Oral+Mucositis

Oral mucositis is the inflammation of oral mucosa resulting from chemotherapeutic agents or ionizing radiation. It is typically characterized by erythema, ulcerations, edema, and atrophy of the oral mucosa. High-dose chemotherapy, such as that used in the treatment of leukemia and hematopoietic stem cell transplant regimens, may produce severe mucositis because the beneficial bacteria and healthy cells are destroyed along with the rapidly-dividing cancer cells. When uncomplicated by infection, oral mucositis typically heals within 2 to 4 weeks after ending chemotherapy. Oral ulcers may increase the risk of developing septicemia by acting as a site for local infection and a portal of entry for oral flora that under normal circumstances would not enter the bloodstream.
 * __Pathophysiology__**


 * __Nursing Interventions__**

Oral mucositis impacts not only oral intake but communication as well. While usually self-limiting, the debilitating nature of this side-effect of chemotherapy can take a psychological as well as physical toll on the patient and family.

Nursing interventions generally include assessment, symptom management, prevention of infection, education, and collaboration with other members of the healthcare team, both in the inpatient and outpatient settings.


 * Ensure that the client receives a comprehensive oral examination before initiation of chemotherapy or radiation, with aggressive preventative dental care given as needed, and provide both verbal and written instructions about frequent oral care to the client.
 * Assess the condition of the oral cavity daily using a guide such as the **Oral Mucositis Assessment Scale** (OMAS) or **Oral Assessment Guide (OAG)** to measure the presence and/or severity of mucositis and the patient's function.
 * Utilize your facility’s oral mucositis protocol which usually includes:
 * Use of a soft toothbrush (replace on a regular basis).
 * Use of a validated tool (such as the OMAS) to assess the condition of the oral cavity.
 * Use cryotherapy with ice chips dissolving in the client’s mouth before, during, and after administration of 5-FU (fluorouracil) to reduce the severity of mucositis.
 * Help the client use a mouth rinse of normal saline or salt and soda every 1-2 hours for prevention and treatment. Instruct the client on how to prepare their own saline rinse.
 * Assess nutritional imbalance and modify oral intake as indicated (request a nutritional consult if warranted).
 * If the platelet count is lower than 50,000/mm3 or the client has a bleeding disorder, use a specially made toothbrush for sensitive or diseased tissue, a toothette (no glycerin or flavorings), or a piece of gauze wrapped around a finger to remove plaque and debris.


 * You may need to consult the physician if the patient’s pain and restriction of oral intake necessitates total parenteral nutrition and/or a need for narcotic analgesics.

From a psychological standpoint, patients with these problems can become withdrawn, socially avoidant, and even clinically depressed as a result of the difficulties and frustrations associated with the living with oral complications. Assisting the patient with guided imagery, breathing techniques, and relaxation techniques may help them through this difficult period. However, it may be necessary to ask for a psychological consultation as well.

