Clinical and histopathological evaluation of sucralfate in prevention of oral mucositis induced by radiation therapy in patients with head and neck malignancies

Effectiveness of sucralfate in preventing esophageal stricture in children after ingestion of caustic agents

Ingestion of caustic agents by children is a serious health issue that can affect the patient for the rest of his life. The role of sucralfate in preventing stricture caused by caustic agents is controversial, and limited studies have been conducted in this field. We aimed to investigate the effect of sucralfate on preventing esophageal stricture in children. Sixty children with mean age of 36.69 ± 20.50 months and grade II B esophageal burns due to ingestion of caustic agents were enrolled in the study. In the intervention group, in addition to the usual treatment, sucralfate was administered orally at a dose of 80 mg/kg every 2 h for 3 days. For the control group, only the usual treatment was prescribed. Stricture development was compared between groups based on endoscopic and radiologic findings. Of the 60 patients enrolled in the study, 53 were examined. The incidence of esophageal stricture in the intervention group was significantly lower than in the control group (37% versus 67%, P-value = 0.042). In addition, the odds of esophageal stricture after sucralfate intervention was significantly reduced after adjustment for potential confounders (OR = 0.198, P-value = 0.031).  Conclusions: The results of this study showed that sucralfate may reduce the development of esophageal stricture in children when used to manage IIB esophageal burns due to ingestion of caustic agents. What is Known: • Ingestion of caustic agents by children is a serious health issue that can affect the patient for the rest of his life. • The role of sucralfate in preventing stricture caused by caustic agents is controversial and limited studies have been conducted in this field. What is New: • It seems that sucralfate significantly reduces the incidence of esophageal stricture following the ingestion of caustic agents in children compared to the control group. • We believe that the prognosis may be improved and the risk of stricture formation may be reduced with high doses of sucralfate therapy in grade IIB esophageal injury.

Characterization of a novel dual murine model of chemotherapy-induced oral and intestinal mucositis

Oral and intestinal mucositis are debilitating inflammatory diseases observed in cancer patients undergoing chemo-radiotherapy. These are devastating clinical conditions which often lead to treatment disruption affecting underlying malignancy management. Although alimentary tract mucositis involves the entire gastrointestinal tract, oral and intestinal mucositis are often studied independently utilizing distinct organ-specific pre-clinical models. This approach has however hindered the development of potentially effective whole-patient treatment strategies. We now characterize a murine model of alimentary tract mucositis using 5-Fluorouracil (5-FU). Mice were given 5-FU intravenously (50 mg/kg) or saline every 48 h for 2 weeks. Post initial injection, mice were monitored clinically for weight loss and diarrhea. The incidence and extent of oral mucositis was assessed macroscopically. Microscopical and histomorphometric analyses of the tongue and intestinal tissues were conducted at 3 interim time points during the experimental period. Repeated 5-FU treatment caused severe oral and intestinal atrophy, including morphological damage, accompanied by body weight loss and mild to moderate diarrhea in up to 77.8% of mice. Oral mucositis was clinically evident throughout the observation period in 88.98% of mice. Toluidine blue staining of the tongue revealed that the ulcer size peaked at day-14. In summary, we have developed a model reproducing the clinical and histologic features of both oral and intestinal mucositis, which may represent a useful in vivo pre-clinical model for the study of chemotherapy-induced alimentary tract mucositis and the development of preventative therapies.

Status of Treatment and Prophylaxis for Radiation-Induced Oral Mucositis in Patients With Head and Neck Cancer

Radiation-induced oral mucositis (RIOM) is one of the most frequent complications in head and neck cancer (HNC) patients undergoing radiotherapy (RT). It is a type of mucosal injury associated with severe pain, dysphagia, and other symptoms, which leads to the interruption of RT and other treatments. Factors affecting RIOM include individual characteristics of HNC patients, concurrent chemoradiation therapy, and RT regimen, among others. The pathogenesis of RIOM is not yet fully understood; however, the release of inflammatory transmitters plays an important role in the occurrence and development of RIOM. The five biological stages, including initiation, primary damage response, signal amplification, ulceration, and healing, are widely used to describe the pathophysiology of RIOM. Moreover, RIOM has a dismal outcome with limited treatment options. This review will discuss the epidemiology, pathogenesis, clinical appearance, symptomatic treatments, and preventive measures related to this disease. We hope to provide a reference for the clinical treatment and prevention of RIOM in HNC patients after RT.

Efficacy of sucralfate ointment in the prevention of acute proctitis in cancer patients: A randomized controlled clinical trial

Background:

Acute radiation proctitis (ARP) is a usual adverse effect in patients undergoing pelvic radiotherapy. The symptoms include diarrhea, rectal blood or mucus discharge, fecal urgency and tenesmus with pain. Sucralfate, an aluminum-based salt of sucrose octasulfate, is a cytoprotective agent that forms a coating barrier at injured sites by adhering to mucoproteins. It has been used in topical management of a wide variety of local lesion. This study was designed to evaluate the preventive effect of rectal sucralfate on acute radiotherapy induced proctitis.

Methods:

Seven percent sucralfate ointment was prepared for topical use. Drug quantification, chemical stability and microbial limit tests were performed carefully. In this randomized double blind placebo controlled trial, fifty-seven patients with pelvic malignancies undergoing radiotherapy were allocated to receive either 1 g of sucralfate or 1 g of placebo, given as a twice daily ointment, one day before and during radiotherapy for six weeks. The eligible patients were evaluated based on RTOG acute toxicity criteria and the following ARP symptoms weekly: rectal hemorrhage, diarrhea, rectal pain, and fecal urgency. The influence of symptoms on lifestyle was also recorded weekly.

Results:

Acute proctitis was significantly less prevalent in patients in the sucralfate group. The incidence of rectal bleeding (P=0.003), diarrhea (P=0.002), rectal pain (P=<0.001) and fecal urgency (P=0.002) was significantly less common in the sucralfate group. No statistical significant difference was observed for radiotherapy induced cystitis in the placebo and sucralfate groups (P=0.27).

Conclusion:

This study suggests that sucralfate7% ointment reduces the incidence of symptoms associated with acute radiation proctitis.

Screening and identification of potential biomarkers and therapeutic drugs in melanoma via integrated bioinformatics analysis

Melanoma is a highly aggressive malignant skin tumor with a high rate of metastasis and mortality. In this study, a comprehensive bioinformatics analysis was used to clarify the hub genes and potential drugs. Download the GSE3189, GSE22301, and GSE35388 microarray datasets from the Gene Expression Omnibus (GEO), which contains a total of 33 normal samples and 67 melanoma samples. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) approach analyze DEGs based on the DAVID. Use STRING to construct protein-protein interaction network, and use MCODE and cytoHubba plug-ins in Cytoscape to perform module analysis and identified hub genes. Use Gene Expression Profile Interactive Analysis (GEPIA) to assess the prognosis of genes in tumors. Finally, use the Drug-Gene Interaction Database (DGIdb) to screen targeted drugs related to hub genes. A total of 140 overlapping DEGs were identified from the three microarray datasets, including 59 up-regulated DEGs and 81 down-regulated DEGs. GO enrichment analysis showed that these DEGs are mainly involved in the biological process such as positive regulation of gene expression, positive regulation of cell proliferation, positive regulation of MAP kinase activity, cell migration, and negative regulation of the apoptotic process. The cellular components are concentrated in the membrane, dendritic spine, the perinuclear region of cytoplasm, extracellular exosome, and membrane raft. Molecular functions include protein homodimerization activity, calmodulin-binding, transcription factor binding, protein binding, and cytoskeletal protein binding. KEGG pathway analysis shows that these DEGs are mainly related to protein digestion and absorption, PPAR signaling pathway, signaling pathways regulating stem cells' pluripotency, and Retinol metabolism. The 23 most closely related DEGs were identified from the PPI network and combined with the GEPIA prognostic analysis, CDH3, ESRP1, FGF2, GBP2, KCNN4, KIT, SEMA4D, and ZEB1 were selected as hub genes, which are considered to be associated with poor prognosis of melanoma closely related. Besides, ten related drugs that may have therapeutic effects on melanoma were also screened. These newly discovered genes and drugs provide new ideas for further research on melanoma.

