Kaugars G E, Silverman S, Lovas J G, Thompson J S, Brandt R B, Singh V N
Dept. of Oral Pathology, Medical College of Virginia, PO Box 980566, USA.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1996 Jan;81(1):5-14. doi: 10.1016/s1079-2104(96)80139-9.
An increasing public awareness of antioxidants may prompt a patient's request to be treated without surgery if a leukoplakic lesion is discovered. However, surgical excision remains the treatment of choice for oral leukoplakia. The use of antioxidant supplements has shown some promise, but the predictability of success remains uncertain and long-term results are unavailable. Before the decision to use any antioxidant is made, it is critical to obtain a histopathologic diagnosis of the lesion. When dealing with a lesion diagnosed as hyperkeratosis, it may be appropriate to choose an antioxidant that may take some time for clinical improvement to occur. However, as the grade of epithelial dysplasia becomes more severe, consideration must be given to the possibility of malignant transformation during antioxidant treatment. We do not recommend the use of antioxidant supplements in the treatment of any carcinoma. The therapeutic use of antioxidant supplements outside of clinical trials conducted at academic medical centers should be done with considerable caution by practitioners in private practice. It should be emphasized that in these clinical trial patients were seen at frequent intervals to monitor their progress and to intervene if there was a noticeable deterioration in the clinical appearance of the lesion. In spite of the uncertainty with respect to antioxidant treatment, there are circumstances in which it should be considered. Recurrence after surgical excision when there is little reason to believe that a second surgical excision would be any more successful is an ideal candidate. Also, patients with widespread leukoplakia that involves a large area of the oral mucosa might be suitable for treatment with antioxidants, as well as patients who have extensive medical problems that make them surgical risks. The choice of which antioxidant(s) to use is complex because thus far there is no combination that is superior to the others. Beta-carotene with ascorbic acid or alpha-tocopherol is attractive because of a lack of side effects, but the range in reported values for lesion improvement has been broad and the clinical improvement typically takes several months. Clinical response with 13-cRA is faster but requires baseline and periodic serologic testing, as well as close monitoring for side effects. In those circumstances in which time is an important consideration, 13-cRA might be useful because clinical improvement can be evaluated within a matter of weeks as compared with beta-carotene. The group from M.D. Anderson Hospital has shown the value of an induction dose of 13-cRA that is followed by a lower maintenance dose. Unfortunately, the problem of recurrence after discontinuation of 13-cRA is quite common. One aspect that has not been evaluated is the combination of conventional surgical excision and the administration of postoperative antioxidants. This would have the obvious advantage of conventional treatment of surgery together with the possible protective effect of the antioxidants. Although this is an attractive hypothesis, we do not know of any studies that have proven this to be beneficial.
公众对抗氧化剂的认识不断提高，这可能会促使患者在发现白斑病变时要求不进行手术治疗。然而，手术切除仍然是口腔白斑的首选治疗方法。使用抗氧化剂补充剂已显示出一些前景，但成功的可预测性仍然不确定，且尚无长期结果。在决定使用任何抗氧化剂之前，对病变进行组织病理学诊断至关重要。当处理诊断为角化过度的病变时，选择一种可能需要一些时间才能出现临床改善的抗氧化剂可能是合适的。然而，随着上皮发育异常的程度变得更严重，必须考虑在抗氧化剂治疗期间发生恶性转化的可能性。我们不建议在任何癌症的治疗中使用抗氧化剂补充剂。在学术医学中心进行的临床试验之外，私人执业医生在使用抗氧化剂补充剂进行治疗时应极其谨慎。应该强调的是，在这些临床试验中，会定期对患者进行检查，以监测他们的进展情况，并在病变的临床表现出现明显恶化时进行干预。尽管抗氧化剂治疗存在不确定性，但在某些情况下仍应考虑使用。手术切除后复发且几乎没有理由相信再次手术切除会更成功的情况是理想的选择。此外，患有广泛白斑且累及大面积口腔黏膜的患者可能适合用抗氧化剂治疗，以及那些有严重医疗问题而使其成为手术风险患者的情况。选择使用哪种抗氧化剂很复杂，因为到目前为止，没有一种组合优于其他组合。β-胡萝卜素与抗坏血酸或α-生育酚的组合很有吸引力，因为没有副作用，但报告的病变改善值范围很广，而且临床改善通常需要几个月时间。使用13-顺式维甲酸（13-cRA）临床反应更快，但需要进行基线和定期血清学检测，以及密切监测副作用。在时间是重要考虑因素的情况下，13-cRA可能有用，因为与β-胡萝卜素相比，几周内就能评估临床改善情况。MD安德森医院的团队已经证明了诱导剂量的13-cRA随后采用较低维持剂量的价值。不幸的是，停用13-cRA后复发的问题相当常见。一个尚未评估的方面是传统手术切除与术后给予抗氧化剂的联合应用。这将具有传统手术治疗的明显优势以及抗氧化剂可能的保护作用。尽管这是一个有吸引力的假设，但我们不知道有任何研究证明这是有益的。
