Oral Mucositis Induced By Anticancer Therapies

Development and psychometric testing of a self-management scale for cancer survivors with radiotherapy/chemotherapy-induced oral mucositis in China

Objective

This study aims to develop and validate a self-management scale for radiotherapy/chemotherapy-induced oral mucositis (SMS-RIOM/CIOM) in cancer survivors, addressing the need for a comprehensive tool to assess self-management capabilities.

Methods

This study employed a two-phase process: (1) initial scale development through literature review, semi-structured interviews, and expert consultations, and (2) psychometric testing with 420 cancer survivors from five wards of Zibo Hospital. The psychometric evaluation included item analysis, content validity testing, reliability assessments, exploratory factor analysis (EFA), and confirmatory factor analysis (CFA).

Results

The finalized SMS-RIOM/CIOM consists of 15 items across four dimensions: medication management, oral pain management, disease monitoring, and daily life management. EFA explained 77.322% of the total variance, while CFA demonstrated an excellent model fit (χ²/df=1.909, RMSEA=0.064, RMR=0.052, GFI=0.911, CFI=0.964, NFI=0.928, TLI=0.955, IFI=0.964). Reliability metrics were robust, including Cronbach's alpha of 0.902, split-half reliability of 0.849, test-retest reliability of 0.862, and a scale content validity index of 0.910.

Conclusions

The SMS-RIOM/CIOM is a reliable and valid tool for assessing self-management in cancer survivors with RIOM/CIOM. It provides valuable insights for clinical practice, enabling targeted interventions to improve self-management and enhance the quality of life for cancer survivors. Further research is recommended to validate its application across diverse populations and healthcare settings.

Atorvastatin attenuates intestinal mucositis induced by 5-fluorouracil in mice by modulating the epithelial barrier and inflammatory response

Chemotherapy-induced intestinal mucositis is a major side effect of cancer treatment. Statins are 3-hydroxy-3-methyl glutaryl coenzyme reductase inhibitors used to treat hypercholesterolemia and atherosclerotic diseases. Recent studies have demonstrated that atorvastatin (ATV) has antioxidant, anti-inflammatory, and resulting from the regulation of different molecular pathways. In the present study, we investigated the effects of ATV on intestinal homeostasis in 5-fluorouracil (5-FU)-induced mucositis. Our results showed that ATV protected the intestinal mucosa from epithelial damage caused by 5-FU mainly due to inflammatory infiltrate and intestinal permeability reduction, downregulation of inflammatory markers, such as Tlr4, MyD88, NF-κB, Tnf-a, Il1β, and Il6 dose-dependent. ATV also improved epithelial barrier function by upregulating the mRNA transcript levels of mucin 2 (MUC2), and ZO-1 and occludin tight junction proteins. The results suggest that the ATV anti-inflammatory and protective effects on 5-FU-induced mice mucositis involve the inhibition of the TLR4/MYD88/NPRL3/NF-κB, iNos, and caspase 3.

Navigating Stomatologic Complications Secondary to Antineoplastic Agents-A Comprehensive Review

This review systematically examines the oral complications associated with conventional and novel anti-cancer therapies. It highlights that while molecularly targeted agents including monoclonal antibodies targeting the vascular endothelial growth factor and its receptor, the epidermal growth factor receptor, tyrosine kinase inhibitors, and immune checkpoint inhibitors tend to exhibit a lower overall toxicity profile compared to traditional cytotoxic chemotherapeutics, they are nonetheless linked to significant oral adverse events. These complications encompass inflammatory mucosal reactions known as mucositis, salivary gland dysfunction leading to a sensation of dryness in the mouth, taste alterations referred to as dysgeusia, and, critically, medication-related osteonecrosis of the jaw. In particular, bone-modifying agents such as bisphosphonates and denosumab disrupt bone remodeling and the formation of new blood vessels, thereby increasing the susceptibility to osteonecrosis of the jaw, especially following invasive dental procedures. The review delineates the multifactorial pathogenesis underlying these toxicities, which involves direct cell toxicity, impaired wound healing, and secondary infections. Furthermore, it emphasizes the importance of pre-treatment dental evaluation and preventive strategies including patient education, prophylactic dental care, and the integration of adjunctive therapies such as laser therapy and autologous platelet concentrates to mitigate these adverse effects. The analysis advocates for interdisciplinary collaboration between oncologists and dental professionals to optimize management protocols, enhance treatment adherence, and ultimately improve the quality of life for oncology patients undergoing anti-cancer therapy.

Potentiality of Curcumin Against Radio-Chemotherapy Induced Oral Mucositis: A Review

In recent era, cancer is a major global health hazard and is mostly treated with either radio or chemotherapy. The above treatment procedure induces a secondary concern named as oral mucositis (OM). The disorder OM is specifically associated with oral mucosa and leads to bleeding, pain, difficulty in swallowing of solids, as well as fluids and speech difficulty. Curcumin is explored for prevention as well as treatment of OM. The article was organized via collection of enormous literatures by using the keywords like oral mucositis, chemotherapy, anti-inflammatory, curcumin, and clinical trials from search engines of different domains like Scopus, PubMed/MEDLINE, Science Direct, and Google Scholar with an increasing order of their year of publications. A numerous antineoplastic therapies resulted OM, as a devastating side effect. Moreover, the expanded pathogenesis of the disease permits a sound predictability over the patient's risk, thereby directing its adaptability and management protocols towards the achievement of novel therapeutics. An augmented interest towards curcumin as a potential therapeutic emerged because of its easy accessibility, antioxidant, anti-inflammatory, antiulcer, antimicrobial, and wound-healing abilities along with reduced side effects. Curcumin can potentially alter OM and OM-induced weight loss but showed a great heterogeneity.

Graphical Abstract

[Clinical analysis of oral mucositis after secondary allogeneic hematopoietic stem cell transplantation in patients with hematological diseases]

Objective: This study aimed to investigate the clinical characteristics of oral mucositis (OM) in patients with hematological diseases who received secondary allogeneic hematopoietic stem cell transplantation (allo-HSCT) . Methods: This study retrospectively analyzed data on 58 patients with hematological diseases who underwent secondary allo-HSCT at the Peking University People's Hospital from January 2018 to December 2023. The control group included 116 randomized patients after primary allo-HSCT during this period (1:2 ratio) with matched gender, age, and diagnosis. The incidence of OM and overall survival (OS) were compared between the two groups. Results: The secondary allo-HSCT and control groups reported 17 (29.31%) and 16 (13.79%) cases that developed OM (P=0.014), whereas 10 (17.24%) and 7 (6.03%) developed grade ≥3 OM (P=0.019). The median time for OM to occur was 4 days (1-9 days) and 5 days (1-10 days) posttransplantation in the secondary allo-HSCT and control groups, respectively. The multivariate analysis revealed that the use of whole-body radiation therapy as the main pretreatment regimen was an independent risk factor for OM occurrence (P=0.019). Among patients with OM, an age of <55 years is a risk factor for developing grade 3-4 OM (P=0.028). All patients who underwent the secondary allo-HSCT received granulocyte implantation. The median time of granulocyte implantation in 17 patients with OM was 14 days posttransplantation, whereas the median time of granulocyte implantation in patients without OM was 12 days posttransplantation. The difference was not statistically significant (P=0.721). The presence of OM did not affect the occurrence of acute graft-versus-host disease (P=0.938). No statistically significant difference was observed in the 2-year OS rate between patients with and without OM during the secondary allo-HSCT (51.9% vs 50.4%, P=0.943). No statistically significant difference was observed in the 2-year OS rate between patients with OM undergoing the secondary allo-HSCT and those undergoing the primary allo-HSCT (51.9% vs 81.3%, P=0.185) . Conclusions: The proportion of patients with concurrent OM was significantly increased in the secondary allo-HSCT, and the severity was more severe. Whether or not to merge OM does not affect granulocyte implantation, acute graft-versus-host disease incidence, and 2-year OS rate.