Current topical trends and novel therapeutic approaches and delivery systems for oral mucositis management

Oral mucositis (OM) is an extremely serious and challenging complication of chemoradiotherapy, which may limit the efficacy of cancer treatment. Complications related to OM include potential nutrition impairment, high economic burden, and negative impacts on patients' quality of life. Current therapeutic options with local traditional pharmaceutical formulations are largely focused on controlling symptoms, and only few agents are available for treatment. Several local supportive and palliative agents are used for the prevention of OM; however, a standard treatment for the disease has not been confirmed yet. The efficacy of treatment could be improved through the introduction of new medical agents with updated dosage forms that can enhance and optimize local drug delivery and create greater therapeutic effects with fewer side effects. The focus of this review was to provide clear and direct information about the currently available topical therapeutic agents in clinical practice used to cure and/or reduce the incidence of ulcerative symptoms of OM, excluding the associated pain and other coexisting complications such as bacterial and fungal infections. The review also provides recent evidences regarding agents that could be used as promising novel therapies in updated local delivering systems. This will support further encouraging options and approaches for the management of OM and will improve compliance that could be translated in better disease control and survival.

Systematic review of antimicrobials, mucosal coating agents, anesthetics, and analgesics for the management of oral mucositis in cancer patients and clinical practice guidelines

PURPOSE

To update the clinical practice guidelines for the use of antimicrobials, mucosal coating agents, anesthetics, and analgesics for the prevention and/or treatment of oral mucositis (OM).

METHODS

A systematic review was conducted by the Mucositis Study Group of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO). The body of evidence for each intervention, in each cancer treatment setting, was assigned an evidence level. The findings were added to the database used to develop the 2014 MASCC/ISOO clinical practice guidelines. Based on the evidence level, the following guidelines were determined: Recommendation, Suggestion, and No Guideline Possible.

RESULTS

A total of 9 new papers were identified within the scope of this section, adding to the 62 papers reviewed in this section previously. A new Suggestion was made for topical 0.2% morphine for the treatment of OM-associated pain in head and neck (H&N) cancer patients treated with RT-CT (modification of previous guideline). A previous Recommendation against the use of sucralfate-combined systemic and topical formulation in the prevention of OM in solid cancer treatment with CT was changed from Recommendation Against to No Guideline Possible. Suggestion for doxepin and fentanyl for the treatment of mucositis-associated pain in H&N cancer patients was changed to No Guideline Possible.

CONCLUSIONS

Of the agents studied for the management of OM in this paper, the evidence supports a Suggestion in favor of topical morphine 0.2% in H&N cancer patients treated with RT-CT for the treatment of OM-associated pain.

Comparison of Radiation-Induced Oral Mucositis Scoring Systems

Background

A number of oral toxicity scoring systems have been described, but their direct comparison has rarely been undertaken and little data exists. An impediment to mucositis research has been the lack of an accepted, validated scoring system. The objective of this study was to design a test and validation of scoring systems.

Materials and methods

Forty-three patients with head and neck malignancies who had been irradiated were evaluated. Five different mucositis scoring systems (World Health Organization, Radiation Therapy Oncology Group, “Hickey”, “Van der Schueren” and “Makkonen”) were compared with each other.

Results

Daily mucositis scores demonstrated a high correlation among scoring systems (P <0.05 and coefficient of correlation κ and r = 0.5 - 0.95). Objective mucositis scores demonstrated a strong correlation with symptoms.

Conclusions

All scoring systems were equally valid. The exact grading of mucositis is achieved by combining clinical information about pain and nutritional status with oral mucosal reactions.

Radiation-Induced Oral Mucositis

Radiation-induced oral mucositis (RIOM) is a major dose-limiting toxicity in head and neck cancer patients. It is a normal tissue injury caused by radiation/radiotherapy (RT), which has marked adverse effects on patient quality of life and cancer therapy continuity. It is a challenge for radiation oncologists since it leads to cancer therapy interruption, poor local tumor control, and changes in dose fractionation. RIOM occurs in 100% of altered fractionation radiotherapy head and neck cancer patients. In the United Sates, its economic cost was estimated to reach 17,000.00 USD per patient with head and neck cancers. This review will discuss RIOM definition, epidemiology, impact and side effects, pathogenesis, scoring scales, diagnosis, differential diagnosis, prevention, and treatment.

Preventive Intervention Possibilities in Radiotherapy- and Chemotherapy-induced Oral Mucositis: Results of Meta-analyses

The aim of these meta-analyses was to evaluate the effectiveness of interventions for the prevention of oral mucositis in cancer patients treated with head and neck radiotherapy and/or chemotherapy, with a focus on randomized clinical trials. A literature search was performed for reports of randomized controlled clinical studies, published between 1966 and 2004, the aim of which was the prevention of mucositis in cancer patients undergoing head and neck radiation, chemotherapy, or chemoradiation. The control group consisted of a placebo, no intervention, or another intervention group. Mucositis was scored by either the WHO, the National Cancer Institute-Common Toxicity Criteria (NCI-CTC) score, or the absence or presence of ulcerations, or the presence or absence of grades 3 and 4 mucositis. The meta-analyses included 45 studies fulfilling the inclusion criteria, in which 8 different interventions were evaluated: i.e., local application of chlorhexidine; iseganan; PTA (polymyxin E, tobramycine, and amphotericin B); granulocyte macrophage-colony-stimulating factor/granulocyte colony-stimulating factor (GM-CSF/G-CSF); oral cooling; sucralfate and glutamine; and systemic administration of amifostine and GM-CSF/G-CSF. Four interventions showed a significant preventive effect on the development or severity of oral mucositis: PTA with an odds ratio (OR) = 0.61 (95% confidence interval [CI], 0.39–0.96); GM-CSF, OR = 0.53 (CI: 0.33–0.87); oral cooling, OR = 0.3 (CI: 0.16–0.56); and amifostine, OR = 0.37 (CI: 0.15–0.89). To date, no single intervention completely prevents oral mucositis, so combined preventive therapy strategies seem to be required to ensure more successful outcomes.

