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Schroter GT, Stopiglia RMM, Carvalho GL, Morimoto S, Mota ME, Alves FA, Jaguar GC, Moreira MS. Osteoradionecrosis treatment in head and neck cancer patients: An overview of systematic reviews. Spec Care Dentist 2024; 44:621-635. [PMID: 37534945 DOI: 10.1111/scd.12910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 07/17/2023] [Accepted: 07/19/2023] [Indexed: 08/04/2023]
Abstract
AIMS Evaluate the existing evidence of osteoradionecrosis (ORN) treatment in adults with head and neck cancer, the methodological quality and the evidence grade within systematic reviews (SRs). METHODS An extensive systematic literature search of SRs that addressed ORN in head and neck cancer patients was conducted with screening of eligible studies, data extraction, methodological (AMSTAR 2) and evidence quality assessment (GRADE) of the SRs by independent and calibrated authors. RESULTS A total of six SRs were enrolled. Based primarily on studies from the 1990s, there is critically low- or moderate-quality evidence that hyperbaric oxygen therapy (HBO) improves ORN healing. From 2005 onward, evidence has been discovered in relation to treatment with pentoxifylline and tocopherol (PENTO). The SRs indicate that the management of ORN with PENTO appears to be promising. The greatest rates of healing are seen in mild and moderate stages of ORN. However, the quality of evidence regarding PENTO, surgery and other treatments remains critically low. CONCLUSION There is no standardized protocol to treat ORN. PENTO appears to be the most promising conservative treatment; however, the current level of evidence regarding PENTO is still critically low. More robust clinical studies are needed to establish the best treatment for ORN.
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Affiliation(s)
| | | | | | - Susana Morimoto
- Postgraduate Program in Dentistry, Ibirapuera University, São Paulo, Brazil
| | - Maria Emília Mota
- Department of Stomatology, School of Dentistry, University of São Paulo (USP), São Paulo, Brazil
| | - Fábio Abreu Alves
- Department of Stomatology, School of Dentistry, University of São Paulo (USP), São Paulo, Brazil
- Department of Stomatology, AC Camargo Cancer Center, São Paulo, Brazil
| | | | - Maria Stella Moreira
- Department of Stomatology, School of Dentistry, University of São Paulo (USP), São Paulo, Brazil
- Department of Stomatology, AC Camargo Cancer Center, São Paulo, Brazil
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Mota ME, Schroter GT, Moreira MS, Alves FA, Jaguar GC, Lopes RN. 3D printing technology to produce intraoral stents for head and neck radiotherapy: A scoping review. Spec Care Dentist 2024; 44:636-644. [PMID: 37909799 DOI: 10.1111/scd.12936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 10/12/2023] [Accepted: 10/13/2023] [Indexed: 11/03/2023]
Abstract
INTRODUCTION Radiotherapy remains one of the main treatments for head and neck cancer; however, it is accompanied by acute and chronic adverse effects. Use of three-dimensional (3D) oral stents to modulate radiation intensity to specific target areas have been developed to minimize these adverse effects. This study aimed to present a scoping review of studies published on 3D printing of oral stents and their clinical applicability. METHODS MEDLINE/Pubmed, Scopus, Web of Science and CENTRAL Cochrane data bases were searched, studies selected, and data collected by three independent reviewers up to December 2022. The review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-analysis-Extension for Scoping Reviews (PRISMA-ScR). RESULTS The search resulted in 404 studies and 5 articles fulfilled the eligibility criteria and were considered for this review. Three-dimensional printed intraoral stents were produced for 56 patients with indication for radiotherapy. 3D-printed stents were well-tolerated by all tested patients and demonstrated great reproducibility of maxillomandibular relation, required less time for production and lower cost to manufacture. Two studies showed great protection of healthy tissues with 3D-printed stents during radiotherapy. CONCLUSIONS Three-dimensional printing is promising for production of intraoral stents, however, more studies are needed to improve the technique and further investigate the safety and prevention of oral toxicities from radiotherapy.
