ORAL Mucositis in the cancer patient: A Tutorial

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ORAL Mucositis in the cancer patientA Tutorial

• By Monique Swiecichowski, BSN,RN,CCRC
• Alverno College
• Picture from Microsoft Clipart

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Objectives

• Identify the five biological phases of mucositis
• Identify at least three risk factors contributing
  to mucositis in cancer patients
• Be able to assess those cancer patients at risk
  for and with mucositis
• Identify at least three preventative measures
  and/or interventions of mucositis
• Identify at least four implications of mucositis
  to the cancer patient

4
Case study

• Mr. M is a 72 year old African American man with
  newly diagnosed Stage III squamous cell carcinoma
  of the hypopharnyx. His treatment plan includes
  concurrent radiation and cisplatin. He states
  that he has not been to a doctor in years and
  admits to smoking half a pack of cigarettes and
  drinking 3 beers a day. He has never been to the
  dentist. You note that he has a history of not
  showing for his appointments.
• Is Mr. M at risk for mucositis? What are his
  risk factors?
• What interventions might you offer Mr. M?
• If Mr. M experiences mucositis what are the five
  biological phases that will
• occur?
• You will be assessing Mr. M frequently, what will
  you be assessing and
• how might you consider documenting it?
• Why is it important to minimize Mr. Ms mucositis?

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TOPICS
PATHOBIOLOGY
REVIEW
CAUSES and RISK FACTORS
ASSESS and DOCUMENT
IMPLICATIONS
GENETICS
INTERVENTIONS
REFERENCES
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REVIEW layers of the oral mucosa
Stratified squamous cells
---Oral epithelium
---Basement membrane---
Loose connective tissue under epithelium
containing capillaries and gland ducts
----Lamina propia
Minor salivary glands, striated muscle, fat,
fibroblasts, endothelial cells, nerves, and
inflammatory cells
------submucosa
Muscle or bone
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REVIEW Acute Inflammation
Activation of macrophages, dendritic call,
histocytes and mastocytes residing in endothelium
Release of inflammatory mediators
-Vasodilatation (rubor) -Heat (calor) -Permeabilit
y of blood vesselsexudation of plasma
proteins/fluid into tissues (edema or
tumor) -Sensitivity to pain (dolor) -Loss of
function (functio laesa)
necrotic loss of tissueexposing lower
layersUlcerative inflammation
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REVIEW affects of stress
Cancer as a stressor
Immune cells (monocytes and lymphocytes)
Cytokines (cross the blood-brain barrier)
Corticosteroid releasing factor
Stress hormone activation (catecholamines,
corticosteroids, growth hormone, glucagon, and
renin)
Neuroendocrinological pathways (sympathetic
nervous system, renin angiotensin system,
hypothalamic pituitary axis)
Acute phase response
Acute phase proteins (inflammatory mediators)
Black, 2002 Porth, 2009
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REVIEW Definition

• Mucositis refers to the inflammation of any
• mucosal membrane
• Stomatitis or oral mucositis describes any
• inflammatory condition of oral tissue
• Not an inflammatory disorder

10
PATHOBIOLOGY

• Historical belief of mucositis in cancer patients
• cytotoxic treatments kills rapidly dividing
  cells cancerous and normal
• Current belief of mucositis in cancer patients
• series of simultaneous events beginning in the
  epithelium
• or submucosa and progressing to other tissue
  layers

• Working model of mucositis5 phases
• Initiation
• Upregulation
• Signaling and Amplification
• Ulceration
• Healing

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• Phase I Initiation
• Chemotherapy (CT) or radiation (RT) exposure
• Begins day 1 of treatment
• Begins in the submucosal endothelium

Radiation will stimulate nuclear
factor-kappaB NF-kB
RT or CT causes direct damage to DNA resulting in
cell death
Chemotherapy will stimulate Ceramide synthase
RT and CT generate reactive oxygen species (ROS)
that damage lipids, DNA, connective tissue and
cell membranes stress response
Sonis et al., 2004 Sonis, 2007 Diagram used
with permission by John Wiley and Sons
12

• Phase II Upregulation
• days 1-3
• Occurs in the epithelium and submucosa
• Multiple pathways resulting in damage

