Volume 2, Issue 3, 1998 ISSN 1329 - 1874 BestPractice Evidence Based Practice Information Sheets for Health Professionals Prevention And Treatment Of Oral Mucositis In Cancer Patients Introduction This Practice Information Sheet Levels of Evidence Oral mucositis, also called Covers The Following Concepts All studies were categorised according to the strength of the evidence based on the following stomatitis, is a common, debilitating classification system. complication of cancer chemo- therapy and radiotherapy, occurring 1. Quality Of Research Level I Evidence obtained from a systematic in about 40% of patients. It results review of all relevant randomised from the systemic effects of controlled trials. Level II cytotoxic chemotherapy agents Evidence obtained from at least one and from the local effects of 2. Treatment Options properly designed randomised radiation to the oral mucosa. Oral controlled trial. Level III.1 mucositis is inflammation of the Evidence obtained from well mucosa of the mouth which ranges designed controlled trials without 3. What Is Effective randomisation. from redness to severe ulceration. Level III.2 Symptoms of mucositis vary from Evidence obtained from well designed cohort or case control pain and discomfort to an inability analytic studies preferably from more to tolerate food or fluids. Mucositis 4. Recommendations - than one centre or research group. may also limit the patient’s ability Level III.3 Oral Care Protocol Evidence obtained from multiple time to tolerate either chemotherapy or series with or without the radiotherapy. Mucositis may be so intervention. Dramatic results in uncontrolled experiments. severe as to delay treatment and Level IV so limit the effectiveness of cancer Opinion of respected authorities, therapy. Patients with damaged 5. Other Treatment Options based on clinical experience, descriptive studies, or reports of oral mucosa and reduced immunity expert committees. resulting from chemotherapy and radiotherapy are also prone to opportunistic infections in the whenever possible, or at least been developed to present the best mouth. The mucositis may affect treated to reduce its severity and available evidence related specifically patients' gum and dental condition, possible complications. to the prevention and treatment of oral speech and self esteem are mucositis induced by chemotherapy or reduced, further compromising Currently there is a bewildering radiotherapy in cancer patients. The patients’ response to treatment number of interventions to choose information presented in this document and/or palliative care. from, but no high quality synthesis is based on a systematic review of the best research evidence for undertaken by The Joanna Briggs It is therefore extremely important these interventions. This Best Institute for Evidence Based Nursing that mucositis be prevented Practice Information Sheet has and Midwifery. volume 2, issue 3, page 1, 1998 Quality Of Research · immunomodulatory agents; mouthwashes 4 to 6 times per day The systematic review of the research · topical anaesthetics; have been evaluated as prophylaxis literature identified a vast number of · antiseptics; against mucositis resulting specifically from the action of 5- interventions that have been · antibacterial, antifungal and fluorouracil chemotherapy. Results of investigated to determine their antiviral agents the meta-analysis support the use of effectiveness in the prevention or · mucosal barriers and coating allopurinol mouthwash to prevent treatment of oral mucositis in cancer agents; mucositis. patients. It is obvious that many · cytoprotectants; · mucosal cell stimulants; interventions used in clinical practice Cryotherapy, or rapid cooling of the have never been rigorously evaluated. · psychotherapy; and oral cavity using ice, causes local Furthermore, many combinations of · analgesics. vasoconstriction and hence reduces agents are advocated by local experts blood flow to the oral mucosa. For without evidence to support their use. Oral Care Protocols cytotoxic and neoplastic drugs such The quality of published papers was Much has been written about oral as 5-fluorouracil, which have a short variable, and although a large number care regimens and many discussion half life and are sometimes of experimental studies were papers have reported locally administered as a bolus injection, identified, some were rejected due to developed regimens. These cryotherapy may reduce the amount deficiencies in study design or in regimens typically include dental of drug reaching the oral mucous reporting. Combining results from work to eliminate caries and existing membranes, and may therefore different studies during the systematic gum disease before beginning reduce mucositis caused by local