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oral mucositis in the cancer patient a tutorial

ORAL Mucositis in the cancer patient:A Tutorial

By Monique Swiecichowski, BSN,RN,CCRC

Alverno College

Picture from Microsoft Clipart

navigation
Navigation

Click on arrow to move back a slide

Click on arrow to move forward a slide

Click on underlined arrow to return to beginning slide

Click on house to return to topic page

TOPICS

Click on desired topic to go directly to content

Word

Role over underlined words for definitions or explanations

V

Click on V to see video depiction on YouTube.

Sound is recommended. Exiting out of or minimizing

YouTube video will return you to the slide you were on.

*** Hint: ‘finger pointing hand’ must be visible

when clicking for commands to work

slide3

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
slide4

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?
slide5

TOPICS

REVIEW

PATHOBIOLOGY

CAUSES and RISK FACTORS

GENETICS

ASSESS and DOCUMENT

IMPLICATIONS

INTERVENTIONS

REFERENCES

slide6

REVIEW

layers of the oral mucosa

Stratified squamous cells

---Oral epithelium

---Basement

membrane---

Loose connective tissue under epithelium containing capillaries and gland ducts

----Lamina propia

Minor salivary glands, striated muscle, fat, fibroblasts, endothelial cells, nerves, and inflammatory cells

------submucosa

Muscle or bone

slide7

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

slide8

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

slide9

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
slide10

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

Sonis et al., 2004

  • Working model of mucositis=5 phases
      • Initiation
      • Upregulation
      • Signaling and Amplification
      • Ulceration
      • Healing
slide11

Phase I: Initiation

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

Radiation will stimulate nuclear factor-kappaB

NF-kB

RT or CT causes direct damage to DNA resulting in cell death

Chemotherapy will stimulate

Ceramidesynthase

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

slide12

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

slide13

Phase II: Upregulation (cont’d)

  • Additional pathways resulting in damage

Do you

remember

the previous

Phase? Click

for a

reminder.

Initiation

Damaged cell membranes stimulate sphingomyelinase

fibronectin break-up leads to increased macrophages, and tissue damage or eventual apoptosis

Ceramide pathway signals cells to enter apoptosis

(V1 )

Excessive apoptosis and/or decreased clearance of apoptotic cells induce secretion of other pro-inflammatory cytokines

Gupta, 2006

Diagram used with permission by John Wiley and Sons

Sonis et al., 2004; Sonis, 2007

V1: Alberts et al, 2002

slide14

Phase III: Signaling and Amplification

        • Day 4-8
        • Pro-inflammatory cytokines= positive feedback loops re-initiating the damage response pathways
        • Mucosal surface still appears clinically normal

Initiation

Upregulation

Do you

remember the

previous Phases?

Click for a

reminder.

NF-kB activates cyclooxygenase-2 (Cox-2) and produces prostaglandins resulting in inflammatory mediation and angiogenesis (V2)

TNF-Alpha activates NF- kB which activates more TNF

**RT induced FEEDBACK LOOP**

PROCESS (cont’d)

MMPdegrades the extracellular matrix (ECM); ECM begins to swell with fluid (inflammatory response)

Tumor Necrosis Factor (TNF)-alpha stimulates apoptosis and sphingomelinase

**Chemo induced FEEDBACK LOOP**

Diagram used with permission by John Wiley and Sons

Sonis et al., 2004; Sonis, 2007

V2: Alberts et al., 2009

slide15

Phase IV: Ulceration

        • Day 8-12
        • Cell death, reduced epithelial regeneration, and apoptosis thin the epithelium
        • Characterized by inflammation and ulceration

Do you

remember

the previous

Phases? Click

for a

reminder.

I. Initiation

II. Upregulation

III. Signaling & amplification

Breakdown of mucosa=ulcers

Bacteria penetrate the submucosa

and stimulate macrophages to

produce and release additional

pro-inflammatory cytokines.

Pro-inflammatory cytokines

Stimulate inflammatory responses.

Bacteria and debris are removed and factors are released to promote proliferation

V3/ V4

Diagram used with permission by John Wiley and Sons

Sonis et al., 2004; Sonis, 2007

V3: http://www.youtube.com/watch?v=CmbWE3jLUgM

V4: http://www.youtube.com/watch?v=uNG-jZxvhcg

slide16

Do you

remember

the previous phases? Click

for a

reminder.

