Download 2011. Oral Mucositis in the Cancer Patient.

By Monique Swiecichowski, BSN,RN,CCRC
Alverno College
Picture from Microsoft Clipart
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TOPICS
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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
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. M’s mucositis?
TOPICS
REVIEW
PATHOBIOLOGY
CAUSES and RISK
FACTORS
GENETICS
ASSESS and
DOCUMENT
IMPLICATIONS
INTERVENTIONS
REFERENCES
REVIEW
layers of the oral mucosa
---Oral epithelium
Stratified squamous cells
---Basement
membrane------Lamina propia
------submucosa
Loose connective tissue under
epithelium containing capillaries
and gland ducts
Minor salivary glands, striated
muscle, fat, fibroblasts, endothelial
cells, nerves, and inflammatory cells
Muscle or bone
REVIEW
Acute Inflammation
Activation of macrophages, dendritic call,
histocytes and mastocytes residing in
endothelium
Release of inflammatory mediators
-Vasodilatation (rubor)
-Heat (calor)
-Permeability of blood vessels=exudation
of plasma proteins/fluid into tissues
(edema or tumor)
-Sensitivity to pain (dolor)
-Loss of function (functio laesa)
necrotic loss of tissue=exposing lower
layers=Ulcerative inflammation
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
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
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 mucositis=5 phases
I. Initiation
II. Upregulation
III. Signaling and Amplification
IV. Ulceration
V. Healing
Sonis et al., 2004
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
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
Chemotherapy will stimulate
Ceramide synthase
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

Phase II: Upregulation (cont’d)

Additional pathways resulting in damage
Do you
remember
the previous
Initiation
Phase? Click
for a
reminder.
fibronectin breakup leads to
increased
macrophages, and
tissue damage or
eventual apoptosis
Damaged cell membranes
stimulate
sphingomyelinase
Ceramide pathway signals
cells to enter apoptosis
(V1 )
Diagram used with permission by John Wiley and Sons
Sonis et al., 2004; Sonis, 2007
V1: Alberts et al, 2002
Excessive apoptosis and/or decreased
clearance of apoptotic cells induce
secretion of other pro-inflammatory
cytokines
Gupta, 2006
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
Do you
remember the
Initiation
previous Phases?
Upregulation
Click for a
reminder.
NF-kB activates cyclooxygenase-2 (Cox-2) and
produces prostaglandins resulting in
inflammatory mediation and
angiogenesis
(V2)
PROCESS (cont’d)
TNF-Alpha activates NF- kB which
activates more TNF
**RT induced FEEDBACK LOOP**
MMP degrades the
extracellular matrix (ECM);
ECM begins to swell with
fluid (inflammatory
response)
Diagram used with permission by John Wiley and Sons
Sonis et al., 2004; Sonis, 2007
V2: Alberts et al., 2009
Tumor Necrosis Factor (TNF)-alpha
stimulates apoptosis and
sphingomelinase
**Chemo induced FEEDBACK LOOP**
Phase IV: Ulceration



Day 8-12
Cell death, reduced epithelial regeneration, and
apoptosis thin the epithelium
Characterized by inflammation and ulceration
Do you
remember
I. Initiation
theUpregulation
previous
II.
Phases?
Click&
III. Signaling
for a
amplification
reminder.
Breakdown of
mucosa=ulcers
Bacteria penetrate the submucosa
and stimulate macrophages to
produce and release additional
pro-inflammatory cytokines.
Pro-inflammatory cytokines
Diagram used with permission by John Wiley and Sons
Sonis et al., 2004; Sonis, 2007
V3: http://www.youtube.com/watch?v=CmbWE3jLUgM
V4: http://www.youtube.com/watch?v=uNG-jZxvhcg
Stimulate inflammatory responses.
Bacteria and debris are removed
and factors are released to
promote proliferation
V3/ V4
Do you
-Initiation
remember
-Upregulation
the previous
-Signaling
phases?
