapeutic treatment, resulting from complex multifaceted biological events involving DNA damage. The clinical manifestations have a negative impact on the life quality of cancer patients. Preventive measures and curative treatment of mucositis are still not well established. The glycine has anti-inflammatory, immunomodulatory, and cytoprotective actions, being a potential therapeutic in mucositis. The objective was to evaluate the effects of glycine on the expression of collagen and growth factors, platelet and epidermal in a hamster model oral mucositis. The mucositis was induced by the protocol of Sonis. There were 40 hamsters used, divided into two groups: Group I-control; Group II-supplemented with 5% intraperitoneal glycine, 2.0 mg/g diluted in hepes. Histopathological sections were used to perform the immune-histochemical method, the evaluation of collagen expression, and the growth factors: Epidermal growth factor (EGF) and platelet (PDGF). It was observed that the group supplemented with glycine experienced higher amounts of collagen expression and predominance type of collagen I. The glycine group presented lower immunoexpression of the growth factors, EGF and PDGF. The group supplemented with glycine showed a marked healing process of the oral mucosite, demonstrated by the predominance of collagen type I and reduction of growth factors, EGF and PDGF.

Adjunctive Treatments for the Prevention of Chemotherapy- and Radiotherapy-Induced Mucositis

Background: Chemoradiotherapy-associated mucositis can manifest as pain, inflammation, dysphagia, diarrhea, weight loss, rectal bleeding, and infection. Mucositis is a major dose-limiting side effect of chemotherapy, affecting nutritional intake and oral and intestinal function. Despite several interventions being available, there is a need for safe and effective preventative and treatment options for treatment-induced mucositis. The goals of this review are to discuss interventions based on foods and natural products and present the research to date. Methods: A narrative literature review identified 60 clinical studies examining various nutritional compounds and 20 examining probiotics. 9 studies on probiotics for the prevention of diarrhea were also assessed on methodological quality and limitations identified. Results: Several compounds have been posited as useful adjuvants for cancer treatment–related mucositis. Probiotics demonstrate efficacy for the prevention and treatment of chemoradiotherapy-induced gastrointestinal toxicity without significant side effects. Glutamine and activated charcoal were reported to reduce chemotherapy-induced diarrhea but not radiation-induced intestinal mucositis. Honey has been reported to decrease treatment interruptions, weight loss, and delays the onset of oral mucositis. Zinc, glutamine, and topical vitamin E were demonstrated efficacy for oral mucositis. Conclusion: There is plausible clinical evidence for the administration of several adjunctive treatments for the prevention and treatment of mucositis. Probiotics were reported to reduce the burden of intestinal mucositis and treatment-induced diarrhea. Activated charcoal and glutamine are beneficial for chemotherapy-induced diarrhea, whereas the administration of honey, zinc, and glutamine reduce the risk of developing oral mucositis during chemotherapy or radiotherapy.

Drug-Drug Interactions, Safety, and Pharmacokinetics of EGFR Tyrosine Kinase Inhibitors for the Treatment of Non-Small Cell Lung Cancer

Inhibitors of the epidermal growth factor receptor (EGFR) are important treatment options for non-small cell lung cancer (NSCLC) patients with activating EGFR mutations. Erlotinib, gefitinib, afatinib, and osimertinib are approved for use in NSCLC patients, and several other agents are in clinical development. The objectives of this article are to review the pharmacokinetic and known drug interaction data for EGFR tyrosine kinase inhibitors (TKIs) available for use in NSCLC patients, as well as adverse events (AEs) commonly observed with EGFR-TKI treatment, and to discuss relevant management strategies. The importance of this information for patient care is explored from the perspective of advanced practitioners. Pharmacokinetic, drug-interaction, and safety data are included for EGFR inhibitors approved for NSCLC (erlotinib, gefitinib, afatinib, and osimertinib). Relevant dose modifications and AE management strategies are also reviewed. The interdisciplinary health-care team plays an essential role in patient education, care planning, and medication administration. As such, it is essential that advanced practitioners understand the safety profiles and the potential for drug interactions with EGFR TKIs to ensure patients achieve the maximum benefit from these agents.