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

Wound repair

V5

V5: Alberts, 2009

Sonis et al., 2004; Sonis, 2007

slide17

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

A

B

C

A

B

C

A

B

C

A

B

C

E

F

E

F

D

E

F

D

E

F

D

E

F

D

E

F

Pre treatment

Phase I

Phase II

Phase III

Phase IV

Phase V

A.Upregulation

B. Healing

C. Signaling and Amplification

D. Initiation

E. Ulceration

F. Normal

Diagram used with permission by Sonis, 2007

slide18

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

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

True

False

slide19

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
slide20

RISK FACTORS (cont’d)

  • #2 Patient-related variables
      • AGE
  • 1.Csiszar ,2008; 2. Niscola et al.,2007; 3.Sonis , 1998; 4. Treister & Woo, 2010; 5.Zalcberg , Kerr, Seymour, & Palmer, 1998
  • 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
slide21

RISK FACTORS (cont’d)

  • #2 Patient-related variables
  • Barasch & Peterson, 2003
  • SALIVARY FUNCTION
    • xerostomia predicts mucositis
      • hyposalivation can be caused by anxiety/stress,medications, alcohol, depression, endocrine disorders, nerve damage from surgery, oxygen, dehydration, tobacco
      • Obstructive nasal disease
  • ORAL HEALTH
    • Poor baseline oral status exacerbates mucositis
      • ill-fitting prostheses or faulty restorations
      • Pre-existing oral infections (viral or fungal)
      • Dental disease
slide22

RISK FACTORS

    • GENETICS
  • Microsoft ClipArt
      • May explain why patients of the same age, treatment regimens,
      • and equivalent oral health status vary in the incidence of mucositis
    • deficiencies of enzymes due to polymorphisms = greater risk of mucositis
    • variations in the metabolism of chemotherapy= different rates of mucositis
    • variations in apoptotic activity = variations in risk
    • Mice with deficiency in the acidic sphingomyelase gene= increased resistance
    • to mucositis
    • Sonis et al., 2004
  • 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
slide23

Testing your knowledge

What are the risk actors associated with mucositis?

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

CLICK WHEN READY TO SEE ANSWERS

slide24

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)

True

False

The radiation and cisplatin will put Mr. M at risk.

True

False

Geneticswill play a role in mucositis.

True

False

Mr. M likely has excellent oral health so is

not a risk for mucositis.

True

False

Mr. M is too old to be at risk.

True

False

Mr. M does not evidence any behaviors to

be concerned about xerostomia.

slide25

ASSESSMENT

    • Pretreatment-stratify risk based on:
  • Each visit: during treatment
  • treatment plan
  • level of xerostomia
  • list of prescribed and over-the-counter medications
  • baseline oral hygiene
  • Examine the lips, tongue, and oral mucosa (after removing dental appliances): Color, moisture, integrity, cleanliness
  • *Adequate illumination; halogen light sources provide consistent intensity and color
  • Sonis et al., 2004
  • Assess for changes: in taste, voice, ability to swallow
  • Examine the saliva: for amount and quality
  • Assess oral pain (0-10 scale)
  • Document all of the above

MicrosoftClipArt

  • Polovich , Whitford, & Olsen , 2009
slide26

DOCUMENTATION

A wide variety of scales have been developed focusing on symptomatic and

functional outcomes:

World Health Organization (WHO)-Oral Mucositis

National Cancer Institute Common Toxicity Criteria (NCI-CTC)-Oral Mucositis

Microsoft ClipArt

slide27

DOCUMENTATION (cont’d)

Another all inclusive Oral Assessment Guide

The key is for all caregivers to consistently use an accepted grading scale throughout all patient’s treatments.

Microsoft ClipArt

Modified from the Oral Assessment Guide with permission by

J. Eilers RN,MSN, UNIVERSITY OF NEBRASKA MEDICAL CENTER, 83 Rev 2-84, 5-84, 4-85, 11-85, 4-86

jeilers@nebraskamed.com

Click here to see original

Oral Assessment Guide with pictures

slide28

ASSESSMENT AND DOCUMENTATION

Let’s focus on the NCI-CTC version 3.0

Microsoft ClipArt

This scale is the most used in documenting the assessment of a patient’s lips, tongue and oral mucosa.

But what else should be assessed and documented? (Click to find out.)

