3

“The wonders of medical science”

Dr. Héliton Spíndola Antunes, Servişo de Pesquisa Clínica, Instituto Nacional de Cancer (INCA), Rua André Cavalcante, n 37, 2 andar, Rio de Janeiro, Brasil, CEP-20231-050, E-mail: hspindola@inca.gov.br.

We have investigated the clinical effects of low power laser therapy (LPLT) on the treatment of conditioning-induced oral mucositis (OM) in patients submitted to hematopoietic stem cell transplantation (HSCT). The evaluation of OM was done using the Oral Mucositis Assessment Scale (OMAS) and World Health Organization (WHO) scale. In the context of a randomized placebo-controlled trial with 38 patients for the evaluation of preventive LPLT, eleven individuals were submitted to allogeneic (AL) HSCT and developed oral mucositis grade 4 (WHO) or a total area of OM of 12 cm (OMAS) and due to that were treated with LPLT with the purpose of symptom relief. The irradiation used was a diode InGaAlP, emitting light at 660 nm, 50 mW and 8 J/cm(2) measured at the end of fiber optic with 0.196cm(2) of section area during the treatment. The tip of the laser device touched the oral mucosa and patients recovered on average 6 days (3-12 days) from the beginning of the laser application. Our results have indicated that the use of LPLT in HSCT patients is a powerful instrument in the treatment of overt OM and is now a standard procedure in this group of patients in our hospital.

PMID: 18305441 [PubMed - in process]

Department of Oral Medicine and Radiology, Manipal College of Dental Sciences, Manipal, Karnatka, India. drarora@gmail.com

OBJECTIVE: The objective of this study was to evaluate the efficacy of low-level lasers for the prevention and treatment of radiotherapy-induced oral mucositis in oral cancer patients. MATERIAL AND METHODS: Twenty-four hospitalized patients with oral cancer, scheduled to undergo radiotherapy at KMC, Manipal, were enrolled in the present study and assigned to laser (Group I)/control group (Group II). They were treated using He-Ne laser (lambda = 632.8nm, output = 10 mW and energy density = 1.8 J/cm(2)). Patients were subjected to treatment using laser scanner for 8 days and subsequently were treated using laser probe at 6 anatomic sites in the oral cavity for 5 minutes each. The patients were evaluated on each day of treatment for pain severity (NRS), functional impairment (FIS), and oral mucositis (RTOG) and were followed until the end of cancer treatment. Statistical analysis was done using SPSS version 10. RESULTS: Laser therapy applied prophylactically during radiotherapy can reduce the severity of oral mucositis, severity of pain, and functional impairment.

PMID: 18230388 [PubMed - indexed for MEDLINE]

Department of Oral Medicine, Seattle Cancer Care Alliance, University of Washington, 825 Eastlake Ave E, Seattle, WA 98109, USA. mschuber@seattlecca.org

INTRODUCTION: Oral mucositis (OM) is a significant early complication of hematopoietic cell transplantation (HCT). This phase III randomized double-blind placebo-controlled study was designed to compare the ability of 2 different low level GaAlAs diode lasers (650 nm and 780 nm) to prevent oral mucositis in HCT patients conditioned with chemotherapy or chemoradiotherapy. MATERIALS AND METHODS: Seventy patients were enrolled and randomized into 1 of 3 treatment groups: 650 nm laser, 780 nm laser or placebo. All active laser treatment patients received daily direct laser treatment to the lower labial mucosa, right and left buccal mucosa, lateral and ventral surfaces of the tongue, and floor of mouth with energy densities of 2 J/cm2. Study treatment began on the first day of conditioning and continued through day +2 post HCT. Mucositis and oral pain was measured on days 0, 4, 7, 11, 14, 18, and 21 post HCT. RESULTS: The 650 nm wavelength reduced the severity of oral mucositis and pain scores. Low level laser therapy was well-tolerated and no adverse events were noted. DISCUSSION: While these results are encouraging, further study is needed to truly establish the efficacy of this mucositis prevention strategy. Future research needs to determine the effects of modification of laser parameters (e.g., wavelength, fluence, repetition rate of energy delivery, etc.) on the effectiveness of LLE laser to prevent OM.

