Topical Treatment of Oral Mucositis in Cancer Patients: A Systematic Review of Randomized Clinical Trials

Nutritional interventions for the prevention and treatment of cancer therapy-induced oral mucositis: an umbrella review of systematic reviews and meta-analysis

CONTEXT

To date, the efficacy of nutritional interventions on oral mucositis (OM) in patients with cancer, and the quality of this evidence have not been explored.

OBJECTIVE

The goal of this umbrella review was to provide a comprehensive evaluation of nutritional interventions for patients with cancer with OM, as well as to assess the quality of this evidence.

DATA SOURCES

Meta-analyses were searched for using PubMed, Scopus, and ISI Web of Science databases until December 2021, with no time restrictions.

DATA EXTRACTION

Meta-analyses of randomized control trials that evaluated the effects of nutritional interventions on the incidence of OM in patients with cancer had inclusion criteria for this umbrella review. Data extraction, quality assessment of meta-analyses, and primary studies were done independently by 2 authors. The Grading of Recommendations Assessment, Development, and Evaluation technique was used to grade the certainty of evidence.

DATA ANALYSIS

A total of 26 meta-analyses were included in this umbrella review. The results showed that honey, glutamine, and propolis can reduce the incidence of severe OM, based on moderate evidence quality. In addition, zinc supplementation significantly reduced the incidence of OM, regardless of symptom severity; however, low certainty of the evidence was observed. The effects of vitamin E, curcumin, and probiotics on OM were not statistically significant.

CONCLUSION

This umbrella review shows that honey, glutamine, and propolis can significantly reduce the incidence of severe OM. These findings need to be confirmed with well-designed, longitudinal randomized controlled trials.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42022301010.

The efficacy of honey or olive oil on the severity of oral mucositis and pain compared to placebo (standard care) in children with leukemia receiving intensive chemotherapy: A randomized controlled trial (RCT)

BACKGROUND

Oral mucositis (OM) is a significant complication occurring in approximately 40 to 80% of patients receiving chemotherapy regimens. Although a wide variety of agents have been tested to prevent OM or reduce its severity, none have provided conclusive evidence.

OBJECTIVES

To determine the efficacy of honey or olive oil on the severity and OM pain in children with leukemia and suffering from OM compared to placebo (standard care) and, to assess which of the two interventions is more beneficial.

METHODS

A single blind randomized controlled study (RCT) was used to evaluate the effect of Manuka honey or olive oil, in the treatment of chemotherapy-related OM in 42 children with leukemia. The primary outcome was the severity of mucositis, using the World Health Organization (WHO) scale and the secondary outcome was the pain assessed using the Visual analogue scale (VAS).

RESULTS

Children who received the honey had less severe OM (assessed on the (WHO) scale), p = 0.00 and less pain (assessed on the VAS scale), p = 0.00, compared to the control group. Children who received the olive oil had less pain than the control group, p = 0.00), although not lower than the honey group.

CONCLUSION

Manuka honey or olive oil can be used as alternative therapies by nurses to children with leukemia and suffering from OM, especially in low and middle-income countries where more expensive therapies may not be available or economical.

PRACTICE IMPLICATIONS

Pediatric nurses may recommend Manuka honey to treat OM in children with leukemia as it is safe and inexpensive compared to other treatment modalities.

Did you choose appropriate mouthwash for managing chemoradiotherapy-induced oral mucositis? The therapeutic effect compared by a Bayesian network meta-analysis

Background

Oral mucositis (OM) is one of the most common adverse effects of radiotherapy and chemotherapy. It greatly affects the patients' quality of life and hinders cancer treatment implementation. Treating OM with mouthwash is a widely used strategy that can effectively relieve symptoms and promote healing. However, the wide mouthwash selection confuses clinicians. This Bayesian network meta-analysis aimed to compare the effects of various mouthwash types used to treat OM and provide high-level evidence-based recommendations for OM treatment.

