Brushing up on mouth care for cancer patients with mucositis Learn how to detect and intervene for oral mucositis. By Caroll Tipian, BSN, RN, OCN

CHEMOTHERAPY AND can damage the mucosa of the RADIATION used to oral cavity and GI tract. This arti - treat head and neck cle discusses mucositis in the oral cancers, as well as cavity, which can cause symptoms high-dose chemo- ranging from a slight sensation therapy given to stem- change to pain and inflammation cell transplant patients, to ulcerative bleeding lesions. Multiple mouth lesions can lead to colonization by microbial flora, resulting in a potentially life- threatening septic infection and prolonged hospital stays. In some cases, mucositis necessitates a treat - ment delay or termination, which can make cancer therapy less effec - tive and increase the risk of residual tumor-cell proliferation. Many pa - tients discontinue cancer treatments due to mucositis; about 60% require hospitalization for the condition, Biological phases of and 70% require tube feedings. mucositis Mucositis can occur at any age. Younger patients have a higher Mucositis occurs in five biological mitotic rate and more epidermal phases—initiation, message genera - growth factor receptors, which can tion, signaling and amplification, increase severity of mucositis. Old - ulceration, and healing. er patients typically have decreased • Initiation: Reactive oxygen species renal function, which slows clear - drive other biological processes that cause direct cellular damage. ance of chemotherapy drugs and • Message generation: Radiation raises the risk of toxicity from high- and chemotherapy activate tran - dose cancer chemotherapy. Other scription factors and other cyto - risk factors for mucositis include kines, causing further tissue poor nutritional status at the start breakdown. of chemotherapy, a history of • Signaling and amplification: Sig - smoking (which can delay healing), naling among transcription fac - and previous cancer treatments that tors continues, altering the mu - caused mucositis. (See Biological cosal environment. At this point, phases of mucositis .) minimal changes can be seen. When caring for a patient under - • Ulceration: Visible changes, such as lesions and ulcers, appear. going cancer treatment, your role is • Healing: Damaged epithelial cells to ensure proper oral care; assess are repaired. for mucositis signs and symptoms, such as pain, infection, dry mouth,

American Nurse Today Volume 9, Number 11 www.AmericanNurseToday.com 38 taste changes, and poor nutrition; and use appropriate interventions.

Assessing and grading mucositis Mucositis is graded based on lesion severity and appearance of the oral cavity. The most commonly used grading criteria are the National Cancer Institute Common Toxicity Criteria (NCI CTC) and the World Health Organization Oral Toxicity Scale. Use one of these scales daily Oncology Nursing Society recommendations to determine if your patient’s mu - cositis is improving or getting The Oncology Nursing Society recommends using an oral protocol to minimize oral worse. mucositis, decrease microbial flora, reduce pain and bleeding, and prevent infec - tion and dental complications. Oral protocols for mucositis differ but should in - clude the following: Intervention • oral-cavity assessment daily or at each patient visit The first step in mouth care for • patient education about oral cavity self-assessment oral mucositis is prevention. Prefer - • brushing the teeth for at least 90 seconds with a soft toothbrush twice daily ably, before cancer treatment starts, • flossing at least once daily or as advised patients should undergo a baseline • rinsing four times daily with a bland rinse dental evaluation with X-rays and • avoiding tobacco, alcohol, and irritating foods have cavities filled. Once treatment • using a water-based moisturizer for the lips begins, instruct patients to brush • maintaining adequate hydration. the teeth with a soft toothbrush for 90 seconds at least twice daily and For more information, see www.ons.org/intervention/oral-care-protocol and to floss at least once daily (unless www.guideline.gov/content.aspx?id=15700 . the patient is thrombocytopenic). As appropriate, advise them to rinse the mouth at least four times Cryotherapy not they receive total-body irradia - daily with saline solution, sodium If your patient’s receiving 5-fluoro- tion when undergoing a stem-cell bicarbonate, or a mixture. Stress uracil bolus chemotherapy, cryo- transplant). In cryotherapy, patients the importance of getting adequate therapy with ice chips for 30 min - suck on ice chips 30 minutes be - hydration and using a water-based utes can reduce severity of muco- fore the chemotherapy infusion be - moisturizer to protect the lips. (See sitis with sores. Some clinicians gins, as well as during and after Oncology Nursing Society recom - also recommend cryotherapy for the infusion. Ice chips constrict mendations .) patients receiving high-dose mel - blood vessels in the mouth, de - Despite preventive measures, phalan chemotherapy (whether or creasing chemotherapy effects on most patients develop NCI CTC the oral mucosa. grade 2 or 3 (moderate to severe) toxicity, depending on the extent of Palifermin chemotherapy and radiation. To re - Interventions to avoid Palifermin, a keratinocyte growth lieve pain from mucositis, guide - Certain agents are ineffective for oral factor that stimulates epithelial-cell lines recommend use of a patient- mucositis; in some cases, they may growth and differentiation, may controlled analgesia pump with even worsen this painful condition. be used to reduce incidence and morphine, especially in stem-cell They include topical antimicrobials, duration of severe oral mucositis transplant patients. In other patients such as polymyxin, tobramycin, and in patients receiving high-dose amphotericin B lozenges, as well as receiving conventional or high-dose chemo therapy and radiation thera - bacitracin, clotrimazole, and gentam - chemotherapy, a transdermal fen - icin. Also avoid antifungal nystatin py who require hematopoietic tanyl patch is preferred. Specifically (no more effective than saline rinses), stem-cell support. It’s given as an in head and neck cancer patients sucralfate, iseganan, and chlorohexi - I.V. bolus injection, 60 mcg/kg/day who undergo radiation, 2% mor - dine, which haven’t been shown to for 3 con secutive days before and phine mouth rinse is suggested, as yield benefits. 3 consecutive days after myelotox - well as 0.5% doxepin rinse. ic therapy.

