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Managing the Oral Effects of Cancer Treatment: Diagnosis to Survivorship Edited by Marilyn L. Haas, PhD, CNS, ANP-BC Deborah L. McBride, RN, MSN, CPON® Oncology Nursing Society Pittsburgh, Pennsylvania ONS Publications Department Interim Publisher and Director of Publications: Barbara Sigler, RN, MNEd Managing Editor: Lisa M. George, BA Technical Content Editor: Angela D. Klimaszewski, RN, MSN Staff Editor II: Amy Nicoletti, BA Copy Editor: Laura Pinchot, BA Graphic Designer: Dany Sjoen Copyright © 2011 by the Oncology Nursing Society. All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form, electronic or mechanical, including photocopying, recording, or by an information storage and retrieval system, without written permission from the copyright owner. For information, write to the Oncology Nursing Society, 125 Enterprise Drive, Pittsburgh, PA 15275-1214, or visit www.ons.org/publications. Library of Congress Cataloging-in-Publication Data Managing the oral effects of cancer treatment : diagnosis to survivorship / edited by Marilyn L. Haas and Deborah L. McBride. p. ; cm. Includes bibliographical references. ISBN 978-1-935864-03-5 (alk. paper) 1. Cancer--Nursing. 2. Cancer--Treatment--Complications. 3. Antineoplastic agents--Side effects. 4. Oral manifestations of general diseases. 5. Radiotherapy. I. Haas, Marilyn. II. McBride, Deborah L. III. Oncology Nursing Society. [DNLM: 1. Neoplasms--nursing. 2. Neoplasms--therapy. 3. Antineoplastic Agents--adverse effects. 4. Oral Manifestations. 5. Radiotherapy--adverse effects. WY 156] RC266.M355 2011 616.99’40231--dc22 2010052059 Publisher’s Note This book is published by the Oncology Nursing Society (ONS). ONS neither represents nor guarantees that the practices described herein will, if followed, ensure safe and effective patient care. The recommendations contained in this book reflect ONS’s judgment regarding the state of general knowledge and practice in the field as of the date of publication. The recommendations may not be appropriate for use in all circumstances. Those who use this book should make their own determinations regarding specific safe and appropriate patient-care practices, taking into account the personnel, equipment, and practices available at the hospital or other facility at which they are located. The editors and publisher cannot be held responsible for any liability incurred as a consequence from the use or application of any of the contents of this book. Figures and tables are used as examples only. They are not meant to be all-inclusive, nor do they represent endorsement of any particular institution by ONS. Mention of specific products and opinions related to those products do not indicate or imply endorsement by ONS. Web sites mentioned are provided for information only; the hosts are responsible for their own content and availability. Unless otherwise indicated, dollar amounts reflect U.S. dollars. ONS publications are originally published in English. Publishers wishing to translate ONS publications must contact ONS about licensing arrangements. ONS publications cannot be translated without obtaining written permission from ONS. (Individual tables and figures that are reprinted or adapted require additional permission from the original source.) Because translations from English may not always be accurate or precise, ONS disclaims any responsibility for inaccuracies in words or meaning that may occur as a result of the translation. Readers relying on precise information should check the original English version. Printed in the United States of America Oncology Nursing Society Integrity • Innovation • Stewardship • Advocacy • Excellence • Inclusiveness Recognizing that our patients travel many different paths during their oncology experience, oncology nurses are blessed to be their traveling companion. For my husband, who has traveled many of my professional paths, I now travel with him down his own cancer path. May this clinical information help us and others improve our care for patients dealing with oral oncology problems as they face their treatments. —Marilyn Louise Younghouse Haas, PhD, CNS, ANP-BC This book was inspired by my work caring for children with cancer. I hope it improves the care of both pediatric and adult patients who are dealing with the oral effects of cancer. I dedicate this book to my husband, Joe, the man whom I am blessed to have as a husband. I would like to thank him for his daily love and support. —Deborah L. McBride, RN, MSN, CPON® Contributors Editors Marilyn L. Haas, PhD, CNS, ANP-BC Deborah L. McBride, RN, MSN, CPON® Nurse Practitioner Carolina Clinical Consultant and CarePartners Supportive and Palliative Services Asheville, North Carolina Chapter 10. Developing a Nursing-Centered “Spray and Weigh” Program Assistant Professor of Nursing Samuel Merritt University Staff Nurse Kaiser Permanente Oakland Medical Center Oakland, California Chapter 15. Special Considerations in Pediatric Populations Authors Mary J. Bacon, MA, CCC-SLP, BRS-S Patricia C. Buchsel, MSN, RN, OCN®, FAAN Associate Professor/Clinical Educator Communication Disorders and Sciences Rush University Medical Center Chicago, Illinois Chapter 8. Speech, Voice, and Swallowing Problems: The Speech Pathologist’s Role Clinical Instructor Seattle University College of Nursing Seattle, Washington Chapter 17. Oral Health Across the Continuum of Care: A Symptom Cluster Model Ingrid Bowser, MS, APRN-BC, AOCNP®, ADM-BC Carrie F. Daly, RN, MS, AOCN® Oncology Nurse Manager/Advanced Practice Nurse Radiation Oncology Department Rush University Medical Center Chicago, Illinois Chapter 6. Xerostomia and Cytoprotection Nurse Practitioner Indiana University Health Goshen Center for Cancer Care Goshen, Indiana Chapter 7. Pain Management Susan D. Bruce, RN, MSN, OCN® Oncology Clinical Nurse Specialist Duke Raleigh Cancer Center Raleigh, North Carolina Chapter 3. Treatment of Side Effects v vi MANAGING THE ORAL EFFECTS OF CANCER TREATMENT: DIAGNOSIS TO SURVIVORSHIP Sarah D’Angelo, RN, BSc, BScN, MN, CON(C) Miranda J. Kramer, RN, MS, ACNP, CNS Vanna M. Dest, MSN, APRN, BC, AOCN® Kristen W. Maloney, MSN, RN, AOCNS® Oncology Nurse Practitioner CyberKnife Coordinator Cancer Genetics Testing Coordinator Hospital of Saint Raphael/Radiation Oncology Specialists of Southern Connecticut New Haven, Connecticut Chapter 1. Oral Health: The Basics Clinical Nurse Specialist, Rhoads Three Nursing Unit—Medical Oncology Hospital of the University of Pennsylvania Philadelphia, Pennsylvania Chapter 14. Considerations for Older Cancer Survivors—Aging, Comorbidity, and Cancer Treatment Catherine H.L. Hong, BDS, MS Maurene McQuestion, RN, BA, BScN, MSc, CON(C) Advanced Practice Nurse Educator Princess Margaret Hospital, University Health Network Toronto, Ontario, Canada Chapter 4. Evidence-Based Practice: Tools to Measure Progress Assistant Professor Department of Preventive Dentistry Faculty of Dentistry National University of Singapore Singapore Chapter 2. Fundamental Skills: Oral Assessment and