Effect of blood oxidative stress indicators on oral mucositis in patients undergoing radiotherapy for nasopharyngeal carcinoma

OBJECTIVES

To investigate the correlation of total antioxidant capacity (T-AOC), glutathione peroxidase (GSH-PX), and advanced oxidized protein product (AOPP) levels in the progression of oral mucositis (OM) during nasopharyngeal carcinoma (NPC) radiotherapy.

METHODS

This prospective study included 102 patients diagnosed with NPC and eligible for radiotherapy indications. T-AOC, GSH-PX, and AOPP were measured before treatment (T0) and during the second week (T1), fourth week (T2), and sixth week (T3) of the intensity-modulated radiation therapy (IMRT) period. Patients were categorized into severe OM (SOM) (n = 21) and Non-SOM (n = 81) groups at week 6. Serum T-AOC, GSH-PX, and AOPP levels were compared at different time periods. The trends of these markers in the two groups during the course of treatment were analyzed. Finally, stepwise logistic regression was conducted to analyze the risk factors for SOM in NPC patients undergoing IMRT.

RESULTS

At T1 and T2 of IMRT, T-AOC and GSH-PX were higher in the SOM group than in the Non-SOM group; At T3, T-AOC and GSH-PX were lower in the SOM group than in the Non-SOM group. T-AOC and GSH-PX had similar change trends in Non-SOM or SOM patients, i.e., T-AOC levels continued to increase at T2 and decreased at T3, and GSH-PX increased significantly at T2 and decreased at T3. Of interest was the fact that T-AOC and GSH-PX decreased significantly more in SOM patients than in Non-SOM patients at T3, and that AOPP levels were in a constant state of increase in SOM patients. Preoperative hypoproteinemia, the absence of oral mucosal protective agents, and the receipt of synchronous chemotherapy were independent risk factors for increasing the course of OM in patients with NPC.

CONCLUSIONS

NPC patients undergoing IMRT exhibit dynamic alterations in blood T-AOC, GSH-PX, and AOPP. Notably, the persistent elevation of these biomarkers, particularly AOPP, is significantly associated with the progression of SOM in these patients. These findings underscore the involvement of oxidative stress imbalance in the pathogenesis of oral mucositis following IMRT.

The Influence of the Microbiome on the Complications of Radiotherapy and Its Effectiveness in Patients with Laryngeal Cancer

INTRODUCTION

Radiotherapy is an effective method of treating cancer and affects 50% of patients. Intensity-modulated radiotherapy (IMRT) is a modernized method of classical radiation used in the treatment of laryngeal cancer. Treatment with intent to preserve the larynx is not always safe or complication-free. The microbiome may significantly influence the effectiveness of oncological treatment, especially radiotherapy, and may also be modified by the toxic response to radiation.

OBJECTIVE

The aim of the study was to prospectively assess the microbiome and its influence on radiotherapy toxicity in patients with laryngeal cancer.

RESULTS

Statistically significant risk factors for complications after radiotherapy were the percentage of Porphyromonas of at least 6.7%, the percentage of Fusobacterium of at least 2.6% and the percentage of Catonella of at least 2.6%.

CONCLUSIONS

The importance of the microbiome in oncology has been confirmed in many studies. Effective radiotherapy treatment and the prevention of radiation-induced oral mucositis is a challenge in oncology. The microbiome may be an important part of personalized cancer treatment. The assessment of the microbiome of patients diagnosed with cancer may provide the opportunity to predict the response to treatment and its effectiveness. The influence of the microbiome may be important in predicting the risk group for radiotherapy treatment failure. The possibility of modifying the microbiome may become a goal to improve the prognosis of patients with laryngeal cancer. Fusobacterium, Porphyromonas and Catonella are important risk factors for radiation-induced oral mucositis in patients with laryngeal cancer.

The Role of Microbiome and Probiotics in Chemo-Radiotherapy-Induced Diarrhea: A Narrative Review of the Current Evidence

BACKGROUND

In this article, we review the most recent research on probiotics effects on diarrhea in both human and animal models of the condition along with the therapeutic potential of these compounds based on their findings.

RECENT FINDINGS

Nearly 50%-80% of cancer patients experience chemotherapy-induced diarrhea (CID), serious gastrointestinal toxicity of chemotherapeutic and radiation regimens that leads to prolonged hospitalizations, cardiovascular problems, electrolyte imbalances, disruptions in cancer treatment, poor cancer prognosis, and death. CID is typically categorized as osmotic diarrhea. The depletion of colonic crypts and villi by radiotherapy and chemotherapy agents interferes with the absorptive function of the intestine, thereby decreasing the absorption of chloride and releasing water into the intestinal lumen. Probiotic supplements have been found to be able to reverse the intestinal damage caused by chemo-radiation therapy by promoting the growth of crypt and villi and reducing inflammatory pathways. In addition, they support the modulation of immunological and angiogenesis responses in the gut as well as the metabolism of certain digestive enzymes by altering the gut microbiota.

CONCLUSION

Beyond the benefits of probiotics, additional clinical research is required to clarify the most effective strain combinations and dosages for preventing chemotherapy and radiotherapy diarrhea.

Thalidomide attenuates radiation-induced apoptosis and pro-inflammatory cytokine secretion in oral epithelial cells by promoting LZTS3 expression

Radiation-induced oral mucositis (RIOM) is a prevalent oral complication that occurs in individuals undergoing radiotherapy or radiation treatment for head and neck tumors. The presence of oral mucosal rupture and ulcerative lesions, which are the defining features of this condition, can significantly affect the quality of life of patients. Additionally, it can interfere with tumor therapy and contribute to an unfavorable prognosis. Current evidence suggests that cellular inflammation and programmed cell death are important factors in disease development. Moreover, thalidomide (THD) has been revealed to reduce the incidence and severity of RIOM in patients undergoing chemoradiotherapy for nasopharyngeal carcinoma. However, the mechanism through which THD improves RIOM remains unknown. This study aimed to investigate the role of LZTS3 in RIOM by analyzing various sequencing datasets and conducting knockdown and overexpression experiments. We used small interfering RNA transfection and LZTS3 overexpression, followed by validation through polymerase chain reaction, western blotting, flow cytometry, and enzyme-linked immunosorbent assay. In this study, we identified LZTS3 as a potential target for THD regulation in RIOM. Through a series of experiments, we confirmed that LZTS3 has the ability to inhibit the inflammatory response and apoptosis of cells. In addition, we also found that THD can regulate the expression of LZTS3 by upregulating, thereby affecting inflammatory response and apoptosis. We repeated these results in a live animal model. In summary, THD has the potential to reduce the occurrence of oral mucositis in patients by upregulating LZTS3 levels. These findings provide a promising avenue for future drug research and development to treat RIOM.

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.