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Affiliation(s)
- Maria Emília Mota
- Department of Stomatology, School of Dentistry, University of São Paulo, São Paulo, São Paulo, Brazil
| | - Gabriella Torres Schroter
- Department of Stomatology, School of Dentistry, University of São Paulo, São Paulo, São Paulo, Brazil
| | - Maria Stella Moreira
- Department of Stomatology, School of Dentistry, University of São Paulo, São Paulo, São Paulo, Brazil
- Department of Stomatology, AC Camargo Cancer Center, São Paulo, São Paulo, Brazil
| | - Fábio Abreu Alves
- Department of Stomatology, School of Dentistry, University of São Paulo, São Paulo, São Paulo, Brazil
- Department of Stomatology, AC Camargo Cancer Center, São Paulo, São Paulo, Brazil
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Porangaba LP, de Melo Garcia F, Rabelo APAA, Andrade AP, de Abreu Alves F, Pellizzon ACA, Jaguar GC. Randomized Double-Blind Placebo-Controlled Study of Salivary Substitute with Enzymatic System for Xerostomia in Patients Irradiated in Head and Neck Region. Curr Oncol 2024; 31:1102-1112. [PMID: 38392076 PMCID: PMC10887544 DOI: 10.3390/curroncol31020082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 02/13/2024] [Accepted: 02/17/2024] [Indexed: 02/24/2024] Open
Abstract
This study aims to compare whether the use of a salivary substitute including an enzymatic system clinically reduces the intensity of xerostomia, as well as exploring the impact that this has on the quality of life, in patients who had received radiotherapy in the head and neck (HNC) region. Forty patients who had completed radiotherapy treatment within 6 months to 1 year previously were allocated into an Enzymatic Spray group (n = 21) or a Placebo arm (n = 19). It should be noted that two patients in the Placebo arm declined to participate during phase 2 of the study. All patients were randomized and used both products three times a day for 30 days. For analysis, xerostomia grade, unstimulated (UWS) and stimulated (SWS) salivary flow rate, and quality of life through the University of Washington Quality of Life Questionnaire validated in Portuguese (UW-QoL) were assessed in two phases: Phase 1 (before the use of the products) and Phase 2 (after 30 days of using the products). All clinical data were collected from medical records. Analyzing the salivary substitute with the enzymatic system, an improvement in xerostomia complaints was observed 30 days after using the product; however, this difference was not statistically significant (p > 0.05). Regarding quality of life, no significant differences were observed in relation to the UW-QoL and saliva domain between the groups in the two phases of the study (p > 0.05). The salivary substitute with the enzymatic system may be effective in reducing radio-induced xerostomia symptoms; however, further research is necessary to evaluate the efficacy of this salivary substitute on oral health.
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Affiliation(s)
- Letícia Pacheco Porangaba
- Stomatology Department, A.C. Camargo Cancer Center, São Paulo 01509-010, Brazil; (L.P.P.); (F.d.M.G.); (F.d.A.A.)
| | - Flávio de Melo Garcia
- Stomatology Department, A.C. Camargo Cancer Center, São Paulo 01509-010, Brazil; (L.P.P.); (F.d.M.G.); (F.d.A.A.)
| | | | | | - Fabio de Abreu Alves
- Stomatology Department, A.C. Camargo Cancer Center, São Paulo 01509-010, Brazil; (L.P.P.); (F.d.M.G.); (F.d.A.A.)
- Stomatology Department, School of Dentistry, São Paulo University, São Paulo 05508-000, Brazil
| | | | - Graziella Chagas Jaguar
- Stomatology Department, A.C. Camargo Cancer Center, São Paulo 01509-010, Brazil; (L.P.P.); (F.d.M.G.); (F.d.A.A.)
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Kirschnick LB, Schuch LF, Gondak R, Rivero ERC, Gomes APN, Etges A, Tarquinio SBC, Mesquita RA, Caldeira PC, da Costa AAS, Mendonça EF, Dos Santos JN, Smit C, Robinson L, Tager EMJR, Mosqueda-Taylor A, Pontes HAR, de Andrade BAB, Fonseca TC, Abrahão AC, Agostini M, Romañach MJ, Alves FA, Jaguar GC, de Mendonça NF, Pinto MBR, da Silva LC, Lopes MA, Vargas PA, van Heerden W, Abreu LG, Martins MD, Vasconcelos ACU. Clinicopathological Features of Metastasis to the Oral and Maxillofacial Region-Multicenter Study. Head Neck Pathol 2023; 17:910-920. [PMID: 37902929 PMCID: PMC10739623 DOI: 10.1007/s12105-023-01588-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 09/29/2023] [Indexed: 11/01/2023]
Abstract
BACKGROUND This study aimed to investigate the clinicopathological features of metastases in the oral and maxillofacial regions. METHODS In this retrospective study, biopsy records were obtained from referral centers for oral and maxillofacial diagnosis in Brazil, Guatemala, Mexico, and South Africa. RESULTS A total of 120 cases were evaluated. Of these, 53.78% affected female patients, with a mean age of 57.64 years. Intraosseous lesions were more frequent, particularly in the posterior region of the mandible (49.58%). Clinically, most cases presented with symptomatic swelling, with an average evolution time of 25 months. The clinical diagnostic hypothesis in most instances was that of a malignant lesion. Breast cancer was the most common primary tumor location in females, while lung origin was most common in males. In most cases, the primary cancer was an adenocarcinoma (44.73%). The follow-up period was available for 29 cases, and out of these, 20 had died due to the disease. CONCLUSION Although this is a rare condition, clinicians should be aware that any oral lesions have the possibility of being metastatic, particularly in individuals with a previous history of cancer. The findings from this study could assist clinicians in prompt diagnosing these lesions and subsequent conducting oncologic assessments and treatment.
