It’s a long time since I worked on a children’s cancer ward, but I do remember that sore mouths were a miserable problem for many and that we did several things to help prevent ulceration, including giving the children ice chips to suck. So I was interested to see a brand new Cochrane review investigating whether making the mouth cold (with ice, iced water, ice cream or ice lollies) is effective in preventing ulceration in people having cancer treatments. Properly termed oral cryotherapy, it’s free, it’s simple, it’s natural, but does it work? It would be good to know.
It’s not just a sore mouth
Oral mucositis is a common side effect of high-dose chemotherapy and radiotherapy to the head and neck, affecting 75% of patients receiving these treatments, and its consequences can be severe. As well as causing pain, interfering with the person’s ability to eat and drink and potentially interrupting their treatment, mouth ulcers provide an entry point for bacteria, which can lead to sepsis and death in immunocompromised patients.
Why would cooling the mouth help?
Oral cryotherapy reduces blood flow to the mouth by narrowing the blood vessels, limiting the amount of chemotherapy drugs delivered to the tissues. Given this mechanism, it is not clear whether it could help those receiving radiotherapy.
What’s the evidence?
Cochrane Oral Health recently published a new review which brought together all the relevant randomized controlled trials on oral cryotherapy for preventing oral mucositis in people receiving treatment for cancer. The review has 14 studies, dating from 1991 to 2015 and including some currently unpublished data. Of the 1316 participants, almost all were adults and most fell into two groups: those with solid tumours receiving fluorouracil-based (5FU) treatment and those receiving high-dose melphalan-based cancer treatment before haematopoietic stem cell transplantation (HSCT). Most studies compared oral cryotherapy with standard care (usually saline mouth rinses) or no treatment. The number of people developing oral mucositis of different severities was compared.
Here’s what they found:
Effectiveness for adults receiving 5FU chemotherapy for solid tumours:
- Oral cryotherapy probably reduces oral mucositis of any severity
- In a population where 728 people in 1000 would develop oral mucositis, oral cryotherapy would reduce this to 444. Four people would need to have oral cryotherapy to prevent one extra person from developing oral mucositis (NNTB – number needed to treat to benefit)
- Severe oral mucositis is probably reduced. Where 300 per 1000 would develop severe oral mucositis, oral cryotherapy would reduce this to 120. NNTB 6
Effectiveness for adults receiving high-dose melphalan-based chemotherapy before HSCT:
- Oral cryotherapy may reduce oral mucositis of any severity
- Severe oral mucositis is probably reduced. Where 427 per 1000 would develop severe oral mucositis, oral cryotherapy would reduce this to 162. NNTB 4
Safety and acceptability:
- Oral cryotherapy was shown to be safe, with very low rates of minor adverse effects (headaches, chills, numbness/taste disturbance, tooth pain)
- Compliance rates were high
How good is the evidence?
The evidence on the risk of oral mucositis at all levels of severity for adults having 5FU treatment is rated as moderate (GRADE), so oral cryotherapy probably leads to the estimated large reductions in the risk of oral mucositis in this population.
The evidence is less reliable for those receiving high-dose melphalan-based cancer treatment when all severities of oral mucositis are considered (rated low quality, GRADE). Whilst oral cryotherapy may reduce the risk of oral mucositis, the effect could be large or small and there is a very small chance that it may even increase the risk. However, moderate quality evidence suggests that oral cryotherapy probably does reduce the risk of severe oral mucositis.
The evidence for the effect of oral cryotherapy on pain, normalcy of diet, interruptions to cancer treatment and duration of hospitalisation is rated low or very low so we remain uncertain about its effects.
This review includes some very recent and currently unpublished data. It strengthens international guideline statements for adults receiving these cancer treatments.
There was not enough evidence to determine the effects of oral cryotherapy in people receiving low-dose methotrexate for preventing graft-versus-host disease (GVHD) after HSCT and people having head and neck radiotherapy. There were no trials conducted with children. The review authors say that more studies are needed on people having high-dose melphalan-based chemotherapy before HSCT, studies comparing oral cryotherapy with other promising preventive treatments and investigation of the optimum cryotherapy regime.
Over to you
Do you offer your patients oral cryotherapy? We’d be interested to hear.
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Oral cryotherapy: preventing mouth soreness and ulcers in people having cancer treatment by Sarah Chapman is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License.
Based on a work at http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD011552.pub2/abstract.
Permissions beyond the scope of this license may be available at http://www.cochrane.org/CD011552/ORAL_can-keeping-mouth-cold-during-cancer-treatment-help-prevent-mouth-soreness-and-ulcers-children-and. Images are not available for reproduction as they have been purchased from istock.com for Evidently Cochrane.
Riley P, Glenny AM, Worthington HV, Littlewood A, Clarkson JE, McCabe MG. Interventions for preventing oral mucositis in patients with cancer receiving treatment: oral cryotherapy. Cochrane Database of Systematic Reviews 2015, Issue 12. Art. No.: CD011552. DOI: 10.1002/14651858.CD011552.pub2.
Plain language summary of this review: http://www.cochrane.org/CD011552/ORAL_can-keeping-mouth-cold-during-cancer-treatment-help-prevent-mouth-soreness-and-ulcers-children-and
Cochrane Oral Health. “Can keeping the mouth cold during cancer treatment help to prevent mouth soreness and ulcers?”. Cochrane Oral Health Editorial Base Blog, 5th January 2016. Web. 14th January 2016. https://cochraneohg.wordpress.com/2016/01/05/can-keeping-the-mouth-cold-during-cancer-treatment-help-to-prevent-mouth-soreness-and-ulcers/