Recombinant Human Keratinocyte Growth Factor Ameliorates Cancer Treatment-Induced Oral Mucositis on a Chip

Oral mucositis (OM) is a severe complication of cancer therapies caused by off-target cytotoxicity. Palifermin, which is recombinant human keratinocyte growth factor (KGF), is currently the only mitigating treatment available to a subset of OM patients. This study used a previously established model of oral mucositis on a chip (OM-OC) comprised of a confluent human gingival keratinocytes (GIE) layer attached to a basement membrane-lined subepithelial layer consisting of human gingival fibroblasts (HGF) and human dermal microvascular endothelial cells (HMEC) on a stable collagen I gel. Cisplatin, radiation, and combined treatments are followed by a recovery period in the OM-OC to determine possible cellular and molecular mechanisms of OM under effects of KGF. Cancer treatments affected the keratinocyte layer, causing death and epithelial barrier loss. Both keratinocytes and subepithelial cells died rapidly, as evidenced by propidium iodide staining. In response to radiation exposure, cell death occurred in the apical epithelial layer, predominantly, within 24h. Cisplatin exposure predominantly promoted death of basal epithelial cells within 32-36h. Presence of KGF in OM-OC protected tissues from damage caused by cancer treatments in a dose-dependent manner, being more effective at 10 ng/mL. As verified by F-actin staining and the Alamar Blue assay, KGF contributed to epithelial survival and induced proliferation of GIE and HGF as well as HMEC within 120h. When the expression of eighty inflammatory cytokines is evaluated at OM induction (Day 12) and resolution (Day 18) stages in OM-OC, some cytokines are identified as potential novel therapeutic targets. In comparison with chemoradiation exposure, KGF treatment showed a trend to decrease IL-8 and TNF-a expression at Day 12 and 18, and TGF-β1 at Day 18 in OM-OC. Taken together, these findings support the utility of OM-OC as a platform to model epithelial damage and evaluate molecular mechanisms following OM treatment.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Voice Changes of Patients With Nasopharyngeal Carcinoma in Eleven Years After Radiotherapy: A Cross-Sectional Study

OBJECTIVES

The objective of this study was to assess voice changes in patients with nasopharyngeal carcinoma (NPC) using subjective and objective assessment tools and to make inferences regarding the underlying pathological causes for different phases of radiotherapy (RT).

METHODS

A total of 187 (123 males and 64 females) patients with post-RT NPC with no recurrence of malignancy or other voice diseases and 17 (11 males and 6 females) healthy individuals were included in this study. The patients were equally divided into 11 groups according to the number of years after RT. The acoustic analyses, GRBAS (grade, roughness, breathiness, asthenia, and strain) scales, and Voice Handicap Index (VHI)-10 scores were collected and analyzed.

RESULTS

The fundamental frequency (F0) parameters in years 1 and 2 and year 11 were significantly lower in patients with NPC than in healthy individuals. The maximum phonation times in years 1 and 11 were significantly shorter than those in healthy individuals. The jitter parameters were significantly different between year 1 and from years 8 to 11 and the healthy individuals. The shimmer parameters were significantly different between years 1, from years 9 to 11, and healthy individuals. Hoarseness was the most prominent problem compared to other items of the GRBAS. The VHI-10 scores were significantly different between years 1 and 2 and year 11 after RT in patients with NPC.

CONCLUSIONS

Voice quality was worse in the first 2 years and from years 8 to 11 but remained relatively normal from years 3 to 7 after RT. Patient-reported voice handicaps began during year 3 after RT. The most prominent problem was perceived hoarseness, which was evident in the first 2 years and from years 9 to 11 after RT. The radiation-induced mucous edema, laryngeal intrinsic muscle fibrosis, nerve injuries, upper respiratory tract changes, and decreased lung capacity might be the pathological reasons for voice changes in post-RT patients with NPC.

Systemic Anti-Inflammatory Agents in the Prevention of Chemoradiation-Induced Mucositis: A Review of Randomised Controlled Trials

Mucositis is a pathological condition characterised by inflammation and ulceration of the mucous membranes lining the alimentary canal, particularly in the mouth (oral mucositis) and the gastrointestinal tract. It is a common side effect of cancer treatments, including chemotherapy and radiotherapy, and it is sometimes responsible for treatment interruptions. Preventing mucositis throughout the alimentary tract is therefore crucial. However, current interventions mainly target either oral or gastrointestinal side effects. This review aimed to investigate the use of systemically administered anti-inflammatory agents to prevent mucositis in cancer patients undergoing cancer treatment. PubMed, Ovid, Scopus, Web of Science, WHO ICTRP and ClinicalTrials.gov were screened to identify eligible randomised controlled trials (RCTs). The published literature on anti-inflammatory agents provides mixed evidence regarding the degree of efficacy in preventing/reducing the severity of mucositis in most anticancer treatments; however, sample size continued to be a significant limitation, alongside others discussed. Our review yielded a list of several anti-inflammatory agents that exhibit potential mucositis-preventive effects in cancer patients undergoing cancer treatment, which can be used to inform clinical practice.

The role of oral microbiota in the development of oral mucositis in pediatric oncology patients treated with antineoplastic drugs: a systematic review

BACKGROUND

In the pediatric oncology population, oral mucositis as a consequence of chemotherapy is a highly prevalent complication which strongly affects both the quality of life and treatment possibilities of the patients. Still, the etiopathological mechanisms carrying to its development are not fully understood, although a possible role of oral dysbiosis has been previously investigated with unclear conclusions. The aim of this systematic review was to assess the available evidence on the role of microbiota in the development of oral mucositis.

METHODS

A systematic literature search was performed following PRISMA guidelines. Three electronic databases were searched up until April 2023 and a following manual search included the reference lists of the included studies and reviews. Studies reporting microbiological and clinical data of pediatric patients treated by antineoplastic drugs were included.

RESULTS

Thirteen studies met the inclusion criteria, reporting an average mucositis prevalence of 57,6%. Candida albicans infections were frequently observed in studies performing microbiological analysis on oral lesions, in contrast with the low rate detection of the Herpes simplex viruses. Bacterial species such as coagulase-negative Staphylococci and Streptococcus viridans were detected more frequently on lesion sites. Studies reporting a quantitative analysis of the general flora did not show comparable results. Risk of bias assessment among studies was generally considered high or very high.

CONCLUSIONS

While the specific role of certain microbiological agents, such as Candida albicans, was frequently reported among studies, data regarding the general dynamics of oral microbiota in the development of oral mucositis are lacking in the current literature. Thus, more studies are needed to provide the knowledge required in order to improve protocols for the prevention and treatment of this threatening complication.

Oral health related quality of life in head and neck cancer survivors within the first year following treatment: a cross-sectional study in Karachi, Pakistan

After completing treatment for head and neck cancer (HNC), patients often face oral complications like oral pain, limited mouth opening and dry mouth which significantly reduce their oral health related quality of life (OHRQoL). These issues impact their overall well-being, social activities and long-term survival. The primary objective of this study was to evaluate OHRQoL and its association with sociodemographic characteristics, oral hygiene practices and oral clinical parameters such as oral hygiene status and oral mucositis grade in patients who have completed treatment for head and neck cancer. This cross-sectional study involved 79 HNC-treated patients within first year after completion of cancer treatment attending ENT and dental clinics at outpatient department (OPD) setting in Karachi. Data was collected electronically using structured questionnaire comprising of EORTC QLQ H&N - 35 to measure OHRQoL, patients were also examined for oral hygiene status using oral hygiene index- simplified (OHI-s) and oral mucositis grade using WHO oral mucositis scale. Multiple linear regression was used to test OHRQoL associations with the sociodemographic and different clinical factors. The result showed an overall mean score for oral health related quality of life (OHRQoL) of 25.02 ± 15.86 (95% CI 21.46-28.57), with difficulty in mouth opening 53.16 ± 18.88 and dry mouth 45.14 ± 24.48 being predominant concerns for decline in the OHRQoL in the population. Male predilection was observed among participants n = 60 (75.9%), majority of the participants n = 41 (51.9%) were below 52 years of age. n = 63 (80%) participants received radiotherapy alongside surgery and chemotherapy. Most of participants n = 66 (83.5%) experienced moderate to severe oral mucositis with poor oral hygiene status n = 56 (71%). Significant associations were found between OHRQoL and BMI, OH status, marital status, monthly income, gender and fluoride toothpaste (p < 0.05). These findings suggest that Quality of Life (QoL) among HNC treated patients is negatively impacted by their poor oral health, post cancer treatment. Therefore, it is important to evaluate and modify the current treatment modalities and involve multidisciplinary teams, to improve their OHRQoL thereby enhancing overall QoL.