PMID: 17393191 [PubMed - indexed for MEDLINE]

Oral Medicine, Department of Dentistry, School of Health Science, University of Brasília, Brasília, Brazil. nemetala@unb.br

PURPOSE: To present an animal model for mucositis induced by fluorouracil in rats, and test two therapeutic options, the GaAIAs laser and topical dexamethasone, analysing them with regard to the quality and quantity of tissue alterations and comparing them with the phases of mucositis. MATERIALS AND METHODS: Forty-five Wistar rats (250 g) were treated with fluorouracil (60 mg/kg) and, in order to mimic the clinical effect of chronic irritation, the palatal mucosa was irritated by superficial scratching with an 18-gauge needle. When all of the rats presented oral ulcers of mucositis, they were randomly allocated to one of three groups: group I was treated with laser (GaAIAs), group II was treated with topical dexamethasone, and group III was not treated. Excisional biopsies of the palatal mucosa were then performed, and the rats were killed. Tissue sections were stained with haematoxylin and eosin for morphological analyses, and with toluidine blue for mast-cell counts. RESULTS: Group I specimens showed higher prevalence of ulcers, bacterial biofilm, necrosis and vascularisation, while group II specimens showed higher prevalance of granulation tissue formation. There were no significant statistical differences in the numbers of mast cells and epithelial thickness between groups. CONCLUSION: For the present model of mucositis, rats with palatal mucositis treated with laser (GaAIAs) showed characteristics compatible with the ulcerative phase of oral mucositis, and rats treated with topical dexamethasone showed characteristics compatible with the healing phase of mucositis. Topical dexamethasone was more efficient in the treatment of rats’ oral mucositis than the laser.

PMID: 17366763 [PubMed - indexed for MEDLINE]

Departments of Physiotherapy , Manipal College of Allied Health Sciences, Kasturba Medical College, MAHE University, Manipal, India. ajmaiya@yahoo.com

BACKGROUND & OBJECTIVES: Oral mucositis is a common debilitating complication of radiotherapy occurring in about 60 per cent of cancer patients. Considerable buccal toxicity of radiotherapy or chemotherapy in cancer patients to become discouraged and can affect their quality of life. In addition, such toxicity can alter the treatment plan. At present, there is no clinically appropriate prophylaxis efficacious antidote for mucositis. The low level laser (LEL) appears to be a simple, non-traumatic technique for the prevention and treatment of radiation induced mucositis. Therefore the present study was carried out to find out the effect of low-level helium-neon (He-Ne) laser in the prevention and treatment of radiation induced mucositis in head and neck cancer patients. METHODS: The patients with carcinoma of oral cavity with stages II-IV a being uniformly treated with curative total tumour dose of 66 Gy in 33 fractions over 6 wk were selected for the study. The patients were divided based on computer generated randamosization into laser (study group) and control groups with 25 patients in each group. Both study and control groups were comparable in terms of site of the lesion, stage of the cancer and histology. The study group patients were treated with He-Ne laser (wavelength 632.8 nm and output of 10mW) and control group patients were given oral analgesics, local application of anaesthetics, 0.9 per cent saline and povidine wash during the course of radiotherapy. RESULTS: All patients tolerated the laser treatment without any adverse effect or reactions. The result showed a significant difference in pain and mucositis (P<0.001) between the two groups. At the end of radiotherapy (after 6 wk) mean pain sure and mucositis grade were significantly lower (P<0.001) in the study group compared to control. INTERPRETATION & CONCLUSION: The low-level He-Ne laser therapy during the radiotherapy treatment was found to be effective in preventing and treating the mucositis in head and neck cancer patients. Further studies need to be done on a larger sample to find the mechanism.

PMID: 17159259 [PubMed - indexed for MEDLINE]

Section of Dentistry, Instituto Nacional de Câncer (INCA), Rio de Janeiro, Brazil. hspindola@inca.gov.br

