运用多样化的牙周特色治疗技术保留更多天然牙

放射性口腔黏膜炎(oral mucositis)是放射线电离辐射引起的急慢性口腔黏膜损伤[1-2]。由于放疗是头颈部肿瘤综合治疗的重要方法之一[3]。     

Laser phototherapy as a treatment for radiotherapy-induced oral mucositis

Oral mucositis is a harmful side effect of radiotherapy (RT) on the head and neck region. There are encouraging reports on the beneficial aspects of the use of laser light on the treatment of oral mucositis. This paper reports the efficacy of laser phototherapy (LPT) on the treatment of oral mucositis in a patient undergoing RT after surgical removal of a squamous cell carcinoma with osseous invasion of the maxilla. Palatal and commissural lesions were treated with λ660 nm, 40 mW, ?=4 mm(2), in contact mode, 5 x 2.4 J/cm(2) per point, 14.4 J/cm(2) per session. For treating the lesion on the patient's nasal mucosa, LPT (?=4 mm(2), λ780 nm, 70 mW, 3 x 2.1 J/cm(2) per point, 6.3 J/cm(2) per session, contact mode) was used on the external area of the nose. A single dose (2.4 J/cm(2)) with the λ660 nm laser, as described before, was applied on the entrance of each nostril. LPT was used 3 times/week during 4 weeks. Treatment results indicate that the use of LPT on oral mucositis was effective and allowed the patient to carry on the RT without interruption. However, long-term and controlled clinical trials are necessary to establish both preventive and curative protocols using LPT.     

放射治疗和化学治疗诱发性口腔黏膜炎的防治

口腔黏膜炎(OM)是接受放射治疗和化学治疗的头颈部肿瘤患者常见的不良反应和剂量限制因素之一,OM的黏膜破损会给患者带来难以忍受的疼痛,影响机体的营养摄入,还可使感染通过黏膜破损扩散到全身,进而影响肿瘤治疗计划。目前虽然防治方式多样,但临床上还未有疗效确切的防治方法被大家公认,本文将对近年来针对防治OM的研究进展进行综述。     

Prevention of oral mucositis during antiblastic chemotherapy

Oral complications of cancer chemotherapy have been studied in a group of 50 adult patients. A number of 25 patients was treated by means of oral hygiene and prophylactic measures: drugs and topical agents, while the other group of 25 patients had not received stomatological prevention. The goal of the research has showed that prevention measures and elimination of existing or potential sources of infection reduce and minimize mucositis, infection etc.     

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.     

国内防治放(化)疗所致口腔黏膜炎研究文献的循证医学分析

目的：评价国内口腔放疗和（或）化疗所致口腔黏膜炎文献的研究质量及治疗方法的有效性。方法：检索中国期刊网全文数据库（CNKI）和中国生物医学文献光盘数据库（CBMDisc）,按照国际循证医学标准对其中采取随机对照设计（randomized controlled trial,RCT）的有关口腔黏膜炎的疗效研究文献进行分析。结果：共检索到论著98篇,符合纳入标准的RCT文献22篇。从设计类型、诊断标准、疗效评定、不良反应等方面对上述文献进行分析。结论：我国治疗口腔黏膜炎的RCT文献无法进行Meta分析;粒细胞-巨噬细胞集落刺激因子（GM-CSF）具有较好的短期疗效。     

Management of chemo- and radiotherapy induced oral mucositis with low-energy laser: initial results of A.C. Camargo Hospital

Background. Oral mucositis is a common complication of some malignancies treatment, causing therapeutic modifications due to patient's debilitation, which often interferes with the prognosis of the disease. Many attempts have been made to find an optimal treatment or preventive method to minimize the severity of oral mucositis. Several studies have shown good results with the use of low-energy laser, with the aim of accelerating the process of wound healing and promoting pain relief. Methods. Patients (n=18) who developed oral mucositis during chemotherapy and/or radiotherapy were submitted to low-energy laser applications until cessation of symptoms. Mucositis severity was scored by an oral mucositis scale based on clinical features and by an oral toxicity scale from the National Cancer Institute based on the ability to swallow; pain severity was scored by subjects on a visual analogue scale before and after the applications. Results. Immediate pain relief was achieved in 66.6% of the patients after the first application. Based on the functional scale, mucositis grade III (not capable to eat solids) was reduced in 42.85% of the cases. According to the scale based on the clinical features, mucositis grade IV (ulcerative lesions) was reduced in 75% of the patients that presented this grade of mucositis at the beginning of laser therapy. Conclusions. Low-energy laser was well-tolerated and showed beneficial effects on the management of oral mucositis, improving the quality of life during the oncologic treatment.     