www.AmericanNurseToday.com November 2014 American Nurse Today 39 Teach patients about Laser therapy secondary to cancer therapy. Cancer . 2014; Low-level laser therapy has been 120(10):1453-461. doi:10.1002/cncr.28592. used to decrease severity and inci - preventive measures Oncology Nursing Society. Mucositis. dence of oral mucositis caused by www.ons.org/practice-resources/pep/mu - chemotherapy or radiation therapy and what foods cositis. Accessed September 15, 2014. in patients with head and neck Raber-Durlacher JE, Von Bültzingslöwen I, cancer. However, few medical cen - Logan RM, et al.; Mucositis Study Group of the Multinational Association of Supportive ters offer this treatment because of to avoid . Care in Cancer/International Society of Oral the expensive equipment required. Oncology (MASCC/ISOO). Systematic review of cytokines and growth factors for the man - Patient education prove your patient’s comfort level agement of oral mucositis in cancer patients. Teach patients about recommended and quality of life during cancer Support Care Cancer . 2013;21(1):343-55. preventive measures as well as treatment by detecting mucositis Rodriguez-Caballero A, Torres-Lagares D, what to avoid during chemothera - early and providing appropriate Robles-Garcia M, et al. Cancer treatment-in - duced oral mucositis: a critical review. Int J py or radiation treatment. (See In - care. O Oral Maxillofac Surg . 2012;41(2):225-38. terventions to avoid .) Advise them Saunders DP, Epstein JB, Elad S, et al.; Mu - not to eat acidic, salty, dry, spicy, Selected references cositis Study Group of the Multinational or hot foods, as these can irritate Eilers J, Million R. Clinical update: Preven - Association of Supportive Care in Cancer/ the mucosa and worsen dry mouth. tion and management of oral mucositis in International Society of Oral Oncology Without proper assessment and patients with cancer. Semin Oncol Nurs . (MASCC/ISOO) . Systematic review of antimi - 2011;27(4):e1-16. crobials, mucosal coating agents, anesthetics, intervention, mucositis can reduce and analgesics for the management of oral Lalla RV, Bowen J, Barasch A, et al.; Mucosi - your patient’s oral intake and cause mucositis in cancer patients. Support Care tis Guidelines Leadership Group of the poor nutritional status, which can Cancer . 2013;21(11):3191-207. Multinational Association of Supportive Care hinder white blood cell recovery in Cancer and International Society of Oral during immunosuppressive chemo- Oncology (MASCC/ISOO). Clinical practice Caroll Tipian is a Clinical Nurse II at Memorial Sloan therapy treatment. You can im - guidelines for the management of mucositis Kettering Cancer Center in New York, New York.

FROMFRROOM TTHEHE HHONORONOR SSOCIETYOCIETY OOFF NNURSING,URSING, SIGMASIGMA TTHETAHETTAA TTATAUAAUU IINTERNATIONALNTERNNAAATTIONNAAL Anatomy of Writing for Publication for Nurses, Second Edition

Learn more at www.nursingknowledge.org/sttibooks.

Published by: Distributed by:

American Nurse Today Volume 9, Number 11 www.AmericanNurseToday.com 40