Disproportionality Analysis of Stomatitis Associated with Anticancer Drugs Using the Japanese Adverse Drug Event Report Database

INTRODUCTION

Anticancer drug-induced stomatitis can affect a patient's quality of life and the continuation of drug treatment. Although there have been reports of the occurrence of stomatitis associated with anticancer agents in clinical trials, few Japanese participants have been enrolled in clinical trials and have not been sufficiently investigated. In addition, there has been little attention on research on anticancer drugs associated with stomatitis by patient stratification with different carcinogenic sites. Therefore, the aim of this study was to determine the disproportionality associated with stomatitis for various types of anticancer drugs in different types of cancer patients using the Japanese Adverse Drug Event Report (JADER) database.

METHODS

The aim of this study was to identify the disproportionality of stomatitis by analyzing the type of anticancer drug and cancer patients using the Japanese Pharmacovigilance Database. Data obtained from spontaneous reports of adverse events with more than 10 stomatitis outbreaks reported in the JADER database between April 2004 and March 2023 were analyzed. The safety signal for an adverse event was defined as the lower limit of the 95% confidence interval of the reported odds ratio of >1.

RESULTS

There were 6,178 reports of drugs associated with stomatitis. Among these, 41 drugs were suggested to be associated with stomatitis, and 41 drugs were detected as signals. These drugs were classified based on their efficacy: antipyrimidines (six drugs), folate metabolism antagonists (three drugs), alkylating agents (four drugs), platinum (three drugs), topoisomerase inhibitors (three drugs), microtubule inhibitors (three drugs), mammalian target of rapamycin (mTOR) inhibitors (two drugs), kinase inhibitors (seven drugs), anti-growth factor antibodies (five drugs) immune checkpoint inhibitors (one drug), and others (four drugs).

CONCLUSION

The drugs that may be associated with stomatitis were cell cycle-dependent drugs, epidermal growth factor receptor-tyrosine kinase inhibitors, and mTOR inhibitors. Moreover, this study suggested that anti-growth factor antibodies and immune checkpoint inhibitors may be associated with stomatitis development.

Cryotherapy for oral mucositis in cancer: review of systematic reviews and meta-analysis

BACKGROUND

One of the most common side effects of cancer treatment is oral mucositis. Although studies have shown that oral cryotherapy has a favourable effect on oral mucositis, the reliability of the results is questionable.

OBJECTIVE

The goal of this umbrella review was to provide insight into the effects of oral cryotherapy against oral mucositis in patients with cancer, as well as to assess the certainty of this evidence.

METHOD

Studies were searched for through PubMed, Scopus and Web of Science, with no restrictions until August 2021. The risk ratio (RR) and 95% CI for each meta-analysis were recalculated using a random-effects model, and the certainty of the evidence was judged using Grading of Recommendations Assessment, Development and Evaluation.

RESULTS

Ten meta-analyses including 25 original RCTs that fit our inclusion criteria were included. The use of oral cryotherapy markedly reduced the occurrence of overall (RR 0.72, 95% CI 0.64 to 0.83, n=20 trials), moderate to severe (RR 0.60, 95% CI 0.45 to 0.80, n=16 trials) and severe oral mucositis (RR 0.48, 95% CI 0.34 to 0.67, n=16 trials), as well as average severity score of oral mucositis (standardised mean difference=-0.94, 95% CI -1.28 to -0.59, n=4 trials) in comparison to a control group; however, the certainty of evidence for all outcomes was rated very low.

CONCLUSION

In patients with cancer, oral cryotherapy appears to greatly lower the severity and occurrence of oral mucositis, but, with very low certainty of evidence.

Oral Problems in Oncology Patients Undergoing Chemotherapy for Solid Tumors: A Prospective Observational Study

PURPOSE

Oral problems in a group of oncological patients undergoing chemotherapy (CT) for solid tumors have been examined. Incidence and severity of patients' self-reported oral problems have been evaluated along their interaction with age, gender, tumor diagnosis and stage, presence of mestastasis, CT agent type, and number of CT cycle. We also analyzed the presence of paraesthesia and anaesthesia and their predisposing factors associated with clinical and treatment-related variables.

METHODS

Patients were asked to fill in a questionnaire to evaluate the onset and the intensity of oral and perioral pain, oral mucositis, salivary gland hypofunction, dysgeusia, dysphagia, dysphonia, and sensitivity neuropathy (paraesthesia or dysaesthesia) since the last CT infusion. We also investigated which types of medications have possibly been used and who recommended it, as well as patients' degree of awareness about the possibility of oral problems arising during CT.

RESULTS

We recruited 194 patients and obtained 491 questionnaires. We found that a metastatic disease was a risk factor for OM (OR 2.02, p = 0.026) and salivary gland hypofunction (OR 1.66, p = 0.042) and that platinum agents, compared to mitotic inhibitors, increased the risk of developing salivary gland hypofunction (OR 2.16, p = 0.013), dysphagia (OR 3.26, p = 0.001), and anaesthesia (OR 5.16, p = 0.041). Young age was a slight protective factor for most symptoms. The 80% of enrolled patients were informed by the oncologist about possible oral problems arising during CT.

CONCLUSIONS

Our study highlighted the importance of collecting observational data from the patients' perspective on oral problems arising during the routine oncology practice, across a range of solid tumors and CT regimens. The relevance of these findings focused on the key role of the multidisciplinary team in advising the patients on the possible occurrence of oral problems, also by recommending their management.

Repurposing EGFR Inhibitors for Oral Cancer Pain and Opioid Tolerance

Oral cancer pain remains a significant public health concern. Despite the development of improved treatments, pain continues to be a debilitating clinical feature of the disease, leading to reduced oral mobility and diminished quality of life. Opioids are the gold standard treatment for moderate-to-severe oral cancer pain; however, chronic opioid administration leads to hyperalgesia, tolerance, and dependence. The aim of this review is to present accumulating evidence that epidermal growth factor receptor (EGFR) signaling, often dysregulated in cancer, is also an emerging signaling pathway critically involved in pain and opioid tolerance. We presented preclinical and clinical data to demonstrate how repurposing EGFR inhibitors typically used for cancer treatment could be an effective pharmacological strategy to treat oral cancer pain and to prevent or delay the development of opioid tolerance. We also propose that EGFR interaction with the µ-opioid receptor and glutamate N-methyl-D-aspartate receptor could be two novel downstream mechanisms contributing to pain and morphine tolerance. Most data presented here support that repurposing EGFR inhibitors as non-opioid analgesics in oral cancer pain is promising and warrants further research.

Secondary lesions of the mucous membrane of the oral cavity as a side effect of complex anticancer treatment: a literature review

Today, both Ukraine and the world at large are faced with a significant number of oncological diseases with various localizations. The current state of diagnosis, prevention, early detection, and access to treatment leads to a substantial number of people in each country's healthcare system who require comprehensive cancer treatments. Modern medical and diagnosis protocols in oncology involve the usage of ionizing radiation and aggressive toxic chemotherapeutic agents which can significantly disrupt the physiology of the mucous membrane of the digestive tract during treatment, especially of the oral cavity. The most common complication of complex anticancer therapy is the development of various lesions of the oral cavity, including mucositis, which harms the patient's quality of life, limits the doses of chemotherapy and radiation therapy the patient can receive, and also negatively affects the effectiveness of complex therapy treatment. Acute oral mucositis is observed among almost 100% of treatment cases. This is a significant problem for clinical oncology as it may also reduce patient compliance with comprehensive anticancer treatment. The results indicate the presence of oral problems in 100% of patients receiving specialized antitumor chemotherapy and radiotherapy, as well as the presence of a high need for specialized dental treatment.

Chinese Oral Cancer Patients' Pain Beliefs: An Application of Leventhal's Common-Sense Model

BACKGROUND

Patients' pain beliefs are the main obstacle to effective pain management. Assessing and correcting negative perceptions is important for improving pain intensity and quality of life of patients with cancer pain.