Efficacy of Sucralfate Mouth Wash in Prevention of 5-fluorouracil Induced Oral Mucositis: A Prospective, Randomized, Double-Blind, Controlled Trial

Sucralfate has been used for the prevention and treatment of radiotherapy- and chemotherapy-induced stomatitis and mucositis in a number of studies, but the results are contradictory. To answer such discrepancies, the present study was designed to evaluate the efficacy of sucralfate mouthwash in prevention of 5-fluorouracil (5-FU)-induced oral mucositis in patients with gastrointestinal malignancies. Patients with gastrointestinal cancers receiving 5-FU-based chemotherapy regimens were included in this randomized, blinded, controlled trial and were randomly allocated to either sucralfate mouthwash (every 6 h) or placebo. The patients were visited at fifth and tenth day of trial; the presence and severity of oral mucositis and the intensity of pain were assessed. The patients receiving sucralfate experienced lower frequency and severity of mucositis (76% vs. 38.5%, P = 0.005 and 84 vs. 38.5%, P < 0.001, respectively) and less intense pain (2.5 ± 2.2 vs. 5.08 ± 3.82, P = 0.004 and 1.33 ± 0.86 vs. 4.12 ± 3.5, P = 0.001, respectively) compared with the placebo group both at day 5 and day 10. Within the sucralfate group, a decrease in frequency and severity of mucositis was observed throughout the trial period, while in the placebo group no such effect was observed. Sucralfate mouthwash reduced the frequency and severity of 5-FU-induced oral mucositis in patients with gastrointestinal malignancies compared with placebo, indicating its efficacy in the prevention of chemotherapy-induced mucositis.

The Efficacy of Sucralfate and Chlorhexidine as an Oral Rinse in Patients with Recurrent Aphthous Stomatitis

Aim. In this study, we compared the efficacy of sucralfate suspension with chlorhexidine as an oral rinse in patients with recurrent aphthous stomatitis (RAS) in terms of pain relief and healing time. Materials and Methods. The subjects with a complaint of recurrent oral aphthous ulcers less than 1 cm in diameter on the first day of the occurrence of the ulcer and between 20 and 40 years were included in the study. Seventy patients completed the study. The patients were randomized into two groups as SCH group and CHX group. Changes in pain scores, healing time, and side effects of the treatments were evaluated. Results. The mean value of pain scores on the days after the treatment from the first day to the seventh day was significantly higher in CHX group than SCH group (P ≤ 0.05). On the seventh day after the treatment, the ulcers were completely reepithelialized in 23 patients in SCH group and in 19 patients in CHX group. The difference was statistically significant (P ≤ 0.05). In SCH group, the mean healing time of ulcers was 1.97 ± 1.56 days whereas it was 2.80 ± 3.00 days in CHX group. The difference was statistically significant (P ≤ 0.05). No side effects were recorded in either of the groups. Conclusion. Topical sucralfate suspension is an easy, safe, inexpensive, and effective treatment option for RAS to obtain pain relief and shorten the healing time of oral ulcers.

Systematic review of antimicrobials, mucosal coating agents, anesthetics, and analgesics for the management of oral mucositis in cancer patients

PURPOSE

The aim of this project was to develop clinical practice guidelines on the use of antimicrobials, mucosal coating agents, anesthetics, and analgesics for the prevention and management of oral mucositis (OM) in cancer patients.

METHODS

A systematic review of the available literature was conducted. The body of evidence for the use of each agent, in each setting, was assigned a level of evidence. Based on the evidence level, one of the following three guideline determinations was possible: recommendation, suggestion, or no guideline possible.

RESULTS

A recommendation was developed in favor of patient-controlled analgesia with morphine in hematopoietic stem cell transplant (HSCT) patients. Suggestions were developed in favor of transdermal fentanyl in standard dose chemotherapy and HSCT patients and morphine mouth rinse and doxepin rinse in head and neck radiation therapy (H&N RT) patients. Recommendations were developed against the use of topical antimicrobial agents for the prevention of mucositis. These included recommendations against the use of iseganan for mucositis prevention in HSCT and H&N RT and against the use of antimicrobial lozenges (polymyxin-tobramycin-amphotericin B lozenges/paste and bacitracin-clotrimazole-gentamicin lozenges) for mucositis prevention in H&N RT. Recommendations were developed against the use of the mucosal coating agent sucralfate for the prevention or treatment of chemotherapy-induced or radiation-induced OM. No guidelines were possible for any other agent due to insufficient and/or conflicting evidence.

CONCLUSION

Additional well-designed research is needed on prevention and management approaches for OM.

Cancer treatment-induced oral mucositis: a critical review

Head and neck cancer represents one of the main oncological problems. Its treatment, radiotherapy and chemotherapy leads to mucositis, and other side effects. The authors reviewed high-quality evidence published over the last 25 years on the treatment of cancer treatment-induced oral mucositis. A Medline search for double blind randomized controlled clinical trials between 1985 and 2010 was carried out. The keywords were oral mucositis, radiotherapy, chemotherapy, and head and neck. The different therapeutic approaches found for cancer treatment-induced oral mucositis included: intensive oral hygiene care; use of topical antiseptics and antimicrobial agents; use of anti-inflammatory agents; cytokines and growth factors; locally applied non-pharmacological methods; antioxidants; immune modulators; and homoeopathic agents. To date, no intervention has been able to prevent and treat oral mucositis on its own. It is necessary to combine interventions that act on the different phases of mucositis. It is still unclear which strategies reduce oral mucositis, as there is not enough evidence that describes a treatment with a proven efficiency and is superior to the other treatments for this condition.

After the bomb drops: a new look at radiation-induced multiple organ dysfunction syndrome (MODS)

PURPOSE

There is increasing concern that, since the Cold War era, there has been little progress regarding the availability of medical countermeasures in the event of either a radiological or nuclear incident. Fortunately, since much is known about the acute consequences that are likely to be experienced by an exposed population, the probability of survival from the immediate hematological crises after total body irradiation (TBI) has improved in recent years. Therefore focus has begun to shift towards later down-stream effects, seen in such organs as the gastrointestinal tract (GI), skin, and lung. However, the mechanisms underlying therapy-related normal tissue late effects, resulting from localised irradiation, have remained somewhat elusive and even less is known about the development of the delayed syndrome seen in the context of whole body exposures, when it is likely that systemic perturbations may alter tissue microenvironments and homeostasis.

CONCLUSIONS

The sequence of organ failures observed after near-lethal TBI doses are similar in many ways to that of multiple organ dysfunction syndrome (MODS), leading to multiple organ failure (MOF). In this review, we compare the mechanistic pathways that underlie both MODS and delayed normal tissue effects since these may impact on strategies to identify radiation countermeasures.

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

Mucositis pain is a major clinical problem associated with cancer treatment. Mucosal tissue injury is a dose-limiting side effect and also limits nutritional intake and oral function, resulting in weight loss and nutritional deficits for many patients. The pathophysiology of mucositis is thought to be a complex array of cytokine-mediated events, which begins with mucosal atrophy and eventually leads to the painful ulceration of the mucosa. This article reviews current research related to pain management for mucositis. Effective treatment for mucositis pain must be targeted at the various factors involved in the pain experience. Although a number of interventions aimed to prevent and treat mucositis have been studied, there is little evidence to recommend any one treatment modality. While current strategies for pain management rely on general treatment for acute pain, research developments are aimed at targeting the specific receptors and enzymes involved in mucositis. As these breakthroughs become available clinically, thorough assessment and timely directed interventions must be implemented in order to limit patient distress from mucositis. This article presents an assessment tool specific to mucositis pain, including physical, functional, and pain parameters.

