Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Neonatal intensive care unit wikipedia , lookup
Focal infection theory wikipedia , lookup
Patient safety wikipedia , lookup
Maternal health wikipedia , lookup
Dental degree wikipedia , lookup
Dental hygienist wikipedia , lookup
Dental emergency wikipedia , lookup
Oral care in children undergoing HSCT G .Marco Deiana Children’s Hospital G.Gaslini, Genoa, Italy. On behalf of Paediatric Committee EBMT Nurses Group Eugenia trigoso, Merja Stenvall, Marco Deiana Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Background The oral cavity is very sensitive to the toxicity of antineoplastic agents. The incidence of oral problems varies 30 to 100% of patients 70–85% patients undergoing myeloablative HSCT The most frequent problems are • mucositis, • taste changes, • xerostomia, • opportunistic infections, • pain • bleeding Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Objective To Evaluate the importance of oral care To make the point about : what it means tools drugs methods for reducing problems originating from the oral cavity Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Method •review of recent literature (English) (last 5 years until September 2010 •Medline databank Keywords: oral care, mucositis, stem cell /bone marrow transplantation •Analysis of the presentations of EBMT meetings. where oral problems and care in HSCT were the main focus I collected 56 useful works 9 reviews 10 paediatric or mixed patients •organization of items in an Excel file •Data analysis Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Review - Limits • • • • • few pediatric studies some studies with small populations different methods of assessment difficult to "weigh"the results of single study inability sometime to identify the bias these limits were found in all the reviews that I have analyzed Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Review three key areas • Methods of oral assessment • Drugs and therapies • Dental care and basic oral cavity hygiene Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Assessment Oral care • Assessment instrument • Continuity in documentation • Pictures of oral cavity to mark areas that are affected • Rules of oral cavity inspection • Trained personnel • Multidisciplinary team • Involve patients Monica Fliedner, MSN ANP Oncology, Bern University Hospital (CH)- EBMT AMNG- 2010 - Vienna Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Assessment • Clinical assessment instruments • World Health Organisation (WHO) • National Cancer Institute (NCI) •Oral Assessment Guide (OAG) •Oral Mucositis Index (OMI) •Oral Mucositis Assessment Scale (OMAS) • Nijmegen Nursing Mucositis Scoring System (NNMSS) •Visual Analogue Scale (VAS) Monica Fliedner, MSN ANP Oncology, Bern University Hospital (CH)- EBMT AMNG- 2010 - Vienna Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Assessment Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Assessment Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Assessment • Supportive Recommendations for clinical practice • Documentation of any changes necessary!) • Identification of risk patients (basic assessment • Define how often assessment should be done • Guideline for preventive and therapeutic measures, e.g. -No irritating mouthwashes, keep oral cavity moist! -Good oral hygiene with soft tooth brush -Dental floss (cave: contraindications) • Multidisciplinary team approach (MASCC = Multinational Association of Supportive Care in Cancer), McGuire et al (2006) Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Assessment No studies for the most appropriate timing or frequency of oral assessment, who should conduct the oral assessment and what instruments should be used during the assessment. Similarly, the acceptability of the assessment process to the children/teenagers was not addressed in the literature. UKCCSG-PONF Mouth Care Group - Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Assessment Twenty-seven individual oral assessment tools were identified. Twelve tools required the calculation of a compound score two tools required complex calculations to be carried out, only one tool was identified by the Guideline Development Group as being appropriate for use in children, both for clinical practice and research purposes. UKCCSG-PONF Mouth Care Group - Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Assessment The Oral Assessment Guide (OAG) produced by Eilers et al. was considered to be user friendly and appropriate for everyday clinical practice with both adults and children, as well as a useful research tool. It has been shown to have good nurse/nurse, nurse/dental hygienist and nurse/dentist inter-rater reliability. UKCCSG-PONF Mouth Care Group - Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Assessment RECOMMENDATIONS FOR ORAL ASSESSMENT DURING CANCER TREATMENT OF CHILDREN - The Eilers’ Oral Assessment Guide offers a valid, reliable and clinically useful tool for assessing oral status. The adaptation is recommended for use in children and young people. -responsible for assessment -Nursing staff should be appropriately trained are best placed for the regular