AIMS

To explore pain beliefs among oral cancer patients using the Common-Sense Model of Self-Regulation as a theoretical framework. The primary components of the model, cognitive representations, emotional representations, and coping responses, were examined.

DESIGN

A qualitative method was used.

SETTINGS

PARTICIPANTS/SUBJECTS:   METHODS: Semi-structured, qualitative, in-depth interviews were conducted with patients newly diagnosed with oral cancer in a tertiary care hospital. The interviews were analyzed using thematic analysis.

RESULTS

Interviews with 15 patients revealed that the pain beliefs of patients with oral cancer included three themes: pain cognitive representations of oral cancer, pain emotional representations of oral cancer, and pain coping responses.

CONCLUSIONS

Negative pain beliefs are common among oral cancer patients. This novel application of the self-regulatory model demonstrates that it can be used to capture the key pain beliefs (i.e., cognitions, emotions, and coping responses) of oral cancer patients within a single, unifying framework.

Management of oral mucositis: a systematic review

INTRODUCTION

Oral mucositis is one of the most common complications following chemotherapy and/or head and neck radiotherapy. Various treatments for oral mucositis have been proposed. However, there has still been no review of the most frequent and most effective type of therapy to treat oral mucositis. This systematic review aims to determine the most frequent and effective types of therapy to treat and reduce the severity of oral mucositis.

EVIDENCE ACQUISITION

The literature search was carried out using PRISMA guidelines. Publications included from 2010 to June 2021 with a clinical trial, prospective, and retrospective observational research design. The following databases were used: PubMed, Cochrane Library, and Wiley Online Library. The search was for limited articles published in English, which were screened and analyzed by three authors. The risk of bias of each study was also assessed by three authors simultaneously, using different types of instruments depending on its study design.

EVIDENCE SYNTHESIS

Forty-seven of 1274 journals were included. From 3577 subjects, oral mucositis was more common in males than females (2.12: 1), with a mean age of 56.39 (18-90 years). The most commonly used types of therapy are low-level laser therapy (396 subjects) and lysozyme-based compounds (314 subjects). Meanwhile, the most effective type of therapy is low-level laser therapy.

CONCLUSIONS

Low-level laser therapy is the most commonly used oral mucositis therapy and is also the most effective in reducing the degree of oral mucositis and associated pain.

Influence of the microbiome on radiotherapy-induced oral mucositis and its management: A comprehensive review

Radiation-induced mucositis is the most common, debilitating and painful acute toxicity associated with active treatment in head and neck cancer area, severely affecting more than 65% of patients. Oral microbiota significantly changes during cancer therapy and appears to be involved on its pathophysiology. This review aims to present a comprehensive update of new etiopathogenic factors and treatments that may decrease the incidence of mucositis, mainly modifications of dietary interventions to modify microbiome. Despite advances in recent years, its management is mainly symptomatic opioid-based with variable results on different substances analyzed for its prevention. Immunonutrition seems to play a significant role, particularly the supplementation of compounds such as fatty acids, polyphenols or selected probiotics have shown to promote commensal bacteria diversity and reduced incidence of ulcerative mucositis. Modification of the microbiome is a promising preventive treatment for mucositis although its evidence is still scarce. Large studies are needed to demonstrate the efficacy of interventions on microbiome and its clinical impact on radiation-induced mucositis.

Treatment of Oral Mucositis Using Platelet-Rich-Fibrin: A Retrospective Study on Oncological Patients

Oral mucositis is an inflammatory mucosal demolition frequently observed during treatments for neoplastic diseases such as chemotherapy or radiation therapy. The side effects of these treatments often drastically reduce patients' quality of life. Oral mucositis is the result of the systemic consequences of chemotherapy and radiotherapy, which due to their cytotoxic and local effects, lead to pain and severe ulceration with a consequent decrease in the quality of life of affected subjects. Plasma rich in fibrin is often used to enhance soft tissue wound healing and fight bacterial sepsis through the presence of leukocytes within it. The retrospective study aimed to evaluate the efficacy and safety of the topic use of platelet gel in the clinical management of oral mucositis to improve the life quality of patients. The results of the study were promising even though the topical application of platelet-rich-fibrin is like a skin-care treatment. Future studies with a larger sample of patients will be needed to understand the real benefits of platelet-rich-fibrin.

Oral Mucosa in Cancer Patients-Putting the Pieces Together: A Narrative Review and New Perspectives

The oral mucosa is a key player in cancer patients and during cancer treatment. The increasing prevalence of cancer and cancer-therapy-associated side effects are behind the major role that oral mucosa plays in oncological patients. Oral mucositis is a debilitating severe complication caused by the early toxicity of chemo and/or radiotherapy that can restrict treatment outcome possibilities, even challenging a patient's survival. It has been referred to as the most feared cancer treatment complication. Predictive variables as to who will be affected, and to what extent, are still unclear. Additionally, oral mucositis is one of the sources of the increasing economic burden of cancer, not only for patients and their families but also for institutions and governments. All efforts should be implemented in the search for new approaches to minimize the apparently ineluctable outburst of oral mucositis during cancer treatment. New perspectives derived from different approaches to explaining the interrelation between oral mucositis and the oral microbiome or the similarities with genitourinary mucosa may help elucidate the biomolecular pathways and mechanisms behind oral mucosa cancer-therapy-related toxicity, and what is more important is its management in order to minimize treatment side effects and provide enhanced cancer support.

The effects of Ankaferd hemostat on preventing oral mucositis in colorectal cancer patients receiving chemotherapy

INTRODUCTION

New agents are introduced each day to be used in the prevention and treatment of mucositis in cancer treatment. One of those agents is the Ankaferd hemostat. Ankaferd hemostat has pleiotropic effects and anti-infective characteristics in tissue healing.

METHODS

The study was designed as a randomized controlled experimental study. The sample of the study comprised a total of 66 patients (33 patients in the Ankaferd hemostat group and 33 patients in the sodium bicarbonate group) with colorectal cancer who received FOLFOX combination chemotherapy treatment in the first cycle of chemotherapy to prevent mucositis. Participants who met the criteria were randomly assigned to the groups. Before the patient received chemotherapy, ECOG performance score and Oral Mucositis Grading Scale were applied on the 7th day and 15th day. The Ankaferd hemostat group brushed teeth at least twice a day for 2 min and gargled with Ankaferd hemostat twice for 2 min for 2 weeks. The sodium bicarbonate group brushed teeth at least 2 min a day and gargled with sodium bicarbonate 4 times for 2 min for 2 weeks. The Consolidated Standards of Reporting Trials diagram was used to illustrate the randomization of patients.

RESULTS

When the Ankaferd hemostat group is compared with the sodium bicarbonate group, there is a significant difference in favor of the Ankaferd hemostat group in the mucositis grade on the 7th day and 15th day after chemotherapy (p < 0.05). In the binary logistic regression analysis, among the factors affecting the formation of mucositis on the 7th day, only neutrophil and thyroid-stimulating hormone (TSH) were included in the model, while only the TSH variable is statistically significant.

CONCLUSIONS

It was determined that Ankaferd hemostat is effective in preventing oral mucositis due to chemotherapy in adult patients diagnosed with colorectal cancer. In addition, it has been suggested to conduct new studies on the effectiveness of Ankaferd hemostat in the prevention of mucositis in different groups.

TRIAL REGISTRATION

The study was registered at ClinicalTrials.gov (ID: NCT05438771, Date: 25.06.2022).

The Effect of Coffee in the Prevention of Oral Mucositis Associated with Head and Neck Radiotherapy

AIM

This study investigates the effect of coffee on the management of oral mucositis associated with head and neck radiotherapy.

METHOD

Twenty-nine patients who underwent radiotherapy for the first time due to head and neck cancer between March 2019 and February 2020 were included in the experimental study. One cup/day of Turkish coffee (6 mg) was given to the patients in the intervention group every day for 3 weeks from the first day of radiotherapy. Data monitoring of both groups was performed once a week for 3 weeks.