NF-kB regulates the pro-inflammatory
cytokines-that lead to an inflammatory
response And promotes apoptosis
direct damage to DNA by ROS
Diagram used with permission by John Wiley and
Sons Sonis et al., 2004 Sonis, 2007

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• Phase II Upregulation (contd)
• Additional pathways resulting in damage

Do you remember
the previous Phase? Click
for a reminder.
Initiation
Damaged cell membranes stimulate sphingomyelinase
fibronectin break-up leads to increased
macrophages, and tissue damage or eventual
apoptosis
Ceramide pathway signals cells to enter
apoptosis (V1 )
Excessive apoptosis and/or decreased clearance of
apoptotic cells induce secretion of other
pro-inflammatory cytokines
Gupta, 2006
Diagram used with permission by John Wiley and
Sons Sonis et al., 2004 Sonis, 2007 V1
Alberts et al, 2002
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• Phase III Signaling and Amplification
• Day 4-8
• Pro-inflammatory cytokines positive feedback
  loops re-initiating the damage response pathways
• Mucosal surface still appears clinically normal

Initiation Upregulation
Do you remember the
previous Phases? Click
for a reminder.
NF-kB activates cyclooxygenase-2 (Cox-2) and
produces prostaglandins resulting in inflammatory
mediation and angiogenesis (V2)
TNF-Alpha activates NF- kB which activates more
TNF RT induced FEEDBACK LOOP
PROCESS (contd)
MMP degrades the extracellular matrix (ECM) ECM
begins to swell with fluid (inflammatory response)
Tumor Necrosis Factor (TNF)-alpha stimulates
apoptosis and sphingomelinase Chemo induced
FEEDBACK LOOP
Diagram used with permission by John Wiley and
Sons Sonis et al., 2004 Sonis, 2007 V2
Alberts et al., 2009
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• Phase IV Ulceration
• Day 8-12
• Cell death, reduced epithelial regeneration, and
  apoptosis thin the epithelium
• Characterized by inflammation and ulceration

Do you remember the
previous Phases? Click for
a reminder.
I. Initiation II. Upregulation III. Signaling
amplification
Breakdown of mucosaulcers
Bacteria penetrate the submucosa and stimulate
macrophages to produce and release additional
pro-inflammatory cytokines.
Pro-inflammatory cytokines
Stimulate inflammatory responses. Bacteria and
debris are removed and factors are released to
promote proliferation V3/ V4
Diagram used with permission by John Wiley and
Sons Sonis et al., 2004 Sonis, 2007 V3
http//www.youtube.com/watch?vCmbWE3jLUgM V4
http//www.youtube.com/watch?vuNG-jZxvhcg
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Do you remember the previous phases?
Click for a reminder.

• -Initiation
• -Upregulation
• -Signaling
• amplification
• -Ulceration

• Phase V Healing
• Day 12-21
• Downregulation of the inflammatory response
• Signaling from extracellular matrix epithelial
  proliferation and
• differentiation
• Epithelial cells multiply and migrate to close
  the ulcers
• Submucosal cells regenerate
• Increased risk of future injury with subsequent
  therapy

Wound repair V5
V5 Alberts, 2009
Sonis et al., 2004 Sonis, 2007
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Testing your knowledge Click on the letter box in
each section below that corresponds to the
correct phase of mucositis listed at the bottom.
A
B
A
B
D
C
C
D
A
B
C
A
C
B
C
B
A
C
B
A
E
F
E
F
D
E
F
F
E
D
F
E
D
F
E
D
Pre treatment
Phase I
Phase II
Phase III
Phase IV
Phase V
A.Upregulation
B. Healing
C. Signaling and Amplification
D. Initiation
E. Ulceration
F. Normal
Diagram used with permission by Sonis, 2007