Efficacy of Plantago major, chlorhexidine 0.12% and sodium bicarbonate 5% solution in the treatment of oral mucositis in cancer patients with solid tumour: A feasibility randomised triple-blind phase III clinical trial

PURPOSE

Oral mucositis is one of the most common adverse effects of chemotherapy and radiotherapy. The aim of this study was to compare the efficacy of Plantago major extract versus chlorhexidine 0.12% versus sodium bicarbonate 5% in the symptomatic treatment of chemotherapy-induced oral mucositis in solid tumour cancer patients.

METHOD

Multicentre randomised controlled trial estimated sample of 45 solid tumour patients with grade II-III mucositis. The participants were randomised to one of three treatments, consisting of sodium bicarbonate 5% aqueous solution together with: an additional dose of sodium bicarbonate 5% aqueous solution, Plantago major extract, or chlorhexidine 0.12%. The primary outcomes were severity of mucositis, pain intensity, oral intake capacity and quality of life. The independent variable was treatment group, and confounders included sociodemographic data, neutrophil count, chemotherapy drug and dose received.

RESULTS

Of the 50 patients enrolled, 68% (n = 34) achieved grade 0 mucositis (none), with those using the double sodium bicarbonate rinse healing in five days on average (95% CI 3.9, 6.5) versus seven days (95% CI 5.3, 9,0) for the chlorhexidine group and seven days (95% CI 5.3, 8.5) for the Plantago major group. The pain experienced by the participants lessened over the 14 days of treatment, but differences in pain intensity between the three groups did not show statistical significance (p = 0.762).

CONCLUSIONS

Healing time was shorter with the double sodium bicarbonate solution compared to the other two rinses, but the differences were not significant. Our results suggest it may be time to reconsider the use of Plantago major extract in the management of oral mucositis.

miRNAs: Important Targets for Oral Cancer Pain Research

Pain is a symptom shared by an incredible number of diseases. It is also one of the primary conditions that prompt individuals to seek medical treatment. Head and neck squamous cell carcinoma (HNSCC) corresponds to a heterogeneous disease that may arise from many distinct structures of a large, highly complex, and intricate region. HNSCC affects a great number of patients worldwide and is directly associated with chronic pain, which is especially prominent during the advanced stages of oral squamous cell carcinoma (OSCC), an anatomical and clinical subtype that corresponds to the great majority oral cancers. Although the cellular and molecular bases of oral cancer pain have not been fully established yet, the results of recent studies suggest that different epigenetic mechanisms may contribute to this process. For instance, there is strong scientific evidence that microRNAs (miRNAs), small RNA molecules that do not encode proteins, might act by regulating the mechanisms underlying cancer-related pain. Among the miRNAs that could possibly interfere in pain-signaling pathways, miR-125b, miR-181, and miR-339 emerge as some of the most promising candidates. In fact, such molecules apparently contribute to inflammatory pain. Moreover, these molecules possibly influence the activity of endogenous pain control systems (e.g., opioidergic and serotonergic systems), which could ultimately result in peripheral and central sensitization, central nervous system (CNS) phenomena innately associated with chronic pain. This review paper focuses on the current scientific knowledge regarding the involvement of miRNAs in cancer pain, with special attention dedicated to OSCC-related pain.

Identifying novel genes and biological processes relevant to the development of cancer therapy-induced mucositis: An informative gene network analysis

Mucositis is a complex, dose-limiting toxicity of chemotherapy or radiotherapy that leads to painful mouth ulcers, difficulty eating or swallowing, gastrointestinal distress, and reduced quality of life for patients with cancer. Mucositis is most common for those undergoing high-dose chemotherapy and hematopoietic stem cell transplantation and for those being treated for malignancies of the head and neck. Treatment and management of mucositis remain challenging. It is expected that multiple genes are involved in the formation, severity, and persistence of mucositis. We used Ingenuity Pathway Analysis (IPA), a novel network-based approach that integrates complex intracellular and intercellular interactions involved in diseases, to systematically explore the molecular complexity of mucositis. As a first step, we searched the literature to identify genes that harbor or are close to the genetic variants significantly associated with mucositis. Our literature review identified 27 candidate genes, of which ERCC1, XRCC1, and MTHFR were the most frequently studied for mucositis. On the basis of this 27-gene list, we used IPA to generate gene networks for mucositis. The most biologically significant novel molecules identified through IPA analyses included TP53, CTNNB1, MYC, RB1, P38 MAPK, and EP300. Additionally, uracil degradation II (reductive) and thymine degradation pathways (p = 1.06-08) were most significant. Finally, utilizing 66 SNPs within the 8 most connected IPA-derived candidate molecules, we conducted a genetic association study for oral mucositis in the head and neck cancer patients who were treated using chemotherapy and/or radiation therapy (186 head and neck cancer patients with oral mucositis vs. 699 head and neck cancer patients without oral mucositis). The top ranked gene identified through this association analysis was RB1 (rs2227311, p-value = 0.034, odds ratio = 0.67). In conclusion, gene network analysis identified novel molecules and biological processes, including pathways related to inflammation and oxidative stress, that are relevant to mucositis development, thus providing the basis for future studies to improve the management and treatment of mucositis in patients with cancer.

