An Updated Review of Natural Products Intended to Prevent or Treat Oral Mucositis in Patients Undergoing Radio-Chemotherapy

Genetic Connectivity of Gut Microbiota and Oral Ulcers: A Mendelian Randomization Study

OBJECTIVES

The aim of this study was to reveal the relationship, if any, between gut microbiota and oral ulcers.

METHODS

We performed a 2-sample Mendelian randomization (MR) study to estimate the roles of gut microbiota in mouth ulcers. The summary datasets of gut microbiota were from the largest genome-wide association study (GWAS) conducted by MiBioGen, and data of mouth ulcers were obtained from UK Biobank. Random effect inverse variance-weighted, weighted median, MR Egger, simple mode and weighted mode were used to estimate the relationship. Sensitivity analyses were conducted to assess the heterogeneity and pleiotropy of instrumental variables. MR Steiger filtering was also applied to orient the causal direction.

RESULTS

Three gut microbiota taxa were positively associated with mouth ulcers: Holdemania (odds ratio [OR] = 1.005, 95% confidence interval [CI]: 1.001-1.009, P = .019), Oxalobacter (OR = 1.004, 95% CI: 1.000-1.007, P = .032), and Ruminococcaceae UCG011 (OR = 1.006, 95% CI: 1.001-1.011, P = .029), while 4 gut microbiota taxa were negatively associated with mouth ulcers: Actinobacteria (OR = 0.992, 95% CI: 0.985-1.000, P = .042), Lactobacillales (OR = 0.995, 95% CI: 0.990-1.000, P = .034), Oscillospira (OR = 0.990, 95% CI: 0.984-0.997, P = .007) and Phascolarctobacterium (OR = 0.992, 95% CI: 0.986-0.997, P = .003). Sensitivity analyses validated the robustness of the association in between.

CONCLUSIONS

This MR study identified a strong association between the quality of gut microbiota and oral ulcers. The findings are likely to expand the therapeutic targets for mouth ulcers.

Nurses' knowledge on assessment and management of cancer therapy-associated oral mucositis

AIM

This study aimed to explore baseline nursing knowledge on assessment and management of patients at risk for developing cancer therapy-associated oral mucositis (OM) at a tertiary hospital in Ghana.

DESIGN

A descriptive generic qualitative study design was conducted. The study population were nurses who cared for patients diagnosed with cancer.

METHODS

Participants were recruited using a purposive non-probability sampling technique. Data were obtained through face-to-face interviews using semi-structured interview guide. Data collection and analysis were done concurrently.

RESULTS

The study found that nurses had knowledge on the pre-treatment assessment of clients undergoing cancer treatment; however, they had insufficient knowledge on the standardized tool for the assessment of OM. They also lack a definitive approach to prevent and treat OM. Nurses provided general education on cancer treatment but paid little attention to the education on the possible side effect that includes OM. Additionally, insufficient knowledge level of nurses on cancer treatment-associated mucositis and lack of structured protocol for OM coupled with unavailable tools for assessing the oral mucosa were also identified as militating against the management of OM. Findings from this study will guide policy that will improve the care that clients who are at risk of oral mucositis receive.

Ayurvedic Drug Triphala in Combination with Providone Iodine Mitigates Radiation-Induced Mucositis in Head and Neck Cancer Patients without Affecting the Tumor Response

Radiation-induced mucositis is a dose-limiting concern in the treatment of head and neck cancers (HNC). This study was conducted to determine the effectiveness of the Ayurvedic drug Triphala in reducing radiation-induced mucositis and influencing tumour control when combined with providone iodine. Data from patient files of HNC patients who received Triphala in conjunction with iodine or iodine alone over the course of curative radiotherapy (> 60 Gy) from May 2013 to February 2015 were extracted for this retrospective chart based study. Data was subjected to statistical analysis, X2 and unpaired t test using the Statistical Package for Social Sciences (SPSS), version 17 (IBM, Chicago, USA). When compared to iodine alone, the group that utilised Triphala gargling was very efficient in delaying mucositis, the extent of weight loss (p = 0.038), the incidence (p = 0.03), and the number (p = 0.02) of treatment breaks. However, it had no influence on the radiation-induced tumour response. According to the observations, Triphala coupled with iodine was more successful in preventing radiation mucositis, and without affecting the killing of tumour cells than iodine gargle alone. According to the authors, this is the first observation to demonstrate the value of combining providone iodine with Triphala in preventing radiation-induced oral mucositis.