Click
&amplification
for
a
-Ulceration
reminder.
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
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
C D C D
E F E F
Pre treatment
Phase I
A.Upregulation
A B
C
A B
C
A B
C
A
B
C
D E
F
D E
F
D E
F
D
E
F
Phase II
B. Healing
Phase III
C. Signaling and
Amplification
F. Normal
Diagram used with permission by Sonis, 2007
Phase IV
D. Initiation
Phase V
E. Ulceration
Now let’s 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
True
False
don’t need to worry because it is too early for any
pathobiological process to have begun.
On Day 3 of Mr. M’s 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
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
BOTH or COMBINED MODALITIES-to the head and neck
Chemosensitizer
Niscola et al., 2007; Sonis, 2004
RISK FACTORS (cont’d)
#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 (>70 year old) has also been associated with
increased mucositis
Diminished organ function 5
chronic inflammation process=elevated
proinflammatory cytokines 1
Oxidative stress of aging=NF-kB activation 1
Elevated NF-kB=programmed cell death 1
1.Csiszar ,2008; 2. Niscola et al.,2007; 3.Sonis , 1998; 4. Treister & Woo, 2010; 5.Zalcberg , Kerr, Seymour, & Palmer, 1998
RISK FACTORS (cont’d)
#2 Patient-related variables
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
Barasch & Peterson, 2003
RISK FACTORS
GENETICS
May explain why patients of the same age, treatment regimens,
and equivalent oral health status vary in the incidence of mucositis
Microsoft ClipArt
 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
• Addison’s disease patients have excess apoptosis;
cancer treatments= higher incidence of mucositis
Sonis,2007
Mice with deficiency in the acidic sphingomyelase gene= increased resistance
to mucositis
Sonis et al., 2004
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
7. antimetabolites, antitumor antibiotics, alkylating agents
CLICK
WHEN
READY
TO SEE
ANSWERS
Now let’s apply it!
Mr. M’s 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. M’s risk factors? (Click on the right answer)
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
True
False
Mr. M does not evidence any behaviors to
be concerned about xerostomia.
ASSESSMENT
I.
Pretreatment-stratify risk based on:
 treatment plan
 level of xerostomia
 list of prescribed and over-the-counter
medications
 baseline oral hygiene
II. Each visit: during treatment
 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
Polovich , Whitford, & Olsen , 2009
Microsoft ClipArt
DOCUMENTATION
A wide variety of scales have been developed focusing on symptomatic and
functional outcomes:
World Health Organization (WHO)-Oral Mucositis
Grade
0
1
2
3
4
Normal
Oral
soreness,
erythema
Ulcers
but able
to eat
solids
Oral
ulcers
and able
to take
liquids
only
Oral
alimentatio
n
impossible
5
N/A
Microsoft ClipArt
National Cancer Institute Common Toxicity Criteria (NCI-CTC)-Oral Mucositis
Grade
0
1
2
3
4
5
Clinical
(version 3.0)
Normal
Erythema
Patchy ulcerations
or
pseudomembranes
Confluent ulcerations
or pseudomembranes;
bleeding with minor
trauma
Issue necrosis;
significant
spontaneous
bleeding; lifethreatening
consequences
Death
Functional
(version 3.0)
No symptoms
Minimal symptoms,
normal diet; minimal
respiratory
symptoms but not
interfering with
function
Symptomatic but
can eat and
swallow modified
diet; respiratory
symptoms
interfering with
unction but not
interfering with
ADL
Symptomatic and
unable to adequately
aliment or hydrate
orally; respiratory
symptoms interfering
with ADL
Symptoms
associated with
life-threatening
consequences
Death
Asymptomatic or
mild symptoms;
intervention not
indicated
Moderate pain; no
interfering with
oral intake;
modified diet
indicated
Severe pain;
interfering with oral
intake
Lifethreatening
consequences;
urgent
intervention
indicated
Death
Version 4.0
DOCUMENTATION (cont’d)
Another all inclusive Oral Assessment Guide
1
Ratings
Category
2
3
Voice
Normal
Deeper or raspy
Difficulty talking or
painful
Swallow
Normal swallow
Some pain on swallow
Unable to swallow
Lips
Smooth and pink and
moist
Dry and cracked
Ulcerated or bleeding
Tongue
Pink and moist and
papillae present
Coated or loss of
papillae with a shiny
appearance with or
without redness
Blistered or cracked
Saliva
Watery
Thick or ropy
Absent
Mucous
Membranes
Pink and moist
Reddened or coated
(increased whiteness)
without ulceration
Ulcerations with or
without bleeding
Gingiva
Pink and stippled and
firm
Edematous with or
without redness
Spontaneous bleeding
or bleeding with
pressure
Clean and no debris
Plaque or debris in
localized areas
(between teeth if
present)
Plaque or debris
generalized along gum
line or denture-bearing
area
Teeth or dentures
or denture-bearing
area
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
[email protected]
Click here to see original
Oral Assessment Guide with
pictures
The key is for all
caregivers to
consistently use an
accepted grading
scale throughout all
patient’s
treatments.