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Affiliation(s)
- Laura Borges Kirschnick
- Oral Diagnosis Department, Piracicaba Dental School, Universidade Estadual de Campinas, Piracicaba, SP, Brazil
| | - Lauren Frenzel Schuch
- Oral Diagnosis Department, Piracicaba Dental School, Universidade Estadual de Campinas, Piracicaba, SP, Brazil
| | - Rogério Gondak
- Department of Pathology, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | | | - Ana Paula Neutzling Gomes
- Diagnostic Center for Oral Diseases, Dental School, Universidade Federal de Pelotas, Pelotas, RS, Brazil
| | - Adriana Etges
- Diagnostic Center for Oral Diseases, Dental School, Universidade Federal de Pelotas, Pelotas, RS, Brazil
| | | | - Ricardo Alves Mesquita
- Department of Oral Surgery and Pathology, School of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Patrícia Carlos Caldeira
- Department of Oral Surgery and Pathology, School of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | | | | | - Jean Nunes Dos Santos
- Department of Oral Pathology, Postgraduate Program in Dentistry and Health, School of Dentistry, Universidade Federal da Bahia, Salvador, BA, Brazil
| | - Chané Smit
- Department of Oral and Maxillofacial Pathology, School of Dentistry, University of Pretoria, Pretoria, South Africa
| | - Liam Robinson
- Department of Oral and Maxillofacial Pathology, School of Dentistry, University of Pretoria, Pretoria, South Africa
| | - Elena María José Román Tager
- Oral Diagnosis Department, Piracicaba Dental School, Universidade Estadual de Campinas, Piracicaba, SP, Brazil
- Pathology Section, Clinical Center of Head and Neck/Hospital Herrera Llerandi, Guatemala City, Guatemala
| | | | | | | | - Thamyres Campos Fonseca
- Department of Oral Diagnosis and Pathology, School of Dentistry, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Aline Corrêa Abrahão
- Department of Oral Diagnosis and Pathology, School of Dentistry, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Michelle Agostini
- Department of Oral Diagnosis and Pathology, School of Dentistry, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Mário José Romañach
- Department of Oral Diagnosis and Pathology, School of Dentistry, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Fábio Abreu Alves
- Stomatology Department, A. C. Camargo Hospital, São Paulo, SP, Brazil
| | | | | | | | - Luan César da Silva
- Oral Diagnosis Department, Piracicaba Dental School, Universidade Estadual de Campinas, Piracicaba, SP, Brazil
| | - Márcio Ajudarte Lopes
- Oral Diagnosis Department, Piracicaba Dental School, Universidade Estadual de Campinas, Piracicaba, SP, Brazil
| | - Pablo Agustin Vargas
- Oral Diagnosis Department, Piracicaba Dental School, Universidade Estadual de Campinas, Piracicaba, SP, Brazil
| | - Willie van Heerden
- Department of Oral and Maxillofacial Pathology, School of Dentistry, University of Pretoria, Pretoria, South Africa
| | - Lucas Guimarães Abreu
- Department of Child and Adolescent Oral Health, School of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Manoela Domingues Martins
- Oral Diagnosis Department, Piracicaba Dental School, Universidade Estadual de Campinas, Piracicaba, SP, Brazil
- Department of Oral Pathology, School of Dentistry, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Ana Carolina Uchoa Vasconcelos
- Diagnostic Center for Oral Diseases, Dental School, Universidade Federal de Pelotas, Pelotas, RS, Brazil.
- Centro de Diagnóstico das Doenças da Boca - CDDB, Faculdade de Odontologia, Universidade Federal de Pelotas, Rua Gonçalves Chaves, 457, sala 607 , Pelotas, RS, Brazil.
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Oliveira Filho OVD, Oliveira DMDA, Medeiros YDL, Pinto CAL, Alves FA, Jaguar GC. Tongue enlargement associated with burning sensation: An atypical case of breast cancer metastasis. Oral Oncol 2023; 146:106565. [PMID: 37683334 DOI: 10.1016/j.oraloncology.2023.106565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 09/03/2023] [Indexed: 09/10/2023]
Affiliation(s)
| | | | | | | | - Fabio Abreu Alves
- Department of Stomatology, A.C.Camargo Cancer Center, São Paulo, SP, Brazil; Department of Stomatology, School of Dentistry, São Paulo University, São Paulo, SP, Brazil
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Carvalho GL, Heguedusch D, Pellizzon ACA, Lira RB, Alves FA, Jaguar GC. Secondary primary tumor mimicking osteoradionecrosis. Autops Case Rep 2022; 12:e2021389. [PMID: 36061099 PMCID: PMC9352367 DOI: 10.4322/acr.2021.389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 05/31/2022] [Indexed: 11/23/2022] Open
Abstract
Nasopharyngeal carcinoma (NPC) is a malignant tumor rarely found in the head and neck, representing about 1% of all malignancies. The main treatment for NPC is radiation therapy, which is often given in combination with chemotherapy. However, such treatment may lead to long‐term complications, including second primary tumors (SPTs) and osteoradionecrosis (ORN). Both complications have similar radiological characteristics, which can lead to erroneous diagnoses. This paper describes a case of a second primary tumor in a patient after 20 years of radiotherapy in the area where a previous extraction was performed, mimicking an osteoradionecrosis process.