Dental Hygiene Maureen B. Huhmann, DCN, RD, CSO Assistant Professor Department of Nutrition Sciences, School of Health Related Professions University of Medicine and Dentistry of New Jersey Cancer Institute of New Jersey New Brunswick, New Jersey Chapter 12. Paradigms of Eating Sarah H. Kagan, PhD, RN, AOCN ® Lucy Walker Honorary Term Professor of Gerontological Nursing School of Nursing Clinical Nurse Specialist Abramson Cancer Center University of Pennsylvania Philadelphia, Pennsylvania Chapter 14. Considerations for Older Cancer Survivors—Aging, Comorbidity, and Cancer Treatment Nurse Practitioner/Clinical Nurse Specialist Assistant Clinical Professor, Physiological Nursing University of California, San Francisco San Francisco, California Chapter 11. Sexuality and Quality of Life Clinical Nurse Specialist, Advanced Practice Nurse Princess Margaret Hospital, University Health Network Toronto, Ontario, Canada Chapter 4. Evidence-Based Practice: Tools to Measure Progress Katherine Katen Moore, MSN, ANP-C, AOCN® Associate Director, Student Health Services Drew University Madison, New Jersey Chapter 9. Complementary and Alternative Medicine and the Mouth Joel J. Napeñas, DDS Director, General Practice Residency Department of Oral Medicine Carolinas Medical Center Charlotte, North Carolina Chapter 2. Fundamental Skills: Oral Assessment and Dental Hygiene Maria Q.B. Petzel, RD, CSO, LD, CNSC Senior Clinical Dietitian Department of Clinical Nutrition University of Texas MD Anderson Cancer Center Houston, Texas Chapter 5. Nutrition Management Strategies for Oral Effects of Cancer Treatment CONTRIBUTORS vii Erika Schroeder, RN, MS, OCN®, CNL Mary Ellyn Witt, RN, MS, AOCN® Pamela Hallquist Viale, RN, MS, CS, ANP, AOCNP® M. Renee Yanke, ARNP, MN, AOCN® Manager, Clinical Trials Anne Arundel Health Systems Research Institute Annapolis, Maryland Chapter 13. Psychosocial Challenges Editor in Chief Journal of the Advanced Practitioner in Oncology Oncology Nurse Practitioner and Consultant Goleta, California Chapter 16. Second Primary Cancers and Recurrence Clinical Research Nurse Radiation Oncology University of Chicago Medical Center Chicago, Illinois Chapter 13. Psychosocial Challenges Oncology Program Manager, Oncology Advanced Practice Nurse Whidbey General Hospital Coupeville, Washington Chapter 9. Complementary and Alternative Medicine and the Mouth Disclosure Editors and authors of books and guidelines provided by the Oncology Nursing Society are expected to disclose to the readers any significant financial interest or other relationships with the manufacturer(s) of any commercial products. A vested interest may be considered to exist if a contributor is affiliated with or has a financial interest in commercial organizations that may have a direct or indirect interest in the subject matter. A “financial interest” may include, but is not limited to, being a shareholder in the organization; being an employee of the commercial organization; serving on an organization’s speakers bureau; or receiving research from the organization. An “affiliation” may be holding a position on an advisory board or some other role of benefit to the commercial organization. Vested interest statements appear in the front matter for each publication. Contributors are expected to disclose any unlabeled or investigational use of products discussed in their content. This information is acknowledged solely for the information of the readers. The contributors provided the following disclosure and vested interest information: Marilyn L. Haas, PhD, CNS, ANP-BC: MedPharma and Meniscus Educational Institute, honoraria Carrie F. Daly, RN, MS, AOCN®: Roche, consultant; IMER, honoraria Vanna M. Dest, MSN, APRN, BC, AOCN®: EUSA Pharma and Myriad Laboratories, honoraria Pamela Hallquist Viale, RN, MS, CS, ANP, AOCNP®: Meniscus Educational Institute and Novartis, consultant; Amgen, Bristol-Myers Squibb, IMER, Meniscus Educational Institute, Merck, and Novartis, honoraria M. Renee Yanke, ARNP, MN, AOCN®: Novartis, consultant, honoraria Contents Preface...................................................................................................................................................... xv Chapter 1. Oral Health: The Basics 1 Introduction............................................................................................................................................. 1 History of Oral Care.............................................................................................................................. 1 Epidemiology of Oral Diseases......................................................................................................... 2 Anatomy of the Oral Cavity................................................................................................................ 5 Common Oral Conditions................................................................................................................... 8 Oral Health and Overall General Health.....................................................................................11 Common Oral Manifestations of Systemic Medical Diseases.............................................12 Oral Manifestations During Women’s Reproductive Years..................................................20 Maintenance of Oral Hygiene and Health..................................................................................21 Conclusion..............................................................................................................................................21 References...............................................................................................................................................22 Chapter 2. Fundamental Skills: Oral Assessment and Dental Hygiene 25 Introduction...........................................................................................................................................25 History Taking........................................................................................................................................25 Diagnostic and Assessment Tools.................................................................................................32 Dental Care in Patients With Cancer ...........................................................................................39 Barriers to Dental Care.......................................................................................................................43 Conclusion..............................................................................................................................................44 References...............................................................................................................................................44 Chapter 3. Treatment of Side Effects 47 Introduction...........................................................................................................................................47 Oral