assessment of the child’s oral status. UKCCSG-PONF Mouth Care Group Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Assessment Oral assessment has not always been consistently and accurately assessed, therefore mucositis may be underreported and undertreated. POMA training demonstrates that appropriate education can help the SCT team achieve consistent OM assessment. The multidisciplinary nursing, physician, and dentist Mucositis Advisory Group plan to extend OM training to centres not involved in POMA in an effort to standardize OM assessment throughout Europe, thereby leading to improved patient care. EBMT Mucositis Advisory Group Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Drugs, therapies and other More than 85 drugs and therapies (or combinations) have been tried to solve or minimize oral cavity health problems of patients undergoing HSCT. Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Drugs, therapies and other Acyclovir Allopurinol mouthwash Aloa vera Amifostine amino acids Amphotericin B Antiseptic and Antimicrobial Agents (topic) Anti-inflammatory rinses Antibiotic pastille or paste versus placebo Azelastine Bacitracin, clotrinazole, gentamicin (BcoG lozenges) Benzydamine Beta carotene versus no treatment control Biperidine Budesonide Calcium phosphate carob versus Chlorhexidine and Nistatin plus carob Chamomille Chaposol Chypotrypsin Chinese medicine Chlorhexidine Ciclosporine Clopidogrel Clotrimazole Coumarin / Troxerutine Episil plus cryotherapy Fluconazole Folinic acid Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Drugs, therapies and other G-CSF Gealclair Glutamine GM-CSF Histamine gel versus placebo Honey Hydrolytic enzymes Ice chips Ice chip plus propantheline Immunoglobulin Interleukin -1 Interleukin-11 Iseganan Itraconazole Keratinocyte GF Ketocolnazole Magic (lidocaine solution, diphenhydramine hydrochloride and aluminium hydroxide suspension ) Manganese superoxide dismutase (detoxifies ROS) Miconazole Misonidazole Misoprostol Mucotrol extracts from licorice root and aloe vera Na-sucrose gel N-Acetyl Cysteine Natamycin Norfloxacin plus amphoterecin B nystatin nystatin plus chlorhexidine nystatin plus amphoterecin B Omega 3 Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Drugs, therapies and other Oral care versus no treatment or limited oral hygiene Assessment of the nurses Papain Pegfilgrastim versus filgrastim Pentoxifylline Pilocarpine Povidone Iodine Prednisone versus placebo Propantheline versus placebo Prostaglandin versus placebo Protegrin Peptides PTA : Polymyxin E, tobramycin, Amphotericin paste Sodium bicarbonate Sucralfate versus placebo Systemic antibiotic clarithromycin versus no treatment Talidomide TGF-beta 3 Thymostimulin Traumeel versus placebo Tretinoin Trypsin Vitamin E Zinc sulphate Laser therapy tramadole and buprenorphin in advance Vitamin E hyaluronic acid Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Dental care and basic oral cavity hygiene Younger patients present more oral problems than adults there are many oncology and HCT protocols every patient should be managed on an individual basis and appropriate consultations with physicians and other dental specialists These patients should be treated within the National Health Service It should be to establish a register of dental problems in pediatric patients with cancer. 1. 1. Guideline on Dental Management of Pediatric Patients Receiving Chemotherapy, Hematopoietic Cell Transplantation, and/or Radiation cancer therapies in the oral cavity. American academy of Pediatric dentistry Linee guida per la promozione della salute orale e la prevenzione delle patologie orali negli individui in età evolutiva che devono essere sottoposti a terapia chemio e/o radio. Ministero della Salute Italiano Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Dental care and basic oral cavity hygiene Before therapy Objectives To identify and stabilize or eliminate existing and potential sources of infection and local irritants in the oral cavity without needlessly delaying the cancer treatment or inducing complications Patients to educate parents 1. importance of optimal oral care Before During After treatment Guideline on Dental Management of Pediatric Patients Receiving Chemotherapy, Hematopoietic Cell Transplantation, and/or Radiation cancer therapies in the oral cavity. American academy of Pediatric dentistry Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Dental care and basic oral cavity hygiene Before therapy EDUCATION It is recommended brushing teeth at least twice a day with a quantity of fluoride toothpaste according to age toothbrush, for the exclusive use of the child, must be changed every three months, or replaced after each episode of infection that has interested in the oral cavity. For infants, parents should be educated on how to clean the mucosa with a gauze / nonwovens. The use of additional tools (dental floss, etc) and applications of topical fluoride should be prescribed by a dental 1. 