Your patient may ask you about the many suggestions on the internet regarding treatment for oral mucositis. Although the Oncology Nurse Society (ONS) has found that very few of these products are based in evidence, the website [|www.chemocares.com], with content provided by the Cleveland Clinic Cancer Center, offers the following recommendations for patients: To treat or prevent infection the following may be used:
 * //**Keep mouth and lips moist:**//
 * Rinse mouth with water frequently (every 2 hrs while awake & when awake during the night). May add salt or baking soda (1/2 to 1 teaspoon in 8 ounces of water).
 * Use saliva substitute (commercially available) if needed.
 * Apply lip moisturizer often (i.e. chap stick).Suck on hard candies.
 * Keep mouth & teeth clean.
 * Use soft-bristle toothbrush (can soften even more by placing brush in very warm water), cotton swabs, mouth swabs (popsicle stick covered with gauze) to clean teeth after each meal and at bedtime.
 * Clean dentures and/or bridge after eating. Leave out dentures if experiencing any discomfort.
 * Floss gently with unwaxed floss (if platelet count adequate).
 * May use Water-Pik.
 * **//Avoid://**
 * Mouthwash containing alcohol.
 * Lemon glycerin swabs.
 * //**Treat the discomfort/pain**//.
 * Use topical or local agents such as Orajel, or Zilactin-B apply generously.
 * Combination mouth wash can be made (ingredients may require prescription).
 * Use equal parts: xylocaine viscous solution, Zovirax ® (alcohol-free), and Maalox ®, or Mylanta ®.
 * Take 2 teaspoons every 2-4 hours as needed (swish around mouth and spit out).
 * May be advised by healthcare provider to swallow if experiencing discomfort while swallowing.
 * //**For severe pain**//: oral or intravenous pain medication* may be required in addition to topical medication . (* prescribed by healthcare provider).
 * **//Enhance healing://**
 * Apply Orabase ®, Ulcerase ® , etc. to irritated areas in mouth or on lips.
 * Apply Vitamin E (puncture cap 400IU and squeeze onto swab. Gently place swab on open area(s).
 * Take an antacid 1/2-1 ounce every 3-4 hours as needed to decrease burning sensation.
 * Maintain good nutrition focusing on high protein and high calorie foods which are soft and/or semi liquid (i.e. scrambled eggs, puddings, blenderized or pureed foods). May use liquid supplements (i.e Carnation Instant Breakfast ®, Ensure ® , Boost ® , etc.).
 * **//Avoid://**
 * Hot, spicy, coarse or rough textured foods.
 * Very hot or cold beverages and foods.
 * Citric juices or foods containing citric acid (tomatoes, oranges, lemon, etc.).
 * Alcoholic beverages or tobacco products.
 * Liquid medication containing alcohol (i.e. some cough medicine) if not essential.
 * Drugs that may be prescribed by your doctor to treat bad mouth sores resulting from chemotherapy, radiation, or other cancer treatments:**
 * **Antifungals:** Such as nystatin,clotrimizole, fluconozole
 * **Antibacterials:** Mouthwash antiseptic, rinses are the basis of the oral decontamination regimen.
 * Chlorhexidine gluconate (Peridex ®, PerioGard ® ).
 * Brush and floss teeth, and completely rinse toothpaste from mouth, before using rinse.
 * **Antivirals:** Such as acyclovir (Zovirax ® ) or famciclovir (Famvir ® )
 * To protect Gastrointestinal (GI) tract from irritants:**
 * **Gastrointestinal agents:** Sucralfate (Carafate ® ), comes in a liquid suspension form, protects the lining of the mouth to the stomach from irritants.
 * **Analgesics for pain control**
 * If you feel your chemo, radiation, or other cancer treatments have resulted in bad mouth sores or other oral issues, the following guidelines suggest when** **to call your doctor or healthcare professional:**
 * Temperature greater than 100.5 F (38 C).
 * Sores or ulcers in mouth or on lips that interfere with eating, drinking or sleeping.
 * Pain or any sign of infection ( i.e tongue heavily coated).
 * Symptoms increasing in severity despite above recommendations.

REFERENCES: [|www.cancer.gov], [|http://www.cancer.gov/cancertopics/pdq/supportivecare/oralcomplications/HealthProfessional/page5#Reference5.1] [|www.medscape.com] [|www.chemocare.com]

__ Drug Therapy: __

Because oral mucositis (OM) is self-limited, management of lesions is divided into 5 main approaches, including the following:


 * Oral debridement: Because patients with oral mucositis lesions are frequently neutropenic and thrombocytopenic, perform oral debridement with caution because toothbrushing can cause gingival bleeding and, more importantly, result in transient bacteremia. In some centers, sponge-tipped applicators and gauze soaked in sodium chloride solution are used for oral debridement because of these concerns. Dried secretions may become caked on the mucosal surfaces, particularly the palate (and often misdiagnosed as candidiasis). Mucolytic agents, such as Alkalol, help to soften and dislodge them.


 * Oral decontamination (mouth care): This regimen consists of antifungal and antibacterial rinses. The fluoride rinses and gels used in some oral care regimens are used primarily for antibacterial activity against gingival plaque; they are not used expressly for the prevention of dental caries. Candidal prophylaxis usually includes nystatin rinses and clotrimazole troches. If patients have a very dry mouth, troches are not as effective because they do not dissolve well in a dry environment. Amphotericin rinses also are occasionally used in place of nystatin. Fluconazole may be used for candidal prophylaxis or for treatment of suspected candidiasis. None of these treatments has been shown to specifically reduce the risk of developing oral mucositis.


 * Topical and systemic pain management: Pain in patients with oral mucositis may be severe and not just limited to the oral mucosa. Local rinses (eg, 2% viscous lidocaine, magic mouthwash preparations, and topical morphine solution) and systemic analgesics are used together to control pain. Topical solutions should be kept in the mouth from 2-5 minutes, as tolerated. Frequent rinsing with sodium chloride solution helps to keep the mucosa moist, reduces caking of secretions, and soothes inflamed/ulcerated mucosa. Topical devices, such as Gelclair (EKR Therapeutics, Inc.) and Caphosol (EUSA Pharma) have also been approved by the US Food and Drug Administration (FDA) for mucositis pain management.


