Voici un article par le Prof. Bensadoun que nous auront le plaisir d'accueillir le 2 Juin à St Rémy de Provence:
Rene´ -Jean Bensadoun, M.D., Ph.D.,1 and Raj G. Nair,
M.Sc. (Oral Med), Ph.D., MRACDS (Oral Med)2
Oral mucositis (OM) is an inevitable complication of radiation therapy
(RT) of the head and neck region, as part of gastrointestinal toxicity in
chemotherapy and hematopoietic stem cell transplantation (HSCT), causing severe
morbidity and affecting the patient’s quality of life. Duration and severity of
OM, especially in higher grades, are critical, as it hampers the cancer
treatment, affects duration of hospital stay, and to a certain extent, predicts
success of treatment and complications such as graft-versus-host disease (GVHD)
in transplantation patients. There is no consensus on a single agent or agents
that can be used either prophylactically or therapeutically in OM.
The
frequency of OM varies from 12% in patients receiving adjuvant chemotherapy to
80% and 100% in patients undergoing HSCT and RT of the orofacial region,
respectively.1,2 The art and science of photomedicine or phototherapy involving
low-level laser therapy (LLLT) or near-infrared light-emitting diodes (NIR-LED)
have become promising and effective tools in prophylactic and therapeutic
interventions for OM and associated orofacial pain.3–7 First reports on LLLT on
OM originated from Nice, France in 1992, and since then there have been reports
of several randomized control studies with promising outcome.4–8 In 2007,
Multinational Association of Supportive Care in Cancer/International Society of
Oral Oncology (MASCC-ISOO) Mucositis Guidelines have upgraded LLLT as a
‘‘recommended’’ method for the prevention of OM during HSCT.9 LLLT of an output
power range from 5 to 200mW with helium/neon (He/Ne) laser of wavelength
632.8nm or diode lasers of various wavelengths ranging from 630 to 680nm, 700 to
830 nm, and 900nm is an efficacious, simple, and atraumatic technique in the
treatment of OM, with no known toxicity in clinical setting.8,10,11 In
addition, LLLT has been found to reduce the total duration and severity of OM in all the
studies, with a few exceptions in which the laser parameters were, perhaps,
inadequate.
Another debilitating effect of OM is orofacial pain, which often
depends upon existing oral health; underlying
disease, type of treatment, severity of OM, and pain threshold. It has been
shown that there is considerable reduction in orofacial pain in those patients
who underwent LLLT. Although side effects were reported, none of them was different
from those experienced by the control group, which is a clear indication of how
well LLLT was tolerated by cancer patients, irrespective of their mode of
cancer treatment.5–7,10 Perhaps one of themain pitfalls inpast reports of
studieswith LLLTis the inconsistency in theparametersused, the calibration of
the laser device, and the manner in which LLLT was delivered to the site.
It is
vital to formulate a protocol on parameters from the existing data on what is
best for both a prophylactic dose and therapeutic effect. Briefly, we recommend
a fairly simple regimen as follows, when considering a commercially available
device: wavelength for a red light source at 633– 685 nm, infrared 780–830nm;
output of diode between 10 and 150mW;dose in the range of 2–3 J/cm2 for
prophylaxis, and not less than 4 J/cm2 for therapeutic effect; application on
single spot on a lesion rather than a scanning motion over the entire lesion.
Also one should follow a simple formula such as
t(s) = D(J)x Surface (cm²)/Power (W)
Lesions
must be evaluated and therapy should be provided by a trained clinician and
should be repeated daily or every other day during RT or other chemotherapy
regimens and HSCT, or a minimum of three times per week until resolution. Options
on commercially available devices are of extra-oral devices and intra-oral devices
(Fig. 1) targeting structures such as cutaneous and oral mucosal surfaces,
respectively. Effects of an extra-oral device (Fig. 2) for LLLT over the cutaneous surface of the affected face may
well reach the intra-oral structures such
as the buccal mucosae, vestibule, and inner epithelial surfaces of the lips,
with wavelengths *830 nm, but not with 630–660
nm.
A combination of the above two devices must be considered while managing
the head and neck RT-induced effects, but not necessarily for chemotherapy
induced intra-oral effects, for which an intra-oral device would suffice. Finally,
following good practice guidelines, such as therapeutic optimization of a commercially
available device by calibrating according to the need, such as RT of the head
and neck, chemotherapy, or a combination of the foregoing by following the
previously mentioned recommendations is critical. We acknowledge the clinical
trials, recent reviews, and guidelines on LLLT and the solid research data
generated, which has tremendously helped us, but it is beyond the scope of this
Editorial to list them all.
, The emerging role of phototherapy in OM is clear,
and it is pragmatic to envisage LLLT in prophylactic and therapeutic intervention
protocols of OM in cancer patients. A joint consensus on this is perhaps the
next step, from the wider community of clinicians such as radiation
oncologists, medical oncologists, hematologists, oral medicine specialists,
nurses, and other professionals involved in supportive care in cancer.
References
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Littlewood, A., McCabe, M.G., Meyer, S., and Khalid, T. (2011). Interventions
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Photomedicine and Laser Surgery
Volume 30, Number 4, 2012
© Mary Ann Liebert, Inc.
Pp. 191-192