2. Guideline on Dental Management of Pediatric Patients Receiving Chemotherapy, Hematopoietic Cell Transplantation, and/or Radiation cancer therapies in the oral cavity. American academy of Pediatric dentistry Linee guida per la promozione della salute orale e la prevenzione delle patologie orali negli individui in età evolutiva che devono essere sottoposti a terapia chemio e/o radio. Ministero della Salute Italiano Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Dental care and basic oral cavity hygiene Before therapy - prevention of oral mucositis The following principles and pharmacological compounds have shown a potential benefit in preventing mucositis in adult patients: Amifostine, Benzodiamina, calcium phosphate, honey, hydrolytic enzymes, zinc sulfate, For the prevention of mucositis secondary to chemo-radio therapy, there is no scientific evidence to recommend the use of the following active ingredients: Allopurinol, aloe vera, bacitracin, gentamicin, beta carotene, chamomile, clarithromycin. The use of antifungal prophylaxis is indicated if there is a high risk for the patient to develop a systemic infection. The scarcity of scientific evidence on the patient in childhood, does not allow a strong recommendation Their use in children for the prevention of radiotherapy and/or chemotherapy induced mucositis can only be considered within the constraints of an RCT - Mouth Care for Children and Young People with Cancer: Evidence-based Guidelines 2UKCCSG-PONF Mouth Care Group - Linee guida per la promozione della salute orale e la prevenzione delle patologie orali negli individui in età evolutiva che devono essere sottoposti a terapia chemio e/o radio. Ministero della Salute Italiano Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Dental care and basic oral cavity hygiene During treatment Dental and oral care during immunosupression periods The objectives of a dental/oral care during cancer therapy are three-fold: 1. to maintain optimal oral health during cancer therapy; 2. to manage any oral side effects that may develop as a consequence of the cancer therapy; 3. to reinforce the patient and parents’ education regarding the importance of optimal oral care in order to minimize oral problems/discomfort during treatment. Guideline on Dental Management of Pediatric Patients Receiving Chemotherapy, Hematopoietic Cell Transplantation, and/or Radiation cancer therapies in the oral cavity. American academy of Pediatric dentistry Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Dental care and basic oral cavity hygiene During treatment •For severe mucositis foam brushes or super soft brushes soaked in chlorhexidine •Otherwise, foam or super soft brushes should be discouraged because they do not allow for effective cleaning • Electric or ultrasonic brushes are acceptable if the patient is capable of using them without causing trauma and irritation. Guideline on Dental Management of Pediatric Patients Receiving Chemotherapy, Hematopoietic Cell Transplantation, and/or Radiation cancer therapies in the oral cavity. American academy of Pediatric dentistry Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Dental care and basic oral cavity hygiene During treatment Diet: Fluoride: non-cariogenic diet high risk of dietary supplements rich in carbohydrate and oral pediatric medications rich in sucrose fluoridated toothpaste fluoride supplements if indicated neutral fluoride gels/rinses or applications of fluoride varnish for patients at risk for caries and/or xerostomia A brush-on technique is convenient, familiar, and simple and may increase the likelihood of patient compliance with topical fluoride therapy Guideline on Dental Management of Pediatric Patients Receiving Chemotherapy, Hematopoietic Cell Transplantation, and/or Radiation cancer therapies in the oral cavity. American academy of Pediatric dentistry Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Dental care and basic oral cavity hygiene During treatment Lip care: Education: Dental care: Lanolin-based creams reinforcing the importance of optimal oral hygiene possible acute and long-term effects of the therapy in the craniofacial complex. elective dental care must not be provided If a dental emergency arises the treatment plan should be discussed with the patient’s physician who will make recommendations for supportive medical therapies (eg, antibiotics, platelet transfusions, analgesia). Guideline on Dental Management of Pediatric Patients Receiving Chemotherapy, Hematopoietic Cell Transplantation, and/or Radiation cancer therapies in the oral cavity. American academy of Pediatric dentistry Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Dental care and basic oral cavity hygiene During treatment Oral hygiene advice should be provided both verbally and in writing should be given by a designated member of the dental team or, member of the medical or nursing team who has received appropriate training. Mouth Care for Children and Young People with Cancer: evidence-based Guidelines - UKCCSG-PONF Mouth Care Group Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Dental care and basic oral cavity hygiene During treatment Oral hygiene advice to brush at least twice a day fluoride toothpaste (containing 1,000 ppm fluoride +/- 10%). toothbrush sole use of the child Changed on a 3 monthly basis when bristles