Mucositis.......................................................................................................................................47 Xerostomia and Hyposalivation.....................................................................................................52 Chronic Graft-Versus-Host Disease...............................................................................................55 Dental Caries and Periodontal Disease ......................................................................................56 ix x MANAGING THE ORAL EFFECTS OF CANCER TREATMENT: DIAGNOSIS TO SURVIVORSHIP Taste Changes........................................................................................................................................57 Persistent Dysphagia..........................................................................................................................60 Trismus.....................................................................................................................................................60 Fungal Infections..................................................................................................................................62 Osteoradionecrosis..............................................................................................................................62 Osteonecrosis........................................................................................................................................63 Conclusion..............................................................................................................................................64 References...............................................................................................................................................64 Chapter 4. Evidence-Based Practice: Tools to Measure Progress 69 Introduction...........................................................................................................................................69 Evidence-Based Practice...................................................................................................................70 Types of Tools........................................................................................................................................71 Description and Critique of Specific Tools ................................................................................78 Special Populations and Considerations.....................................................................................85 Naturopathic, Complementary, and Alternative Medicine..................................................86 Conclusion..............................................................................................................................................87 References...............................................................................................................................................88 Chapter 5. Nutrition Management Strategies for Oral Effects of Cancer Treatment 93 Introduction...........................................................................................................................................93 Mucositis.................................................................................................................................................94 Xerostomia.............................................................................................................................................97 Dysgeusia and Hypogeusia..............................................................................................................98 Dysphagia...............................................................................................................................................99 Other Oral Effects of Treatment.....................................................................................................99 Nutrition Support............................................................................................................................. 100 Conclusion........................................................................................................................................... 101 References............................................................................................................................................ 101 Chapter 6. Xerostomia and Cytoprotection 103 Introduction........................................................................................................................................ 103 Sjögren Syndrome of the Oral Cavity........................................................................................ 106 Review of Oral Cancers................................................................................................................... 107 Treatment for Oral Cancers........................................................................................................... 109 Advances in Radiation Therapy................................................................................................... 111 Cytoprotection................................................................................................................................... 114 Quality of Life..................................................................................................................................... 118 Conclusion........................................................................................................................................... 118 References............................................................................................................................................ 119 Chapter 7. Pain Management 125 Introduction........................................................................................................................................ 125 Causes of Oral Pain.......................................................................................................................... 125 CONTENTS xi Assessment.......................................................................................................................................... 127 Interventions for Oral Pain............................................................................................................ 128 Other Treatments.............................................................................................................................. 135 Barriers to Pain Management....................................................................................................... 140 Conclusion........................................................................................................................................... 143 References............................................................................................................................................ 143 Chapter 8. Speech, Voice, and Swallowing Problems: The Speech Pathologist’s Role 147 Introduction........................................................................................................................................ 