Methods

Database search included PubMed, Embase, Cochrane Library, and Web of Science from inception to April 21, 2022. The primary outcome was OM score improvement following the World Health Organization grades. The randomized controlled trial (RCT) bias risk assessment tool provided in the Cochrane Handbook assessed the studies' risk of bias. We performed pairwise and Bayesian network meta-analysis with random effects following the PRISMA guideline.

Results

The study included 13 RCTs with 570 patients. Pairwise comparisons showed that povidone-iodine was more effective than chlorhexidine (weighted mean difference [WMD], -2.64; 95% confidence interval [CI], -2.72 to -2.56) but inferior to granulocyte-macrophage colony-stimulating factor (GM-CSF; WMD, 0.20; 95% CI, 0.06-0.34) after one week of mouthwash treatment. Vitamin E (WMD, -0.94; 95% CI, -1.03 to -0.85), natural drugs (WMD, -0.93; 95% CI, -1.46 to -0.40), and phenytoin (WMD, -0.38; 95% CI, -0.59 to -0.17) exhibited better therapeutic effects than a placebo after three weeks of treatment. Bayesian network meta-analysis showed that povidone-iodine was superior to chlorhexidine in treating OM (WMD, 2.63; 95% CI, 0.20-5.01). Other mouthwashes showed no significant differences. Rank probability indicated that the best OM therapeutic mouthwashes were GM-CSF (54%), vitamin E (24%), and natural drugs (43%) after one, two, and three weeks of treatment, respectively.

Conclusion

GM-CSF was the most effective mouthwash type for OM treatment. When considering the cost and effectiveness, povidone-iodine and sodium bicarbonate might be the most advantageous. Furthermore, natural drugs have the same potential in treating OM. Safety and acceptability are their most outstanding characteristic.

The chromatographic constitution of andiroba oil and his healing effects, compared to the LLLT outcomes, in oral mucositis induced in golden Syrian hamsters: a new treatment option

The oral mucositis is a mucosal alteration that usually arises from oncological treatments, such as chemotherapy, and it is characterized as an inflammatory process. The aim of this study is to demonstrate the chromatographic constitution of Andiroba oil, comparing and evaluating Andiroba oil and laser scarring efficiency in treatments of oral mucositis in hamsters. These animals were submitted to 5-Fluorouracil. A total of 122 animals were used, randomized and divided into the following groups: (a) positive control; (b) laser associated to andiroba oil; (c) laser; (d) andiroba oil; (e) negative control; (f) cyclophosphamide (genotoxicity control). The induction of oral mucositis occurred by the administration of intraperitoneal Fluorouracila (60 mg/kg) and trauma to the mucosa. The laser protocol was performed once a day and the andiroba oil applied 3 times a day (1,5 ml/day). The mucosae were photographed and removed for clinical and histopathological analysis on day 4, 8, 12 and 15. The analysis was based in OM severity, in specific scoring for the clinical and histopathological aspect. Toxicity was evaluated on day 15 using comet assay and it was performed by variant DNA damage parameters. The data were analysed using analysis of variance (ANOVA) Tukey post-test and Kruskal-Wallis Dunn post-test. The "andiroba oil" and "laser" groups presented better results when compared to the control groups and the treatment associations. The andiroba oil presented the best scarring results, even considering its efficiency proximity to the laser treatment. Andiroba and laser, separately, did not present genotoxicity, however their association evidences damage to DNA.

Effect of synbiotic mouthwash on oral mucositis induced by radiotherapy in oral cancer patients: a double-blind randomized clinical trial

PURPOSE

Considering the complex pathobiology of oral mucositis, especially in oral cancer patients, the prevention and treatment of oral mucositis in patients undergoing radiotherapy remains an essential and clinically crucial unmet need. The present study aims to investigate and compare the effects of synbiotic mouthwash with normal saline mouthwash on the prevention and control of radiotherapy-induced oral mucositis in oral cancer patients.