We investigated the clinical effects of low-power laser therapy (LPLT) on prevention and reduction of severity of conditioning-induced oral mucositis (OM) for hematopoietic stem cell transplantation (HSCT). We randomized 38 patients who underwent autologous (AT) or allogeneic (AL) HSCT. A diode InGaAlP was used, emitting light at 660 nm, 50 mW, and 4 J/cm2, measured at the fiberoptic end with 0.196 cm2 of section area. The evaluation of OM was done using the Oral Mucositis Assessment Scale (OMAS) and the World Health Organization (WHO) scale. In the LPLT group, 94.7% of patients had an OM grade (WHO) lower than or equal to grade 2, including 63.2% with grade 0 and 1, whereas in the controls group, 31.5% of patients had an OM grade lower than or equal to grade 2 (P < .001). Remarkably, the hazard ratio (HR) for grades 2, 3, and 4 OM was 0.41 (range, 0.22-0.75; P = .002) and for grades 3 and 4 it was 0.07 (range, 0.11-0.53; P < .001). Using OMAS by the calculation of ulcerous area, 5.3% of the laser group presented with ulcers of 9.1 cm2 to 18 cm2, whereas 73.6% of the control group presented with ulcers from 9.1 cm2 to 18 cm2 (P = .003). Our results indicate that the use of upfront LPLT in patients who have undergone HSCT is a powerful instrument in reducing the incidence of OM and is now standard in our center.

Publication Types:

• Randomized Controlled Trial

PMID: 17053058 [PubMed - indexed for MEDLINE]

Pediatric Oncology Unit, Federal University of Rio Grande do Sul, Porto Alegre, Brazil. lcruz@hcpa.ufrgs.br

BACKGROUND: This study assessed the use of low-energy laser in the prevention or reduction of the severity of oral mucositis. PROCEDURE: A randomized clinical trial was carried out. Patients from 3 to 18 years of age treated with chemotherapy or hematopoietic stem-cell transplantation between May, 2003 and February, 2005 were eligible. The intervention group received laser application for 5 days following the start of chemotherapy. The grade of oral mucositis was assessed by the WHO per NCI-CTC common toxicity criteria and the assessments were made on days 1, 8 and 15 by a trained examiner blind to the intervention. RESULTS: Sixty patients were evaluable for analysis; thirty-nine (65%) were males, 35 (58%) patients had a diagnosis of leukemia or lymphoma, and 25 (42%) had solid tumors. The mean age was 8.7 +/- 4.3 years. Twenty-nine patients were randomized in the laser group and 31 in the control group. On day 1, no patients presented with mucositis. On day 8, of 20 patients (36%) who developed mucositis, 13 of them were from the laser group and 7 from the control group. On day 15, of 24 patients (41%) who developed mucositis, 13 of them were from the laser group and 11 from the control group. There was no significant difference between groups concerning the grades of mucositis on day 8 (P = 0.234) or on day 15 (P = 0.208). CONCLUSIONS: This study showed no evidence of benefit from the prophylactic use of low-energy laser in children and adolescents with cancer treated with chemotherapy when optimal dental and oral care was provided.

PMID: 16862549 [PubMed - indexed for MEDLINE]

Department of Pharmacy Practice, College of Pharmacy, Ferris State University, Big Rapids, Michigan, USA. saadehc@ferris.edu

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.

PMID: 15977916 [PubMed - indexed for MEDLINE]

Laboratoire d’Investigation Clinique H.J. Tagnon, Institut Jules Bordet, Centre des Tumeurs, Université Libre de Bruxelles, Bruxelles, Belgium.

PURPOSE OF REVIEW: Oral mucositis is a common morbid condition associated with chemotherapy or radiotherapy for which there is no standard prophylaxis or treatment. There is increasing evidence that the use of low-level laser can reduced the severity of mucositis associated with chemotherapy or radiation therapy. The purpose of this review is to examine the available evidence for it. RECENT FINDINGS: For most approaches commonly used to prevent or treat chemotherapy-associated or radiotherapy-associated oral mucositis, a recent panel of experts could not find sufficient levels of evidence to recommend or suggest their use. As for low-level laser therapy, the results are difficult to assess and compare because of interoperator variability and because clinical trials are difficult to conduct in that field. Nevertheless, there is accumulating evidence in support of low-level laser therapy. SUMMARY: On the basis of literature data, it is reasonable to conclude that the evidence that low-level laser therapy may be useful in decreasing the severity of chemotherapy-associated or radiotherapy-associated mucositis is substantial, even though there have been few controlled studies in the field of prevention.