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

CONTEXT

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

OBJECTIVE

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

DATA SOURCES

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

DATA EXTRACTION

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

DATA ANALYSIS

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

CONCLUSION

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

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42022301010.

Naringin Inhibits Colorectal Carcinogenesis by Inhibiting Viability of Colorectal Cancer Cells

OBJECTIVE

To explore the therapeutic effect of naringin on colorectal cancer (CRC) and the related mechanism.

METHODS

Cell counting kit-8 (CCK-8) assay and annexin V-FITC/PI assay were used to detect the effect of naringin (50-400 µg/mL) on cell proliferation and apoptosis of CRC cells, respectively. The scratch wound assay and transwell migration assay were used to assess the effect of naringin on CRC cell migration. Four-week-old male nude mice were injected with HCT116 cells subcutaneously to establish the tumor xenograft model. Naringin was injected intraperitoneally at 50 mg/(kg·d), with solvent and 5-fluorouracil treatment as control. The width and length of the tumors were measured and recorded every 6 days, and tumor tissues were photographed and weighed on the last day of the 24-d observation period. Immunohistochemical staining for caspase-3, proliferating cell nuclear antigen and TUNEL assay were used to evaluate the effect of naringin on cell proliferation and apoptosis in tumor tissues. The body weight, food and water intake of mice were recorded, and the major organs in different treatment groups were weighed on the last day and stained with hematoxylin and eosin for histological analysis. Meanwhile, the routine blood indicators were recorded.

RESULTS

CCK-8 and annexin V-FITC/PI results confirmed that naringin (100, 200, and 400 µg/mL) could inhibit proliferation and promote apoptosis. The scratch wound assay and transwell migration assay results confirmed the inhibitory activity of naringin against CRC cells migration. In vivo results demonstrated the inhibitory effect of naringin on tumor growth with good bio-compatibility.

CONCLUSION

Naringin inhibited colorectal carcinogenesis by inhibiting viability of CRC cells.

Ecdysterone Attenuates the Development of Radiation-Induced Oral Mucositis in Rats at Early Stage

Oral mucositis is a common adverse reaction of radiotherapy used for head and neck cancers. Our research investigates the therapeutic effect and potential mechanisms of ecdysterone, a compound which was used as a functional food additive, isolated from the root of medicine-food herbs Achyranthes bidentata (Blume), on radiation-induced oral mucositis in rats during the early development stages of mucositis. In this study, male Sprague-Dawley rats received a single 20 Gy X-ray dose to the head and neck after placement of each animal in a specially-constructed 5-mm lead jig. At 24 h postirradiation, ecdysterone was administrated orally. Therapeutic effects of ecdysterone were investigated by observing weight changes and development of mucositis on days 5 and 10 after treatment. Determination of superoxide dismutase and malondialdehyde concentration was performed 5 days after treatment. H&E and leukocyte common antigen staining and TUNEL assays were performed 10 days after treatment. After 10 days of treatment, total protein from the tongue samples was extracted and Western blot analysis was performed to evaluate changes in protein expression. The results of this study showed that ecdysterone prevented the development of radiation-induced oral mucositis in rats during the early stages. Ecdysterone significantly attenuated radiation-induced decrease in cellular superoxide dismutase concentration and increase in malondialdehyde concentration. Ecdysterone was also linked to up-regulation of anti-apoptotic protein Bcl-2 and down-regulation of pro-apoptotic proteins Bax and cleaved caspase-3. In conclusion, these findings suggest that orally administrated ecdysterone alleviates the development of radiation-induced oral mucositis in rats with remarkable anti-oxidant and anti-apoptotic activities at early stages after irradiation.

Ethnopharmacological Knowledge for Management of Oral Mucositis in Zahedan, Southeast Iran

Objectives

Oral mucositis is among the complications of cancer therapy that affects quality of life and imposes remarkable financial costs for patients with cancer. This study aimed to explore, preserve, and scientifically investigate the ethnomedicinal knowledge of traditional healers for treatment of oral mucositis in Zahedan, Iran.

Materials and Methods

Field surveys were performed from September 2018 to October 2018 in Zahedan. Data was collected using a structured questionnaire in Persian. All species recorded for the treatment of oral mucositis were sampled. Samples were identified by a botanist and a voucher specimen of them was deposited in the Herbarium Center of the Faculty of Pharmacy in Kerman, Iran. Information, such as scientific name, family, local name, parts used, and preparation method, were also provided. Literature review on available data on effect of the addressed plant species on mucositis and other relative pharmacological actions, such as wound healing and anti-inflammatory properties, was performed.