splay following an oral infective episode. If the child has a sore mouth a soft brush with a small head should be used. Mouth Care for Children and Young People with Cancer: evidence-based Guidelines - UKCCSG-PONF Mouth Care Group Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Dental care and basic oral cavity hygiene During treatment For children up to the age of 6 years, parents/carers should be instructed on how to brush their child’s teeth. For babies without teeth, parents/carers should be instructed on how to clean the mouth with oral sponges. The sponge should be moistened with water. For children where it is not possible to brush teeth parents/carers should be instructed on how to clean the mouth with oral sponges as a temporary measure The sponge should be moistened with water or an antimicrobial agent such as diluted chlorhexidine. Additional aids, such as flossing and fluoride supplements should only be prescribed according to risk assessment by a member of the dental team. The need to restrict sugary food and drink to meal times only should be emphasised. Mouth Care for Children and Young People with Cancer: evidence-based Guidelines - UKCCSG-PONF Mouth Care Group Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Dental care and basic oral cavity hygiene During treatment – drugs and other The following have all been shown to be potentially beneficial for the prevention of mucositis in adult populations Their use in children for the prevention of radiotherapy and/or chemotherapy induced mucositis can only be considered within the constraints of an RCT Amifostine GM-CSF/G-CSF Allopurinol mouthwash (for 5-FU therapy) Benzydamine Antibiotic pastilles/pastes (containing polymyxin E, Ice-chips Povidone-iodine tobramycin and amphotericin (PTA)) Pilocarpine (not currently available in a form suitable for children) Hydrolytic enzymes. Mouth Care for Children and Young People with Cancer: evidence-based Guidelines - UKCCSG-PONF Mouth Care Group Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Dental care and basic oral cavity hygiene During treatment – drugs and other The administration of opiates in pain control is recommended. Taking ice before bolus chemotherapy reduces the absorption of chemotherapeutic The use of chlorhexidine is not recommended for mucositis in pediatric patients because of its typical side effects (burning and dysgeusia) The use of local anesthetics such as viscous lidocaine followed by non-steroidal anti-inflammatory agents can be recommended to reduce pain in mucositis. Posts with the soft laser may be indicated in cases of ulcerative mucositis and refractory 1. Linee guida per la promozione della salute orale e la prevenzione delle patologie orali negli individui in età evolutiva che devono essere sottoposti a terapia chemio e/o radio. Ministero della Salute Italiano June 2010 Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Dental care and basic oral cavity hygiene During treatment – drugs and other Expert Opinion Bland Rinses Rinses are used to remove loose debris and aid with oral hydration. Bland rinses include 0.9% saline (normal saline), sodium bicarbonate , and a saline and sodium bicarbonate mixture. Typical mixtures contain one teaspoon salt or sodium bicarbonate per pint of water. Any of those rinses can be administered at room temperature or refrigerated, and all are inexpensive. Patients should be instructed to take a tablespoon of the rinse, swish it in the oral cavity for at least 30 seconds, and expectorate. Sodium bicarbonate reduces the acidity of oral fluids, (Dodd et al., 2000; Eilers, 2004; Rubenstein et al., 2004; Scully et al., 2006; Shih et al., 2002). Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Dental care and basic oral cavity hygiene After HSCT The objectives of a dental/oral examination after cancer therapy ends are : to maintain optimal oral health to reinforce to the patient/parents the importance of optimal oral and dental care for life Guideline on Dental Management of Pediatric Patients Receiving Chemotherapy, Hematopoietic Cell Transplantation, and/or Radiation cancer therapies in the oral cavity. American academy of Pediatric dentistry Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Dental care and basic oral cavity hygiene After HSCT Oral hygiene: Diet: Patients must brush their teeth 2 to 3 times daily with a soft nylon toothbrush. Brushes should be airdried between uses. Patients should floss daily. Dental practitioners should encourage a non-cariogenic diet and advise patients/parents about the high cariogenic potential of dietary supplements rich in carbohydrate and oral pediatric medications rich in sucrose. Guideline on Dental Management of Pediatric Patients Receiving Chemotherapy, Hematopoietic Cell Transplantation, and/or Radiation cancer therapies in the oral cavity. American academy of Pediatric dentistry Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Dental care and basic oral cavity hygiene After HSCT Fluoride: use of fluoridated toothpaste, fluoride supplements if indicated, neutral fluoride gels/rinses, or applications of fluoride varnish for patients at risk for caries and/or xerostomia. A