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Royal United Hospital Bath NHS Trust
Prevention and Treatment of Stomatitis & Mucositis in patient receiving chemotherapy
Prevention and Treatment of Stomatitis & Mucositis in patient
receiving chemotherapy
Reference Number:
406 2006
Author / Manager Responsible:
Karen Skelley
First Reviewed:
November 2005
Next Review Date:
December 2008
Ratified by:
Oncology / Haematology Drugs and
Therapeutic Committee
Date Ratified:
December 2005
Related Policies
Version 2 Local Policy
Oncology/ Haematology Department
Page 1 of 12
Royal United Hospital Bath NHS Trust
Prevention and Treatment of Stomatitis & Mucositis in patient receiving chemotherapy
INDEX
Section
Policy -
Page
-
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4
Introduction -
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4
Definition
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4
Standard Mouth care Protocol
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4
Health Promotion
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5
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Increased Risk Factors for Mucositis/Stomatitis
5
List of Stomatotoxic drugs -
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-
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7
Specific Interventions
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8
Individual Interventions
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9
Lips / Corners of mouth
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9
Candida / Infection -
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9
Tongue
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9
Dry mouth
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9
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10
Swallowing or chewing
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10
Comfort
Teeth/dentures
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-
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10
References -
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11
Version 2 Local Policy
Oncology/ Haematology Department
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Royal United Hospital Bath NHS Trust
Prevention and Treatment of Stomatitis & Mucositis in patient receiving chemotherapy
CONSULTATION AND RATIFICATION SCHEDULE
Name and Title of Individual
Date Consulted
Rosie Simpson Oncology Pharmacist
Maggie Crowe Nurse consultant
Caroline Gilleece Matron Oncology/ Haematology
Dept
Dr Gliby Oncologist
November 2005
November 2005
November 2005
Name of Committee
Drug and Therapeutic Meeting
Date of Committee
24/11/05
October 2005
Version 2 Local Policy
Oncology/ Haematology Department
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Royal United Hospital Bath NHS Trust
Prevention and Treatment of Stomatitis & Mucositis in patient receiving chemotherapy
POLICY
INTRODUCTION
The evidence suggests that stomatitis and mucositis is not preventable in patients receiving
chemotherapy, but its severity can be minimized through the implementation of effective oral
health practices (Kennedy and Diamond 1997). A realistic objective is to reduce the severity
and duration of stomatitis / mucositis and to minimize the complications of pain, oral and
systemic infection, bleeding and malnutrition. To achieve this, it is important to:
Identify those patients at risk of developing oral complications as soon as possible.
Have a knowledge and understanding of chemotherapy agents used and their effects.
The most important factor in oral care is the frequency rather than product used. It is also
important the mouth is kept moist and free from debris (Campbell at al, 1995).
DEFINITION:
Mucositis:
Oral mucositis is soreness, inflammation or ulceration of the mouth lining, which can cause pain
and discomfort. These ulcers can become infected and bleed. The pain can be severe enough
to make eating or drinking very difficult.
Stomatitis:
Stomatitis is a general term applied to diffuse inflammatory, erosive and ulcerative condition
affecting the mucous membranes lining the mouth. Which may involve the cheeks, gums,
tongue, lips, and roof or floor of the mouth?
STANDARD MOUTHCARE PROTOCOL
All patients will have an oral assessment undertaken with each cycle or daily for inpatients:
a) To identify usual oral care routine
b) To identify the advice/care required to maintain or promote individual oral hygiene.
 The Oral Assessment Guide using Modified Jenkins Mouth care Assessment Tool should be
implemented for all patients identified with problems or at high risk, and assessment undertaken
daily
Teeth and tongue should be cleaned twice daily with a medium small head toothbrush and
fluoride toothpaste. The mouth should be rinsed thoroughly with water after cleaning
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Prevention and Treatment of Stomatitis & Mucositis in patient receiving chemotherapy
Dentures should be
a) Removed a minimum of twice a day, cleaned with a brush and rinsed with water
b) Soaked overnight in water or the patient’s usual solution, cleaned with a brush and rinsed
prior to putting back into patient’s mouth
Adequate oral fluid intake and self care measures should be encouraged and the necessary
Equipment/Information/Education provided to meet individual needs
Care should be negotiated with the patient and the level of assistance required identified
HEALTH PROMOTION
Prior to commencement of treatment (where possible)
a) Ensure all head and neck patients (excluding Larynx) have been referred to Head and Neck
Clinical Nurse Specialist.