Results

A total of 29 informants (attars) were interviewed and 18 medicaments were recommended, of which three samples were of synthesis or mineral origin and 15 samples were of herbal origin. Drugs were administered both topically and orally. According to recent studies, two herbs were evaluated for their direct effect on mucositis. Some pharmacological properties related to mucositis treatment by the other 11 samples have been confirmed.

Conclusion

This study provides information on the characteristics of medicinal plants from Zahedan, Iran based on their ethnopharmacological knowledge and pharmacological properties for mucositis treatment.

Clinical applicability of natural products for prevention and treatment of oral mucositis: a systematic review and meta-analysis

OBJECTIVE

A systematic review and meta-analysis was carried out to verify evidence regarding the efficacy and safety of the clinical applicability of natural products in the prevention and treatment of oral mucositis induced by chemotherapy and/or radiotherapy.

METHODOLOGY

An electronic research according to the PICOS strategy, using the terms "natural products" and "oral mucositis," was carried out at Pubmed, Cochrane, Embase, and "gray literature." The stages of eligibility, data extraction, and quality assessment of the studies were carried out independently and in duplicate.

RESULTS

The number of studies identified as eligible was 151, including 47 randomized controlled trials, reporting a total of 3075 participants undergoing some therapy with natural products on oral mucositis. The included clinical trials covered a variety of 31 types of natural products. Considering the risk of bias of the clinical trials, 24 studies (51.1%) were considered to have a low overall risk of bias, nine (19.1%) were at moderate risk, and 14 clinical trials (29.8%) were at high risk of bias. Honey was the most assessed natural agent. Fourteen studies (3.4%) reported that natural agents reduced pain.

CONCLUSION

The results of the meta-analysis support a positive effect of honey and Aloe vera in reducing mucositis in patients receiving cancer therapy.

CLINICAL RELEVANCE

The results found add relevant information to the scientific community regarding the prevention and treatment of mucositis. Graphical abstract.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Naringin and naringenin as anticancer agents and adjuvants in cancer combination therapy: Efficacy and molecular mechanisms of action, a comprehensive narrative review

Although the rates of many cancers are controlled in Western countries, those of some cancers, such as lung, breast, and colorectal cancer are currently increasing in many low- and middle-income countries due to increases in risk factors caused by development and societal problems. Additionally, endogenous factors, such as inherited mutations, steroid hormones, insulin, and insulin-like growth factor systems, inflammation, oxidative stress, and exogenous factors (including tobacco, alcohol, infectious agents, and radiation), are believed to compromise cell functions and lead to carcinogenesis. Chemotherapy, surgery, radiation therapy, hormone therapy, and targeted therapies are some examples of the approaches used for cancer treatment. However, various short- and long-term side effects can also considerably impact patient prognosis based on clinical factors associated with treatments. Recently, increasing numbers of studies have been conducted to identify novel therapeutic agents from natural products, among which plant-derived bioactive compounds have been increasingly studied. Naringin (NG) and its aglycone naringenin (NGE) are abundantly present in citrus fruits, such as grapefruits and oranges. Their anti-carcinogenic activities have been shown to be exerted through several cell signal transduction pathways. Recently, different pharmacological strategies based on combination therapy, involving NG and NGE with the current anti-cancer agents have shown prodigious synergistic effects when compared to monotherapy. Besides, NG and NGE have been reported to overcome multidrug resistance, resulting from different defensive mechanisms in cancer, which is one of the major obstacles of clinical treatment. Thus, we comprehensively reviewed the inhibitory effects of NG and NGE on several types of cancers through different signal transduction pathways, the roles on sensitizing with the current anticancer medicines, and the efficacy of the cancer combination therapy.

Radioprotective Effects of Plants from the Lamiaceae Family

BACKGROUND

Edible and medicinal plants are still an interesting source of promising biologically active substances to drug discovery and development. At a time of increasing cancer incidence in the world, alleviating the bothersome side effects of radiotherapy in debilitated cancer patients is becoming an important challenge.

OBJECTIVE

The aim of the study was to overview the literature data concerning the radioprotective activity of extracts, essential oils, and some chemical compounds obtained from 12 species belonging to the Lamiaceae family, gathering of numerous spice and medicinal plants rich in valuable phytochemicals.