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Affiliation(s)
| | - Daniele Heguedusch
- A.C. Camargo Cancer Center, Departamento de Estomatologia, São Paulo, SP, Brasil
| | | | - Renan Bezerra Lira
- A.C. Camargo Cancer Center, Departamento de Cirurgia de Cabeça e Pescoço e Otorrinolaringologia, São Paulo, SP, Brasil.
| | - Fábio Abreu Alves
- A.C. Camargo Cancer Center, Departamento de Estomatologia, São Paulo, SP, Brasil
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Campanhã D, PereiraLIMA EN, Alves FA, Jaguar GC. Bethanechol used to prevent salivary gland dysfunction in patients submitted to radioactive iodine therapy: A double blind, placebo-controlled, randomized study. J Stomatol Oral Maxillofac Surg 2021; 123:e626-e630. [PMID: 34954424 DOI: 10.1016/j.jormas.2021.12.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 11/05/2021] [Accepted: 12/21/2021] [Indexed: 02/02/2023]
Abstract
Symptoms related to salivary gland damage are one of the most frustrating complications after radioactive iodine (131I) therapy. To the best of our knowledge, this is the first study that aimed to evaluate the prophylactic effect of Bethanechol on the radioiodine content of salivary gland. Fifty patients who were referred to 131I therapy were randomized into Bethanechol and placebo groups. Patients received Bethanechol or Placebo (25 mg, 2 times daily), starting 2 h after 131I therapy to 1-month. Both groups were compared at baseline, 10, 30 and 90 days after 131I therapy based on the following: symptoms related to salivary gland damage; unstimulated whole saliva (UWS) and quality of life using University of Washington Quality of Life 4 questionnaire. Bethanechol group presented significantly lower complaints of dry mouth on 10 (p = 0.047) and 30 (p = 0.003) days compared with placebo. Salivary gland pain and swelling were more frequent among placebo patients at 10 days (p = 0.047). Comparison of the two groups by UWS, no statistical difference was found. Placebo group presented worse score related to activity (p = 0.034), saliva (p = 0.05) and humor (p = 0.05) at 10 days; palate (p = 0.05) and saliva (p = 0.05) at 1 month. Interestingly, Bethanechol patients who received 131I dose > 125mCi, showed better xerostomia indices when compared to the Placebo with same dose. Bethanechol during 131I therapy was found to be effective in decreasing the acute salivary gland damage with impact on patients' quality of life.
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Affiliation(s)
- Daniel Campanhã
- A.C. Camargo Cancer Center, Stomatology Department, 211 Bairro: Liberdade, São Paulo, SP 01509-900, Brazil
| | | | - Fábio Abreu Alves
- A.C. Camargo Cancer Center, Stomatology Department, 211 Bairro: Liberdade, São Paulo, SP 01509-900, Brazil.
| | - Graziella Chagas Jaguar
- A.C. Camargo Cancer Center, Stomatology Department, 211 Bairro: Liberdade, São Paulo, SP 01509-900, Brazil.
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Scaraficci AC, Fernandes PM, Abreu Alves F, Filho JS, Jaguar GC. Oral manifestations of graft-versus-host disease in patients submitted to allogeneic hematopoietic stem cell transplantation: the experience of a Brazilian Cancer Center. Support Care Cancer 2021; 30:567-573. [PMID: 34341851 DOI: 10.1007/s00520-021-06349-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 06/08/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE Graft-versus-host disease (GVHD) is an important complication of allogeneic hematopoietic stem cell transplantation (AHCT) that affects several organs, including the mouth. OBJECTIVES The aim of the present study was to describe the prevalence and clinical manifestations of oral GVHD, to determine the time interval from AHCT to the onset of oral GVHD manifestations, to identify predictive factors of oral GVHD, and to evaluate the survival rates of patients diagnosed with oral GVHD. METHODS Medical records of 147 patients who underwent AHCT between January 2010 and January 2015 were reviewed for clinical features and the statistical establishment of risk factors. RESULTS Of the 147 patients in the study, 99 (67.3%) developed GVHD. The skin was the most affected site (45.6%), followed by the gastrointestinal tract (27.9%) and oral cavity (17.7%). The mean post-AHCT oral GVHD development time was 229 days. Among patients with oral GVHD, pain was the main complaint (96.2%) followed by xerostomia (65.4%). The most common oral manifestations were ulcers (53.8%) followed by striae-associated ulcers (19.2%), mostly affecting the buccal mucosa and tongue. Seventy-three patients (48.6%) died within 20 months of receiving AHCT. Cox regression analysis indicated that patients who received myeloablative conditioning regimen had higher survival rate than those who underwent a reduced-intensity conditioning regimen (RR = 0.541; 95% CI, 0.334-0.878; p = 0.03). CONCLUSION The mouth was the third most common GVHD-affected site. Pain, xerostomia, and ulcers with or without striae were the main clinical manifestations of GVHD observed in our study cohort. Reduced-intensity conditioning regimen showed significant relationship with mortality risk.
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Affiliation(s)
- Ana Cláudia Scaraficci
- Stomatology Department, A.C. Camargo Cancer Center, Rua Prof. Antônio Prudente, 211 - Liberdade, São Paulo, SP, 01509-010, Brazil
| | - Patrícia Maria Fernandes
- Stomatology Department, A.C. Camargo Cancer Center, Rua Prof. Antônio Prudente, 211 - Liberdade, São Paulo, SP, 01509-010, Brazil
- Department of Oral Diagnosis, Piracicaba Dental School, University of Campinas - UNICAMP - Piracicaba, Piracicaba, Brazil
| | - Fabio Abreu Alves
- Stomatology Department, A.C. Camargo Cancer Center, Rua Prof. Antônio Prudente, 211 - Liberdade, São Paulo, SP, 01509-010, Brazil
| | - Jayr Schmidt Filho
- Department of Hematology, Hematopoietic Stem Cell Transplant Unit, A.C. Camargo Cancer Center, São Paulo, Brazil
| | - Graziella Chagas Jaguar
- Stomatology Department, A.C. Camargo Cancer Center, Rua Prof. Antônio Prudente, 211 - Liberdade, São Paulo, SP, 01509-010, Brazil.