Microsoft ClipArt
ASSESSMENT AND DOCUMENTATION
Let’s focus on the NCI-CTC version 3.0
Grade
Clinical
(version 3.0)
Functional
(version 3.0)
0
Normal
No
symptoms
1
Erythema
Minimal
symptoms,
normal
diet;
minimal
respiratory
symptoms
but not
interfering
with
function
2
3
Patchy
ulcerations or
pseudomembranes
Confluent
ulcerations or
Symptomatic
but can eat and
swallow
modified diet;
respiratory
symptoms
interfering
with unction
but not
interfering
with ADL
Symptomatic
and unable to
adequately
aliment or
hydrate orally;
respiratory
symptoms
interfering with
ADL
pseudomembrane-
bleeding with
minor trauma
4
5
Issue necrosis;
significant
spontaneous
bleeding; lifethreatening
consequences
Death
Symptoms
associated
with lifethreatening
consequence
Death
Microsoft ClipArt
This
Changes
scale is in
thetaste
most
and
used
voice,
in documenting
amount and quality
the assessment
of saliva,of a
oral pain.patient’s
As well lips,
as vital
tongue
signsand
for oral
signsmucosa.
of infection and
But what else should be assessed
dehydration.
and documented? (Click to find out.)
ASSESSMENT AND DOCUMENTATION
Grade 0
Grade 1
Normal/No symptoms
Erythema/minimal symptoms, normal diet
Grade 2
Patchy ulcerations or pseudomembranes/
symptomatic but can eat and swallow modified
diet
G 0 from Microsoft ClipArt/ G1-4 photos used with permission from
EUSA Pharma @ www.caphosol.com/patients/oral-mucosiis/index.php
Grade 3
Confluent ulcerations or pseudomembranes (contiguous
patches > 1.5 cm in diameter)/Symptomatic and unable to
adequately ailment or hydrate orally
ASSESSMENT AND DOCUMENTATION
(cont’d)
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
Testing your knowledge
Grade 3
Pseudomembranes;
bleeding with
minor trauma
Grade 0
Not mucositisHairy tongue:
decreased
salivary flow
causes debris
that is normally
washed away by
saliva builds up
in the oral cavity.
Grade 4
Tissue necrosis and
spontaneous
bleeding;
life-threatening
especially for bone
marrow transplant
patients and other
immunosupressed
patients
Click on the picture of a:
1. Grade 0 mucositis
2. Grade 1 mucositis
3. Grade 2 mucositis
4. Grade 3 mucositis
5. Grade 4 mucositis
Images reprinted with permission from Medscape.com, 2011. Available at:
http//emedicine.medscape.com/article/1079570-overview
Grade 2 or 3
Depending on
extent and
intake ability
Grade 2
Can eat a
modified diet
Grade 1
Erythema:
Eating a normal diet
Now let’s 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 don’t 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.