RESULTS

Most of the patients participating in the study were at local stage (65.2%), and 72.4% underwent head and neck radiotherapy with the diagnosis of nasopharynx and larynx cancer. Although the development rate of oral mucositis was lower in the intervention group, no statistically significant difference was determined (p > 0.05). In the repeated follow-up, the quality of life scores was found to be similar in both groups.

CONCLUSION

We concluded that coffee application is not an effective approach in the prevention of oral mucositis associated with head and neck radiotherapy. Further studies with larger sample sizes are needed to determine the prophylactic effect of coffee in the management of oral mucositis.

Rodent models for anticancer toxicity studies: contributions to drug development and future perspectives

Antineoplastic treatment induces a type of gastrointestinal toxicity known as mucositis. Findings in animal models are usually easily reproducible, and standardized treatment regimens are often used, thus supporting translational science. Essential characteristics of mucositis, including intestinal permeability, inflammation, immune and oxidative responses, and tissue repair mechanisms, can be easily investigated in these models. Given the effects of mucositis on the quality of life of patients with cancer, and the importance of experimental models in the development of more effective new therapeutic alternatives, this review discusses progress and current challenges in using experimental models of mucositis in translational pharmacology research. Teaser Experimental models for studying gastrointestinal mucositis have provided a wealth of information improving the understanding of antineoplastic toxicity.

Efficacy of Cryotherapy and Hangeshashinto for Radiation-induced Oral Stomatitis: Preliminary Study

BACKGROUND/AIM

Radiation-induced stomatitis is one of the main acute disorders in patients with head and neck cancer. Since its treatment is often delayed or discontinued, the control of perioperative oral function is necessary. It has been reported that Hangeshashinto (Japanese traditional herbal medicine) and cryotherapy (known as frozen therapy) alleviate oral stomatitis and the accompanying pain. In the present study, the combination effect of Hangeshashinto and cryotherapy on radiation-induced stomatitis in patients with head and neck cancers was investigated for the first time.

PATIENTS AND METHODS

Fifty patients with head and neck cancer were subjected to radiation therapy with concomitant administration of anticancer drugs. They were separated into two groups, matched according to age, stage of cancer progression, total radiation dose, and type of concomitant anticancer drugs. One group was orally administrated frozen Hangeshashinto, while another group was not. Oral mucosal damage was assessed by the grade classification CTCAE v4.0 of the National Cancer Institute of the United States (Japanese JCOG version). Duration time of radiation-induced stomatitis was determined by the appearance of grade 1 redness to its disappearance.

RESULTS

Frozen Hangeshashinto significantly alleviated, delayed the onset, and reduced the duration time of the radiation-induced stomatitis.

CONCLUSION

Cryotherapy in combination with Hangeshashinto can be used for the treatment of radiation-induced oral stomatitis.

Photobiomodulation for Chemotherapy-Induced Oral Mucositis in Pediatric Patients

Oral mucositis (OM) is a common side effect in patients undergoing chemotherapy (CT), especially in children due to their rapid epithelial mitotic rate. It has been associated with a significant reduction in life quality since it leads to pain, an inadequate intake of nutrients, an increased risk of opportunistic infections, and interruptions of CT. Photobiomodulation (PMB) with low-level laser therapy (LLLT) has shown faster healing, reduction in pain, and the reduced use of analgesic compared to placebo groups. The purpose of this review is to analyze and compare the existing clinical trials and identify their shortcomings in hope to make future research easier. Using MeSH terms and keywords, the Embase, Medline, and PubMed databases we searched for the period of the last 5 years. We identified a total of 15 clinical trials, with a total of 929 pediatric patients analyzed in this review. We compared different light sources and other laser technique characteristics used in clinical trials such as wavelength, energy and power density, spot size, irradiation time, PBM protocol, and OM evaluation. The main findings show inconsistent laser parameter quotations, differences in the PBM protocol along with a laser application technique, and a lack of clinical trials. Based on that, more studies with a high methodological quality should be conducted in order to provide a unified PBM protocol suitable for the pediatric population.

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.

Efficacy of polyacrylate silver salt/polyvinylpyrrolidone-based liquid oral gel in management of concurrence chemoradiotherapy-induced oral mucositis

BACKGROUND/PURPOSE

Acute oral mucositis (OM) is a painful complication of concurrent chemoradiotherapy (CCRT). This severe adverse symptom may impact on patient's quality of life, lead to malnutrition. Thus, finding more effective methods in OM management is very important. The purpose of this study is to evaluate the efficacy of polyacrylate silver salt/Polyvinylpyrrolidone-based liquid oral gel (named as polyacrylate silver salt oral gel) in improving the symptomatic relief of CCRT-induced oral mucositis and oral dysfunction in neck and head cancer patients.

METHODS

In this study, 24 oral cancer patients underwent CCRT and having OM grade 2 or higher were randomly assigned into the test group and the control group. Both groups followed Multinational Association of Supportive Care in Cancer and International Society of Oral Oncology (MASCC/ISOO) clinical practice guidelines for the management of mucositis, but adding rinsing with 15 g oral gel right after oral hygiene treaded the test group. Clinical OM and oral function were assessed weekly for 4 consecutive weeks till 5-10 days after the completion of radiotherapy. For evaluation, Common Terminology Criteria for Adverse Events (CTCAE) v3.0 was used for collecting the data of OM grade.

RESULTS

The results showed that polyacrylate silver salt oral gel had better effect for relieving the oral mucositis. There were statistically significant differences in OM grades (1.59 vs. 2.8, p < 0.0001) between the test group and the control group.

CONCLUSION

Our clinical studies demonstrated that polyacrylate silver salt oral gel is an effective interventional option in terms of rapid mucositis healing.

The Cytotoxic and Inhibitory Effects of Plant Derivatives on Candida albicans Biofilms: A Scoping Review

Candida albicans infections are related to biofilm formation. The increase in antifungal resistance and their adverse effects have led to the search for therapeutic options as plant derivatives. This scoping review aims to identify the current status of in vitro research on the cytotoxicity and inhibitory effects of plant derivatives on C. albicans biofilms. In this study, PRISMA items were followed. After recognition of the inclusion criteria, full texts were read and disagreements were resolved with a third party. A risk of bias assessment was performed, and information was summarized using Microsoft Office Excel. Thirty-nine papers fulfilling the selection criteria were included. The risk of bias analysis identified most of the studies as low risk. Studies evaluated plant derivatives such as extracts, essential oils, terpenes, alkaloids, flavonoids and polyphenols. Some studies evaluated the inhibition of C. albicans biofilm formation, inhibition on preformed biofilms or both. The derivatives at concentrations greater than or equal to those that have an inhibitory effect on C. albicans biofilms, without showing cytotoxicity, include magnoflorin, ellagic acid, myricetin and eucarobustol from Eucalyptus robusta and, as the works in which these derivatives were studied are of good quality, it is desirable to carry out study in other experimental phases, with methodologies that generate comparable information.

Oral Side Effects in Patients with Metastatic Renal Cell Carcinoma Receiving the Antiangiogenic Agent Pazopanib-Report of Three Cases

Pazopanib is a potent multi-kinase inhibitor that hinders angiogenesis and blocks tumor growth. It has been approved for the treatment of metastatic renal cell carcinoma (mRCC) and advanced soft tissue sarcoma. There is emerging evidence that bleeding is a common adverse effect of pazopanib and other targeted therapies in patients with mRCC. In addition, jaw osteonecrosis related to pazopanib was recently described in the literature. We report three cases of patients with mRCC who developed adverse oral events related to pazopanib. The first patient, treated with pazopanib as monotherapy, presented with gingival bleeding and oral burning sensation. The other two patients receiving pazopanib as monotherapy and pazopanib followed by sunitinib, respectively, presented complaining about mandibular pain; a diagnosis of medication-related osteonecrosis of the jaw (MRONJ) was rendered in both cases. Gingival bleeding and MRONJ may develop as oral side effects of pazopanib use. The cases presented here aim to alert and inform health care professionals about the risk of adverse oral events in patients with mRCC receiving the antiangiogenic agent pazopanib.