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Ramos-Pinto MB, de Lima Gusmão TP, Schmidt-Filho J, Jaguar GC, Martins MD, Alves FA. Intraoral versus extraoral photobiomodulation therapy in the prevention of oral mucositis in HSCT patients: a randomized, single-blind, controlled clinical trial. Support Care Cancer 2021; 29:6495-6503. [PMID: 33905011 DOI: 10.1007/s00520-021-06228-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 04/15/2021] [Indexed: 11/30/2022]
Abstract
To compare the efficacy of intraoral and extraoral photobiomodulation (PBM) protocols for the prevention of oral mucositis (OM) in hematopoietic stem cell transplantation (HSCT) patients. A total of 60 patients was randomized into intraoral PBM (IOPBM) and extraoral PBM (EOPBM) groups. Both PBM protocols were well tolerated and no side effects were observed. EOPBM session times were one fourth of IOPBM durations. Of 60 patients, 35 (58.3%) developed ulcerated OM between day +3 and day +12. No intergroup difference was observed in OM healing times (p = 0.424). The lateral border of the tongue was the most common site affected in both groups. However, the incidence of mucositis on buccal mucosa was significantly reduced in the EOPBM group (p = 0.021). Young patients (OR.5.35, 95%CI 0.94-30.4, p = 0.058) and those who had received myeloablative conditioning (OR.55.1, 95%CI 2.69-1129.3, p = 0.009) were more likely to develop ulcerated OM, whereas autologous HSCT recipients (OR 0.079, 95% CI 0.009-0.67, p = 0.021) had a lower probability of developing ulcerated OM independent of PBM protocol. EOPBM protocol was as effective as IOPBM in the management of OM in HSCT patients, with the advantage of shorter treatment sessions. Trial registration number: RBR-7nww56. Date of trial registration submission: 30th September 2019.
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Affiliation(s)
| | | | | | | | - Manoela Domingues Martins
- Department of Oral Pathology, School of Dentistry, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Fábio Abreu Alves
- Stomatology Department, A.C. Camargo Cancer Center, Sao Paulo, Brazil. .,Stomatology Department, School of Dentistry, Sao Paulo University, Sao Paulo, Brazil. .,Departamento de Estomatologia, AC Camargo Cancer Center, R: Prof. Antônio Prudente, 211, Bairro: Liberdade, São Paulo, SP, CEP: 01509-900, Brazil.
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Jaguar GC, Antunes HS, de Mendoça NF, de Macedo LD, Martins MD, Alves FA. Management of oral care related to oncological treatment. A proposal for the "new normal". Photodiagnosis Photodyn Ther 2020; 33:102166. [PMID: 33388435 DOI: 10.1016/j.pdpdt.2020.102166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/23/2020] [Accepted: 12/21/2020] [Indexed: 10/22/2022]
Affiliation(s)
| | | | | | - Leandro Dorigand de Macedo
- Dentistry and Stomatology Division, Ophthalmology, Otolaryngology and Head and Neck Surgery Department, Clinical Hospital of Ribeirão Preto School of Medicine, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Manoela Domingues Martins
- Department of Oral Medicine, Hospital de Clínicas de Porto Alegre (HCPA/UFRGS), Porto Alegre, Rio Grande do Sul, Brazil; Department of Oral Pathology, School of Dentistry, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Fabio Abreu Alves
- Stomatology Department - A.C. Camargo Cancer Center, Sao Paulo, Brazil; Stomatology Department - School of Dentistry, Sao Paulo University, Sao Paulo, Brazil.
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de Carvalho PAG, Lessa RC, Carraro DM, Assis Pellizzon AC, Jaguar GC, Alves FA. Three photobiomodulation protocols in the prevention/treatment of radiotherapy-induced oral mucositis. Photodiagnosis Photodyn Ther 2020; 31:101906. [PMID: 32619713 DOI: 10.1016/j.pdpdt.2020.101906] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 06/16/2020] [Accepted: 06/26/2020] [Indexed: 12/20/2022]
Abstract
PURPOSE To compare three Photobiomodulation protocols to prevent/treat oral mucositis associated to radiotherapy. METHODS Seventy-three patients with cancer in oral cavity, oropharynx, and nasopharynx, who underwent RT with dose in facial fields equal or higher than 6000 cGy were randomized into three groups (mean RT dose = 66 cGy ±4.9). Protocols of Group 1 was 660 nm, 15 mW, 3.8 J/cm2, Group 2 660 nm, 25 mW, 6.3 J/cm2 both starting on the first day of radiotherapy, and group 3 660 nm, 15 mW, 3.8 J/cm2 for therapeutic purpose. The patients of group 1 and 2 were irradiated at 40 points daily covering non-keratinizing oral mucosa. The spot size (probe's tip surface size) was 0.040 cm2 for all groups. Oral mucositis was evaluated according to both WHO and NCI scales, and pain related to oral mucositis was scored using the VAS. RESULTS Patients from group 1 presented with grade II oral mucositis later than groups 2 and 3 (p < 0.001). Moreover, groups 2 and 3 also presented with a mean higher of oral mucositis grade than group 1, p < 0.001. Pain scores were lower in group 1 (p = 0.002). CONCLUSIONS The Photobiomodulation used in Group 1 was more effective than the protocols used in groups 2 and 3 in controlling the grade II oral mucositis intensity, and mean pain scores.