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Now lets apply it! Remember Mr. M? He is a
72 year old African American man with newly
diagnosed Stage III squamous cell carcinoma of
the hypopharnyx. His treatment plan
includes concurrent radiation and cisplatin.
Click on the right answer. Mr. M began
his chemotherapy and radiation today. You
dont need to worry because it is too early for
any pathobiological process to have begun.
On Day 3 of Mr. Ms treatment, you suspect
that there will be multiple damage
response pathways resulting in damage. On
Day 6, due to all the activity of TNF-alpha and
the feedback loops in Phase III, you
anticipate Mr. M will have sign of
mucositis. When you see Mr. M on day 11 he
might complain of a sore mouth. When you
assess him chances are there might be signs
of biological phase IV mucositis. If Mr. M
develops mucositis, once it resolves. You
expect that he will not be a risk with
further therapy.
True
False
True
False
True
False
True
False
True
False
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• RISK FACTORS
• 1 Causative risk is the cancer therapy being
  administered
• RADIATION-to the head and neck
• Conventional external beam (once a day)
• Hyperfractionated (twice a day)
• CHEMOTHERAPY- of any cancer type
• Thymide synthetase inhibitors methotrexate
• Topoisomerase II inhibitors Etoposide,
  irinotecan
• Pyrmidine analogs cytarabine, 5-FU
• Alkylating agents busulfan, melphalan, cytoxan,
  cisplatin
• Purine analogs 6-MP
• Intercalating drugs idarubicin, doxorubicin,
  daunorubicin
• 
  
  
  
  
  
  Pictures from Microsoft Clipart

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• RISK FACTORS (contd)
• 2 Patient-related variables
• AGE

• Younger age is associated with more severe
  mucositis 3
• higher basal cell proliferation rate4
• greater epidermal growth factor receptors

• Older age may be at risk due to other factors
• Decreases salivary flow increased prevalence of
  gingivitis
• poor oral health at baseline 2

• Very old age (gt70 year old) has also been
  associated with increased mucositis
• Diminished organ function 5
• chronic inflammation processelevated
• proinflammatory cytokines 1
• Oxidative stress of agingNF-kB activation 1
• Elevated NF-kBprogrammed cell death 1

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RISK FACTORS (contd) 2 Patient-related
variables Barasch Peterson,
2003

• SALIVARY FUNCTION
• xerostomia predicts mucositis
• hyposalivation can be caused by anxiety/stress,
  medications, alcohol, depression, endocrine
  disorders, nerve damage from surgery, oxygen,
  dehydration, tobacco
• Obstructive nasal disease

• ORAL HEALTH
• Poor baseline oral status exacerbates mucositis
• ill-fitting prostheses or faulty restorations
• Pre-existing oral infections (viral or fungal)
• Dental disease

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• RISK FACTORS
• GENETICS
• 
  
  
  
  
  Microsoft ClipArt
• May explain why patients of the same age,
  treatment regimens,
• and equivalent oral health status vary in the
  incidence of mucositis
• deficiencies of enzymes due to polymorphisms
  greater risk of mucositis
• variations in the metabolism of chemotherapy
  different rates of mucositis
• variations in apoptotic activity variations in
  risk

• Example
• psoriasis patients lack apoptosis of the skin
• when treated for cancer lower incidence of
  mucositis
• Addisons disease patients have excess
  apoptosis
• cancer treatments higher incidence of
  mucositis
• Sonis,2007

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Testing your knowledge
What are the risk actors associated with
mucositis?

• Across
•  
• 2. conventional external beam or
  hyperfractionated
• 4. young or old
• 5. ill-fitting dentures, gingivitis, caries,
  broken teeth
• 6. may cause variations in drug metabolizing
  enzymes and
• deficiencies in metabolizing enzymes
•  
• Down
•  
• 1. radiation with chemotherapy (chemosensitizer)
• 3. caused by medications, alcohol, tobacco, nerve
  damage from
• surgery, dehydration
• antimetabolites, antitumor antibiotics,
  alkylating agents 

CLICK WHEN READY TO SEE ANSWERS
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Now lets apply it!
Mr. Ms treatment plan includes concurrent
radiation and cisplatin. He states that he
has never been to a dentist and admits to smoking
half a pack of cigarettes and drinking 3
beers a day. Since his last visit he has
established a primary care physician, was
found to have hypertension and depression, and
was placed on corresponding medications.
What are Mr. Ms risk factors? (Click on the
right answer)
True
False
The radiation and cisplatin will put Mr. M at
risk.
True
False
Genetics will play a role in mucositis.
True
False
Mr. M likely has excellent oral health so is not
a risk for mucositis.
True
False
Mr. M is too old to be at risk.
True
False
Mr. M does not evidence any behaviors to be
concerned about xerostomia.
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• ASSESSMENT
• Pretreatment-stratify risk based on