 * Prophylaxis/prevention: Cryotherapy with ice chips has been shown to effectively attenuate the onset and severity of mucositis in patients undergoing bolus chemotherapy with 5-fluorouracil and melphalan. Patients should suck on ice chips for 30 minutes prior to and during the chemotherapy infusion. Palifermin (keratinocyte growth factor) is FDA approved for the prevention of oral mucositis in patients undergoing hematopoietic cell transplantation (HCT) with myeloablative conditioning (see below). Antimicrobial prophylaxis is generally limited to antivirals to prevent herpes simplex virus (HSV) reactivation; however, some centers use fluconazole as prophylaxis against candidiasis. Neither antiviral nor antifungal prophylaxis prevents mucositis.

// References: //

// •American Academy of Pediatric Dentistry - Guideline on dental management of pediatric patients receiving chemotherapy, hematopoietic cell transplantation, and/or radiation // // •American Dietetic Association - Oncology evidence-based nutrition practice guideline // // •American Society of Clinical Oncology - American Society of Clinical Oncology 2008 clinical practice guideline update: use of chemotherapy and radiation therapy protectants // // •American Cancer Society -Nutrition and physical activity during and after cancer treatment: An American Cancer Society guide for informed choices // __ oralcancerfoundation.org/dental/pdf/mucocitis __
 * __ Websites: __**

__ RESCOURCES: __

 * [[image:CANCER.png link="imgres"]]
 * ====[|Caphosol.com Home Page | Caphosol for **oral mucositis** and dry **...**]==== ||

Oct 31, 2011 **...** New Caphosol Website offers comprehensive **resource** on **Oral Mucositis.**

 * ====[|**Oral** Health **Resources** for Cancer Patients]==== ||

**Oral mucositis**-related morbidity and **resource** utilization in a prospective study of head and neck cancer patients. Isitt et al. 2007, The Journal of Supportive **...**

 * ==== www.iusd.iupui.edu/ohccp/resources_cancer/lit_mucositis.aspx www.iusd.iupui.edu/ohccp/resources_cancer/lit_mucositis.aspx ==== ||
 * ====[|**Mucositis**]==== ||

Mucositis Study Group & **Resource** Center **...** "The following link leads to National Cancer Institute information on **Oral Mucositis** (health professional version).

 * ==== www.mascc.org/mc/page.do?sitePageId=86973&orgId=mascc www.mascc.org/mc/page.do?sitePageId=86973&orgId=mascc ==== ||

__ [|www.cancerhopenetwork.org] __

 * ====[|American][|**Cancer**][| Society :: Information and][|**Resources**][| for][|**Cancer**] [|**...**]==== ||

Dedicated to helping persons who face **cancer**. Supports research, patient services, early detection, treatment and education.

 * ==== [|www.cancer.org/] ==== || ====[|Imerman Angels | One-On-One **Cancer Support**: Connecting Cancer **...**]==== ||

Imerman Angels provides personalized connections that enable 1-on-1 **support** among **cancer** fighters, survivors and caregivers. Get Connected! Angel Gear On **...**

 * ==== www.imermanangels.org/ ==== ||
 * ====[|**Cancer Resources**][| | OncoLink - The Web's First][|**Cancer Resource**]==== ||

Ways for cancer patients and caregivers to cope with cancer, side effects, nutrition, general **cancer support** issues, grief/end of life issues, and shared survivor's **...**

 * ====[|www.oncolink.org/resources/]==== || ====[|CancerCare | Free professional **support** for anyone affected by **cancer**]==== ||

CancerCare is a national nonprofit organization that provides free, professional **support** services for anyone affected by **cancer**.

 * ==== [|www.cancercare.org/] ==== ||
 * ====[|**Resources**][| for Financial Assistance for Patients and Their Families]==== ||

U.S. National Institutes of Health · National **Cancer** Institute **...** Your local telephone directory has contact information for these **resources**. For more information on **...**

 * ==== cissecure.nci.nih.gov/factsheet/FactSheetSearch8_3.aspx ==== ||
 * ====[|**Cancer Support** Community - Home]==== ||

Non-profit organization dedicated to providing free emotional **support**, education and hope for people with **cancer** and their loved ones.

 * ==== www.thewellnesscommunity.org/ ==== ||