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Affiliation(s)
| | | | - Dirce Maria Carraro
- Laboratory of Genomics and Molecular Biology, International Research Center/CIPE, Brazil
| | | | | | - Fábio A Alves
- Stomatology Department- A.C. Camargo Cancer Center, Sao Paulo, Brazil; Stomatology Department School of Dentistry, Sao Paulo University, Sao Paulo, Brazil.
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Siqueira JM, Fernandes PM, de Oliveira ACF, Vassallo J, Alves FDA, Jaguar GC. Primary diffuse large B-cell lymphoma of the mandible. Autops Case Rep 2019; 9:e2019109. [PMID: 31528626 PMCID: PMC6709649 DOI: 10.4322/acr.2019.109] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 04/02/2019] [Indexed: 12/26/2022] Open
Abstract
Primary intraosseous non-Hodgkin lymphoma in the mandible is uncommon, representing about 0.6% of all extranodal lymphomas. We present the case of a 51-year-old male with a 4-month complaint of mandibular swelling and paresthesia, which had been previously submitted to an unsuccessful periodontal treatment. The intra-oral evaluation showed an extensive swelling with teeth mobility in the right mandible body. The panoramic radiography and computed tomography images showed an extensive osteolytic lesion. An incisional biopsy was performed and the histopathological and immunohistochemical analysis established the diagnosis of diffuse large B-cell lymphoma. The treatment included six cycles of chemotherapy with complete remission. The patient is under the seventh month of follow-up with no evidence of relapse. Although uncommon in the oral cavity, lymphoma should be considered in the differential diagnosis.
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Affiliation(s)
| | - Patrícia Maria Fernandes
- A.C. Camargo Câncer Center, Stomatology Department. São Paulo, SP, Brazil.,University of Campinas - UNICAMP, Piracicaba Dental School, Department of Oral Diagnosis. Piracicaba, SP, Brazil
| | | | - José Vassallo
- A.C. Camargo Cancer Center, Pathologic Anatomy Department. São Paulo, SP, Brazil
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Miniello TG, Araújo JP, Silva MLG, Paulo Kowalski L, Rocha AC, Jaguar GC, Abreu Alves F. Influence of bisphosphonates on clinical features of osteoradionecrosis of the maxilla and mandible. Oral Dis 2019; 25:1344-1351. [DOI: 10.1111/odi.13081] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 02/06/2019] [Accepted: 02/24/2019] [Indexed: 11/27/2022]
Affiliation(s)
| | - Juliane Pirágine Araújo
- Stomatology Department, School of Dentistry São Paulo University São Paulo Brazil
- Stomatology Department A.C. Camargo Cancer Center São Paulo Brazil
| | | | - Luiz Paulo Kowalski
- Head and Neck Surgery and Otorhinolaryngology Department A.C. Camargo Cancer Center São Paulo Brazil
| | | | | | - Fábio Abreu Alves
- Stomatology Department, School of Dentistry São Paulo University São Paulo Brazil
- Stomatology Department A.C. Camargo Cancer Center São Paulo Brazil
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Nakamura GP, Moraes RM, Siqueira JM, de Oliveira ACF, Begnami MDFDS, Jaguar GC. Oral ulcerative lesions in a post-liver-transplantation patient. Autops Case Rep 2019; 9:e2018046. [PMID: 30863727 PMCID: PMC6394359 DOI: 10.4322/acr.2018.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 08/15/2018] [Indexed: 11/23/2022] Open
Abstract
Oral involvement is rarely found in histoplasmosis, except in its disseminated form, which is mostly observed in the severely immunocompromised host. Herein, we presented the case of a 36-year-old female with a previous history of liver transplant, who was hospitalized due to fever, chills, night sweats, diarrhea, and painful oral lesions over the last 3 days. The oral examination revealed the presence of painful shallow ulcers lined by a pseudomembrane in the gingiva and the soft and hard palate. The initial working diagnosis comprised cytomegalovirus reactivation or herpes simplex virus infection. The diagnostic work-up included incisional biopsies of the gingiva and the sigmoid colon. Both biopsies confirmed the diagnosis of histoplasmosis. Intravenous itraconazole was administered with significant improvement after 7 days. Although oral involvement is rare, histoplasmosis should be included in the differential diagnosis of oral lesions, particularly when the patient is immunosuppressed. This study reports a rare presentation of histoplasmosis involving the mucosa of the oral cavity and the colon.