Publication Types:

• Review

PMID: 15818167 [PubMed - indexed for MEDLINE]

Buskerud University, Drammen, Norway. s-oddmun@online.no

BACKGROUND: Intensive cancer therapy normally affects malignant and normal cells with high replication rates. Cells in the gastrointestinal tract are therefore commonly affected by cytotoxins. This often results in the development of chemotherapy-induced oral mucositis (COM). COM is the inflammatory response of the oral mucous membrane to the chemotherapy drugs. Low level laser therapy (LLLT) has proved to be effective in treating and repairing biologically damaged tissue and to reduce pain. LLLT has also proven to be an efficient method for the prevention of oral mucositis. OBJECTIVE: To investigate the effect of LLLT on pain relief among patients who have developed COM. METHOD: The study was performed as a clinical test with a sample consisting of 13 adult patients receiving oncology treatment. The patients were treated during a 5-day period, and the pain was measured before and after each laser application. The laser used was an AsGaAl, with a wavelength of 830 nm and a potency of 250 mW. The energy given was 35 J cm(-2). ANALYSIS: The results were analysed using the Wilcoxon test. RESULTS: There was a significant (P = 0.007) 67% decrease in the daily average experience of pain felt before and after each treatment, confirming that LLLT can relieve pain among patients who have developed COM. STUDY LIMITATIONS: The low number of COM patients at the hospital did not allow a control group to be included in the study, and therefore the results contain a potential placebo effect. IMPLICATIONS FOR NURSING CARE: The most important benefit the authors consider to be the value for the patients of better and quicker treatment with a drastic reduction in painful mucositis.

Publication Types:

• Clinical Trial

PMID: 15725279 [PubMed - indexed for MEDLINE]

Department of Prosthodontics, Clinical Hospital Centre Zagreb, Dobojska 38-D, 10000 Zagreb, Croatia. mirela.maver@zg.htnet.hr

BACKGROUND AND OBJECTIVE: Denture stomatitis (DS) is a common inflammatory condition that affects denture wearers. The aim of this study was to examine, in vivo, the effect of diode laser irradiation on fungal growth in both the palatal mucosa and in denture base materials, in denture wearing patients. STUDY DESIGN/MATERIALS AND METHODS: In total, 70 patients with clinical study design evidence of DS participated in this parallel, single blind, and placebo controlled study. The subjects were randomly assigned to one of four different treatment regimens: (1) irradiation with a 685 nm wavelength laser for 10 minutes (30 mW); (2) irradiation with a 830 nm wavelength laser for 5 minutes (60 mW). A semiconductor diode laser, BTL-2000 (BTL-2 Dravotnicka Technika, Prague, Czech Republic), was used in both treatment cases using an energy density of 3.0 J/cm(2) and a continuous working mode for five consecutive days; (3) placebo-sham irradiation of patients; (4) antimicotic-self treatment of patient’s palatal mucosa with an antifungal oral gel and the use of an antiseptic solution for their dentures. The effect of laser light on fungal growth in vivo was evaluated after final treatment using the swab method and a semi-quantitative estimation of Candida albicans colonies cultivated on agar plates. RESULTS: A fungicidal effect was achieved in the laser treated and antimicotic treated groups, whereas most subjects in the placebo group were found to have unchanged conditions on both their palate (P = 0,004) and dentures (P < 0,001). CONCLUSIONS: Light from a low-power laser (LLLT) may be valuable in the treatment of DS. This is of great importance since the rate of recurrence of disease is high, whereas an optimal treatment modality has not yet been found. (c) 2004 Wiley-Liss, Inc.

PMID: 15493034 [PubMed - indexed for MEDLINE]

Department of Maxillofacial Prosthetics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.

This article reports the successful use in our clinic of CO(2)-laser to reduce severe pain in the treatment of oral aphthosis. The patients, presenting stress-related, chemoradiotherapy-induced, and immuno-related oral aphthosis, reported immediate pain relief and rapid recovery. Treatment technique and laser parameters are described.

PMID: 15024356 [PubMed - indexed for MEDLINE]

University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.

We report a case of severe oral stomatitis caused by lichenoid chronic graft-vs.-host disease in which low-level laser therapy applied to the oral mucosa, in addition to standard systemic immunosuppressive treatment, resulted in quick healing and symptomatic relief.