• Each visit during treatment

• treatment plan
• level of xerostomia
• list of prescribed and over-the-counter
  medications
• baseline oral hygiene

• Examine the lips, tongue, and oral mucosa (after
  removing dental appliances) Color, moisture,
  integrity, cleanliness
• Adequate illumination halogen light sources
  provide consistent intensity and color
• Sonis et al., 2004
• Assess for changes in taste, voice, ability to
  swallow
• Examine the saliva for amount and quality
• Assess oral pain (0-10 scale)
• Document all of the above

Microsoft ClipArt
Polovich , Whitford, Olsen , 2009
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DOCUMENTATION A wide variety of scales have
been developed focusing on symptomatic and
functional outcomes World Health
Organization (WHO)-Oral Mucositis National
Cancer Institute Common Toxicity Criteria
(NCI-CTC)-Oral Mucositis
Microsoft ClipArt
27
DOCUMENTATION (contd) Another all inclusive
Oral Assessment Guide

The key is for all caregivers to consistently use
an accepted grading scale throughout all
patients treatments.
Microsoft ClipArt
Modified from the Oral Assessment Guide with
permission by J. Eilers RN,MSN, UNIVERSITY OF
NEBRASKA MEDICAL CENTER, 83 Rev 2-84, 5-84, 4-85,
11-85, 4-86 jeilers_at_nebraskamed.com
Click here to see original Oral Assessment
Guide with pictures
28
Used courtesy of and permission by J. Eilers
RN,MSN, 83 Rev 2-84, 5-84, 4-85, 11-85, 4-86 The
UNIVERSITY OF NEBRASKA MEDICAL CENTER
jeilers_at_nebraskamed.com
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ASSESSMENT AND DOCUMENTATION
Lets focus on the NCI-CTC version 3.0
Microsoft ClipArt
This scale is the most used in documenting the
assessment of a patients lips, tongue and oral
mucosa. But what else should be assessed and
documented? (Click to find out.)
Changes in taste and voice, amount and quality of
saliva, oral pain. As well as vital signs for
signs of infection and dehydration.
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ASSESSMENT AND DOCUMENTATION
Grade 0
Grade 1
Erythema/minimal symptoms, normal diet
Normal/No symptoms
Grade 2
Grade 3
Patchy ulcerations or pseudomembranes/
symptomatic but can eat and swallow modified diet
Confluent ulcerations or pseudomembranes
(contiguous patches gt 1.5 cm in
diameter)/Symptomatic and unable to adequately
ailment or hydrate orally
G 0 from Microsoft ClipArt/ G1-4 photos used with
permission from EUSA Pharma _at_ www.caphosol.com/pa
tients/oral-mucosiis/index.php
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ASSESSMENT AND DOCUMENTATION (contd)
Grade 4
Grade 5
DEATH (indirectly from mucositis sepsis and
other treatment related side effects)
Tissues necrosis significant spontaneous
bleeding/symptoms associated with
life-threatening consequences
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Testing your knowledge
Grade 3 Pseudomembranes bleeding with minor
trauma
Grade 2 or 3 Depending on extent and intake
ability
Grade 4 Tissue necrosis and spontaneous
bleeding life-threatening especially for bone
marrow transplant patients and other
immunosupressed patients
Grade 0 Not mucositis- Hairy tongue decreased
salivary flow causes debris that is normally
washed away by saliva builds up in the oral
cavity.
Grade 2 Can eat a modified diet
Grade 1 Erythema Eating a normal diet

• Click on the picture of a
• Grade 0 mucositis
• Grade 1 mucositis
• Grade 2 mucositis
• Grade 3 mucositis
• Grade 4 mucositis