b) Ensure all head and neck patients are referred to Dietician
c) Ensure appropriate chemotherapy patients identified at increased risk of mucositis are
referred Dietician
Encourage, six monthly visits to the dentist. Advise patients to seek advice prior to
undergoing any ongoing treatment
Encourage patient to stop smoking and drinking alcohol
 General advice with regards to sugary snacks
INCREASED RISK FACTORS FOR MUCOSITIS/ STOMATISIS
Cancer of the head and neck
Intensive chemotherapy regimes/Bone marrow transplantation /Leukaemia
Elderly and children
Deficits in self care ability
Altered fluid or nutritional status (dehydration, malnutrition)
Receiving certain medications, particularly steroids
Exposed to additional stressors (alcohol, tobacco, drugs, oxygen therapy)
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Prevention and Treatment of Stomatitis & Mucositis in patient receiving chemotherapy
Liver/renal impairment
Previous experience of mucositis
Receiving Stomatotoxic drugs
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Oncology/ Haematology Department
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Royal United Hospital Bath NHS Trust
Prevention and Treatment of Stomatitis & Mucositis in patient receiving chemotherapy
LIST OF STOMATOTOXIC DRUGS
Moderate risk
Bleomycin
Cytarabine
Dactinomycin
Mitomycin-C
Paclitaxel
Ralititrexed
Thioguanine
Vinblastine
High risk
Capecitabine
Docetaxel
Doxorubicin
Epirubicin
Fluorouracil
Liposomal Doxorubicin
High dose Melphalan
Methotrexate
6 Mercaptopurine
Idarubicin
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Prevention and Treatment of Stomatitis & Mucositis in patient receiving chemotherapy
SPECIFIC INTERVENTIONS
Specific Interventions
Mucous Membranes Assessment Chemotherapy;
:
Score 1-7
Follow standard mouth care protocol.
Use soft toothbrush whilst
Healthy Mouth
Neutropenic
Score 7-14
Mild – Moderate Mucositis
Continue Standard mouth care
protocol, increasing tooth brushing to
follow meals and at bed time. Use
soft toothbrush
Painless ulcers with erythema or mild
soreness in the absence of lesions
or
Painful erythema, oedema or ulcers
but can eat or swallow
Score 14-21
+
Introduce chlorhexidine mouthwash
twice daily for all patients if able to
tolerate
+
Refer to Consultant / Registrar for
appropriate antifungal / antibacterial
/antiviral agents
Continue standard mouth care
protocol as long as possible.
Severe Mucositis
Severe ulceration or requires
parenteral or enteral nutritional
support
+
Continue chlorhexidine mouthwash
twice or QDS if patient is neutropenic
daily if able to tolerate.
+
Refer to Consultant / Registrar for
appropriate antifungal / antibacterial
/antiviral agents
+
Intravenous fluids / parenteral support
may be required
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Prevention and Treatment of Stomatitis & Mucositis in patient receiving chemotherapy
INDIVIDUAL INTERVENTIONS
Lips / corners of mouth:
Use yellow soft paraffin as a moisturizer for lips. Use sparingly – Do not apply directly before
radiotherapy treatment as it will act as another layer of skin, resulting in potentially affecting the
depth of treatment.
Observe for herpes simplex and refer to Consultant / Registrar for appropriate antiviral agent.
Candida / Infection:
Observe for white patches or creamy white areas. These could be an indication of infection,
thrush or radiation plaque (fibrin)
Monitor for any signs of halitosis – Oraldene mouthwash may be effective
Refer to Consultant / Registrar for appropriate antifungal / antibacterial /antiviral agents.
Tongue:
Blistered / Cracked
Increase fluid intake, particularly water
Ensure adequate analgesia
Encourage the use of mouthwashes
Dry Mouth (xerostomia)
Increase fluid intake
Increase use of sauces, gravies etc
Consider use of crushed ice, artificial saliva and sugar free chewing gum. Note, if ice pops are
used, use sugar free juice. Patients often find sucking boiled sweets helpful. Encourage low
sugar variety in dentulous patients.