Efficacy of low-level laser therapy and aluminum hydroxide in patients with chemotherapy and radiotherapy-induced oral mucositis

This study evaluated the efficacy of low-level laser therapy (LLLT) and aluminum hydroxide (AH) in the prevention of oral mucositis (OM). A prospective, comparative and non-randomized study was conducted with 25 patients with head and neck cancer subjected to radiotherapy (RT) or radiochemotherapy (RCT). Twelve patients received LLLT (830 nm, 15 mW, 12 J/cm²) daily from the 1st day until the end of RT before each sessions during 5 consecutive days, and the other 13 patients received AH 310 mg/5 mL, 4 times/day, also throughout the duration of RT, including weekends. OM was measured using an oral toxicity scale (OTS) and pain was measured using the visual analogue scale (VAS). EORTC questionnaires were administered to the evaluate impact of OM on quality of life. The LLLT group showed lower mean OTS and VAS scores during the course of RT. A significant difference was observed in pain evaluation in the 13th RT session (p=0.036). In both groups, no interruption of RT was needed. The prophylactic use of both treatments proposed in this study seems to reduce the incidence of severe OM lesions. However, the LLLT was more effective in delaying the appearance of severe OM.

Interventions for preventing oral mucositis for patients with cancer receiving treatment

BACKGROUND

Treatment of cancer is increasingly more effective but is associated with short and long term side effects. Oral side effects remain a major source of illness despite the use of a variety of agents to prevent them. One of these side effects is oral mucositis (mouth ulcers).

OBJECTIVES

To evaluate the effectiveness of prophylactic agents for oral mucositis in patients with cancer receiving treatment, compared with other potentially active interventions, placebo or no treatment.

SEARCH STRATEGY

Electronic searches of Cochrane Oral Health Group and PaPaS Trials Registers (to 16 February 2011), CENTRAL (The Cochrane Library 2011, Issue 1), MEDLINE via OVID (1950 to 16 February 2011), EMBASE via OVID (1980 to 16 February 2011), CINAHL via EBSCO (1980 to 16 February 2011), CANCERLIT via PubMed (1950 to 16 February 2011), OpenSIGLE (1980 to 2005) and LILACS via the Virtual Health Library (1980 to 16 February 2011) were undertaken. Reference lists from relevant articles were searched and the authors of eligible trials were contacted to identify trials and obtain additional information.

SELECTION CRITERIA

Randomised controlled trials of interventions to prevent oral mucositis in patients receiving treatment for cancer.

DATA COLLECTION AND ANALYSIS

Information regarding methods, participants, interventions, outcome measures, results and risk of bias were independently extracted, in duplicate, by two review authors. Authors were contacted for further details where these were unclear. The Cochrane Collaboration statistical guidelines were followed and risk ratios calculated using random-effects models.

MAIN RESULTS

A total of 131 studies with 10,514 randomised participants are now included. Overall only 8% of these studies were assessed as being at low risk of bias. Ten interventions, where there was more than one trial in the meta-analysis, showed some statistically significant evidence of a benefit (albeit sometimes weak) for either preventing or reducing the severity of mucositis, compared to either a placebo or no treatment. These ten interventions were: aloe vera, amifostine, cryotherapy, granulocyte-colony stimulating factor (G-CSF), intravenous glutamine, honey, keratinocyte growth factor, laser, polymixin/tobramycin/amphotericin (PTA) antibiotic pastille/paste and sucralfate.

AUTHORS' CONCLUSIONS

Ten interventions were found to have some benefit with regard to preventing or reducing the severity of mucositis associated with cancer treatment. The strength of the evidence was variable and implications for practice include consideration that benefits may be specific for certain cancer types and treatment. There is a need for further well designed, and conducted trials with sufficient numbers of participants to perform subgroup analyses by type of disease and chemotherapeutic agent.

New thoughts on the initiation of mucositis

It has been slightly more than a decade since the classic mechanistic paradigm that defined the pathogenesis of mucositis was revised. A five-stage sequence of linked biological events forms the basis for our current understanding of how regimen-related mucosal injury occurs. The first stage is the initiation phase, although the gateway to toxicity has been the least studied. This essay proposes new thoughts on the phase's components, how they might interact, and how they present new opportunities for treatment interventions and mucositis risk prediction.

Interventions for preventing oral mucositis for patients with cancer receiving treatment

BACKGROUND

Treatment of cancer is increasingly more effective but is associated with short and long term side effects. Oral side effects remain a major source of illness despite the use of a variety of agents to prevent them. One of these side effects is oral mucositis (mouth ulcers).

OBJECTIVES

To evaluate the effectiveness of prophylactic agents for oral mucositis in patients with cancer receiving treatment, compared with other potentially active interventions, placebo or no treatment.

SEARCH STRATEGY

Electronic searches of Cochrane Oral Health Group and PaPaS Trials Registers (to 1 June 2010), CENTRAL (The Cochrane Library 2010, Issue 2), MEDLINE via OVID (1950 to 1 June 2010), EMBASE via OVID (1980 to 1 June 2010), CINAHL via EBSCO (1980 to 1 June 2010), CANCERLIT via PubMed (1950 to 1 June 2010), OpenSIGLE (1980 to 2005) and LILACS via the Virtual Health Library (1980 to 1 June 2010) were undertaken. Reference lists from relevant articles were searched and the authors of eligible trials were contacted to identify trials and obtain additional information.

SELECTION CRITERIA

Randomised controlled trials of interventions to prevent oral mucositis in patients receiving treatment for cancer.

DATA COLLECTION AND ANALYSIS

Information regarding methods, participants, interventions, outcome measures, results and risk of bias were independently extracted, in duplicate, by two review authors. Authors were contacted for further details where these were unclear. The Cochrane Collaboration statistical guidelines were followed and risk ratios calculated using random-effects models.

MAIN RESULTS

A total of 131 studies with 10,514 randomised participants are now included. Nine interventions, where there was more than one trial in the meta-analysis, showed some statistically significant evidence of a benefit (albeit sometimes weak) for either preventing or reducing the severity of mucositis, compared to either a placebo or no treatment. These nine interventions were: allopurinol, aloe vera, amifostine, cryotherapy, glutamine (intravenous), honey, keratinocyte growth factor, laser, and polymixin/tobramycin/amphotericin (PTA) antibiotic pastille/paste.

AUTHORS' CONCLUSIONS

Nine interventions were found to have some benefit with regard to preventing or reducing the severity of mucositis associated with cancer treatment. The strength of the evidence was variable and implications for practice include consideration that benefits may be specific for certain cancer types and treatment. There is a need for further well designed, and conducted trials with sufficient numbers of participants to perform subgroup analyses by type of disease and chemotherapeutic agent.