The effects of sucralfate suspension and diphenhydramine syrup plus kaolin-pectin on radiotherapy-induced mucositis.

A prospective, double-blind study compared the effectiveness of sucralfate suspension with diphenhydramine syrup plus kaolin-pectin in reducing severity and pain of radiation-induced oropharyngeal mucositis. Fourteen patients who received at least 4600 cGy to the oral cavity used one of the mouth rinses four times a day, beginning at 1600 cGy. Data were collected on daily perceived pain and helpfulness of mouth rinse, weekly mucositis grade, weight change, and interruption of therapy. Analysis of data revealed no statistically significant differences between the two groups in any parameter. A retrospective review of 15 patients who had received at least 4600 cGy radiation to the oropharynx but had not used a daily mouth-coating rinse, was compared with the study group. Comparison of the two groups suggested that consistent daily oral hygiene and use of a mouth-coating agent will result in less pain and may reduce weight loss and interruption of radiation because of severe mucositis.     

Cancer therapy-related oral mucositis

Oral mucositis is a common side effect of cancer therapies, particularly radiation therapy for head and neck cancer and various forms of chemotherapy. It commonly results in severe oral pain that can compromise the duration and success of cancer management. Hospitalizations are common because patients lose the ability to take anything by mouth due to severe pain and must have alimentation supported during this period. Pain management usually requires potent narcotic analgesia. Cancer therapy-related oral mucositis is commonly described as the most significant and debilitating acute complication associated with radiation therapy and chemotherapy. Until recently, cancer therapy-induced oral mucositis was thought to be a process involving the epithelium only. Evidence is building that the process of oral mucositis involves far more than just the epithelium, but includes multiple cellular processes of the submucosa as well. Many strategies have been evaluated to prevent oral mucositis, but the data is confusing since it is often conflicting. Therapy with the growth factor, KGF1, appears promising, as it is the only medication currently approved by the FDA. A multifaceted approach that targets the entire mucositis process will probably be needed to optimize overall prevention.     

癌症患者化疗或放疗后口腔黏膜炎的预防

数据来源：检索MEDLINE、Embase和CINAHL数据库，同时查阅其参考文献。     

Prevention of oral mucositis and oral candidiasis for patients with cancer treated with chemotherapy: cochrane systematic review

The objectives of this study were to determine whether oral prophylactic agents are superior to placebo or no treatment on the incidence of oral mucositis and oral candidiasis for patients with cancer. A Cochrane systematic review was conducted of randomized trials of oral (and topical) prophylactic agents for mucositis and oral candidiasis, anywhere in the world, among patients with cancer (excluding head and neck) who were receiving chemotherapy. Eleven studies were included in the meta-analysis for mucositis. Of the six prophylactic agents used for mucositis, only one--ice chips--was effective (relative risk 0.57, 95% CI 0.43 to 0.77). Fifteen studies were included in the meta-analysis for oral candidiasis. There is evidence that antifungal agents that are partially or fully absorbed from the gastrointestinal tract prevent oral candidiasis and that the partially absorbed agents may be more effective than the fully absorbed agents. The RR for partially absorbed agents was 0.13 (95% CI 0.06 to 0.27). In conclusion, there is weak and unreliable evidence that ice chips prevent mucositis. There is evidence that prophylactic use of antifungal agents, which are absorbed or partially absorbed from the gastrointestinal tract, reduce the clinical signs of oral candidiasis.     

Management of oral mucositis pain

Effective pain control for mucositis requires constant attention and willingness on the part of managing clinicians to evaluate and adapt pain relieving strategies throughout the period of risk for oral mucositis. By utilizing the principles of a individualized, tiered approach to pain management, that address the multidimensional components of a patient's pain, maximum comfort can be consistently provided while reducing the risk for side-effects.     