Avoid citrus drinks if this causes further pain or discomfort.
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Prevention and Treatment of Stomatitis & Mucositis in patient receiving chemotherapy
Teeth / Dentures:
Ensure any patients with loose teeth, ill fitting dentures or caries are encouraged to see their
dentists.
Encourage patient to remove dentures overnight and soak in water or patients usual solution.
Swallowing or chewing:
Consider nutritional impact. Commence nutritional care plan. Ensure referral to dietician.
Comfort: There are a range of interventions which help to reduce
discomfort/pain, depending on severity. Information is given on some of the
most common preparation, when and how they should be given
comments
Give ½ an hour before meals and
Paracetamol mixture Dispersible
before. Do not exceed maximum
4grams daily dose and do not take
with other medicines containing
paracetamol
10mls as required 4 x daily. ½hour
Benzydamine (Difflam) before meals. Can cause stinging.
May be diluted 50/50 with water. Use
for 7 consecutive days only.
Tolerance may develop
Use before meals. May have some
Sucralfate Suspension 1g in 5mls
prophylactic value and promote
healing / reduce severity of mucositis.
Use as a mouthwash (swish and spit
out) or swallow to relieve oral
discomfort.
If pain still not under adequate control, consider adding:
Dispersible co-codamol 30/500
Monitor bowel function as aperients may need to be titrated accordingly. Can
be given 4-6 hourly but do not exceed maximum daily dose. 8tablets/daily
If pain control still ineffective move onto opioids either orally or by
subcutaneous injection
Controlled systemic analgesia
Oramorph
Zormorph
Monitor bowel function as aperients
may need to be titrated accordingly.
Diamorphine subcutaneous pump
or equivalent
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Prevention and Treatment of Stomatitis & Mucositis in patient receiving chemotherapy
REFERENCES
Clarkson J E, Worthington H V, Eden OB, (2003) Interventions for preventing oral mucositis for
patients with cancer receiving treatment (Cochrane Review). The Cochrane Library, Issue 4,
Chichester, UK: John Wiley & Sons
Campbell S J, Evans M A and MacTavish F. (1995). Guidelines for mouth care.
Second Edition. The Royal College of Nursing. Paediatric Oncology Nursing Forum.
Dose A. M. (1995) the symptom experience of mucositis, stomatitis and xerostomi. Seminars in
oncology nursing. Vol.11.no.4. pp248-255
Kennedy L and Diamond J. (1997) Assessment and management of chemotherapy induced
mucositis in children. Journal of paediatric oncology nursing. Vol. 14
Version 2 Local Policy
Oncology/ Haematology Department
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Royal United Hospital Bath NHS Trust
Prevention and Treatment of Stomatitis & Mucositis in patient receiving chemotherapy
CONSULTATION CHECKLIST
Author, please attach this to each copy of the policy being sent to a meeting for
comments.
Dear Chairman, please would you review this policy at your committee and return any
amendments / comments to ____________________________ by _____ / _____ / _____
Title of meeting Oncology / Haematology _Drugs and therapeutic committee
Date of meeting 24th November 2005 _____
The name of policy Prevention and Treatment of Stomatitis & Mucositis in patient receiving
chemotherapy
Name of author
Karen Skelley
Yes
Are there any elements of this policy which present operational
issues that require further discussion? If yes, please provide a
contact name for the author.
___________________________________
Is the policy referenced?
No
N/A
✔
✔
Does the policy include a training plan?
✔
If you are the appropriate forum, have the necessary
resources been agreed to implement this policy?
Is there a plan for policy implementation?
Does your meeting recommend further consultation with
groups or staff other than listed at the front of the policy?
Other comments
from meeting.
Policy accepted without further comment. (Please circle)
Policy needs further amendment. (Please circle)
✔
✔
Yes / No
Yes / No
Name of Chris Knechtli Clinical Lead Oncology / Haematology
Signature ______________________________
Date _____ / _____ / _____
Rosie Simpson Chair of Oncology / Haematology Drugs Therapeutic Committee
Signature ______________________________
Date _____ / _____ / _____
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