Changes in taste and voice, amount and quality of saliva,

oral pain. As well as vital signs for signs of infection and dehydration.

slide29

ASSESSMENT AND DOCUMENTATION

Grade 0

Grade 1

Erythema/minimalsymptoms, normal diet

Normal/No symptoms

Grade 2

Grade 3

Patchy ulcerations or pseudomembranes/ symptomatic but can eat and swallow modified diet

Confluent ulcerations or pseudomembranes (contiguous patches > 1.5 cm in diameter)/Symptomatic and unable to adequately ailment or hydrate orally

G 0 from Microsoft ClipArt/ G1-4 photos used with permission from

EUSA Pharma @ www.caphosol.com/patients/oral-mucosiis/index.php

slide30

ASSESSMENT AND DOCUMENTATION

(cont’d)

Grade 4

Grade 5

DEATH

(indirectly from mucositis: sepsis and other treatment related side effects)

Tissues necrosis; significantspontaneous bleeding/symptoms associated with life-threatening consequences

slide31

Testing your knowledge

Grade 3

Pseudomembranes; bleeding with minor trauma

Grade 2 or 3

Depending on extent and intake ability

Grade 4

Tissue necrosis and spontaneous bleeding;

life-threatening especially for bone marrow transplant patients and other immunosupressed patients

Grade 0

Not mucositis-

Hairy tongue: decreased salivary flow causes debris that is normally washed away by saliva builds up in the oral cavity.

Grade 2

Can eat a modified diet

Grade 1

Erythema:

Eating a normal diet

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

Images reprinted with permission from Medscape.com, 2011. Available at:

http//emedicine.medscape.com/article/1079570-overview

slide32

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

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 life-threatening

4

He is still alive!!!

5

photo used with permission from

EUSA Pharma @ www.caphosol.com/patients/oral-mucosiis/index.php

slide33

WHY IS IT IMPORTANT?

  • AFFECTS PATIENT OUTCOMES
    • Decreases the efficacy of RT, chemotherapy, and chemo/RT
    • Studies indicate this is due to:
  • Rosenthal, 2007
  • 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
  • -Tumor growth during the breaks
  • -a dose-response threshold; increases in the dose are needed for tumor control
slide34

IMPLICATIONS

  • PAIN
    • “…reported as the most distressing symptom by patients receiving treatment for head and neck cancer...” Harris (2006, p.252)
    • Domino affect:
    • Fatigue
    • PAIN Reduced oral intake Weight Loss/Malnutrition
  • Death
    • If severe enough requires opiods
  • Keefe et al., 2007
slide35

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
slide36

IMPLICATIONS (cont’d)

              • ECONOMIC IMPACT
              • Ulceration
  • Local infection Reduced oral intake
  • Systemic infection Pain Malnutrition/dehydration
  • IV antibiotics IV opiods TPN/feeding tube
  • ?Hospitalization?
slide37

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
slide38

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
slide39

Testing your knowledge

Which of the following implications of severe mucositis could affect our patient Mr. M? (Click on the best answer.)

True

False

Severe mucositis would not affect M. M’s quality of life.

True

False

Treatment breaks due to toxicity might affect his cancer outcomes and compliance to therapy.

True

False

Infections are a very real issue with severe mucositis.

True

False

Severe mucositis would not have any nutritional

implications.

True

False

Severe mucositis could place significant financial burden on Mr. M.

slide40

INTERVENTIONS

  • Before therapy begins
  • Evidenced-based
  • Comprehensive oral/dental consult
  • Oral cleaning
  • Removal of excess plaque
  • Treatment of all dental caries
  • Extraction of teeth with poor prognosis
  • Check prosthesis fit
  • Consider a fluoride tray

Microsoft clipart

Bhatt et al., 2010; Bensinger, 2008

slide41

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

slide42

INTERVENTIONS: cont’d

During therapy

Evidenced-based

  • Nursing interventions

Microsoftclipart

  • 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
slide43

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

slide44

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

slide45

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

Eaton, 2009 & Bensinger, 2008

slide46

INTERVENTIONS

Review

(click on box to review)

DENTAL CARE

Oral cleaning

Removal of excess plaque

Treatment of cavities

Pull teeth as needed

Check fit of dentures and partials

PATIENT EDUCATION

Mouth care

Recommended intake

Food, behaviors, and products to avoid

NURSING INTERVENTIONS

EDUCATION

Cryotherapy

Mouth rinses

Honey?

MEDICAL INTERVENTIONS

Palifermin

CRT or 3D-CRT

LLLT

Gelclair?

slide47

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
slide48

Xerostomia Management

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

Microsoft clipart

Eaton, 2009 & Strohl, 2006

slide49

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

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?

Preventative therapies

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?

Dentalexam

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

Patient education

Very important for quality of life and although nursing is important for assessing pain at onset most treatments involve prescribe medications. Anything else?

Pain management

slide50

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

  • Assisted Mr. M in making a dental appointment?

YES

NO

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

YES

NO

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

YES

NO

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

YES

NO

  • Pain assessment and management such as
  • topical swish and spit medications?
great job
GREAT JOB!

Microsoft clipart

Thank you for viewing this tutorial

For questions or comments: swiecime@alverno.edu

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