Alleviation of 5-fluorouracil-induced intestinal mucositis in rats by vitamin E via targeting oxidative stress and inflammatory markers

BackgroundIntestinal mucositis is a major concern related with cancer therapy. It is well established that overproduction of reactive oxygen species and inflammatory mediators plays vital role in the pathogenesis of mucositis. The aim of the study was to investigate the modulatory effect of vitamin E (vit. E) on 5-fluorouracil (5-FU)-induced intestinal mucositis by targeting oxidative stress and inflammatory markers in rats. MethodsRats were randomly divided into four groups of six animals each. All four-group animals received normal standard diet and water throughout the experimental period which last up to 10 days. Rats were gavaged with vit. E (300 mg/kg b. wt.) daily for 10 days (day 1-10) and were given intraperitoneal injection of 5-FU (150 mg/kg b. wt.) or saline (control) on day 8 to induce mucositis. Results We found that vit. E supplementation ameliorated 5-FU-induced lipid peroxidation, myeloperoxidase activity, activation of nuclear factor κB, expression of cyclooxygenase-2, inducible nitric oxide synthase and mucin depletion. Vit. E administration also attenuated 5-FU-induced histological anomalies such as neutrophil infiltration, loss of cellular integrity, villus and crypt deformities. ConclusionsFindings of the study suggest that vit. E inhibits 5-FU-induced mucositis via modulation of oxidative stress, activation of redox sensitive transcription factor and its downstream targets.

Oral Mucositis: Melatonin Gel an Effective New Treatment

The current treatment for cervico-facial cancer involves radio and/or chemotherapy. Unfortunately, cancer therapies can lead to local and systemic complications such as mucositis, which is the most common dose-dependent complication in the oral cavity and gastrointestinal tract. Mucositis can cause a considerably reduced quality of life in cancer patients already suffering from physical and psychological exhaustion. However, the role of melatonin in the treatment of mucositis has recently been investigated, and offers an effective alternative therapy in the prevention and/or management of radio and/or chemotherapy-induced mucositis. This review focuses on the pathobiology and management of mucositis in order to improve the quality of cancer patients' lives.

Treatment of severe mucositis pain with oral ketamine mouthwash

PURPOSE

Mucositis is a significant complication of intensive chemotherapy or hematopoietic cell transplantation (HCT), with few treatment options. Ketamine mouthwashes have been used for pain relief, but supporting evidence is limited. The primary objective of this study was to assess the reduction in pain intensity of stomatodynia and odynophagia compared to baseline assessment.

METHODS

This open-label, prospective, phase II interventional study (NCT01566448) was conducted from February 2012 through July 2015. Patients with grade 3 or 4 oral mucositis according to the World Health Organization (WHO) scale as a result of chemotherapy were treated with ketamine mouthwash 20 mg/5 mL four times daily and every 4 h as needed.

RESULTS

Thirty patients were enrolled and a total of 136 assessments were conducted. A statistically significant reduction in pain scores of 2 and 3 points was achieved after 1 h and 3 days, respectively (p < 0.0001, p = 0.0003). Pain scores were significantly improved while swallowing, reduced 1 and 4 points at 1-h and 3-day assessment, respectively (p = 0.0006, p = 0.0001). No patients developed adverse effects related to ketamine administration.

CONCLUSION

Ketamine mouthwashes resulted in clinically meaningful and statistically significant reduction in pain scores, have an acceptable safety profile, and can be a useful adjunctive treatment in the multi-modal management of severe mucositis.