0
There is erythema, but
there is more, Try again.
1
YES!! There is patchy
pseudomembranes and
symptoms: soreness,
and soft diet
2
photo used with permission from
EUSA Pharma @ www.caphosol.com/patients/oral-mucosiis/index.php
Try again. He could
bleed with trauma,
but he is able to eat
3
No, not yet. The tissue is
not necrotic and his
symptoms are not lifethreatening
4
5
He is still alive!!!
WHY IS IT IMPORTANT?
AFFECTS PATIENT OUTCOMES
Decreases the efficacy of RT, chemotherapy, and chemo/RT
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
-chemotherapy dose reductions in breast cancer patients result
in a higher recurrence rate
Studies indicate this is due to:
-Tumor growth during the breaks
-a dose-response threshold; increases in the dose are needed
for tumor control
Rosenthal, 2007
IMPLICATIONS
PAIN
 “…reported as the most distressing symptom by patients receiving treatment for
head and neck cancer...” Harris (2006, p.252)
Domino affect:
PAIN
Reduced oral intake
If severe enough requires opiods
Keefe et al., 2007
Weight Loss/Malnutrition
Fatigue
Death
IMPLICATIONS (cont’d)
INFECTION
Ulceration
Compromise of mucosal barrier
Local invasion of colonizing microorganisms
Local infection: Streptococcal/candida/reactivation of HSV-1
Systemic infection: sepsis, bacteremia, and systemic fungal infection
IMPLICATIONS (cont’d)
ECONOMIC IMPACT
Ulceration
Local infection
Systemic infection
IV antibiotics
Reduced oral intake
Pain
IV opiods
?Hospitalization?
Malnutrition/dehydration
TPN/feeding tube
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 hospitalization=$23,000
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
IMPLICATIONS (cont’d)
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
Testing your knowledge
Which of the following implications of severe mucositis could affect our patient Mr. M?
(Click on the best answer.)
Severe mucositis would not affect M. M’s quality of
life.
True
False
True
False
True
False
Severe mucositis would not have any nutritional
implications.
True
False
Severe mucositis could place significant financial
burden on Mr. M.
True
False
Treatment breaks due to toxicity might affect his cancer
outcomes and compliance to therapy.
Infections are a very real issue with severe
mucositis.
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
Bhatt et al., 2010; Bensinger, 2008
Microsoft clipart
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)
Avoid
Smoking
Rough hard foods
Acidic foods (grapefruit, lemon, orange, tomatoes)
Alcohol
Alcohol-containing and highly flavored oral products
Microsoft clipart
Strohl & Camp-Sorrell , 2006
INTERVENTIONS: cont’d
During therapy
Evidenced-based
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
 Patient Education
Change tooth brush q month or with each chemo cycle
(Plt <50K and WBC <1,000 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 staff…interact with the patient more frequently
than the physician” Besinger, (2008, p. 17).
Microsoft clipart
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
INTERVENTIONS
During therapy
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
Prevention
Not recommended for
Practice
GM-CSF mouthwash
Sucralfate
Antimicrobial
lozenges
Hydrogen peroxide
Chlorhexidine
INTERVENTIONS
Review
(click on box to review)
Oral cleaning
Removal of excess plaque
Treatment of cavities
DENTAL
CARE
Pull teeth as needed
Check fit of dentures and
partials
EDUCATION
NURSING
Cryotherapy
Mouth rinses
INTERVENTIONS
Honey?
Mouth care
Recommended
intake
PATIENT
Food, behaviors, and products
EDUCATION
to avoid
Palifermin
MEDICAL
CRT or 3D-CRT
LLLT
INTERVENTIONS
Gelclair?
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
 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
Eaton, 2009 & Strohl, 2006
Microsoft clipart
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.
Indeed, this is very important as
therapy will affect salivary function
and it’s role in mucosal protection.
But what else?
