Brushing Up on Mouth Care for Cancer Patients with Mucositis: Learn How to Detect and Intervene for Oral Mucositis

By Tipian, Caroll | American Nurse Today, November 2014 | Go to article overview

Brushing Up on Mouth Care for Cancer Patients with Mucositis: Learn How to Detect and Intervene for Oral Mucositis


Tipian, Caroll, American Nurse Today


CHEMOTHERAPY AND RADIATION used to treat head and neck cancers, as well as high-dose chemotherapy given to stemcell transplant patients, can damage the mucosa of the oral cavity and GI tract. This article discusses mucositis in the oral cavity, which can cause symptoms ranging from a slight sensation change to pain and inflammation to ulcerative bleeding lesions.

Multiple mouth lesions can lead to colonization by microbial flora, resulting in a potentially life-threatening septic infection and prolonged hospital stays. In some cases, mucositis necessitates a treatment delay or termination, which can make cancer therapy less effective and increase the risk of residual tumor-cell proliferation. Many patients discontinue cancer treatments due to mucositis; about 60% require hospitalization for the condition, and 70% require tube feedings.

Mucositis can occur at any age. Younger patients have a higher mitotic rate and more epidermal growth factor receptors, which can increase severity of mucositis. Older patients typically have decreased renal function, which slows clearance of chemotherapy drugs and raises the risk of toxicity from high-dose cancer chemotherapy. Other risk factors for mucositis include poor nutritional status at the start of chemotherapy, a history of smoking (which can delay healing), and previous cancer treatments that caused mucositis. (See Biological phases of mucositis.)

When caring for a patient undergoing cancer treatment, your role is to ensure proper oral care; assess for mucositis signs and symptoms, such as pain, infection, dry mouth, taste changes, and poor nutrition; and use appropriate interventions.

Assessing and grading mucositis

Mucositis is graded based on lesion severity and appearance of the oral cavity. The most commonly used grading criteria are the National Cancer Institute Common Toxicity Criteria (NCI CTC) and the World Health Organization Oral Toxicity Scale. Use one of these scales daily to determine if your patient's mucositis is improving or getting worse.

Intervention

The first step in mouth care for oral mucositis is prevention. Preferably, before cancer treatment starts, patients should undergo a baseline dental evaluation with X-rays and have cavities filled. Once treatment begins, instruct patients to brush the teeth with a soft toothbrush for 90 seconds at least twice daily and to floss at least once daily (unless the patient is thrombocytopenic). As appropriate, advise them to rinse the mouth at least four times daily with saline solution, sodium bicarbonate, or a mixture. Stress the importance of getting adequate hydration and using a water-based moisturizer to protect the lips. (See Oncology Nursing Society recommendations.)

Despite preventive measures, most patients develop NCI CTC grade 2 or 3 (moderate to severe) toxicity, depending on the extent of chemotherapy and radiation. To relieve pain from mucositis, guidelines recommend use of a patient-controlled analgesia pump with morphine, especially in stem-cell transplant patients. In other patients receiving conventional or high-dose chemotherapy, a transdermal fentanyl patch is preferred. Specifically in head and neck cancer patients who undergo radiation, 2% morphine mouth rinse is suggested, as well as 0.5% doxepin rinse.

Cryotherapy

If your patient's receiving 5-fluorouracil bolus chemotherapy, cryotherapy with ice chips for 30 minutes can reduce severity of mucositis with sores. Some clinicians also recommend cryotherapy for patients receiving high-dose melphalan chemotherapy (whether or not they receive total-body irradiation when undergoing a stem-cell transplant). In cryotherapy, patients suck on ice chips 30 minutes before the chemotherapy infusion begins, as well as during and after the infusion. Ice chips constrict blood vessels in the mouth, decreasing chemotherapy effects on the oral mucosa.

Palifermin

Palifermin, a keratinocyte growth factor that stimulates epithelial-cell growth and differentiation, may be used to reduce incidence and duration of severe oral mucositis in patients receiving high-dose chemotherapy and radiation therapy who require hematopoietic stem-cell support. …

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