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Photobiomodulation for oral mucositis – a breakthrough

By Jan Tunér

Oral mucositis is a major factor in increasing treatment costs for head and neck squamous cell carcinoma (HNSCC) patients treated with chemo-radiation (CRT). The use of low level lasers to treat and prevent oral mucositits was pioneered in France in the late 80ies, and in 1999 Bensadoun (1) presented the first phase III study, showing a significant effect of this treatment. Since then more than 50 studies have confirmed the efficacy (2). Nevertheless, few institutions worldwide have paid attention to this simple method of limiting suffering among HNSCC patients. It was therefore gratifying news to learn that the method has been integrated into the Brazilian healthcare system (3). The recommended therapies are:

  1. a) guidance on good oral hygiene;
  2. b) avoiding hot food, hot drinks, with pronounced acidity, and hard consistency.
  3. c) use toothpastes of mild flavor;
  4. d) use of saline or sodium bicarbonate in mouthwashes, 3 or 4 times a day;
  5. e) topical anesthetics (lidocaine 2% or diphenhydramine solution),
  6. e) early treatment with low-level laser

It is obvious that only low level laser (PBM) has a curative effect, while other methods are merely reducing the symptoms.

Several studies have proved the usefulness of PBM, but only recently has the cost-effectiveness of the method been evaluated. Such an approach would be of interest to health care decision makers. The first paper came in 2014. The aim of a study by Bezinelli (4) was to determine the cost-effectiveness of the introduction of a specialised oral care programmme including laser therapy in the care of patients receiving HSCT (hematopoietic stem cell transplantation) with regard to morbidity associated with oral mucositis. Clinical information was gathered on 167 patients undergoing HSCT and divided according to the presence (n=91) or absence (n=76) of laser therapy and oral care. Cost analysis included daily hospital fees, parenteral nutrition (PN) and prescription of opioids. It was observed that the group without laser therapy (group II) showed a higher frequency of severe degrees of OM with a significant association between this severity and the use of PN, prescription of opioids, pain in the oral cavity and fever > 37.8 degrees C. Hospitalisation costs in this group were up to 30% higher.

In early 2016, a study by Antunes (5) arrived. From June 2007 to December 2010, 94 patients with HNSCC of nasopharynx, oropharynx, and hypopharynx entered a prospective, randomized, double blind, placebo-controlled, phase III trial. CRT consisted of conventional radiotherapy (RT: 70.2Gy, 1.8Gy/d, 5times/wk) + concurrent cisplatin (100mg/m2) every 3weeks. A 660 nm-100 mW-4 J/cm2 laser diode was used for LLLT. The results indicate that morbidity was lower in the Laser Group and that LLLT was more cost-effective than placebo up to a threshold of at least US$ 5000 per mucositis case prevented.

PBM to prevent and reduce the incidence of oral mucositis has been well documented for 15 years and still not being widely accepted. Now that there is evidence of a cost saving method we might experience a renewed interest, because Money Talks.

(1) Bensadoun R-J, Franqiun J C, Ciais C et al. Low energy He/Ne laser in the prevention of radiation-induced mucositis: A multicenter phase III randomized study in patients with head and neck cancer. Support Care Cancer. 1999; 7 (4): 244-252.

(2) Bjordal J M, Bensadoun R J, Lopes–Martins R A, Tunér J, Pinheiro A, Ljunggren A E. A systematic review of low level laser therapy (LLLT) in cancer therapy-induced oral mucositis. Support Care Cancer. 2011; 19 (8): 1069-1077.

(3) MINISTRY OF HEALTH CARE SAÚDE SECRETARIA. Ordinance SAS / MS No. 516, OF 17 JUNE 2015. Official Diary of the Union; Executive Branch, Brasilia, DF 18 June 2015. Section I, p.61-67.

(4) Bezinelli L M, de Paula Eduardo F, da Graca Lopes R M, Biazevic M G, de Paula Eduardo C, Correa L, Hamerschlak N, Michel-Crosato E. Cost-effectiveness of the introduction of specialized oral care with laser therapy in hematopoietic stem cell transplantation. Hematol Oncol. 2014; 32 (1): 31-39.

(5) Antunes HS, Schluckebier LF, Herchenhorn D, Small IA, Araújo CM, Viégas CM, Rampini MP, Ferreira EM, Dias FL, Teich V, Teich N, Ferreira CG. Cost-effectiveness of low-level laser therapy (LLLT) in head and neck cancer patients receiving concurrent chemoradiation. Oral Oncol. 2016; 52: 85-90.