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Jaguar GC, Patrício ÉF, Oliveira CS, Santana JB, Nakamura GP, De Souza Begnami MDF, Alves FA. Oral Manifestation of Histoplasmosis Mimicking A Herpes Simplex Infection in an Immunocompromised Patient: Challenges in the Diagnosis. Oral Surg Oral Med Oral Pathol Oral Radiol 2018. [DOI: 10.1016/j.oooo.2018.02.508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Campanhã D, De Campos L, De Souza Campos JP, Moreira FS, Prado JD, Lima ENP, Jaguar GC. Double-Blind Randomized Prospective Trial of Use of Bethanechol in the Prevention of Iodotherapy-Induced Salivary Gland Dysfunction. Oral Surg Oral Med Oral Pathol Oral Radiol 2018. [DOI: 10.1016/j.oooo.2018.02.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Jaguar GC, Prado JD, Campanhã D, Alves FA. Clinical features and preventive therapies of radiation-induced xerostomia in head and neck cancer patient: a literature review. ACTA ACUST UNITED AC 2017. [DOI: 10.1186/s41241-017-0037-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Moraes RM, Alves FA, Carvalho BFDC, Costa FD, Lopes RN, Jaguar GC. Mandible metastasis of small cell lung cancer mimicking a residual cyst. Autops Case Rep 2017; 7:37-41. [PMID: 28536686 PMCID: PMC5436920 DOI: 10.4322/acr.2017.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Accepted: 01/19/2017] [Indexed: 11/24/2022]
Abstract
Small cell lung carcinoma (SCLC) is an uncommon tumor characterized by an aggressive behavior with early metastasis, usually to the contralateral lung, liver, brain, and bones. There are only five cases of this particular tumor metastasizing to the oral cavity described in the English literature. We present the case of metastatic SCLC in the mandible with radiographic findings resembling a residual cyst. A 66-year-old man with previous diagnosis and treatment for a SCLC was referred to the Stomatology Department with a history of persistent pain in the mandible 1 year after the inferior right pre-molar tooth extraction. The radiographic exam showed a well-delimited radiolucent area on that extracted tooth’s region resembling a residual cyst. Biopsy was performed yielding the diagnosis of metastatic SCLC. The patient was referred to the clinical oncologist for chemotherapy. Although uncommon, this tumor should be included in the differential diagnosis of jawbone lesions, particularly when the patient presents a previous diagnosis of SCLC.
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Affiliation(s)
| | - Fabio Abreu Alves
- Stomatology Department - A.C. Camargo Cancer Center, São Paulo/SP - Brazil.,Stomatology Department - Universidade de São Paulo, São Paulo/SP - Brazil
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Jaguar GC, Luiz AC, Lopes RN, da Silva WG, Brandão TB. Oral Manifestation of NK/T-Cell Non-Hodgkin Lymphoma Mimicking Mucositis: Challenges in Diagnosis and Management. Oral Surg Oral Med Oral Pathol Oral Radiol 2015. [DOI: 10.1016/j.oooo.2015.02.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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Jaguar GC, Lima ENP, Kowalski LP, Pellizzon AC, Carvalho AL, Boccaletti KW, Alves FA. Double blind randomized prospective trial of bethanechol in the prevention of radiation-induced salivary gland dysfunction in head and neck cancer patients. Radiother Oncol 2015; 115:253-6. [PMID: 25890572 DOI: 10.1016/j.radonc.2015.03.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 03/16/2015] [Accepted: 03/16/2015] [Indexed: 12/24/2022]
Abstract
This study assessed the prophylactic bethanechol use to prevent salivary gland dysfunction during radiotherapy. A total of 97 head and neck cancer patients were allocated into two groups: Bethanechol or Placebo. Bethanechol group presented significantly improve of salivary parameters. Bethanechol was effective in decreasing the salivary gland damage.
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Affiliation(s)
| | | | | | | | | | | | - Fabio Abreu Alves
- Stomatology Department, A.C. Camargo Cancer Center, São Paulo, Brazil.
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21
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Araujo JP, Jaguar GC, Alves FA. Syphilis related to atypical oral lesions affecting an elderly man. a case report. Gerodontology 2013; 32:73-5. [DOI: 10.1111/ger.12047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2013] [Indexed: 11/28/2022]
Affiliation(s)
| | | | - Fabio Abreu Alves
- Stomatology Department; Hospital AC Camargo; São Paulo Brazil
- Stomatology Department; University of São Paulo; São Paulo Brazil
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Jaguar GC, Rodrigues GH, Guollo A, Camandoni VO, Melo LMMP, Alves FA, Lima VCC. Impact of oral mucositis on outcomes of multiple myeloma patients treated with high-dose melphalan conditioning and autologous stem cell transplantation (ASCT). J Clin Oncol 2013. [DOI: 10.1200/jco.2013.31.15_suppl.7037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
7037 Background: High-dose melphalan is the standard conditioning regimen for patients with multiple myeloma (MM) undergoing ASCT. However, this therapy is commonly associated with severe oral mucositis (OM). Low-level laser therapy (LLLT) has been reported as an effective method in preventing this complication. The aim of this study was to define the potential impact of OM on outcomes in patients with MM undergoing ASCT and receiving preventive LLLT. Methods: We describe a retrospective cohort of 79 consecutive patients with MM who received high-dose melphalan conditioning. All patients received prophylactic LLLT application performed daily from the beginning of the conditioning regimen up to day +2. The patients continued receiving LLLT in case of OM grade ≥ 2 until complete remission of the lesions. OM severity was assessed daily using WHO scale from the beginning of conditioning until hospital discharge. We examined the relationship between worst OM grade and clinical outcomes, including days with oral pain, days of total parenteral nutrition, days of LLLT and days with neutropenic fever. Results: Of 79 patients, 55 (69.62%) experienced OM grade 0-1, 16 (20.25%) experienced OM grade 2, 7 (8.86%) grade 3 and 1 (1.26%) grade 4. Patients with OM grade 0-2 had statistically fewer days of oral pain compared with grade 3-4 (0.88 and 6.25 days, respectively, p = 0.0001). The worst OM grade was also significantly (p < 0.05) associated with days of narcotic therapy and length of LLLT. Severe OM was not associated with febrile days or the use of parenteral nutrition. Conclusions: Severe OM is associated with worse clinical outcomes. In this transplantation setting, severe OM was not common as previously reported in literature, probably due to LLLT. Controlled randomized trials should be performed to confirm the real benefit of LLLT in this scenario as well as the pharmacogenomics and pharmacokinetic studies to better understand interpatient variability of melphalan exposure and toxicity.