PMID: 14962242 [PubMed - indexed for MEDLINE]

Department of Oral and Maxillofacial Sciences, Gifu University School of Medicine, Gifu, Japan. toida@cc.gifu-u.ac.jp

OBJECTIVE: The aim of this study was to evaluate the usefulness of low-level laser therapy (LLLT) for the control of painful stomatitis in patients with hand-foot-and-mouth disease (HFMD). BACKGROUND DATA: LLLT has been successfully applied to various painful oral mucosal diseases, although there have been few reports on LLLT for HFMD patients. MATERIALS AND METHODS: Through a randomized double-blind placebo controlled trial, the painful period of HFMD stomatitis was compared between the LLLT group (n=11) and the placebo LLLT one (n=9), which had similar clinical backgrounds. The LLLT parameters supplied were as follows: wavelength of 830 nm, power of 30 mW, frequency of 30 Hz, and energy output of 1.1 J/cm2. Acceptability and safety of the treatment were also evaluated. RESULTS: The painful period was shorter in the LLLT group (4.0 +/- 1.3 days) than in the placebo LLLT one (6.7 +/- 1.6 days) with a statistically significant difference (p<0.005). The treatment was judged acceptable for 90.0% (18 of 20) of patients. No adverse events were observed in any cases. CONCLUSION: LLLT is a useful method to control HFMD stomatitis by shortening the painful period, with its high acceptability and lack of adverse events.

Publication Types:

• Clinical Trial
• Randomized Controlled Trial

PMID: 14709221 [PubMed - indexed for MEDLINE]

• Cancer J. 2002 May-Jun;8(3):236-8.

Pilot study of laser effects on oral mucositis in patients receiving chemotherapy.

Wong SF, Wilder-Smith P.

Western University of Health Sciences, College of Pharmacy, Division of Hematology/Oncology, Pomona, California 91766, USA.

PURPOSE: The purpose of this study was to examine the effectiveness of laser therapy in the prevention and/or healing of chemotherapy-induced oral mucositis lesions. This study also evaluated the ease and feasibility of the laser therapy and the impact of the treatment on improving the patient’s quality of life. PATIENTS AND METHODS: Fifteen patients with an episode of prior chemotherapy-induced grade 3 or 4 mucositis with 5-fluorouracil continuous infusion consented to participate in this study. All patients were provided with standardized mouth care instructions at the initiation of chemotherapy treatments. Enrolled patients received laser therapy treatments 24 hours before the chemotherapy and then recommenced weekly with evenly distributed exposure to the standardized designated areas by one operator during the entire cycle of chemotherapy at the same doses until the mucositis resolved or the chemotherapy cycle was completed. lntraoral perfusion was measured by laser Doppler technology. Patients were assessed for response to laser therapy according to standardized mucositis grading criteria by evaluating development of lesions, extent and duration of lesions, and time to healing. The effect of laser therapy on ability to continue planned chemotherapy, the reduction in dose, delays, and ability to maintain planned dose intensity were assessed. The impact of laser therapy on pain control was evaluated using the visual analogue score. A quality-of-life survey was completed by each patient at the initiation of chemotherapy and then weekly throughout the chemotherapy. RESULTS: Eleven of 15 patients experienced grade 0 mucositis, three patients experienced grade 1 to 2 mucositis, and one patient experienced grade 3 to 4 mucositis. Fourteen patients completed the lasertherapy as planned, and none of the patients withdrew from the laser therapy treatments because of noncompliance. One patient continued to experience grade 4 mucositis that necessitated an interruption in the planned chemotherapy regimen and, consequently, the laser treatment. Patients tolerated the laser therapy very well and did not report any increased discomfort. No significant changes in perfusion were observed as a result of laser therapy. DISCUSSION: In this pilot study, laser therapy significantly reduced the incidence and the severity of mucositis in chemotherapy patients. The laser therapy does not appear to promote wound healing by affecting the intraoral perfusion, as assessed by Doppler measurements. The mechanisms involved in the mediating of the observed effects remain unknown at this time. Continued research is warranted to determine the optimal laser wavelength and parameters.

PMID: 12074324 [PubMed - indexed for MEDLINE]

• Cancer J. 2002 May-Jun;8(3):247-54.

Low level laser therapy: a real hope in the management of chemo-induced and radiation-induced mucositis?

Bensadoun RJ.

Department of Radiation Oncology, Centre Antoine-Lacassagne, Nice, France.

Publication Types:

• Comment

PMID: 12074321 [PubMed - indexed for MEDLINE]