In May 2018, NICE published Interventional procedures guidance [IPG615] on current evidence on the safety of low-level laser therapy for preventing or treating oral mucositis caused by radiotherapy or chemotherapy. The procedure shows no major safety concerns. Evidence on efficacy is adequate in quality and quantity. Therefore, NICE recommended that the procedure can be used provided that standard arrangements are in place for clinical governance, consent and audit.
Oral mucositis is a common side effect of chemotherapy or radiotherapy used for treating head and neck cancer or before bone marrow transplantation. Symptoms usually start 5 to 10 days after chemotherapy or 14 days after radiotherapy and include dryness, halitosis, pain, inflammation and oral mucosa ulceration. Chemotherapy-associated oral mucositis can resolve within a few days after completion of chemotherapy, but radiotherapy-associated oral mucositis can last for weeks. Oral mucositis can affect nutritional status (which may need enteral or parental nutrition) and quality of life, and can increase hospital stay. It can also require interruptions or dose reductions in chemotherapy or radiotherapy treatment.
Comprehensive oral hygiene, good hydration, a bland soft diet and avoiding alcohol and tobacco may increase the person's comfort. Ice, water-based moisturisers, painkillers and non-steroidal anti-inflammatory drugs can help reduce symptoms. Drugs such as palifermin are sometimes used to prevent or treat oral mucositis. Antibiotics may be needed to treat infectious complications.
Low-level laser therapy aims to treat or prevent oral mucositis by promoting healing, reducing inflammation and increasing cell metabolism. A hand-held probe is used to deliver light in the red or near-infrared spectrum to the oral mucosa. It can be delivered intra-orally or extra-orally, or as a combination of both approaches. During intra-oral treatment the probe, which is about the size of a dental curing light, is introduced into the mouth. For extra-oral treatment the probe is positioned close to the cheek. The procedure typically takes 20 to 30 minutes, and is delivered 2 to 5 times a week for the duration of the oncology treatment. The procedure may be started before treatment with chemotherapy or radiotherapy begins, with the intention of preventing oral mucositis.
To inform the appraisal committee, NICE did a rapid review of the published literature on the efficacy and safety of this procedure. This comprised a comprehensive literature search and detailed review of the evidence from 11 sources, which was discussed by the appraisal committee. The evidence included 3 systematic reviews and meta-analysis and 7 randomised controlled trials (1 of which also reported outcomes from a prospective case series) and 1 non-randomised comparative study.
The specialist advisers and the appraisal committee considered the key efficacy outcomes to be: improved quality of life, reduction in oral mucositis, reduction in pain and the need for analgesia, reduction in dysphagia and the need for feeding tubes, improved nutrition, and reduction in chemotherapy treatment breaks.
Four commentaries from patients who had experience of this procedure were received, which were discussed by the appraisal committee.
The committee comments are:
- The procedure can be used in children, but most of the evidence reviewed by the committee was from adults.
- Most of the evidence reviewed by the committee was for treatment delivered intra-orally, and related to prophylactic use of this procedure.
- The greatest benefit from the procedure appears to be in patients having radiotherapy for head and neck cancers, or having chemotherapy for haematological malignancies.