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Jaguar GC, Perez DEDC, Kowalski LP, Pinto CAL, Esteves CM, Alves FA. The impact of graft-versus-host disease in the development of oral cancer after allogeneic hematopoietic stem cell transplantation: report of 2 cases. ACTA ACUST UNITED AC 2013. [DOI: 10.7243/2052-434x-1-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Verrone JR, Alves FDA, Prado JD, Boccaletti KW, Sereno MP, Silva MLG, Jaguar GC. Impact of intraoral stent on the side effects of radiotherapy for oral cancer. Head Neck 2012; 35:E213-7. [DOI: 10.1002/hed.23028] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2012] [Indexed: 11/11/2022] Open
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Carvalho PAG, Jaguar GC, Pellizzon AC, Prado JD, Lopes RN, Alves FA. Evaluation of low-level laser therapy in the prevention and treatment of radiation-induced mucositis: a double-blind randomized study in head and neck cancer patients. Oral Oncol 2011; 47:1176-81. [PMID: 21911312 DOI: 10.1016/j.oraloncology.2011.08.021] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Revised: 08/23/2011] [Accepted: 08/24/2011] [Indexed: 12/22/2022]
Abstract
The purpose of this prospective study was to determine the effect of the low-level laser in the prevention and treatment of mucositis in head and neck cancer patients. A total of 70 patients with malignant neoplasms in the oral cavity or oropharynx were evaluated. The patients were randomized into two low-level laser therapy groups: Group 1 (660nm/15mW/3.8J/cm(2)/spot size 4mm(2)) or Group 2 (660nm/5mW/1.3J/cm(2)/spot size 4mm(2)) starting on the first day of radiotherapy. Oral mucositis was assessed daily and weekly using the NCI and WHO scales. Oral pain was scored daily with a visual analogue scale before laser application. The patients in Group 1 had a mean time of 13.5days (range 6-26days) to present mucositis grade II, while the patients in Group 2 had a mean time of 9.8days (range 4-14days) (both WHO and NCI p=0.005). In addition, Group 2 also presented a higher mucositis grade than Group 1 with significant differences found in weeks 2 (p=0.019), 3 (p=0.005) and 4 (p=0.003) for WHO scale and weeks 2 (p=0.009) and 4 (p=0.013) for NCI scale. The patients in Group 1 reported lower pain levels (p=0.004). Low-level laser therapy during radiotherapy was found to be effective in controlling the intensity of mucositis and pain.
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Affiliation(s)
- P A G Carvalho
- Stomatology Department - Hospital A.C. Camargo, São Paulo, Brazil
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Jaguar GC, da Cruz Perez DE, de Lima VC, Campos AH, Alves FA. Palatal ulcerations and midfacial swelling. ACTA ACUST UNITED AC 2009; 108:483-7. [PMID: 19778739 DOI: 10.1016/j.tripleo.2009.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2008] [Revised: 03/09/2009] [Accepted: 06/08/2009] [Indexed: 10/20/2022]
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Jaguar GC, Prado JD, Nishimoto IN, Pinheiro MC, de Castro DO, da Cruz Perez DE, Alves FA. Low-energy laser therapy for prevention of oral mucositis in hematopoietic stem cell transplantation. Oral Dis 2008; 13:538-43. [PMID: 17944669 DOI: 10.1111/j.1601-0825.2006.01330.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM To evaluate the clinical effects of laser therapy on the prevention and reduction of oral mucositis in patients who underwent hematopoietic stem cell transplantation (HSCT). PATIENTS AND METHODS From January 2003 to September 2004, 24 patients received prophylactic laser therapy (L+ group). The applications started from the beginning of the conditioning regimen up to day +2. The oral assessment was performed daily until day +30. This group was compared with historical controls, namely 25 patients, who did not receive laser therapy (L- group). RESULTS All patients developed some grade of mucositis. However, the L- group presented initial mucositis by 4.36 days, whereas the L+ group presented it in 6.12 days (P = 0.01). The maximum mucositis occurred between day +2 and day +6 with healing by day +25 in the L- group and between day +2 and day +7 with healing by day +14 for the L+ group (P = 0.84). Laser therapy also reduced the time of oral pain from 5.64 to 2.45 days (P = 0.04), and decreased the consumption of morphine (P = 0.07). CONCLUSION This study suggests that laser therapy can be useful in oral mucositis to HSCT patients and improve the patient's quality of life. However, controlled randomized trials should be performed to confirm the real efficacy of laser therapy.
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Affiliation(s)
- G C Jaguar
- Department of Stomatology, Cancer Hospital A.C. Camargo, São Paulo, Brazil
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