Polaprezinc prevents oral mucositis associated with radiochemotherapy in patients with head and neck cancer

Oral mucositis is frequent but serious adverse event associated with radiotherapy or radiochemotherapy in head and neck cancer severely impairs health-related quality of life, leading to poor prognosis due to discontinuation of the therapy. Although a number of compounds have been tested for prophylaxis of oral mucositis, few of them are satisfactory. We investigated the effect of polaprezinc (zinc L-carnosine), a gastric mucosal protective drug, on radiochemotherapy-induced oral mucositis, pain, xerostomia and taste disturbance in patients with head and neck cancer. Patients were randomly assigned to receive polaprezinc (n = 16) or azulene oral rinse as the control (n = 15). The incidence rates of mucositis, pain, xerostomia and taste disturbance were all markedly lower in polaprezinc group than in control. Moreover, the use of analgesics was significantly (p = 0.003) less frequent and the amount of food intake was significantly (p = 0.002) higher in polaprezinc group than in control. On the other hand, tumor response rate in patients with neoadjuvant radiochemotherapy was not significantly affected by polaprezinc, in which the response rate (complete plus partial response) was 88% for polaprezinc and 92% for control (p = 1.000). Therefore, it is highly assumable that polaprezinc is potentially useful for prevention of oral mucositis and improvement of quality of life without reducing the tumor response.

Prevention and management of antineoplastic therapy induced oral mucositis

With the scientific advancements in the management of malignant diseases, the treatment is expensive and bears high morbidity in term of oral mucositis. It is a debilitating condition and has been researched extensively for its pathogenesis and treatment. Various treatment options include barrier forming, mucosal protectants, mouth rinses, growth factors, lasers and midline-sparing procedures. Some agents are used locally while others are administered systemically. Despite the availability of a wide range of treatment options for mucositis, a cost-effective treatment is yet to be evolved.

Oral health status of 207 head and neck cancer patients before, during and after radiotherapy

The aim of this retrospective study was to describe the oral health status of patients before, during, and after radiotherapy (RT) for the treatment of head and neck cancer (HNC). Before RT, the following data was collected: presence of unrecoverable teeth, residual roots, unerupted teeth, use of dentures, periodontal alterations, caries, candidiasis, and xerostomia. Mucositis, candidiasis, and xerostomia were evaluated during RT. Patients continued to be followed after RT for evaluation of mucositis, candidiasis, xerostomia, radiation caries, and osteoradionecrosis. For statistical analysis, 95% confidence intervals (CI) were determined using sample size, population, and percentages. Before RT, 120 (57.9%) patients presented with alterations in the oral cavity namely, 85 (41.0%) with periodontal disease, 44 (21.2%) with residual roots, 25 (12.0%) with caries, 15 (7.2%) with candidiasis, and 12 (5.8%) had an unerupted tooth present. Xerostomia was a complaint of 19 patients (9.1%). Restorations were indicated for 33 patients (15.9%), whereas extraction was indicated for 104 (50.2%) patients. During RT, mucositis was found in 80 (61.7%) patients, candidiasis in 60 (45.8%), and xerostomia was a complaint of 82 patients (62.6%). After RT, mucositis persisted in 21 patients (19.2%), candidiasis was identified in 23 patients (21.1%), and xerostomia was reported by 58 patients (53.2%). Radiation caries developed in 12 patients (11.0%), whereas six patients (5.5%) developed osteoradionecrosis. The demographic profile herein presented will be useful as baseline data to provide additional epidemiological information and to determine future measures for prevention and treatment of RT-induced complications and sequelae.

Mucosite bucal rádio e quimioinduzida

O aumento da intensidade da quimioterapia e radioterapia no tratamento do câncer tem elevado a incidência de efeitos colaterais, em especial da mucosite bucal. OBJETIVO E MÉTODO: Através de revisão bibliográfica realizou-se atualizar informações quanto à definição, características clínicas, incidência, etiologia, patofisiologia, morbidade associada, prevenção e tratamento dessa manifestação clínica. RESULTADOS: Estudos atuais definem a mucosite bucal como uma inflamação e ulceração dolorosa bastante freqüente na mucosa bucal apresentando formação de pseudomembrana. Sua incidência e severidade são influenciadas por variáveis associadas ao paciente e ao tratamento a que ele é submetido. A mucosite é conseqüência de dois mecanismos maiores: toxicidade direta da terapêutica utilizada sobre a mucosa e mielossupressão gerada pelo tratamento. Sua patofisiologia é composta por quatro fases interdependentes: fase inflamatória/vascular, fase epitelial, fase ulcerativa/bacteriológica e fase de reparação. É considerada fonte potencial de infecções com risco de morte, sendo a principal causa de interrupção de tratamentos antineoplásicos. Algumas intervenções mostraram-se potencialmente efetivas para sua prevenção e tratamento. Entretanto, faz-se necessária a realização de novos estudos clínicos mais bem conduzidos para obtenção de melhor evidência científica acerca do agente terapêutico de escolha para o controle da mucosite bucal, permitindo a realização da quimioterapia e radioterapia do câncer em parâmetros ideais.

Radiation therapy and chemotherapy-induced oral mucositis

TIncreasing the intensity of radiation therapy and chemotherapy in the management of cancer has increased the incidence of adverse effects, especially oral mucositis.

Aim and methods

a bibliographical review was conducted on the definition of oral mucositis, its clinical findings, the incidence, its etiology, the pathofisiology, associated morbidity, prevention and treatment.

Results

current studies define oral mucositis as a very frequent and painful inflammation with ulcers on the oral mucosa that are covered by a pseudo membrane. The incidence and severity of lesions are influenced by patient and treatment variables. Oral mucositis is a result of two major mechanisms: direct toxicity on the mucosa and myelosuppression due to the treatment. Its pathofisiology is composed of four interdependent phases: an initial inflammatory/vascular phase; an epithelial phase; an ulcerative/bacteriological phase; and a healing phase. It is considered a potential source of life-threatening infection and often is a dose-limiting factor in anticancer therapy. Some interventions have been shown to be potentially effective to prevent and treat oral mucositis. Further intensive research through well-structured clinical trials to obtain the best scientific evidence over the standard therapy of oral mucositis is necessary to attain ideal parameters for radiotherapy and chemotherapy.

Histomorphometry and immunohistochemical features of grade I (WHO) oral radiomucositis

AIMS

The aims of this study were to describe the immunohistopathological and morphometric features of oral mucositis grade I (WHO).

MATERIAL AND METHODS

Ten samples of oral mucositis were biopsied and submitted to histopathological, morphometric and immunohistochemical analyses (CD68, Ki-67 and p53). The samples were compared with the buccal mucosa of head and neck cancer patients before radiotherapy (NMCP), normal buccal mucosa (NM) and oral dysplasia (OD).

RESULTS

Epithelial thickness, area and perimeter were decreased in oral mucositis and inflammatory components, increased when compared with NMCP. CD68 immunoreactivity, near to the epithelium, was more evident in oral mucositis than in NMCP (P = 0.01). The Ki-67 counts were higher in oral mucositis than in NM and NMCP (P = 0.001 and P = 0.043, respectively), but without any difference with OD (P = 0.284). The p53 staining was present in all cases of mucositis and oral dysplasia, but negative in NMCP and NM.