Xerostomia
management
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
Yes, oral hygiene is extremely
important before and during
therapy.
What else?
Re-enforce oral
hygiene
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!!!!!
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
Very important for quality of life and
although nursing is important for
assessing pain at onset most
treatments involve prescribe
medications. Anything else?
Patient education
Preventative
therapies
Pain management
Now let’s apply it!
Let’s 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
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?
YES
Assisted Mr. M in making a dental appointment?
Educated Mr. M on oral hygiene, foods to avoid and
those to try, tobacco cessation, alcohol avoidance?
NO
Microsoft clipart
Thank you for viewing this tutorial
For questions or comments: [email protected]
• Alberts, Bray, Hopkin, Johnson, Lewis, Raff, Roberts, Walter, (2009). Essential cell biology, 3rd edition:
angiogenesis. from http://www.youtube.com/watch?v=7YgwJeVEgvU
• Alberts, Johnson, Lewis, Raff, Roberts, Walters, 2002. Molecular biology of the cell, 4th edition: apoptosis.
From http://www.youtube.com/watch?v=witLM--V2v8
• Alberts, Johnson, Lewis, Raff, Roberts, Walters, 2002. Molecular biology of the cell, 4th edition: wound healing.
From http://www.youtube.com/watch?v=pn2TOGqHMrI
• Barasch, A., & Peterson, D. (2003). Risk factors for ulcerative oral mucositis in cancer patients: unanswered
questions. Oral Oncology 39, 91-100.
• Bensinger, W., Schubert, M., Ang, K., Brizel, D., Brown, E., Eilers, J., Elting, L., Mittal, B., Schattner, M.,
Spielberger, R., Treister, N., & Troti, A. (2008). NCCN task force report: prevention and management of
mucositis in cancer care. Journal of the National Comprehensive Cancer Network 6 [supplement 1].
• Bhatt, V., Vendrell, N., Nau, K., Crumb, D., & Roy, V. (2010). Implementation of a standardized protocol for
prevention and management of oral mucositis in patients undergoing hematopoietic cell transplantation.
Journal of Pharmacy Practice, 16, 195-204.
• Black, P. (2002) Stress and the inflammatory response: a review of neurogenic inflammation. Brain, Behavior,
and Immunity, 16, (6):622-53.
• Chung, Y., Lee, M., & Pui, N., (2009). Epigenetic therapy using the histone deacetylase inhibitor for increasing
therapeutic gain in oral cancer: prevention of radiation-induced oral mucositis and inhibition of
chemical- induced carcinogenesis. Carcinogenesis 30 (8), 1387-1397.
• Cancer Therapy Evaluation Program, Common Terminology Criteria for Adverse Events (CTCAE) version 3.0
(2003)and 4.0 (2010). DCD, NIH, NCI, DHHS. http://ctep.cancer.gov.
• Csiszar, A., Wang, M., Lakata, E., & Ungvari (2008). Inflammation and endothelial dysfunction during
aging: role o f NF-kB. Journal of Applied Physiology 105: 1333-1341.
• Eaton, L. & Tipton, J. (Eds.) (2009). Putting Evidence into Practice-Improving Oncology Patient Outcomes.
Pittsburgh, Pennsylvania: ONS
• Gupta, S., Agrawal, A., Agrawal, S., Gollapudi, H, & Gollapudi, S. (2006) . A paradox of immunodeficiency
in human aging: lessons learned from apoptosis. Immunity and Aging. 3 (5). doi:10.1186/1742-4933-3-5.
• Harris, D. (2006). Cancer treatment-induced mucositis pain: strategies for assessment and management.
Therapeutics and Clinical Risk Management 2(3), 251-258.
• Isitt, J., Murphy, A., Beaumont, J., Garden, A., Gwede, C., Trotti, A., Meredith, R., Epstein, J., Brizel, D.,
Bellm, L., Wells, N., & Cella, D. (2007). Oral Mucositis-related morbidity and resource utilization in a
prospective study of head and neck cancer patients. The Journal of Supportive Oncology 5 (4) [supplement 2],
54-55.