review and meta-analysis was limited cancer treatment, followed by cytotoxic activity of these drugs. mostly because of differences thorough and frequent cleaning of the Studies support the use of between the study participants', oral cavity with a variety of products, cryotherapy as a cheap and effective interventions, and the timing and some form of pain relief, anti- method of minimising mucositis induced by bolus 5-fluorouracil, but it method of measuring outcomes. inflammatory treatment as required and aggressive antimicrobial is not effective for continuous infusions. While many interventions used for the treatment for any new mouth treatment or prevention of mucositis infections. However there have been Mouthwashes With Mixed Actions very few experimental studies have some evidence supporting their A variety of mouthwashes with mixed use, no intervention has been designed to test the effectiveness of actions have been evaluated and conclusively validated by research. particular oral care protocols. It include benzydamine hydrochloride, Consequently, the recommendations should also be noted that most of the corticosteroids and chamomile. in this information sheet have been specific interventions for mucositis Benzydamine hydrochloride is a drug based on research findings and prevention and treatment reviewed which has anti-inflammatory, pain supplemented by expert clinical below were tested against a relieving, antipyretic and antimicrobial opinion. background of good oral care. There activities, and has been used as a appears to be broad support for gargle or mouthwash to prevent and Treatment Options some form of oral care protocol as a treat oral mucositis. There is good evidence that benzydamine Many different treatments are used to commonsense preventive measure, hydrochloride mouthwash is effective prevent or treat mucositis. To aid the but further research is required to in improving the symptoms of discussion of findings these optimise specific oral care regimens. radiation-induced mucositis in interventions have been categorised patients with head and neck cancer. under the following headings; Interventions Which Reduce The However, further work is needed to · general oral care protocols; Mucosal Toxicity Of Chemotherapy evaluate the effectiveness of this · interventions to reduce the Drugs agent for chemotherapy-induced mucosal toxicity of chemotherapy The interventions used to minimise mucositis, and to compare drugs; mucosal toxicity include allopurinol benzydamine with other pre- · mouthwashes with mixed action; and cryotherapy. Allopurinol parations. volume 2, issue 3, page 2, 1998 Chamomile is said to have anti- patients whose oral mucositis pain nystatin, clotrimazole and PTA inflammatory and spasmolytic effects is severe, but currently there is no lozenges. Nystatin is a broad spectrum and to promote mucosal healing, evidence to support their use. antifungal agent, and comparison however there is no evidence to Comparisons between dyclonine between nystatin mouthwash, saline support its use. Corticosteroids have HC1, viscous lignocaine with 1% or placebo failed to show any also been used in mouthwash cocaine and a solution containing significant difference in mucositis preparations as treatment for kaolin-pectin, diphenhydramine and severity or oral ulceration score. mucositis and there is limited saline, found dyclonine provided Clotrimazole alone, or in combination evidence in favour of corticosteroid better pain relief. with polymixin B and tobramycin has mouthwash. been evaluated, and while one study Antiseptics suggests it is more effective than Immunomodulatory Agents A range of antiseptic solutions have chlorhexidine, issues of The effectiveness of colony been used including chlorhexidine, methodological quality of these studies stimulating factors and povidone iodine and hydrogen make it difficult to draw firm immunoglobulin have been peroxide. Chlorhexidine is perhaps conclusions. evaluated. Granulocyte-macrophage one of the most commonly used colony stimulating factor (GM-CSF) mouthwash solutions identified in Antibiotic lozenges designed to and granulocyte colony stimulating studies and has been used as dissolve in the mouth and factor (G-CSF) are cytokines which prophylaxis for both chemotherapy decontaminate the oral mucosa have stimulate haemopoiesis and and radiotherapy induced mucositis. been developed and have been widely modulate leukocyte functions. No However, the evidence does not recommended to reduce oral beneficial effect has been support its use, indeed it has been infections associated with mucositis. demonstrated with a mouthwash suggested that water mouthwashes The lozenges contain polymixin E, containing GM-CSF, but the results of are as effective as chlorhexidine.