METHODS

Double-blind, randomized clinical trial (RCT) performed on 64 oral cancer patients who underwent radiotherapy (IRCT20201106049288N1, registration date: 2020-12-23). Patients were divided randomly into the case (32 subjects) and control (32 subjects) groups. All patients underwent intensity-modulated radiotherapy and received 6000 cGY of radiotherapy in 34 fractions. All patients received the usual treatment for mucositis, but in the case group, synbiotic mouthwash was prescribed and in the control group, normal saline mouthwash was prescribed from a day before the start to the end of radiotherapy treatment. Patients were monitored every session for 6 weeks to check the progression, oral involvement severity, and mucositis grade.

RESULTS

The case group showed a significant reduction in the oral mucositis severity. The mucositis grade in the case group from the 7th session of oral examination was significantly lower than the control (p < 0.05), and this significant difference persisted until the last session of oral examination. Incidence rates of severe oral mucositis (grade 3) during the treatment period were 11.59% in the case and 36.45% in control (p < 0.001).

CONCLUSION

Synbiotic mouthwash significantly reduces and prevents oral mucositis intensity in oral cancer patients undergoing radiotherapy.

Personalized or unified approach in the prevention and treatment of oral mucositis in patients with malignant neoplasms of the head and neck organs: the choice of the optimal solution

Introduction. The prevalence of oncological diseases of the oropharyngeal region continues to grow steadily, but there is an increase for a number of nosologies in the five-year survival rate of this category of patients, which naturally leads to the actualization of accompanying treatment programs and the desire to improve the quality of life of oncological patients. One of the areas of maintenance therapy in oncology is dental support, the choice of approaches and methods of which is not systematically organized.

Aim. To determine the optimal method of dental support for patients with malignant neoplasms of the head and neck organs for the prevention and treatment of oral mucositis.

Materials and methods. At the Russian Scientific Center of Roentgenoradiology, retrospective analysis of scientific clinical results of oral mycosis treatment in patients with malignant tumors of the head and neck receiving antitumor therapy was performed.

Results. Two main approaches have been identified for the prevention and treatment of oral mucositis in patients with malignant neoplasms of the head and neck organs: personalized and unified approach. using personalized approach, maximal mean value of oral mycosis severity during the whole antitumor treatment period per the Radiation therapy Oncology group (RTOg) classification was 2.19 ± 0.13. The quality of life of patients is reduced by 26.1 %. using unified approach, maximal mean value of oral mycosis severity during the whole antitumor treatment period per the RTOg classification was 2.44 ± 0.05. The quality of life of patients is reduced by 51.5 %, but at the same time, absolutely all patients retain the ability to eat independently and take care of the oral cavity.

Conclusion. Both personalized and unified approaches for the prevention and treatment of oral mucositis are possible for use in clinical practice.

Effectiveness of sodium bicarbonate and zinc chloride mouthwashes in the treatment of oral mucositis and quality of life in patients with cancer under chemotherapy

Aim

The purpose of the study is to evaluate the effectiveness of sodium bicarbonate and zinc chloride mouthwashes on oral mucositis and quality of life in patients undergoing chemotherapy.

Design

The present study was a randomized controlled trial study.

Methods

One hundred forty‐four patients with a cancer diagnosis were randomly assigned into three groups: sodium bicarbonate mouthwash (n = 48), zinc chloride mouthwash (n = 48) and placebo group (n = 48). The severity of mucositis and quality of life were examined blindly at the baseline and 3‐week follow‐up.

Results

The grade of oral mucositis decreased at the end of the third weeks in the sodium bicarbonate and zinc chloride groups rather than the placebo group (p < .001). The severity of oral mucositis in the sodium bicarbonate and zinc chloride groups decreased from end of the first week until third week (p < .001). In addition, there was significant difference in the severity of oral mucositis among the groups at the end of the second (p = .014) and the third weeks (p < .001). Also, there was a statistically significant difference in quality of life scores between the sodium bicarbonate and zinc chloride mouthwash with the placebo group (p < .001).

