CATEGORY 86 AUSTRALASIAN DENTIST CLINICAL Cancer can be treated in many ways but the therapies may come with side e ects. e most common complication of radiotherapy (RT) of head and neck (H&N) cancer is oral mucositis (OM)1. ese are the in ammatory and/or ulcerative lesions of the mouth and throat resulting in pain, dysphagia and impairment of speech2. It is also a lesser complication of haemopoietic stem cell transplantation (HSCT) and chemotherapy3. Mucositis occurs in 20–40% of the patients receiving anti-cancer treatments for solid tumours, 60–80% of patients undergoing HSCT, and is experienced by almost all patients receiving radiotherapy for head and neck (H&N) cancers4. In Australia, standard care currently for OM is symptomatic, directed towards pain management and the prevention of infection5,6. Pain control usually requires the use of topical anaesthetic and in severe cases may require opioid analgesics7–10. Additionally, the pain and discomfort may require enteral or parenteral nutrition and reduces the patient’s quality of life in terms of their ability to socialise, speak and perform normal daily functions8,9,11,12. Mucositis also has a considerable economic impact due to costs associated with symptoms management, nutritional support, management of secondary infection, and abrupt and/or extended hospitalisation13,14. It is therefore a highly signi cant and sometimes dose-limiting factor of the toxicity of cancer therapy. Following successful cancer therapy, the most common long-term complication is xerostomia due to salivary gland hypofunction with a prevalence of 93% during RT and 74%-85% following RT15. Not only does xerostomia signi cantly impair patients’ quality-of-life (QoL) but it also has important medical sequelae, incurring high medical and dental costs15. While there are saliva substitutes and sialagogic agents to stimulate saliva, they are unable to replace the antibacterial and immunological components of the saliva so high caries risk and oral infections become more prevalent16. e biological e ects of photobiomodulation (PBM) therapy were discovered by Endre Mester in 196717. PBM therapy aims to treat or prevent oral mucositis complications by reducing in ammation, reducing cellular damage, increasing cell metabolism and promoting healing18. It was rst used for the prevention and treatment of radiation-induced mucositis in 1999 by Bensadoun and coworkers19. According to systematic reviews and meta-analyses, photobiomodulation therapy has been shown to enhance survival rates, decrease the occurrence and intensity of mucositis, shorten its duration, alleviate pain, mitigate xerostomia, minimize interruptions in cancer treatment, and enhance nutritional outcomes20–23. ese results were shown in both adult and paediatric populations24,25. A prospective RCT of PBM for OM showed statistically signi cant di erences between the groups from week 5 of oncological treatment; 73% of the laser group showed normal mucosa (Table 1), while in the control group, 20% showed grade 0 mucositis and 40% showed grade 2 mucositis (P < 0.01)26. Table 1 World Health Organization Oral Mucositis Grading Scale Grade Description Mild 0 (none) None, normal mucosa I (mild) Oral soreness, erythema, no ulceration II (moderate) Oral erythema, ulcers, solid diet tolerated Severe III (severe) Oral ulcers, extensive erythema, liquid diet only IV (life- Oral feeding not possible, threatening) requires parenteral nutrition Photobiomodulation therapy is currently the recommended treatment for preventing oral mucositis when using certain treatment modalites, as recently outlined in the clinical practice guidelines of the Multinational Association for Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO)27. Expanding on these recommendations, the World Association of photobiomoduLation erapy (WALT) group outlines evidence and prescribes PBM treatment parameters for prophylactic and therapeutic use in supportive care of radiodermatitis, dysphagia, xerostomia, dysgeusia, trismus, mucosal and bone necrosis, lymphedema, hand-foot syndrome, alopecia, oral and dermatologic chronic graft-versus- host disease, voice/speech alterations, peripheral neuropathy, and late brosis amongst cancer survivors28. e challenge faced by the patient is that the treatment should ideally be administered every 48 hours, or practically, three times per week. However, maintaining a regular attendance schedule can pose challenges in addition to their hospital visits. Both lasers and LEDs can be used to perform photobiomodulation but the use of laser often results in shorter treatment times and immediate pain relief. e advantage of LEDs are that they can be selfadministered by the patient at home, unlike laser PBM which needs to be performed by a certi ed laser practitioner. Case Report 1 A 79-year old male attended our clinic to have PBM therapy in conjunction with radiochemotherapy. A prophylactic protocol for OM commenced on the day of cancer treatment and continued three times a week for the duration of his cancer treatment. 650 nm laser PBM therapy was done around the mouth in accordance with dosimetry parameters recommended29,30. e patient was able to remain mucositisfree for the duration of his cancer treatment (Fig. 1) Case Report 2 A 64-year old male presented to our clinic with large ulcerated lesions on his cheek, tongue and lip due to chemotherapy for pancreatic cancer. is marked his second round of chemotherapy and the ulcers had worsened compared to the previous round. As his chemotherapy was scheduled every 3rd week, some ulcers were not able to heal Dr. Jason Pang Laser photobiomodulation for the management of oral cancer complications By Dr Jason Pang BDS, BSc, MSc (Laser Dentistry)
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