Images reprinted with permission from
Medscape.com, 2011. Available at http//emedicine.
medscape.com/article/1079570-overview
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Now lets apply it! Mr. M comes in and you
assess him. He states that his mouth is sore.
When asked about what he is eating he
admits that he is not eating his usual fried
chicken dinners due to pain but is able to
eat the mashed potatoes, grits and apple sauce.
He admits that they dont taste the same.
You notice that his voice is a bit raspy.
When you check his oral mucosa
you find this Furthermore, you note that his
lips are without erythema or lesions, his saliva
is thick, there is food at his gum line, it
takes a lot of effort for him to swallow, and
when asked his pain level he ranks it at a 4/10.
You would document level of
xerostomia ? oral hygiene?, taste ?, voice?,
color of oral mucosa ? You would also
indicate the grade of mucositis so as to gage his
mucositis compared to past assessments and to
aid in future assessments.
Using the NCI-CTC Oral Mucosa Scale. What grade
would you assess his mucositis to be?
Oops this is not normal! Try again.
There is erythema, but there is more, Try again.
YES!! There is patchy pseudomembranes and
symptoms soreness, and soft diet
Try again. He could bleed with trauma, but he is
able to eat
No, not yet. The tissue is not necrotic and his
symptoms are not life-threatening
He is still alive!!!
0
1
2
3
4
5
photo used with permission from EUSA Pharma _at_
www.caphosol.com/patients/oral-mucosiis/index.php
34

• WHY IS IT IMPORTANT?
• AFFECTS PATIENT OUTCOMES
• Decreases the efficacy of RT, chemotherapy, and
  chemo/RT
• Studies indicate this is due to

Studies have shown -treatment breaks in RT were
predictive of local recurrence and overall
survival in locally advanced head and neck
patients. -treatment breaks were associated with
higher rates of first relapse, rate of failure in
the chest, and rate of failure in the brain for
limited small-cell lung cancer patients -chemother
apy dose reductions in breast cancer patients
result in a higher recurrence rate
-Tumor growth during the breaks -a dose-response
threshold increases in the dose are needed for
tumor control
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• IMPLICATIONS
• PAIN
• reported as the most distressing symptom by
  patients receiving treatment for head and neck
  cancer... Harris (2006, p.252)
• Domino affect
• 
  
  Fatigue
• PAIN Reduced oral intake
  Weight Loss/Malnutrition
• 
  
  Death
• If severe enough requires opiods

36

• IMPLICATIONS (contd)
• INFECTION
• Ulceration
• Compromise of mucosal barrier
• Local invasion of colonizing microorganisms
• Local infection Streptococcal/candida/reactivatio
  n of HSV-1
• Systemic infection sepsis, bacteremia, and
  systemic fungal infection

37

• IMPLICATIONS (contd)
• ECONOMIC IMPACT
• Ulceration
• Local infection
  Reduced oral intake
• Systemic infection Pain
  Malnutrition/dehydration
• IV antibiotics
  IV opiods
  TPN/feeding tube
• ?Hospitalization?

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• ECONOMIC IMPACT

• Study of 75 patients treated for head and neck
  cancer
• 78 of opiods prescribed were for pain of the
  mouth and throat
• 51 had a feeding tube placed
• 30 were hospitalized due to mucositis (length of
  stay 4.9 days)
• Average cost for a 5-day hospitalization23,000
• Isitt et al., 2007

• Study of bone marrow transplant patients in US,
  Canada, and Europe
• correlation between severity of mucositis,
  days of injectable narcotics, TPN, and injectable
  antibiotics
• Hospital costs were 43,000 higher for patients
  with ulcerations than those without
• Papas et al., 2003

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• IMPLICATIONS (contd)
• NUTRITION/HYDRATION
• Mucositis
• Oral intake
• Malnutrition/dehydration

• DECREASED QUALITY OF LIFE
• NON-COMPLIANCE to THERAPY
• may not show for treatments
• may not take oral chemotherapeutics

40
Testing your knowledge Which of the following
implications of severe mucositis could affect our
patient Mr. M? (Click on the best answer.)
True
False
Severe mucositis would not affect M. Ms quality
of life.
True
False
Treatment breaks due to toxicity might affect his
cancer outcomes and compliance to therapy.
True
False
Infections are a very real issue with severe
mucositis.
True
False
Severe mucositis would not have any nutritional
implications.
True
False
Severe mucositis could place significant
financial burden on Mr. M.
41