RESULTS AND CONCLUSION

The analysis of available publications showed radioprotective effectiveness of essential oils and complex extracts containing phenolic acids and flavonoids in various in vitro and in vivo models. Relatively welldocumented preventive properties exhibited the following species: Mentha × piperita, Ocimum tenuiflorum, Origanum vulgare, and Rosmarinus officinalis. However, few plants such as Lavandula angustifolia, Mentha arvensis, M. spicata, Plectranthus amboinicus, Salvia miltiorrhiza, S. officinalis, Scutellaria baicalensis, and Zataria multiflora should be more investigated in the future. Among the mechanisms of radioprotective effects of well-studied extracts and phytochemicals, it can be mentioned mainly the protection against chromosomal damage, scavenging free radicals, decreasing of lipid peroxidation and elevating of glutathione, superoxide dismutase, catalase, and alkaline phosphatase enzyme levels as well as the reduction the cell death. The plant substances protected the gastrointestinal tract, bone marrow and lung fibroblasts. In conclusion, studied species of Lamiaceae family and their active chemical compounds are potent in alleviating the side effects of radiotherapy and should be considered as a complementary therapy.

Oleandrin: A bioactive phytochemical and potential cancer killer via multiple cellular signaling pathways

Nerium oleander, a member of family Apocynaceae, is commonly known as Kaner in various countries of Asia and Mediterranean region. This plant has been renowned to possess significant therapeutic potential due to its various bioactive compounds which have been isolated from this plant e.g., cardiac glycosides, oleandrin, α-tocopherol, digitoxingenin, urosolic acid, quercetin, odorosides, and adigoside. Oleandrin, a saponin glycoside is one of the most potent and pharmacologically active phytochemicals of N. oleander. Its remarkable pharmacotherapeutic potential have been interpreted as anticancer, anti-inflammatory, anti-HIV, neuroprotective, antimicrobial and antioxidant. This particular bioactive entity is known to target the multiple deregulated signaling cascades of cancer such as NF-κB, MAPK, and PI3K/Akt. The main focus of the current study is to comprehend the action mechanisms of oleandrin against various pathological conditions. The current review is a comprehensive summary to facilitate the researchers to understand the pharmacological position of the oleandrin in the arena of drug discovery, representing this compound as a new drug candidate for further researches. Moreover, in vivo and in silico based studies are required to explore the mechanistic approaches regarding the pharmacokinetics and biosafety profiling of this compound to completely track its candidature status in natural drug discovery.

Effects of a Plantago ovata-based herbal compound in prevention and treatment of oral mucositis in patients with breast cancer receiving chemotherapy: A double-blind, randomized, controlled crossover trial

BACKGROUND

Oral mucositis (OM) is one of the most common complications of mucotoxic cancer therapy. Mucositis induces clinically significant pain, increases the risk of infections and affects the patients' quality of life.

OBJECTIVE

This study investigated the effects of an herbal preparation from Plantago ovata hydrocolloid in the prevention and treatment of OM, in breast cancer patients undergoing chemotherapy with a regimen including adriamycin.

DESIGN, SETTING, PARTICIPANTS, AND INTERVENTIONS

This research was a double-blind, randomized, controlled crossover trial. The herbal compound consisted of a mixture of 500 mg of P. ovate husk in 30 mL water plus three drops of vinegar per dose, which was used as a mouthwash. Phytochemical and physicochemical tests of the compound were also performed. Twenty-eight patients who developed mucositis during the chemotherapy screening cycle were randomized to the herbal compound (n = 14) and placebo (n = 14) groups. They received herbal compound or placebo three times per day during their next chemotherapy cycle (cycle 1 of treatment). Patients were crossed over during cycle 2 of treatment and received the alternative therapy. An oral care protocol was prescribed to all patients in cycles 1 and 2 of the treatment.

MAIN OUTCOME MEASURES

The patients were visited at baseline, the end of the first and second weeks of the screening cycle, and the end of the first and second weeks of each of two treatment cycles. The degree of mucositis was used as the main treatment outcome. Other indexes, such as the severity of pain, xerostomia grade and the quality of life were also measured.

RESULTS

Compared with the placebo, the herbal compound significantly reduced the degree of mucositis, the severity of pain and the xerostomia grade; it also improved the patients' quality of life (P < 0.05). Comparison between the screening cycle and placebo treatment group showed that the oral care protocol had a significant effect in the reduction of OM (P < 0.05).

CONCLUSION

The oral care protocol and the herbal compound based on P. ovata are effective ways for preventing and treating OM in patients undergoing mucotoxic cancer therapy.

TRIAL REGISTRATION

Iranian registry of clinical trials IRCT20180923041093N1.