147 Common Speech, Voice, and Swallowing Problems Related to Radiation Therapy and Chemotherapy for Oral and Oropharyngeal Cancers........................ 148 Pretreatment Involvement of Speech Pathology.................................................................. 149 Speech Pathology Evaluations..................................................................................................... 149 Speech Pathology Treatment....................................................................................................... 151 Conclusion........................................................................................................................................... 154 References............................................................................................................................................ 155 Chapter 9. Complementary and Alternative Medicine and the Mouth 157 Introduction........................................................................................................................................ 157 Definitions............................................................................................................................................ 159 Evidence for Use................................................................................................................................ 159 Interventions for Dysgeusia.......................................................................................................... 160 Interventions for Oral Mucositis................................................................................................. 160 Interventions for Orofacial Pain (Excluding Oral Mucositis)............................................. 168 Interventions for Xerostomia....................................................................................................... 168 Conclusion and Nursing Implications....................................................................................... 170 References............................................................................................................................................ 171 Chapter 10. Developing a Nursing-Centered “Spray and Weigh” Program175 Introduction........................................................................................................................................ 176 Oral Cavity Assessment.................................................................................................................. 177 Symptom Assessment..................................................................................................................... 182 Dental Health...................................................................................................................................... 183 Oral Hygiene at Home.................................................................................................................... 183 Conclusion........................................................................................................................................... 183 References............................................................................................................................................ 184 Chapter 11. Sexuality and Quality of Life 185 Introduction........................................................................................................................................ 185 Factors in Sexuality........................................................................................................................... 185 xii MANAGING THE ORAL EFFECTS OF CANCER TREATMENT: DIAGNOSIS TO SURVIVORSHIP Patient Oral Symptoms and Their Effects on Sexuality and Intimacy........................... 186 Assessing Sexual Health................................................................................................................. 188 Assessments and Interventions................................................................................................... 189 Conclusion........................................................................................................................................... 191 References............................................................................................................................................ 191 Chapter 12. Paradigms of Eating 193 Introduction........................................................................................................................................ 193 Diet Following Chemotherapy..................................................................................................... 193 Bisphosphonate-Associated Osteonecrosis........................................................................... 194 Stem Cell Transplantation and Oral Development............................................................... 194 Diet Following Radiation Therapy.............................................................................................. 196 Diet Following Surgery: Dysphagia............................................................................................ 199 Conclusion........................................................................................................................................... 200 References............................................................................................................................................ 200 Chapter 13. Psychosocial Challenges 205 Introduction........................................................................................................................................ 205 Oral Complications of Survivorship .......................................................................................... 207 Financial Challenges........................................................................................................................ 209 Assessment Tools.............................................................................................................................. 212 Screening Tools for Patients With Oral Complications....................................................... 214 Additional Resources....................................................................................................................... 217 Conclusion........................................................................................................................................... 218 References............................................................................................................................................ 218 Chapter 14. Considerations for Older Cancer Survivors— Aging, Comorbidity, and Cancer Treatment 221 Introduction........................................................................................................................................ 221 Oral Health and the Aging Population..................................................................................... 