• INTERVENTIONS
• Before therapy begins
• Evidenced-based
• Comprehensive oral/dental consult

• Oral cleaning
• Removal of excess plaque
• Treatment of all dental caries
• Extraction of teeth with poor prognosis
• Check prosthesis fit
• Consider a fluoride tray

Microsoft clipart
Bhatt et al., 2010 Bensinger, 2008
42

• Patient education

Mouth care Floss once a day Brush w/soft-bristle
toothbrush for 90 seconds 3 times a day Use
fluoride toothpaste Rinse w/bland (non-alcohol
based) rinse Keep lips lubricated

Harris, 2006
Recommended intake Drink 1-3 liters of fluid a
day Maintain nutrition emphasize intake of high
protein foods Eat non-acidic fruits (banana,
mango, melon, peach)
Microsoft clipart Strohl Camp-Sorrell
, 2006
Avoid Smoking Rough hard foods Acidic foods
(grapefruit, lemon, orange, tomatoes) Alcohol Alco
hol-containing and highly flavored oral products
43
INTERVENTIONS contd During therapy Evidenced-bas
ed

• Nursing interventions

Microsoft clipart

• Likely to be effective
• Cryotherapy ice chips 30 minutes prior and
  during melphalan and
• bolus 5-FU (agents with short half-life)
  local vasoconstriction
• Normal saline (with or without baking soda)
  mouthwash
• 30 ml swish 30 seconds and spit after meals
  and bedtime removes
• debris without compromising healing
• Eaton, 2009 Besinger, 2008

• Effectiveness not established
• Raw honey 20ml honey applied 15 min before and
  15 min after
• radiation 6 hrs later active enzymes have
  antimicrobial properties
• 
  Eaton, 2009 Khanal et
  al, 2010 Rashad et al, 2008
• Fluoride chewing gum chew 5 pieces x 20 minutes
  each every day
• increases salivary flow
• Eaton, 2009

44

• Patient Education

• Change tooth brush q month or with each chemo
  cycle
• (Plt lt50K and WBC lt1,000 use moistened gauze
  sponge)
• Rinse w/saline mouthwash after meals and a
  bedtime
• Salt/sodium bicarbonate 1 part salt/1-2
  parts baking soda
• mix ½-1 tsp dry mix in 1 cup water
• Use fluoride mouth rinse, tray, or toothpaste
  daily
• Re-enforce what to avoid and recommendations for
  intake
• NOTIFY PROVIDER WITH ANY SIGNS AND SYMPTOMS

Polovich, Whitford Olsen, 2009
Per NCCN Guidelines Adequate patient education
and communication between the patient and all
members of the cancer care team are critical,
particularly since nursing staffinteract with
the patient more frequently than the physician
Besinger, (2008, p. 17).
Microsoft clipart
45
INTERVENTIONS During therapy

• Prevention/reduce severity
• Likely to be effective (medical
  interventions)

• Palifermin- IV bolus (for high dose
  chemotherapy/Bone Marrow Transplant)
• Mid-line radiation blocks and conformal
  radiotherapy(CRT) or (3D) CRT
• Benzydamine- mouhwash for head and neck radiation
  patients (In the NCCN guidelines but not
  available in the US)
• Gelclair (EKR Therapeutics, Inc)-mix product
  w/2-3 T water, swish for 1 minute and spit, 3x a
  day. Recommended to not eat or drink or 1 hour
  after use. (Approved as a medical device for oral
  mucositis Not a NCCN recommended treatment and
  conflicting ONS recommendations) Eaton, 2009
  Polovich, Whitford Olsen, 2009
• Low-level laser therapy (LLLT) not generally
  used due to cost

Bensinger, 2008
46
INTERVENTIONS During therapy

• Prevention
• Not recommended for
• Practice
• GM-CSF mouthwash
• Sucralfate
• Antimicrobial lozenges
• Hydrogen peroxide
• Chlorhexidine