Conclusion

Zinc chloride and sodium bicarbonate mouthwashes were effective in treating and reducing the severity of oral mucositis, and subsequently improving quality of life in patients with cancer under chemotherapy. Therefore, we can recommend zinc chloride and sodium bicarbonate at the beginning of chemotherapy to improve oral health and promoting quality of life in these patients.

A Systematic Review and Meta-Analysis on the Efficacy of Curcumin/Turmeric for the Prevention and Amelioration of Radiotherapy/Radiochemotherapy Induced Oral Mucositis in Head and Neck Cancer Patients

BACKGROUND

Oral Mucositis(OM) is an acute debilitating dose limiting toxicity of Radiotherapy/Radiochemotherapy(RT/RCT) in management of Head and Neck Cancer (HNC). Curcumin/Turmeric may reduce OM in patients.

AIM

Efficacy of Curcumin/Turmeric for preventing and ameliorating the onset and severity of RT/RCT induced OM was analysed in this review.

METHODS

A systematic literature search with meta-analysis were performed using Mesh terms in PubMed, Google scholar, Science Direct, Cochrane library and manual searching, articles published from 2010 to April 2021 were included. Clinical trials that studied the efficacy/effects of turmeric / curcumin in management of RT/RCT induced OM in HNC patients were included. Statistical Analysis were done to calculate the pooled Risk ratio at 95%confidence interval with significance at p.

Effectiveness of green tea mouthwash for improving oral health status in oral cancer patients: A single-blind randomized controlled trial

BACKGROUND

Painful oral mucositis or trismus, caused by cancer therapy, reduces patients' willingness to maintain basic oral hygiene and eventually results in a poor oral health status. Using mouth rinses and cleaning the tongue are popular ways to improve the oral health status.

OBJECTIVES

To evaluate the effectiveness of green tea mouthwash for improving the oral health status in oral cancer patients undergoing cancer treatment.

DESIGN

This was a prospective, single-blind, randomized, controlled trial.

SETTINGS

Patients were recruited from a major regional teaching hospital that provides specialist cancer care services in Chia-Yi, Taiwan, from July 2018 to June 2020.

PARTICIPANTS

A total of 63 patients met the following criteria: > 20 years old; newly diagnosed with oral cancer by a physician; treated with oral surgery within one month prior; and completion of follow-up, with or without chemotherapy or radiation therapy. The exclusion criteria were mental illness; an acute and severe illness; complete edentulism; and inability to open the mouth more than 1 cm.

METHODS

Patients were randomly assigned to 2 groups: the mouthwash with green tea (intervention) group or the tap water (control) group. After each teeth-brushing procedure, those in the intervention group rinsed the mouth with 100 ml of a green tea solution for 60 seconds, and those in the control group rinsed the mouth with 100 ml of tap water for 60 seconds. The primary outcome was the oral health status, which was evaluated according to the Oral Assessment Guide and measured at baseline and at every monthly outpatient follow-up until six months by the same nurse.

RESULTS

There were 31 subjects in the intervention group and 30 subjects in the control group in the final analysis. The results of t-test showed that compared with baseline, the improvement in the oral health status in the intervention group was significantly better than that in the control group at 4 months after the intervention began. At 4 to 6 months after the intervention began, the oral health status score in the intervention group significantly decreased, by 1.71, 2.97 and 2.93 points, respectively, compared with that in the control group.

CONCLUSIONS

The oral health status can be improved and maintained for a long time with the continuous use of green tea mouthwash. Green tea mouthwash is a simple, natural, effective and safe intervention that should be recognized as a nonpharmacological treatment option for protecting the oral mucosa.

TRIAL REGISTRATION

clinicaltrials.gov identifier NCT04615780.