brush-on technique is convenient, familiar, and simple and may increase the likelihood of patient compliance with topical fluoride therapy. Lip care: Lanolin-based creams and ointments are more effective in moisturizing and protecting against damage than petrolatum-based products. Guideline on Dental Management of Pediatric Patients Receiving Chemotherapy, Hematopoietic Cell Transplantation, and/or Radiation cancer therapies in the oral cavity. American academy of Pediatric dentistry Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Dental care and basic oral cavity hygiene After HSCT Education: reinforce to emphasize the need for regular follow-ups with a dental professional risk for or have developed. at least every 6 months or in shorter intervals Periodic evaluation: if issues such as chronic oral GVHD, xerostomia, or trismus are present Patients who have experienced moderate or severe mucositis and/or chronic oral GVHD should be followed closely for malignant transformation of their oral mucosa (eg, oral squamous cell carcinoma). Orthodontic treatment: after completion of all therapy after at least a 2 year disease-free survival when the risk of relapse is decreased and the patient is no longer using immunosuppressive drugs Guideline on Dental Management of Pediatric Patients Receiving Chemotherapy, Hematopoietic Cell Transplantation, and/or Radiation cancer therapies in the oral cavity. American academy of Pediatric dentistry Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Dental care and basic oral cavity hygiene Mucositis Mucositis care remains focused on palliation of symptoms 24 Studies on the use of chlorhexidine conflicting results. Most studies have not demonstrated a prophylactic impact, although reduced colonization of candidial species has been shown. 24 Patient-controlled analgesia has been helpful in relieving pain associated with mucositis, reducing the requirement for oral analgesics. There is no significant evidence of the effectiveness or tolerability of mixtures containing topical anesthetics (eg, “Philadelphia mouthwash”, “magic mouthwash”). The use of topical anesthetics often is recommended for pain management although there are no studies available to assess the benefit and potential for toxicity. Lidocaine use may obtund or diminish taste and the gag reflex and/or result in a burning sensation, in addition to possible cardiovsascular and central nervous system effects. Local application may be useful for painful ulcers The Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology –2007 update guidelines Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Dental care and basic oral cavity hygiene Mucositis Oral mucosal infections: Close monitoring of the oral cavity allows for timely diagnosis and treatment of fungal, viral, and bacterial infections. Prophylactic nystatin is not effective for the prevention and/or treatment of fungal infections Oral cultures and/or biopsies of all suspicious lesions should be performed and prophylactic medications should be initiated until more specific therapy can be prescribed. The Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology –2007 update guidelines Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Protocol suggestion The basic components of an oral care protocol include assessment, patient education, tooth brushing, flossing, and oral rinses. A multidisciplinary, collaborative team approach is important for implementation of the protocol. Oral assessment, using a validated tool, also should be conducted regularly to assess function, pain, and the oral mucosa. The participation of a dentist is recommended throughout treatment and followup (Multinational Association of Supportive Care in Cancer [MASCC], 2005). Bland rinses, recognized as an important part of oral hygiene, have not been studied adequately to meet the criteria for the Recommended for Practice category. Putting Evidence Into Practice®: evidence-Based Interventions for the Management of Oral Mucositis Clinical Journal of Oncology Nursing • Volume 12, Number 1 2008 Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Protocol suggestion Clinicians • Collaborate with a multidisciplinary team in all phases of treatment. • Conduct a systematic assessment at least daily or at each patient visit. In the outpatient setting, teach patients to perform oral assessment daily. Teach patients when to report findings to the clinician. • Provide written instruction and education to patients regarding oral care. Verify understanding with return explanation and demonstration. Patients • Brush all tooth surfaces for at least 90 seconds, twice daily using a soft toothbrush. Allow toothbrush to air dry before storing. Replace toothbrush on a regular basis. • Floss at least once daily or as advised by the clinician. • Rinse mouth four times daily with a bland rinse. • Avoid tobacco, alcohol, or irritating foods (acidic, hot, rough, spicy). • Use water-based moisturizers to protect lips. • Maintain adequate hydration. Note. Based on information from Dodd et al., 2000; Eilers, 2004; Kwong, 2004; Multinational Association of Supportive Care in Cancer, 2005; Rubenstein et al., 2004; Scully et al., 2006; Shih et al., 2002. Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Protocol example -Daily nursing mucositis evaluation. -Brushings twice daily with soft bristle toothbrush. **Foam toothbrush can be substituted if patient is experiencing oral pain** -Cryotherapy: Ice chips 30 min prior to and throughout Melphalan infusion **Only if patient is receiving Melphalan as part of conditioning treatment** -Chlorhexidine gluconate mouthwash: 15 mL swish for 30 s and spit four times daily. **Discontinue at first sign of mucositis** **After meals and at bedtime** -Normal saline mouthwash: 30 mL swish for 30 s and spit four times daily -Caphosol® mouthwash: 30 mL swish for 1 min with 15 mL of the solution and spit out. Repeat with the remaining 15 mL of the solution and spit out. Repeat four times daily after nomal saline mouthwash. -Magic mouthwash: 15 mL swish and spit four times daily as needed oral pain **Initiate at first sign of mucositis* -Cepastat® lozenges *Sugar Free*: Dissolve in mouth every 2 h as needed oral pain. At physician’s discretion Palifermin (Kepivance® 60 mcg/kg/day IV bolus for 3 days with third dose 24–48 h before myelotoxic therapy. 60 mcg/kg/day IV bolus three consecutive days after myelotoxic therapy. **Palifermin should not be administered within 24h before, during infusion of, or within 24h after administration of myelotoxic chemotherapy* Post-myelotoxic therapy: Three doses after, with first dose immidiately after HCT infusion, if at least 4 days have elapsed after most recent palifermin administration. Department of Pharmacy, Mayo Clinic Florida, Jacksonville, FL, USA. Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Protocol example The following management protocol was recommended : • Patient education • Patient-controlled analgesia (morphine in HCST) • Radiotherapy – Midline blocks & 3D radiotherapy – Benzydamine • Chemotherapy, cryotherapy for – 30 min before 5-FU – 20 min before Edatrexate • Possibly, low level laser therapy Do not use • Chlorhexidine • Aciclovir • Pentoxifylline. Minimal care is good oral hygiene plus narcotic analgesics, but a number of other approaches can be helpful (Sonis and Haley, 1996). Rubenstein et al, 2004. Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Protocol example Mouth Care for Children and Young People with Cancer: Evidence-based Guidelines Guideline Report Version 1.0 February 2006 Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation Conclusion The focus of oral care protocols is not on specific agents, but on feasibility, adherence, and patient education. The protocol also may be specific to patients’ diagnosis and treatment Some studies in the pediatric setting have demonstrated the superiority of using protocols over general oral care The results of this review did not demonstrate superiority of a specific rinse, but rather, reinforced the importance of oral care Implementation of a standardized oral care protocol for mucositis management resulted in a decreased incidence, duration and severity of mucositis, and also reduced the global negative impact of mucositis. Future studies may further evaluate the global impact by adjusting for confounding factors. Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation I believe that more studies proposed and conducted by pediatric nurses, may help us in our work in future The European Group for Blood and Marrow Transplantation Credits 1. Guideline on Dental Management of Pediatric Patients Receiving Chemotherapy, Hematopoietic Cell Transplantation, and/or Radiation cancer therapies in the oral cavity. American academy of Pediatric dentistry 2008 2. Linee guida per la promozione della salute orale e la prevenzione delle patologie orali negli individui in età evolutiva che devono essere sottoposti a terapia chemio e/o radio. Ministero della Salute Italiano 2010 3. Putting Evidence Into Practice®:Evidence-Based Interventions for the Management of Oral Mucositis Department of Pharmacy, Mayo Clinic Florida, Jacksonville, FL, USA. 2008 4. School of Nursing, University of Maryland, Baltimore, USA; HealthQuest, Minneapolis, USA;Colle ge of Dental Medicine, Nova Southeastern University,Fort Lauderdale, USA ; on benhalf of MASCC / ISOO 2006 5. Eastman Dental Institute, University College London, University of London, London, UK; 2Department of Oral Medicine and Diagnostic Sciences, Harvard School of Dental Medicine, Divisions of Oral Medicine, Oral and Maxillofacial Surgery and Dentistry, Brigham and Women’s Hospital and the Dana Farber Cancer Institute, Boston, MA, USA; 3Special Needs Unit, School of Medicine and Dentistry, University of Santiago de Compostela, Spain 2006 6. UKCCSG-PONF Mouth Care Group 2006 7. the EBMT Prospective Oral Mucositis Audit (POMA) 2007 8. MASCC The Multinational Association of Supportive Care in Cancer Clinical Practice Guidelines: Keefe et al 2007 9. The Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology 10. Monica Fliedner, MSN ANP Oncology, Bern University Hospital (CH) 2010 Paris, 5 April 2011 The European Group for Blood and Marrow Transplantation The European Group for Blood and Marrow Transplantation