• Prevention
• Unlikely to be effective
• Oral aloe vera
• Pilocarpine
• Oral povidone-iodine
• Iseganan
• Misopostol
• Topical vitamin E
• Flurbiprofen tooth patch
• G-CSF
• IM Immunoglobulin
• Wobe-mugos E
• Amifostine for mucositis
• has not been determined

Eaton, 2009 Bensinger, 2008
47
INTERVENTIONS Review (click on box to review)
DENTAL CARE
PATIENT EDUCATION
Oral cleaning Removal of excess plaque Treatment
of cavities Pull teeth as needed Check fit of
dentures and partials
Mouth care Recommended intake Food, behaviors,
and products to avoid
NURSING INTERVENTIONS
MEDICAL INTERVENTIONS
EDUCATION Cryotherapy Mouth rinses Honey?
Palifermin CRT or 3D-CRT LLLT Gelclair?
48

• Pain Management

• Nociceptive pain
• -mediated by C fibers
• relieved w/opioids
• Other strategies-Cox-2 inhibitors, NSAIDS,
  gabapentin
• 
  
  
  
  
  Harris, 2006

Microsoft clipart

• Incidental pain
• -caused by movement and contact
• -mediated by A-8 fibers
• Only effective treatment is functional exclusion
  of the anatomic parts
  
  Niscola
  et al. (2007, p.226)

• Temporary relief strategies
• Magic mouthwash 15ml swish and spit QID
  (however, little evidence to support)
  
  Eaton, 2009
• Various lidocaine/xylocaine rinses (not
  recommended due to compromise of the gag reflex
  and possibility of incidental injury when numb)
• Besinger, 2008

49

• Xerostomia Management

• Frequent fluid intake
• Artificial saliva (i.e. Biotene, Oasis)
• Sucrose-free lemon drops
• Caphosol mouthwash (EUSA Pharma, Inc)
  prescription supersaturated (with calcium and
  phosphate ions) mouthwash
• Not listed in current ONS or NCCN guidelines

Microsoft clipart
Eaton, 2009 Strohl, 2006
50
Testing your knowledge
Which of the following is the most important
nursing intervention for a
patient at high risk for mucositis? Click on the
correct response.
Although there are non-prescriptive therapies
that nurses can offer such as cryotherapy, normal
saline mouthwash, pushing fluids is there
anything that encompasses more?
Yes, oral hygiene is extremely important before
and during therapy. What else?
Indeed, this is very important as therapy will
affect salivary function and its role in mucosal
protection. But what else?
Xerostomia management
Re-enforce oral hygiene
Preventative therapies
Very important for quality of life and although
nursing is important for assessing pain at onset
most treatments involve prescribe medications.
Anything else?
YES!!!!! Patients and families need to
understand the importance of oral hygiene , ways
to reduce their risk of xerostomia and
mucositis, s/s oral inflammation, and the
importance of notifying providers of s/s
Right, patients at significant risk, such as head
and neck cancer patients should be assessed and
treated by a dental professional prior to
initiating cancer therapy. What else?
Dental exam
Patient education
Pain management
51
Now lets apply it!
Lets review. Mr. M is your 72 year old
patient with head and neck cancer. His
treatment included concurrent radiation and
cisplatin. At treatment onset, he
admitted to smoking half a pack of cigarettes and
drinking 3 beers a day. He had never been
to the dentist. During treatment he was placed
on hypertensive and antidepressant
medications. You assessed him with a Grade 2
mucositis. What have been your
interventions?
YES
NO

• Assisted Mr. M in making a dental appointment?

YES
NO

• Educated Mr. M on oral hygiene, foods to avoid
  and those to try, tobacco cessation, alcohol
  avoidance?

YES
NO

• Activated the preventative measures of normal
  Saline mouthwash, honey, cryotherapy and GM-CSF
  mouthwash?

YES
NO

• Xerostomia management including oral fluids, oral
  moisturizers, and sugar free lemon drops?

YES
NO

• Pain assessment and management such as
• topical swish and spit medications?

52
GREAT JOB!
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Thank you for viewing this tutorial For
questions or comments swiecime_at_alverno.edu
53
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