Natural Product Interventions for Chemotherapy and Radiotherapy-Induced Side Effects

Cancer is the second leading cause of death in the world. Chemotherapy and radiotherapy are the common cancer treatments. However, the development of adverse effects resulting from chemotherapy and radiotherapy hinders the clinical use, and negatively reduces the quality of life in cancer patients. Natural products including crude extracts, bioactive components-enriched fractions and pure compounds prepared from herbs as well as herbal formulas have been proved to prevent and treat cancer. Of significant interest, some natural products can reduce chemotherapy and radiotherapy-induced oral mucositis, gastrointestinal toxicity, hepatotoxicity, nephrotoxicity, hematopoietic system injury, cardiotoxicity, and neurotoxicity. This review focuses in detail on the effectiveness of these natural products, and describes the possible mechanisms of the actions in reducing chemotherapy and radiotherapy-induced side effects. Recent advances in the efficacy of natural dietary supplements to counteract these side effects are highlighted. In addition, we draw particular attention to gut microbiotan in the context of prebiotic potential of natural products for the protection against cancer therapy-induced toxicities. We conclude that some natural products are potential therapeutic perspective for the prevention and treatment of chemotherapy and radiotherapy-induced side effects. Further studies are required to validate the efficacy of natural products in cancer patients, and elucidate potential underlying mechanisms.

The protective role of melatonin in chemotherapy-induced nephrotoxicity: a systematic review of non-clinical studies

BSTRACT Introduction: The aim of this study was to investigate the potential role of melatonin in the prevention of chemotherapy-induced nephrotoxicity at the preclinical level. Areas to be covered: To illuminate the possible role of melatonin in preventing chemotherapy-related nephrotoxicity, Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was followed. A comprehensive search strategy was developed to include PubMed, Web of Science, Scopus, and Embase electronic databases from their inception to May 2018. Based on a set of prespecified inclusion and exclusion criteria, 21 non-clinical articles were ultimately included in the study. Expert opinion: Our findings clearly demonstrate that melatonin has a protective role in the prevention of chemotherapy-induced nephrotoxicity which may be caused by different chemotherapy agents such as cyclophosphamide, cisplatin, doxorubicin, methotrexate, oxaliplatin, etoposide, and daunorubicin. On the basis of current review of non-clinical studies, this protective effect of melatonin is attributed to different mechanisms such as reduction of oxidative stress, apoptosis, and inflammation. The findings presented in this review are based on non-clinical studies and thus conducting appropriate clinical trials to evaluate the real effectiveness of the concurrent use of chemotherapy agents with melatonin in the cancer patients is necessary.

A PPAR gamma agonist protects against oral mucositis induced by irradiation in a murine model

BACKGROUND

Due to its anti-inflammatory, antifibrotic and antineoplastic properties, the PPAR gamma agonist rosiglitazone is of interest in prevention and therapy of radiation-induced toxicities. We aimed to evaluate the radioprotective effect of rosiglitazone in a mouse model of radiation-induced oral mucositis.

MATERIAL AND METHODS

Oral mucositis was obtained by irradiation of the oral region of C57BL/6J mice, pretreated or not with rosiglitazone. Mucositis was assessed by macroscopic scoring, histology and molecular analysis. Tumor xenograft was obtained by s.c. injection of Hep-2 cells in CD1 mice. Tumor volume was measured twice a week to evaluate effect of rosiglitazone alone and combined with radiotherapy.

RESULTS

Irradiated mice showed typical features of oral mucositis, such as oedema and reddening, reaching the peak of damage after 12-15days. Rosiglitazone markedly reduced visible signs of mucositis and significantly reduced the peak. Histological analysis showed the presence of an inflammatory cell infiltrate after irradiation; the association with rosiglitazone noticeably reduced infiltration. Rosiglitazone significantly inhibited radiation-induced tnfα, Il-6 and Il-1β gene expression. Rosiglitazone controlled the increase of TGF-β and NF-kB p65 subunit proteins induced by irradiation, and enhanced the expression of catalase. Irradiation and rosiglitazone significantly reduced tumor volume as compared to control. Rosiglitazone did not protect tumor from the therapeutic effect of radiation.

CONCLUSION

Rosiglitazone exerted a protective action on normal tissues in radiation-induced mucositis. Moreover, it showed antineoplastic properties on head-neck carcinoma xenograft model and selective protection of normal tissues. Thus, PPAR gamma agonists should be further investigated as radioprotective agents in head and neck cancer.