Impact of systemic dexamethasone administration on oral mucositis induced by anthracycline-containing regimens in breast cancer treatment

Oral mucositis (OM) is one of the most common complications associated with chemotherapy. Here, we evaluated whether systemic dexamethasone (DEX) dosage in prophylactic antiemetics affected the incidence of OM in anthracycline-containing regimens. Patients receiving anthracycline-containing regimens for breast cancer were divided into high- and low-DEX dose groups and retrospectively evaluated. The incidence of all-grade OM in the first cycle in the high- and low-dose groups was 27.3% and 53.5%, respectively, and was significantly lowered by increasing the DEX dose (P < 0.01); thus, the study met its primary endpoint. The result in all treatment cycles was also significant (P = 0.02). In contrast, the incidence of dysgeusia was similar between the high- and low-dose groups in the first and all cycles (13.6% and 16.3% in the first cycle [P = 0.79] and 27.3% and 34.9% in all cycles [P = 0.42], respectively). Multivariate analysis revealed that low DEX dosage was an independent risk factor for all-grade OM development. In conclusion, our study suggests that DEX attenuates OM in anthracycline-containing regimens for breast cancer treatment in a dose-dependent manner. Further evaluation of OM prophylaxis, including DEX administration, is required for better control.

Oral mucositis on a chip: modeling induction by chemo- and radiation treatments and recovery

Oral mucositis (OM) is a debilitating complication affecting roughly 70% of head and neck cancer patients receiving chemotherapy and/or radiation treatment. No broadly effective preventative treatment for OM exists. Therefore, anin vitromodel of cancer treatment-induced OM would aid studies into possible origins of the pathology and future drug targets to ameliorate it. In this study, we present a microfluidic oral mucosa triculture tissue construct consisting of a keratinocyte layer attached to a subepithelial fibroblast and endothelial cell-embedded collagen gel. To address the typically low stability of mucosal constructs in microfluidics, ruthenium-catalyzed photocrosslinking was implemented to strengthen the collagen gel and prevent the invasion of keratinocytes, thus maintaining tissue construct geometry and oral mucosa barrier function for over 18 d of culture. Next, the OM chip was exposed to cisplatin (day 10) and damaging radiation (day 11, ± cisplatin at day 10), mimicking damage from cancer therapy. Damage to and then recovery of the tissue layers and function were observed over days 11-18. Therefore, several important features of OM induction and resolution were modeled in microfluidic culture. The OM model on a chip allows for more sophisticated studies into mechanisms of OM and potential treatments.

J-SUPPORT research policy for oral mucositis associated with cancer treatment

BACKGROUND

Oral mucositis is one of the main areas of research in supportive and palliative care of cancer patients. However, the methodology of prospective clinical trials on oral mucositis has not been established, despite its uniqueness. Here, we propose a novel research policy on oral mucositis, including an implementable set of recommendations for researchers conducting clinical trials.

METHODS

The first draft was developed by an expert panel of six specialists from the Japanese Supportive, Palliative, and Psychosocial Care Study Group. A provisional draft was developed after review by the following medical societies: the Japanese Association of Supportive Care in Cancer, the Japanese Association of Oral Supportive Care in Cancer, the Japanese Cancer Association, and the receipt of public comments.

RESULTS

The research policy on oral mucositis mainly consists of the following components: (i) definition of oral mucositis; (ii) characteristics of oral mucositis; (iii) characteristics of oral mucositis research; (iv) target population for oral mucositis research; (v) endpoints and assessment measures in oral mucositis; (vi) eligibility criteria; (vii) research design; (viii) minimally recommended intervention in oral mucositis research as a supplement. The final policy (Ver1.0) was completed on August 16, 2021.

CONCLUSIONS

This policy may serve as a significant reference for planning and conducting clinical trials for the management of oral mucositis.

Anti-inflammatory mouthwashes for the prevention of oral mucositis in cancer therapy: an integrative review and meta-analysis

PURPOSE

Mucositis is severely painful and often reported as one of the most distressing adverse effects of cancer therapy; it is a significant threat to quality of life as well as life itself. Anti-inflammatory agents may modulate physiologic mechanisms that perpetuate mucositis and be useful in prevention efforts. Because systemic anti-inflammatory agents are not appropriate for many patients, locally acting agents (mouthwashes) may be more feasible for use. This review and meta-analysis evaluates the role that anti-inflammatory mouthwashes have in preventing or reducing oral mucositis associated with chemotherapy and radiation therapy.

METHODS

A systematic literature review was conducted to identify studies evaluating the efficacy of anti-inflammatory mouthwashes to prevent therapy-associated mucositis. Meta-analysis was conducted to determine efficacy in preventing any mucositis and dose-limiting mucositis.

RESULTS

Eight peer-reviewed publications were identified; corticosteroid and nonsteroidal anti-inflammatory mouthwashes are effective in reducing overall incidence of mucositis and are associated with lower severity of mucositis. Meta-analysis reveals significant reduction in symptomatic mucositis incidence (OR 6.00, 95% CI 4.39-8.20, p < 0.0001) and reduction of dose-limiting mucositis (OR 2.12, 95% CI 1.07-4.28, p = 0.032).

CONCLUSION

Mouthwashes containing anti-inflammatory agents are a potential effective means to prevent or reduce mucositis associated with cancer therapy. There are limited adverse effects from these agents, and adherence is high, indicating safety and feasibility of use. Anti-inflammatory mouthwashes should be considered for supportive care in persons at risk for mucositis and must be further evaluated to investigate efficacy across multiple chemotherapy agents, adverse effects, and impacts on symptoms, pain, and quality of life.

Oral Microbiota during Childhood and Its Role in Chemotherapy-Induced Oral Mucositis in Children with Cancer

The human oral cavity harbors the second most abundant microbiota after the gastrointestinal tract, with over 700 species currently identified in the oral microflora. The oral microbiota develops from intrauterine life and after birth is continuously shaped by several influencing factors. The perturbation of the diversity and proportions of species within the oral microbiota leads to dysbiosis and associated increased risk of local and systemic diseases. In children who receive chemotherapy for cancer, oral mucositis is a common and painful side effect that decreases quality of life (QoL) and treatment adherence. The oral microbiota undergoes a substantial dysbiosis as an effect of cancer and its treatment, characterized by lower richness and less diversity. Furthermore, this dysbiosis seems to promote pro-inflammatory cytokine release and pro-apoptotic mediators, enhancing the oral tissue damage. Further studies on the role of the oral microbiota in the pathogenesis of oral mucositis should be performed among children with cancer who receive chemotherapy, to find preventive and protective factors against the pathogenesis of oral mucositis.

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

Background

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

Methods

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

Results

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

Conclusion

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

Head and neck radiotherapy effects on the dental pulp vitality and response to sensitivity tests. A systematic review with meta-analysis

BACKGROUND

There is no consensus whether radiotherapy for head and neck cancer (HNC) could induce pulp necrosis. Therefore, a systematic review of clinical studies is necessary.

OBJECTIVES

To evaluate the evidences on radiotherapy for HNC and pulp status.

METHODS

A systematic search of articles published until November 2021 was performed in the MEDLINE/PubMed, Cochrane Library, Web of Science (All Databases), Scopus, EMBASE and Open Grey databases. The eligibility criteria were based on the PICOS strategy, as follows: (P) vital teeth of adult patients with intraoral and/or oropharyngeal cancer; (I) radiotherapy; (C) control group or values of the same tooth before radiotherapy (basal values); (O) pulpal status after radiotherapy; (S) clinical studies. The Cochrane Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool was used to assess the quality of the included studies. Meta-analyses were performed using fixed and random effects. The overall quality of evidence was assessed through the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool.