Interventions for treating oral mucositis for patients with cancer receiving treatment

Background: Treatment of cancer is increasingly effective but associated with short and long‐term side effects. Oral side effects, including oral mucositis (mouth ulceration), remain a major source of illness despite the use of a variety of agents to treat them. Objectives: To assess the effectiveness of interventions for treating oral mucositis or its associated pain in patients with cancer receiving chemotherapy or radiotherapy or both. Search strategy: Computerized searches of Cochrane Oral Health Group’s Trials Register; Cochrane Pain, Palliative and Supportive Care Group’s Trials Register; CENTRAL; MEDLINE and EMBASE were undertaken. Reference lists from relevant articles were searched and the authors of eligible trials were contacted to identify trials and obtain additional information. Date of the most recent searches June 2006: CENTRAL (The Cochrane Library 2006, Issue 2). Selection criteria: All randomized controlled trials comparing agents prescribed to treat oral mucositis in people receiving chemotherapy or radiotherapy or both. Outcomes were oral mucositis, time to heal mucositis, oral pain, duration of pain control, dysphagia, systemic infection, amount of analgesia, length of hospitalization, cost and quality of life. Data collection and analysis: Data were independently extracted, in duplicate, by two review authors. Authors were contacted for details of randomization, blindness and withdrawals. Quality assessment was carried out on these three criteria. The Cochrane Oral Health Group statistical guidelines were followed and risk ratio (RR) values calculated using fixed effect models. Main results: Twenty‐six trials involving 1353 patients satisfied the inclusion criteria. Four agents, each in single trials, were found to be effective for improving (allopurinol RR 3.33, 95% confidence interval (CI) 1.06 to 10.49; granulocyte macrophage‐colony stimulating factor RR 4.23, 95% CI 1.35 to 13.24; immunoglobulin RR 1.81, 95% CI 1.24 to 2.65; human placentral extract RR 4.50, 95% CI 2.29 to 8.86) or eradicating mucositis (allopurinol RR 19.00, 95% CI 1.17 to 307.63). Three of these trials were rated as at moderate risk of bias and one as at high risk of bias. The following agents were not found to be effective: benzydamine HCl, sucralfate, tetrachlorodecaoxide, chlorhexidine and ‘magic’ (lidocaine solution, diphenhydramine hydrochloride and aluminum hydroxide suspension). Six trials compared the time to heal and mucositis was found to heal more quickly with two interventions: granulocyte macrophage‐colony stimulating factor when compared to povidone iodine, with mean difference ?3.5 days (95% CI ?4.1 to ?2.9) and allopurinol compared to placebo, with mean difference ?4.5 days (95% CI ?5.8 to ?3.2). Three trials compared patient controlled analgesia (PCA) to the continuous infusion method for controlling pain. There was no evidence of a difference, however, less opiate was used per hour for PCA, and the duration of pain was shorter. One trial demonstrated that pharmacokinetically based analgesia (PKPCA) reduced pain compared with PCA: however, more opiate was used with PKPCA. Authors’ conclusions: There is weak and unreliable evidence that allopurinol mouthwash, granulocyte macrophage‐colony stimulating factor, immunoglobulin or human placental extract improve or eradicate mucositis. There is no evidence that patient controlled analgesia (PCA) is better than continuous infusion method for controlling pain, however, less opiate was used per hour, and duration of pain was shorter, for PCA. Further, well designed, placebo‐controlled trials assessing the effectiveness of allopurinol mouthwash, granulocyte macrophage‐colony stimulating factor, immunoglobulin, human placental extract, other interventions investigated in this review and new interventions for treating mucositis are needed.     

Effect of multidrug solution for the treatment of chemotherapy-induced oral mucositis in vivo

ObjectiveEvaluate the effect of a multidrug solution, adopted by a referral hospital for cancer to control and treat chemotherapy-induced oral mucositis in rats.MethodsOral mucositis (OM) was induced by 5-Fluorouracil (5-FU), and the animals were treated with saline (n = 8, G1), 0.12% chlorhexidine (n = 8, G2); and multidrug solution (n = 8, G3). The animals were submitted to clinical and histological analysis of the lesion using mucosal fragments. The animals' food consumption during treatment was also evaluated.ResultsClinical improvement (p < 0.05) was observed in the groups treated with the multidrug solution and 0.12% chlorhexidine digluconate. In G2 and G3, there was a prevalence of reepithelialization covering <50% of the lesion. Evaluation of the inflammatory infiltrate indicated that the G1 treatment permitted an intense inflammatory response in all animals, yet this evaluation parameter was moderate in groups G2 and G3. The G3 group (p < 0.05) presented higher food consumption than the other groups.ConclusionsThe multidrug solution improved the clinical and histological parameters of the chemotherapy-induced oral mucositis, as well as promoted an increase in food intake.