222 Oral Health Problems Among Older Adults........................................................................... 223 Considerations in Assessment and Intervention for Oral Effects in Older Survivors......................................................................................................................................... 231 Conclusion........................................................................................................................................... 232 References............................................................................................................................................ 232 Chapter 15. Special Considerations in Pediatric Populations 237 Introduction........................................................................................................................................ 237 Oral Complications Associated With Cancer Treatment in Children............................. 238 Pediatric Oral Assessment Tools.................................................................................................. 242 Infections Associated With Cancer Treatment....................................................................... 242 Salivary Gland Dysfunction........................................................................................................... 244 Oral and Dental Management..................................................................................................... 244 Oral Care After Cancer Treatment.............................................................................................. 245 CONTENTS xiii Conclusion........................................................................................................................................... 247 References............................................................................................................................................ 247 Chapter 16. Second Primary Cancers and Recurrence 251 Introduction........................................................................................................................................ 251 Scope of the Problem...................................................................................................................... 251 Chemoprevention............................................................................................................................. 255 Fear of Recurrence and Psychosocial Effect on Patients With Oral Cancer................ 256 Nursing Implications........................................................................................................................ 257 Conclusion........................................................................................................................................... 258 References............................................................................................................................................ 259 Chapter 17. Oral Health Across the Continuum of Care: A Symptom Cluster Model 263 Introduction........................................................................................................................................ 263 Major Advances in Treatment of Oral Problems in Cancer Treatments....................... 264 Clinical and Functional Impairments......................................................................................... 265 Prevention and Early Detection of Oral Complications .................................................... 265 Oral Care Protocols ......................................................................................................................... 266 Symptom Clusters ........................................................................................................................... 271 Case Study in an Allogeneic Hematologic Stem Cell Transplant Recipient................ 272 Conclusion........................................................................................................................................... 276 References............................................................................................................................................ 276 Index281 Preface The mouth is a “mirror”: the oral cavity can reflect the general health of a patient and reveal toxicities from oncology treatments. Oral diseases may not be life threatening, but they can have systemic effects and greatly affect a person’s quality of life. Oral cancers can be devastating, and the toxicities from oncology treatments can compound problems already experienced by patients who suffer from poor oral health and periodontal diseases. Concomitant high-dose radiation therapy and chemotherapy (targeted therapies) improves locoregional control of cancers but increases toxicities. Oral health becomes one of the primary responsibilities of the entire multidisciplinary team. Healthcare providers should employ interventions that prevent oral problems or anticipate oral side effects and be aggressive in treating the problems so as to not delay or interrupt therapy. Once the patient has completed therapy, follow-up over time is extremely important to maintain oral health. This is the first oncology textbook available to guide physicians, nurse practitioners/physician assistants, and nurses who care for patients with cancer through the management of oral health problems. Comprehensive information about evidence-based principles and practice guidelines in caring for the oncology patient who has developed oral problems is presented. Managing the Oral Effects of Cancer Treatment: Diagnosis to Survivorship begins with an indepth discussion about the fundamental skills of oral assessment and dental hygiene, treatment side effects as they relate to the oral cavity, management strategies, and insight into survivorship issues. Initial chapters will discuss general overall oral health care, explain the necessary fundamental skills to perform a comprehensive oral assessment, and explain oral side effects from oncology treatments. Evidence-based tools to describe the progress back toward oral health will be shared. The second section will discuss management strategies to improve nutrition status, identify advantages of cytoprotection interventions, and gain control over pain issues. Speech therapy resources, complementary therapies, and an innovative mini-oral clinic will be discussed to improve the patient’s tolerance with onxv xvi MANAGING THE ORAL EFFECTS OF CANCER TREATMENT: DIAGNOSIS TO SURVIVORSHIP cology treatments. Finally, the third section will provide in-depth insight into survivorship issues, sexuality, changing eating habits, psychosocial issues, older adult and pediatric challenges, recurrent cancers, and a symptom cluster model of care. This textbook shares the efforts of many authors to synthesize scientific information to support patients toward better oral health care. Applying oral healthcare principles will improve the quality of care for patients with cancer.