Management of Pain Associated with Selected Conditions in Dermatology

Dermatologists face a wide range of pain control challenges in daily practice, from the transient pain of dermatologic surgery to the persistent pain that plagues some chronic dermatologic conditions. Although the pathophysiology of pain is well described and the profound impact of dermatological pain on patients' quality of life is well appreciated, there is an identified need for clear therapeutic plans for providing symptomatic pain relief of common painful dermatoses. In this paper, we will review and clearly outline approaches to pain management of a number of common painful dermatoses such as herpes zoster and post-herpetic neuralgia, ulcers, oral dermatoses, dysesthesias, and many others.

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

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

Effect of Chewing Gum on Oral Mucositis in Children Undergoing Chemotherapy: A Randomized Controlled Study

BACKGROUND

Oral mucositis is an adverse effect of chemotherapy. Type of chemotherapy regimen is the most important factor causing mucositis. Oral mucositis is usually associated with transient decrease in saliva production. The goal was to study effects of gum consumption on oral mucositis in children undergoing chemotherapy.

MATERIALS AND METHOD

This randomized controlled trial was done in Amir Kabir Hospital, Arak, Iran. 130 children 5 to 15 years of age were studied. Control group was composed of 65 children who received mucotoxic drugs. Test group was made up of 65 patients received similar drugs in addition to sugar free gums. Patients consumed 6 pieces of gums per day for 15 days. A standardized follow up form and World Health Organization (WHO) grading system for oral mucositis were used for evaluation of patients during 15 days of treatment.

RESULTS

Severe oral mucositis occurred in 30 (46%) of 65 patients in the test group and in 26 of 65 (40%) patients in the control group. Difference was not statistically significant (P > 0.05). Rate of mild to moderate mucoitis (grade 1 and 2) was significantly lower in patients who used gums (15 % vs. 35%, P < 0.05).

CONCLUSION

Our study showed that stimulation of saliva flow by chewing gum could decrease mild to moderate inflammatory injuries of the oral mucosa during chemotherapy. However, it was not effective to subside severe mucositis.

Ascorbic acid attenuates antineoplastic drug 5-fluorouracil induced gastrointestinal toxicity in rats by modulating the expression of inflammatory mediators

Damage to the mucous membrane is a serious issue associated with chemotherapy. Gastrointestinal (GI) toxicity is complex and multistep process and unregulated production of reactive oxygen species (ROS) and inflammatory mediators play vital role in the development of GI toxicity. In the present study we have investigated the attenuating potential of vitamin C (vit. C) on 5 fluorouracil (5-FU) induced GI toxicity by targeting oxidative stress and inflammatory markers in Sprague Dawley (SD) rats. Rats were gavaged with vit. C (500 mg/kg b. wt.) or vehicle daily (day 1-10) and were given intraperitoneal injection of 5-FU (150 mg/kg b. wt.) or saline (control) on day 8 to induce mucositis. We found that vit. C supplementation attenuated 5-FU induced lipid peroxidation, myeloperoxidase (MPO) activity, activation of NF-kB and expression of COX-2. Histological observations further supported the protective potential of vit. C against 5-FU induced intestinal anomalies such as neutrophil infiltration, loss of cellular integrity, villus and crypt deformities. Thus the biochemical, molecular and histological findings of the present study demonstrate that oxidative stress and inflammation play vital role in 5-FU induced GI toxicity and the inhibitory potential of vit. C is may be due to the modulation of oxidative stress, activation of redox sensitive transcription factor and also its downstream target molecules.

Chemo-radiotherapy induced oral mucositis during IMRT for head and neck cancer - An assessment

BACKGROUND

This study is conducted mainly to evaluate the changes in quality and quantity of oral epithelial cells during the course of IMRT.

MATERIAL AND METHODS

30 Patients undergoing chemo-radiotherapy were followed through course of treatment. They were compared with a group of age- and sex-matched healthy individuals. The procedure involved WHO clinical scoring, collection of oral washings and preparation of buccal smears from both study group and control group. The changes occurred were recorded as a way of assessing the severity of oral mucositis.

RESULTS

revealed a significant occurrence of oral mucositis in almost all patients during weekly follow up. There was a significant increase in percentage of viable buccal epithelial cells in study group when compared to normal controls (P<0.005) during and at the end of chemo-radiotherapy.

CONCLUSIONS

quantification of oral mucositis can be done at cellular level by determining the oral mucosal cell viability and their maturation during IMRT.