RESULTS

Six studies were included for qualitative analysis. Five were classified as serious risk of bias and one as moderate risk of bias. Four studies reported altered pulp responses to cold thermal test after radiotherapy initiation. Meta-analyses were performed using three included studies. From these, all were included in the meta-analysis for pulp response values to cold sensitivity test immediately after radiotherapy initiation (risk ratio: 0.00[CI:0.00, 0.02], P < 0.00001; I² = 0%); and two in the meta-analysis for pulp response values to cold sensitivity test after 4-5 months of radiotherapy (risk ratio: 0.01[CI: 0.00. 0.06], P < 0.00001; I² = 0%). Two reported progressively higher readings to pulp response in the electrical test after radiotherapy initiation (mean difference: -11.46[-13.09, -9.84], P < 0.00001; I² = 68%) and at all periods evaluated. Two studies demonstrated a pulp oxygen saturation (SpO₂ ) decrease at the end of radiotherapy; and increase after 4-6 months of radiotherapy beginning. And other demonstrated normal dental pulp SpO₂ 4 to 6 years after treatment. GRADE analysis presented a moderate certainty of evidence.

DISCUSSION

This review verified that radiotherapy for HNC causes significant alterations on the dental pulp responses, but does not seem to induce pulp necrosis. Significant limitations regarding controlling for confounding factors, classification of interventions and measurement of outcomes were verified, evidencing the need for well-designed studies.

CONCLUSIONS

This systematic review demonstrated that radiotherapy for HNC induced significant changes in the pulp response with moderate quality of evidence. Such altered responses cannot determine pulp status accurately.

The Interplay among Radiation Therapy, Antibiotics and the Microbiota: Impact on Cancer Treatment Outcomes

Radiation therapy has been used for more than a century, either alone or in combination with other therapeutic modalities, to treat most types of cancer. On average, radiation therapy is included in the treatment plans for over 50% of all cancer patients, and it is estimated to contribute to about 40% of curative protocols, a success rate that may reach 90%, or higher, for certain tumor types, particularly on patients diagnosed at early disease stages. A growing body of research provides solid support for the existence of bidirectional interaction between radiation exposure and the human microbiota. Radiation treatment causes quantitative and qualitative changes in the gut microbiota composition, often leading to an increased abundance of potentially hazardous or pathogenic microbes and a concomitant decrease in commensal bacteria. In turn, the resulting dysbiotic microbiota becomes an important contributor to worsen the adverse events caused in patients by the inflammatory process triggered by the radiation treatment and a significant determinant of the radiation therapy anti-tumor effectiveness. Antibiotics, which are frequently included as prophylactic agents in cancer treatment protocols to prevent patient infections, may affect the radiation/microbiota interaction through mechanisms involving both their antimicrobial activity, as a mediator of microbiota imbalances, and their dual capacity to act as pro- or anti-tumorigenic effectors and, consequently, as critical determinants of radiation therapy outcomes. In this scenario, it becomes important to introduce the use of probiotics and/or other agents that may stabilize the healthy microbiota before patients are exposed to radiation. Ultimately, newly developed methodologies may facilitate performing personalized microbiota screenings on patients before radiation therapy as an accurate way to identify which antibiotics may be used, if needed, and to inform the overall treatment planning. This review examines currently available data on these issues from the perspective of improving radiation therapy outcomes.

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 broadening scope of oral mucositis and oral ulcerative mucosal toxicities of anticancer therapies

Oral mucositis (OM) is a common, highly symptomatic complication of cancer therapy that affects patients' function, quality of life, and ability to tolerate treatment. In certain patients with cancer, OM is associated with increased mortality. Research on the management of OM is ongoing. Oral mucosal toxicities are also reported in targeted and immune checkpoint inhibitor therapies. The objective of this article is to present current knowledge about the epidemiology, pathogenesis, assessment, risk prediction, and current and developing intervention strategies for OM and other ulcerative mucosal toxicities caused by both conventional and evolving forms of cancer therapy.

Oral Mucositis Association with Periodontal Status: A Retrospective Analysis of 496 Patients Undergoing Hematopoietic Stem Cell Transplantation

BACKGROUND

Hematopoietic stem cell transplantation (HSCT) can induce serious oral complications, including oral mucositis (OM). The presence of periodontal inflammation before HSCT is believed to be associated with OM. The aim of our study was to determine the prevalence and severity of OM in patients undergoing HSCT and its relation to periodontal status.

PATIENTS AND METHODS

This is a retrospective study of patients who underwent HSCT and a detailed dental examination between 2007 and 2015. The dental and periodontal status of all patients was evaluated by clinical and radiographic examination prior to HSCT. Oral health was assessed with the gingival index, the the community periodontal index, presence of plaque-related gingivitis, and marginal periodontitis. During the HSCT period, patients were examined daily for the presence of OM, which was graded according to World Health Organization (WHO) classification if present. The patients were assigned to the groups according to type of transplantation: autologous HSCT, myeloablative allogeneic HSCT, and non-myeloablative allogeneic HSCT.

RESULTS

A total of 496 patients were included in the study. OM was present in 314 of 496 patients (63.3%): 184/251 (73.3%) in the autologous group, 100/151 (66.2%) in the myeloablative allogeneic group, and 30/94 (31.9%) in the nonmyeloablative allogeneic group. Significantly more patients suffered from OM in the autologous and myeloablative groups versus the nonmyeloablative conditioning group (p < 0.001). The presence of periodontal inflammation did not significantly differ among the groups. There was only a borderline trend for the higher prevalence of OM in the non-myeloablative allogeneic nonmyeloablative group when periodontal inflammation was present (0.073939).

CONCLUSIONS

Oral mucositis prevalence and severity after stem cell transplantation is not widely affected by the oral hygiene and periodontal disease presence before HSCT. We confirmed the wide-known connection of the conditioning regimen intensity to the prevalence of OM.

Brazilian Nutritional Consensus in Hematopoietic Stem Cell Transplantation: children and adolescents

The Brazilian Nutritional Consensus in Hematopoietic Stem Cell Transplantation: Children and Adolescents was developed by dietitians, physicians, and pediatric hematologists from 10 Brazilian reference centers in hematopoietic stem cell transplantation. The aim was to emphasize the importance of nutritional status and body composition during treatment, as well as the main characteristics related to patient´s nutritional assessment. This consensus is intended to improve and standardize nutrition therapy during hematopoietic stem cell transplantation. The consensus was approved by the Brazilian Society of Bone Marrow Transplantation.

A Narrative Review about Nutritional Management and Prevention of Oral Mucositis in Haematology and Oncology Cancer Patients Undergoing Antineoplastic Treatments

Cancer is a prevalent disease worldwide, and treatments such as radiotherapy and chemotherapy sometimes lead to adverse events. Oral mucositis is one of the most disabling adverse events, and clinical guidelines do not take into account nutritional interventions. The primary endpoint was to gather the evidence about the efficacy of nutritional interventions in the prevention and/or treatment of antineoplastic-induced oral mucositis in oncological patients. A bibliographic review was carried out in the PubMed data base by combining MeSH terms with Boolean operators. Articles were selected based on inclusion and exclusion criteria; 50 final articles were found. Although further evidence is needed, glutamine, honey, and vitamins appear to be good therapeutic options. The rest of the compounds presented controversial or insufficient results, making it difficult to draw conclusions over their utilization as prevention or treatment options. Little evidence is reported about oral mucositis nutritional interventions in spite of them being attainable and affordable compounds. Scarce evidence is shown in paediatric patients compared with adults. Developing higher quality studies and combinations with the compounds researched is necessary for creating a stronger body of evidence.