CONCLUSIONS

Oral mucositis grade I (WHO) presented epithelial atypia and atrophy, increased inflammatory response, with relevant Ki-67 count and positiveness for p53.

Comparing pain control and ability to eat and drink with standard therapy vs Gelclair: a preliminary, double centre, randomised controlled trial on patients with radiotherapy-induced oral mucositis

GOAL OF THE WORK: Oral mucositis (OM) is a functionally destructive complication of aggressive head and neck cancer therapy, often resulting in intense pain, an inability to eat and drink and secondary malnutrition and dehydration. The barrier-forming properties of Gelclair have shown promise in relieving such symptoms. The aim of this randomised-controlled trial was to evaluate the efficacy of Gelclair, as compared to standard therapy, as a means of short-term symptom control for patients suffering from radiotherapy-induced OM.

MATERIALS AND METHODS

Twenty patients, with radiotherapy-induced OM seen in two oncology centres in Devon, were randomised to either standard therapy (Sucralfate and Mucaine) or Gelclair and assessed over 24 h. Both treatments were taken four times during the 24-h period, 30 min before meals.

MAIN RESULTS

No significant difference was found between the Gelclair and standard therapy arms in terms of general pain (F = 1.512, df = 1, 17, ns). There did appear to be a trend towards pain improvement initially after the use of Gelclair, but this did not last for the full 24-h assessment period. There was no significant reduction in pain on speaking (F = 0.261, df = 1, 17, ns) nor an improvement in capacity to eat and drink, although the effects of standard therapy did appear to last longer than the Gelclair.

CONCLUSION

This study indicates that Gelclair is no more effective than current standard practice in relieving the pain associated with radiotherapy-induced OM. Nevertheless, observations from this preliminary study warrant further investigation, with a view to shaping the way forward for head and neck cancer practice on a national level.

Oral mucositis

Mucositis and xerostomia are the most common oral complications of the non-surgical therapy of cancer. Mucositis, a common sequel of radio- (DXR), chemo-(CXR) and radiochemo-therapy in patients with cancer, or patients requiring haemopoietic stem cell transplants (HSCT), has a direct and significant impact on the quality of life and cost of care, and also affects survival--because of the risk of infection. Apart from dose reduction, preventive and treatment options for mucositis are scarce, although multiple agents have been tested. Evidence suggests that cryotherapy, topical benzydamine and amifostine might provide some benefit in specific situations. The recombinant human keratinocyte growth factor Palifermin (Kepivance) was recently approved as a mucositis intervention in patients receiving conditioning regimens before HSCT for the treatment of haematological malignancies. A number of mechanistically based interventions are in various stages of development. Unfortunately, many other approaches have not been rigorously tested. This paper reviews the clinical features, prevalence, diagnosis, complications, pathogenesis, prophylaxis and management of mucositis.

Interventions for preventing oral mucositis for patients with cancer receiving treatment

BACKGROUND

Treatment of cancer is increasingly more effective but is associated with short and long-term side effects. Oral side effects remain a major source of illness despite the use of a variety of agents to prevent them. One of these side effects is oral mucositis (mouth ulcers).

OBJECTIVES

To evaluate the effectiveness of prophylactic agents for oral mucositis in patients with cancer receiving treatment, compared with other potentially active interventions, placebo or no treatment.

SEARCH STRATEGY

The Cochrane Oral Health Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE were searched. Reference lists from relevant articles were scanned and the authors of eligible studies were contacted to identify trials and obtain additional information. Date of most recent searches: April 2004.

SELECTION CRITERIA

Trials were selected if they met the following criteria: design - random allocation of participants; participants - anyone with cancer receiving chemotherapy or radiotherapy treatment for cancer; interventions - agents prescribed to prevent oral mucositis; outcomes - prevention of mucositis, pain, amount of analgesia, dysphagia, systemic infection, length of hospitalisation, cost and patient quality of life.

DATA COLLECTION AND ANALYSIS

Information regarding methods, participants, interventions and outcome measures and results were independently extracted, in duplicate, by two review authors. Authors were contacted for details of randomisation and withdrawals and a quality assessment was carried out. The Cochrane Oral Health Group statistical guidelines were followed and risk ratios (RR) calculated using random-effects models.

MAIN RESULTS

Two hundred and two studies were eligible. One hundred and thirty two were excluded for various reasons, usually as there was no useable information on mucositis. Of the 71 useable studies all had data for mucositis comprising 5217 randomised patients. Interventions evaluated were: acyclovir, allopurinol mouthrinse, aloe vera, amifostine, antibiotic pastille or paste, benzydamine, beta carotene, calcium phosphate, camomile, chlorhexidine, clarithromycin, folinic acid, glutamine, GM-CSF, honey, hydrolytic enzymes, ice chips, iseganan, keratinocyte GF, misonidazole, oral care, pentoxifylline, povidone, prednisone, propantheline, prostaglandin, sucralfate, traumeel and zinc sulphate. Of the 29 interventions included in trials, 10 showed some evidence of a benefit (albeit sometimes weak) for either preventing or reducing the severity of mucositis. Interventions where there was more than one trial in the meta-analysis finding a significant difference when compared with a placebo or no treatment were: amifostine which provided minimal benefit in preventing moderate and severe mucositis RR = 0.84 (95% confidence interval (CI) 0.75 to 0.95) and 0.60 (95% CI 0.37 to 0.97), antibiotic paste or pastille demonstrated a moderate benefit in preventing mucositis RR = 0.87 (95% CI 0.79 to 0.97), hydrolytic enzymes reduced moderate and severe mucositis with RRs = 0.52 (95% CI 0.36 to 0.74) and 0.17 (95% CI 0.06 to 0.52), and ice chips prevented mucositis at all levels RR = 0.63 (95% CI 0.44 to 0.91), 0.43 (95% CI 0.23 to 0.81), 0.27 (95% CI 0.11 to 0.68). Other interventions showing some benefit with only one study were: benzydamine, calcium phosphate, honey, oral care protocols, povidone and zinc sulphate. The number needed to treat (NNT) to prevent one patient experiencing moderate or severe mucositis over a baseline incidence of 60% for amifostine is 10 (95% CI 7 to 33), antibiotic paste or pastille 13 (95% CI 8 to 56), hydrolytic enzyme 4 (95% CI 3 to 6) and ice chips 5 (95% CI 3 to 19). When the baseline incidence is 40%/90% the NNTs for amifostine are 16/7, for antibiotic paste or pastille 19/7, for hydrolytic enzyme 5/3 and for ice chips 7/3. The general reporting of RCTs was poor. However, the assessments of the quality of the randomisation improved when the authors provided additional information.

AUTHORS' CONCLUSIONS

Several of the interventions were found to have some benefit at preventing or reducing the severity of mucositis associated with cancer treatment. The strength of the evidence was variable and implications for practice include consideration that benefits may be specific for certain cancer types and treatment. There is a need for well designed and conducted trials with sufficient numbers of participants to perform subgroup analyses by type of disease and chemotherapeutic agent.

The effectiveness of sucralfate against stricture formation in experimental corrosive esophageal burns

PURPOSE

In this study, the effectiveness of sucralfate against stricture formation in experimental corrosive esophageal burn is reported.

