Research controversies in management of oral mucositis

Abstract

The management of mucositis is the subject of many controversies, and the optimal treatment is still not known. Several evaluation scoring systems have been described, but no one of these is appropriate to all clinical situations: a simple scale such as that devised by the WHO can be used routinely, and more sophisticated ones can be implemented by trained experimenters working in research. We have considered the impact of each of the treatments currently available on each stage of mucositis. In attempts at prevention, self-care, in the sense of oral hygiene, must remain atraumatic. It is probably advisable to differentiate patients with good previous oral care, in whom tooth brushing is beneficial, from others, in whom the risk of hemorrhage and infection excludes any brushing. Before the dosage of chemotherapy is reduced, the curative or palliative intent of the strategy must be carefully evaluated. In the vascular phase protection of the proliferating cells is attempted by means of vasoconstriction (cryotherapy), cytoprotection (prostaglandin E2 and other antioxidants) or epithelial cell-inhibiting factors such as TGF-B3. Treatments applied in the epithelial phase are directed at increasing the cell proliferation to accelerate epithelial restoration by sucralfate and several growth factors: hematopoietic GF, which has demonstrated a direct effect on the mucosa (GM-CSF), or epithelial growth factors such as keratinocyte GF. In the ulcerative and bacteriological phase attempts are made to attenuate sepsis by means of antiseptics (chlorhexidine), amphotericin B and antiviral agents or antibiotic lozenges. In the healing phase application of the low-energy helium-neon laser has demonstrably been followed by a later time of onset, less pronounced peak severity and shorter duration of oral mucositis. After cancer treatment, oral hygiene, inhibition of oral flora, and pain relief are the main goals. Physiopathogen-specific treatment is the next step, with the emphasis on the inhibition of epithelial cell proliferation during drug exposure and facilitation of epithelial maturation and healing.

Granulocyte Colony-Stimulating Factor and Granulocyte-Macrophage Colony-Stimulating Factor Promote Malignant Growth of Cells from Head and Neck Squamous Cell Carcinomas In vivo

“…Although originally identified as hematopoietic growth factors (10), both factors are also produced by a variety of nonhematopoietic cells, including fibroblasts, endothelial cells, and keratinocytes (11,12). They induce the proliferation and migration of endothelial cells, thereby contributing to angiogenesis (13,14), and can promote keratinocyte proliferation (5,15,16), resulting in a stimulatory role on wound healing (17)(18)(19). In normal cells (e.g., keratinocytes), the expression of both factors is strictly regulated (20), requiring induction by appropriate stimuli, such as interleukin-1, tumor necrosis factor-a, or lipopolysaccharides (16,21).…”

“…On the other hand, due to their role as recruitment, proliferation, and maturation factors for granulocytes and macrophages as well as their stimulatory effect on wound healing, G-CSF and GM-CSF are commonly used in cancer therapy to ameliorate mucositis and neutropenia and to accelerate wound healing (18,19,26). In the therapy of HNSCC, oropharyngeal mucositis is a painful, often dose-limiting side effect of radiotherapy and chemotherapy (27).…”

Efetividade profilática e terapêutica do laser de baixa intensidade na mucosite bucal em pacientes submetidos ao tratamento do câncer

“…Quando é absorvida em diferentes tecidos, dependendo do tipo de laser, a radiação resulta em efeitos fotoquímicos, térmicos e não lineares 3 . Essa interação com o tecido está diretamente relacionada com o comprimento de onda, dose ou fluência (densidade de energia), intensidade (densidade de potência), regime de operação do laser, taxa de repetição ou frequência do pulso e características óticas do tecido, como o coeficiente de absorção e espalhamento, para que se possa estabelecer o número de aplicações e dose ótima de radiação 3,[22][23][24][25]28 .…”

“…Contudo, parâmetros como período de início e término de sua aplicação, potência do equipamento, comprimento de onda, densidade de energia, área da fibra ótica e frequência são fatores que influenciam no resultado do tratamento, assim como seus efeitos e razões de aplicação tanto curativa como profilática [19][20][21][22][23][24][25][26] .…”

Effects of Palifermin on Antitumor Activity of Chemotherapeutic and Biological Agents in Human Head and Neck and Colorectal Carcinoma Xenograft Models

“…Mucositis can be extremely painful, puts patients at risk of potentially life-threatening infections, increases overall health care use, and has been associated with increased overall mortality in cancer patients (4)(5)(6)(7)(8)(9). It is considered one of the most common dose-limiting toxicities of some anticancer therapies and can force dose reductions or interruptions in cancer treatment that may contribute to suboptimal clinical outcomes (6,(10)(11)(12)(13)(14).…”