|LETTER TO THE EDITOR
|Ahead of print publication
Prime time of herbal mouthwash treatments and future approaches for radiation-induced oral mucositis
Angela R Zambrano1, Francisco J Bonilla-Escobar2
1 Department of Hemato-Oncology, Centro de Investigaciones Clínicas, Faculty of Health Sciences, Fundación Valle del Lili, Universidad Icesi, Cali, Colombia
2 SCISCO Foundation, Science to Serve the Community/Fundación SCISCO, Somos Ciencia al Servicio de la Comunidad; Service of Ophthalmology, Faculty of Health, Universidad del Valle, Cali, Colombia; Department of Ophthalmology, Institute for Clinical Research Education, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
|Date of Submission||30-Mar-2021|
|Date of Decision||03-Apr-2021|
|Date of Web Publication||11-Nov-2022|
Francisco J Bonilla-Escobar,
Calle 4B No 36-00, Sede San Fernando, Universidad del Valle, Cali
Source of Support: None, Conflict of Interest: None
We read with interest the article by Manoharan et al., entitled: “Effectiveness of mouthrinses in prevention and treatment of radiation-induced mucositis: A systematic review.” Based on the lack of a standardized evidence and demonstrated effectiveness of mouthrinses for prevention and/or treatment of radiation-induced mucositis in patients with head-and-neck cancer, the authors highlight the relevance of and need for a systematic review of this topic. It has been established that patients undergoing radiotherapy will develop mucositis; however, given the costly impacts of mucositis in terms of quality of life and medical and oncological care, prevention, and treatment strategies are under continuous study around the globe.
The “magic mouthwash” has been under scrutiny in recent years, and positive results have been described, especially with regard to radiation-induced mucositis. However, there are serious concerns surrounding this therapeutic option. First, there is not a standardized formula for the solution with variation in ingredients and concentrations. Second, trials evaluating its effects have methodological limitations which in consequence restricts the results of meta-analyses.
This article calls our attention to the wide range of variability in the effects of the evaluated outcomes and the need for further research. Future studies should use Manoharan et al., findings such as essays with small sample sizes, lack of randomization, and without a baseline oral hygiene assessment, among others. Addressing these issues will produce stronger evidence and therefore benefits for patients. The authors also found that herbal-based products showed comparative efficacy and less adverse events than their deeply studied pharmacological counterpart. These findings should encourage further research including new interventions combining the goodness of herbal products with effective pain relievers such as opioids.
Several different options to prevent and treat mucositis were extensively described in another revision published in 2013 about herbal treatments for mucositis caused by chemotherapy. Some of the more promising substances are powerful antioxidants. As reactive oxygen species (ROS) are one of the first steps in the pathophysiology of radiation-induced mucositis, these herbal treatments could interrupt and decrease the activity of these ROS, which may therefore help prevent and treat mucositis. For instance, green tea has been widely used around the globe with demonstrated safety in its populational use. Nevertheless, research about its efficacy to prevent/treat mucositis remains scarce, even though these properties have been demonstrated both in vitro and in vivo.
The challenge that remains for researchers is the standardization of the mouthwash preparation, and the guarantee that the antioxidant properties are keep functional. In addition, there is a need to improve the methodologies of the trials testing the efficacy of mouthwashes. Further research with interdisciplinary approaches is needed to find reliable solutions for this situation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| > References|| |
Manoharan V, Fareed N, Battur H, Khanagar S, Praveena J. Effectiveness of mouthrinses in prevention and treatment of radiation induced mucositis: A systematic review. J Cancer Res Ther 2020;16:S1-10.
Sherr DL. Finding the magic in magic mouthwash. JAMA Intern Med 2019;179:723-4.
Meyer-Hamme G, Beckmann K, Radtke J, Efferth T, Greten HJ, Rostock M, et al
. A survey of chinese medicinal herbal treatment for chemotherapy-induced oral mucositis. Evid Based Complement Alternat Med 2013;2013:1-16.
Oketch-Rabah HA, Roe AL, Rider CV, Bonkovsky HL, Giancaspro GI, Navarro V, et al
. United States Pharmacopeia (USP) comprehensive review of the hepatotoxicity of green tea extracts. Toxicol Rep 2020;7:386-402.
Shin YS, Shin HA, Kang SU, Kim JH, Oh YT, Park KH, et al
. Effect of epicatechin against radiation-induced oral mucositis: in vitro
and in vivo
study. PLoS One 2013;8:e69151.