• Keefe, D., Schubert, M., Elting, L., Sonis, S., Epstein, J., Raber-Durlacher, J., Migliorati, C., McGuire, D.,
Hutchins, R., & Peterson, D. (2007). Updated clinical practice guidelines for prevention and treatment
of mucositis. Cancer 109(5), 820-831.
• Khanal, B., Baliga, N., Uppal, N. (2010). Effect of topical honey on limitation of radiation-induced oral
mucositis: an intervention study. International Journal of Oral & Maxillofocal Surgery 39 (12), 1181-1185.
• Niscola, P., Romani, Cupelli, L., Scaramucci, L., Tendas, A., Dentamaro, T., Amadori, S.,
& de Fabritiis, P. (2007). Mucositis in patients with hematologic malignancies: an overview.
Haemtologica 92, (2), 222-231. doi:10.3324/haematol.10232
• Papas, A., Clark, R., Martuscelli, G., O’Loughlin, K., Johansen, E., Miller, K. (2003). A prospective,
randomized trial or the prevention of mucositis in patients undergoing hematopoietic stem cell
transplantation. Bone Marrow Transplantation. 00, 1-8. Doi:10.1038/sj.bm.1703870
• Polovich, M. Whitford, J., Olsen, M. (Eds.) (2009). Chemotherapy and Biotherapy Guidelines and
recommendations for Practice. (3rd ed.). Pittsburgh, Pennsylvania: ONS, 163-182.
• Porth, C. & Matfin, G. (2009) Pathophysiology: concepts of altered health states. Philadelphia, PA: Lippincot
Williams & Wilkins.
• Rashad, U., Al-Gezawy, S., El-Gezawy, E., Azzaz, A. (2009). Honey as topical prophylaxis against
radiotherapy-induced mucositis in head and neck cancer. The Journal of Laryngology & Otology, 123(2),
223-228.
• Rosenthal, D. (2007). Consequences of mucositis-induced treatment breaks and dose reductions on
head and neck cancer treatment outcomes. The Journal of Supportive Oncology 5,(9) [supplement 4],23-31.
• Sonis, S. (2004). Oral mucositis in cancer therapy. The Journal of Supportive Oncology, 3(3), 3-8.
• Sonis, S., Elting, L., Keefe, D., Peterson, D., Schubert, M., Hauer-Jensen, M., Bekele, N.B.,
Raber-Durlacher, J., Donnelly, J.P., & Rubenstein, E. (2004). Perspectives on cancer therapy-induced
mucosal injury. Cancer Supplement 100(9), 1995-2025.
• Sonis, S. (2007). Pathobiology of oral mucositis: novel insights and opportunities. The Journal of Supportive
Oncology 5(9, supplement 4), 3-11.
• Sonis, S. (1998) Mucositis as a biological process: a new hypothesis for the development of
chemotherapy-induced stomatoxicity. Oral Oncology 34, 39-43.
• Strohl, R., & Camp-Sorrell, D., (2006). Stomatitis/xerostomia. In Camp-Sorrell, D., & Hawkins, R. (Eds.)
Clinical Manual for the Oncology Advanced Practice Nurse.. (2nd ed.), 73-77. Pittsburgh, Pennsylvania: ONS
• Treister, N. & Woo, S-B. Chemotherapy-induced oral mucositis.
http://emedicine.medscape.com/article/1079570
• World Health Organization (1979). WHO handbook for reporting the results of cancer treatment.
http://whqlibdoc.who.int/publications/9241700483.pdf
• Zalcberg, J., Kerr, D., Seymour, L., & Palmer, M.(1998) Haematological and non-haematological toxicity
after 5-fluorouracil and leucovorin in patients with advanced colorectal cancer is significantly
associated with gender, increasing age and cycle number. European Journal of Cancer 34, (12), 1871-1875.