METHODS

Sixty-four Swiss albino adult male rats were divided into three groups, group A (control; n, 7), group B (esophageal burn induced but not treated; n, 25), and group C (esophageal burn induced and treated with sucralfate, n, 32). Groups B and C were further subdivided into subgroups for evaluation on days 2, 7, and 28. A standard esophageal burn was performed by the method of Gehanno, using 50% NaOH. Oral sucralfate treatment was given to group C at a dosage of 50 mg/100 g twice daily. The rats were then killed after 2, 7, or 28 days. Levels of tissue hydroxyproline were measured in excised abdominal esophageal segments, and a histopathological evaluation was performed with hematoxylin-eosin and Masson's trichrome staining.

RESULTS

The tissue hydroxyproline levels were significantly lower in group C than in group B (P = 0.017). There was a significant difference in the stenosis index between groups B and C (P = 0.016). When compared with group B, the collagen deposition in the submucosa and tunica muscularis was significantly lower in group C (P = 0.02).

CONCLUSION

Sucralfate has an inhibitory effect on stricture formation in experimental corrosive burns and can be used in the treatment of corrosive esophageal burns to enhance mucosal healing and suppress stricture formation.

A guide to managing the pain of treatment-related oral mucositis

Oral mucositis is a common complication of chemotherapy and/or radiotherapy and can be a significant problem for patients undergoing cancer treatment or bone marrow transplantation. Frequently, there is a major adverse impact on quality of life, particularly with pain and interference with oral function. In patients who are immunocompromised or debilitated, this complication can become life threatening. Currently, there is no single intervention that completely prevents or treats oral mucositis. The object of this article is to provide an overview for the nurse of the evidence for several options that may be of value in managing the pain which is often associated with this condition.

Cancer pain assessment in clinical trials. A review of the literature (1999-2002)

The aim of this review was to evaluate the methods of pain measurement in controlled clinical trials in oncology published between 1999 and 2002. An electronic literature search strategy was used according to established criteria applied to the Medline database and PubMed search engine. Articles were selected to include only studies that had chronic cancer pain as the primary or secondary objective of a controlled clinical trial. A specific evaluation scheme was used to examine how pain measurement methods were chosen and implemented in the study procedures. The search strategy identified 613 articles, and 68 were selected for evaluation. Most articles (69%) chose unidimensional pain measurement tools, such as visual analogue scales, numerical rating scales and verbal rating scales, whereas others used questionnaires. The implementation of the pain assessment method was problematic in many studies, especially as far as time frame of pain assessment (70%), administration modalities (46%), and use of non-validated measurement methods (10%). Design of study and data analysis were often unclear about the definition of pain outcome measure (40%), patient compliance with pain assessment (98%), and impact of missing data (56%). Statistical techniques were seldom appropriate to the type of data collected and often inadequate to describe the pain variable under study. It is clear from this review that most authors were aware of the need of valid pain measurement tools to be used in clinical trials. However, too often these tools were not appropriately used in the trial, or at least their use was not described with sufficient accuracy in the trial methods.

Chemotherapy- and Radiotherapy-Induced Oral Mucositis: Review of Preventive Strategies and Treatment

Oral mucositis is a frequently encountered and potentially severe complication associated with administration of chemotherapy and radiotherapy. Although many pharmacologic interventions have been used for the prevention and treatment of oral mucositis, there is not one universally accepted strategy for its management. Most preventive and treatment strategies are based on limited, often anecdotal, clinical data. Basic oral hygiene and comprehensive patient education are important components of care for any patient with cancer at risk for development of oral mucositis. Nonpharmacologic approaches for the prevention of oral mucositis include oral cryotherapy for patients receiving chemotherapy with bolus 5-fluorouracil, and low-level laser therapy for patients undergoing hematopoietic stem cell transplantation. Chlorhexidine, amifostine, hematologic growth factors, pentoxifylline, glutamine, and several other agents have all been investigated for prevention of oral mucositis. Results have been conflicting, inconclusive, or of limited benefit. Treatment of established mucositis remains a challenge and focuses on a palliative management approach. Topical anesthetics, mixtures (also called cocktails), and mucosal coating agents have been used despite the lack of experimental evidence supporting their efficacy. Investigational agents are targeting the specific mechanisms of mucosal injury; among the most promising of these is recombinant human keratinocyte growth factor.

Modification of radiation-induced acute oral mucositis in the rat

PURPOSE

A new non-toxic drug (compound A) consisting of curcumin, alpha-tocopherol and sunflower oil was developed and its efficacy tested in the treatment of radiation-induced oral mucositis in the rat.

MATERIAL AND METHODS

Mature (12 weeks old, 200-225 g) female Sprague-Dawley rats were used. While under general anaesthesia, the tongues of the animals were slightly extended outside and a region of the underside of the tongue was irradiated in-situ with single doses of 2.27 MeV beta-rays from a 5-mm diameter 90Sr/90Y plaque. The dose-rate of the source was about 10 Gy min(-1) at the surface of the mucus membrane. Irradiations and subsequent assessment of the lesion were carried out under general anaesthesia maintained by a 1.5% halothane/oxygen mixture. Six groups of animals were irradiated with single doses of 13.5, 15.0, 16.5 or 18Gy. One subgroup (radiation only) received no further treatment, while the other five groups received 0.5 ml day(-1) of either compound A, sunflower oil, alpha-tocopherol, curcumin or water containing 10% ethanol by oral gavage until the end of experiments. Mucosal ulceration (erosion of mucosal epithelium) was considered as an end-point. From the day after irradiation until any acute radiation-induced oral mucosal lesion had healed, the tongues of the animals were assessed daily for the presence of radiation-induced mucositis (mucosal ulceration). Quantal data for the incidence of radiation-induced mucositis were analysed using logit analysis and a dose-modification factor was obtained.

RESULTS

There was a modest increase in ED50, the dose expected to cause mucositis in 50% of the animals after both alpha-tocopherol and sunflower oil were administered. This resulted in dose-modification factors of 1.05. While curcumin treatment resulted in a dose-modification factor of 1.09. Compound A significantly reduced the incidence of radiation-induced mucositis with a statistically significant dose-modification factor of 1.2 +/- 0.1.

CONCLUSIONS

Curcumin and other components of compound A appeared to be effective in the prevention of radiation-induced oral mucositis. However, the overall effect observed with the combination drug (compound A) appeared greater than additive.

Oral mucositis: a challenging complication of radiotherapy, chemotherapy, and radiochemotherapy: part 1, pathogenesis and prophylaxis of mucositis

BACKGROUND

Oral mucositis is a common sequel of radiotherapy, chemotherapy, and radiochemotherapy in patients with cancer or patients requiring hemopoietic stem cell transplants. Mucositis has a direct and significant impact on the duration of disease remission and cure rates, because it is a cancer treatment-limiting toxicity. Mucositis also affects survival because of the risk of infection and has a significant impact on the quality of life and cost of care.

METHODS

This article reviews publications on the etiopathogenesis and prevention of oral mucositis accessible from a MEDLINE search using as key words, mucositis, radiotherapy, chemotherapy, hemopoietic stem cell transplant, and oral.

CONCLUSIONS

Of the current available products, ice chips and benzydamine have the strongest scientific evidence of support for prophylaxis of mucositis.

Prevention and Treatment of Oropharyngeal Mucositis Following Cancer Therapy

Oropharyngeal mucositis is an acute and distressing toxic effect of chemotherapy and head and neck irradiation. This oral sequela significantly impairs the daily functioning and quality of life of patients. The biological basis of mucositis is quite complex, involving sequential interaction of chemotherapeutic drugs or irradiation on mitosis of proliferating epithelium, a number of cytokines, and elements of oral microbial environment. Various interventions based on biological attenuation have been tested for mucositis. Such interventions have been reviewed elsewhere; however, most reviews focus on biomedical outcomes. Little attention has been paid to mucositis outcomes with oral morbidity or psychosocial aspects. The purpose of this article is to review the current research studies on the prevention and treatment of oropharyngeal mucositis following chemotherapy, radiotherapy, and bone marrow transplantation with an emphasis on biomedical, oral symptomatic, and functional impairment outcomes. In addition, further avenues of mucositis management, including psychotherapeutic intervention and integrated and stage-based treatment approaches are discussed.

Zinc sulfate in the prevention of radiation-induced oropharyngeal mucositis: a prospective, placebo-controlled, randomized study

PURPOSE

To determine the effect of oral zinc sulphate supplementation on radiation-induced oropharyngeal mucositis in patients with head-and-neck cancer.

MATERIALS AND METHODS

Thirty patients with head-and-neck cancer were randomly assigned to receive either zinc sulfate or placebo. Primary tumors were localized in the larynx in 14 patients, in the nasopharynx in 4, in the oral cavity in 4, in a salivary gland in 1, in the maxillary sinus in 1, in neck nodes (lymphoma presenting primarily) in 3 and in neck metastases from an unknown primary in 3. In the placebo group, 3 patients were excluded; 1 patient died during treatment, 1 left the study, and 1 did not come to the 6 week control visit. The patients were treated with telecobalt radiotherapy at conventional fractionation (2 Gy/fraction, five fractions weekly, for 20-35 fractions within 4-7 weeks). The median radiation dose was 6400 cGy (4000-7000 cGy). Oral mucositis was assessed by two independent physicians, experts in radiation oncology, using the Radiation Therapy Oncology Group Acute Radiation Morbidity Scoring criteria.

RESULTS

In the zinc sulfate group, Grade 3-4 mucositis was not detected in any patient; Grade 0 mucositis was detected in 2, and Grade 1 in 8, and Grade 2 in 5 patients. In the placebo group, Grade 2 mucositis was detected in 4 and Grade 3 in 8 patients. We observed that the degree of mucositis in the patients in the zinc sulfate group was significantly lower than that in the placebo group (p < 0.05). Confluent mucositis developed earlier in the placebo group than in the zinc sulfate group after the onset of treatment (p < 0.05) and started to improve sooner in the zinc sulfate group than in the placebo group (p < 0.05).

CONCLUSIONS

Zinc sulfate is beneficial in decreasing the severity of radiation-induced mucositis and oral discomfort. These results should be confirmed by additional evaluation in randomized studies with a larger number of patients.

Oral and intestinal mucositis - causes and possible treatments

Chemotherapy and radiotherapy, whilst highly effective in the treatment of neoplasia, can also cause damage to healthy tissue. In particular, the alimentary tract may be badly affected. Severe inflammation, lesioning and ulceration can occur. Patients may experience intense pain, nausea and gastro-enteritis. They are also highly susceptible to infection. The disorder (mucositis) is a dose-limiting toxicity of therapy and affects around 500 000 patients world-wide annually. Oral and intestinal mucositis is multi-factorial in nature. The disruption or loss of rapidly dividing epithelial progenitor cells is a trigger for the onset of the disorder. However, the actual dysfunction that manifests and its severity and duration are greatly influenced by changes in other cell populations, immune responses and the effects of oral/gut flora. This complexity has hampered the development of effective palliative or preventative measures. Recent studies have concentrated on the use of bioactive/growth factors, hormones or interleukins to modify epithelial metabolism and reduce the susceptibility of the tract to mucositis. Some of these treatments appear to have considerable potential and are at present under clinical evaluation. This overview deals with the cellular changes and host responses that may lead to the development of mucositis of the oral cavity and gastrointestinal tract, and the potential of existing and novel palliative measures to limit or prevent the disorder. Presently available treatments do not prevent mucositis, but can limit its severity if used in combination. Poor oral health and existing epithelial damage predispose patients to mucositis. The elimination of dental problems or the minimization of existing damage to the alimentary tract, prior to the commencement of therapy, lowers their susceptibility. Measures that reduce the flora of the tract, before therapy, can also be helpful. Increased production of free radicals and the induction of inflammation are early events in the onset of mucositis. Prophylactic administration of scavengers or anti-inflammatories can partially counteract or limit some of these therapy-mediated effects, as can the use of cryotherapy. The regular use of mouthwashes, mouth coatings, antibiotics and analgesics is essential, prior to and during loss and ablation of the epithelial layer. Granulocyte-macrophage colony-stimulating factor/granulocyte colony-stimulating factor or the use of laser light therapy may aid restitution and repair. Glutamine supplements may be beneficial in the repair/recovery phase.

Oral mucositis: time for more studies

Oral Mucositis (OM) is a frequent cause of severe morbidity in patients receiving chemotherapy and/or radiotherapy. The pathophysiology of OM involves direct cytotoxic effects, local inflammatory responses, and alterations in oral microflora. There are currently no approved agents for the prevention or treatment of OM. In this review we briefly describe current knowledge of the pathophysiology, clinical presentation, and management of OM. We then discuss investigational agents being studied in OM with a particular focus on local antimicrobial agents, hemopoietic growth factors, and cytokines. Measures to reduce the incidence of OM and/or alleviate its clinical sequelae should be incorporated into all chemotherapy or radiotherapy studies.

Mucositis reduction by selective elimination of oral flora in irradiated cancers of the head and neck: a placebo-controlled double-blind randomized study

PURPOSE

The aim of the study was to test the hypothesis that aerobic Gram-negative bacteria (AGNB) play a crucial role in the pathogenesis of radiation-induced mucositis; consequently, selective elimination of these bacteria from the oral flora should result in a reduction of the mucositis.

METHODS AND MATERIALS

Head-and-neck cancer patients, when scheduled for treatment by external beam radiation therapy (EBRT), were randomized for prophylactic treatment with an oral paste containing either a placebo or a combination of the antibiotics polymyxin E, tobramycin, and amphotericin B (PTA group). Weekly, the objective and subjective mucositis scores and microbiologic counts of the oral flora were noted. The primary study endpoint was the mucositis grade after 3 weeks of EBRT.

RESULTS

Seventy-seven patients were evaluable. No statistically significant difference for the objective and subjective mucositis scores was observed between the two study arms (p = 0.33). The percentage of patients with positive cultures of AGNB was significantly reduced in the PTA group (p = 0.01). However, complete eradication of AGNB was not achieved.

CONCLUSIONS

Selective elimination of AGNB of the oral flora did not result in a reduction of radiation-induced mucositis and therefore does not support the hypothesis that these bacteria play a crucial role in the pathogenesis of mucositis.