The most widely recognized side effects of cancer treatment are hair loss and nausea, but 40% of patients also experience oral mucositis (Beck, 2004), an inflammatory and potentially ulcerative process in the mucous membranes of the oral cavity. The condition can impair patients’ ability to eat, swallow, and talk, and it can lead to pain, malnutrition, bleeding, and local and systemic infection (Eilers, 2004). How can nurses do more than pay lip service to this common and distressing symptom?
Oncology Nursing Society puts evidence into practice
To promote nursing practice that is based on evidence, the Oncology Nursing Society (ONS) launched the Putting Evidence Into Practice (PEP) program in 2005. ONS PEP teams consisting of advanced practice nurses, staff nurses, and a nurse scientist were charged with reviewing the literature to determine what treatments and interventions are proven to alleviate many cancer-related problems that are sensitive to nursing interventions. Each team classified interventions under the following categories: recommended for practice, likely to be effective, benefits balanced with harms, effectiveness not established, effectiveness unlikely, and not recommended for practice. Interventions recommended for practice were those for which effectiveness was demonstrated by strong evidence from rigorous studies, meta-analysis, or systematic reviews, and for which any expectation of harm was small compared to benefits (Eaton & Tipton, 2009).
Oral mucositis: causes and risk factors
The cytotoxic effects of chemotherapy and radiation may launch an inflammatory response from mucosal epithelial cells. The inflammation may occur on all surfaces with mucous membranes, from the mouth to the rectum. However, the ONS PEP team examined oral mucositis rather than gastrointestinal mucositis because more extensive literature is available and because of its clinical morbidity and impact on functional status and quality of life.
Patients most at risk of developing oral mucositis are those who are very young or older, are female, have poor oral health and hygiene, have poor salivary function, have a low body mass index, have renal toxicity, have a history of smoking, have had previous cancer treatment, and are receiving chemotherapy, radiation, biotherapy, stem cell transplantation, or a combination (Beck, 2004; Eilers & Million, 2007; Jaroneski, 2006).
Recommended for practice
Oral care is the best way to maintain oral health, integrity, and function. Although oral care protocols have not been demonstrated to prevent oral mucositis, they can minimize it, reduce microbial flora, decrease pain and bleeding, and prevent infection and dental complications. Protocols for oral care differ, but all should include the following (Dodd et al., 2000; Eilers, 2004; Kwong, 2004; Multinational Association of Supportive Care in Cancer, 2005; Rubenstein et al., 2004; Scully, Sonis, & Diaz, 2006; Shih, Miaskowski, Dodd, Stotts, & MacPhail, 2002).
- Oral assessment daily or at each patient visit (see Figure 1 for assessment tools)
- Patient education about self-assessment of the oral cavity and what to report to the healthcare team
- Tooth brushing: At least 90 seconds twice daily with a soft toothbrush
- Flossing at least once daily or as advised
- Rinsing four times daily with a bland rinse
- Avoiding tobacco, alcohol, and irritating foods
- Water-based moisturizers for lips
- Adequate hydration
Table 1. Examples of Oral Mucositis Assessment Tools
Common Terminology Criteria for Adverse Events from the National Cancer Institute (2006)
Oral Assessment Guide (Eilers, Berger, & Petersen, 1988)
Likely to be effective
The ONS PEP team found that mucositis may be prevented with cryotherapy, the application of ice chips or ice-cold water to the oral cavity before, during, and after rapid infusions of mucotoxic agents. The literature supports cryotherapy for patients receiving bolus 5-fluorouracil (Multinational Association of Supportive Care in Cancer, 2005) and high-dose melphalan (Lilleby et al., 2006; Mori et al., 2006). Cryotherapy is not to be used with agents that require patients to be careful with exposure to cold (e.g., oxaliplatin), and other agents require further study. The optimal duration and intensity of cryotherapy are not established, but patients generally hold ice or ice-cold water in their mouths for at least five minutes before, during, and 30 minutes after treatment.
Another treatment with enough evidence to be considered likely to be effective is palifermin, a recombinant human karatinocyte growth factor that stimulates the growth of epithelial cells. It has been shown to reduce mucositis’ duration and severity in patients with hematologic malignancy receiving high-dose chemotherapy and total body irradiation with autologous stem cell transplantation (Spielberger et al., 2004). The dose studied was 60 ug/kg per day via IV for three days prior to the conditioning regimen and for three days after transplantation. However, palifermin is expensive and should be used for patients most likely to develop severe mucositis.
Many agents studied by the ONS PEP team were classified as “effectiveness not established” because of lack of trials, inadequate sample sizes, methodologic flaws, or conflicting evidence. They can be found in Figure 2, in addition to interventions categorized as “effectiveness unlikely” or “not recommended for practice.”
Table 2. Interventions for Oral Mucositis (Based on information from Eaton & Tipton, 2009)
Recommended for practice: oral care protocol
Likely to be effective: cryotherapy, palifermin
Effectiveness not established: allopurinol, amifostine, anti-inflammatory rinses, antimicrobial agents, benzydamine HCl, caphosol, chlorhexidine, fluoride chewing gum, flurbiprofen tooth patch, granulocyte–colony-stimulating factor (subcutaneous), Gelclair®, granulocyte macrophage–colony-stimulating factor (subcutaneous), honey, immunoglobulin, L-alanyl-L-glutamine, low-level laser therapy, multi-agent rinses (also known as “magic” or “miracle” rinses), oral aloe vera, pilocarpine, povidone-iodine (oral), tetracaine, zinc supplementation
Effectiveness unlikely: iseganan, misoprostol, vitamin E (topical), wobe-mugos E
Not recommended for practice: chlorhexidine, GM-CSF mouthwash, sucralfate
Nursing assessment and patient education will help alleviate the common and distressing symptom of oral mucositis. More research is needed to examine effective interventions, but healthcare professionals can rely oral care protocols to maintain patients’ functional status and quality of life.
Keightley Amen is a staff editor on the Publishing Team at the Oncology Nursing Society.
Find Evidence-Based Interventions for 15 Other Symptoms
Learn more about ONS’s PEP resources for other symptoms at http://www.ons.org/Research/PEP.
Need More Symptom Management Information? There’s an App for That!
The new ONS PEP app for iPhones and the iPod Touch gives you evidence-based symptom management information with the click of a button. Available through the iTunes Store, the 16 apps offer interventions for 16 common side effects of cancer and its treatment, including CINV, pain, mucositis, and fatigue. Simply go to the iTunes Store and search for ONS PEP. The Mucositis app can be downloaded for free; others cost $1.99 each.
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Dodd, M.J., Dibble, S.L., Miaskowski, C., MacPhail, L., Greenspan, D., Paul, S.M., Larson, P. (2000). Randomized clinical trial of the effectiveness of 3 commonly used mouthwashes to treat chemotherapy-induced oral mucositis. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics, 90(1), 39-47.
Eaton, L.H., & Tipton, J.M. (Eds.). (2009). Putting Evidence Into Practice: Improving oncology patient outcomes. Pittsburgh, PA: Oncology Nursing Society.
Eilers, J. (2004). Nursing interventions and supportive care for the prevention and treatment of oral mucositis associated with cancer treatment. Oncology Nursing Forum, 31(Suppl. 4), 13-23.
Eilers, J., Berger, A.M., & Petersen, M.C. (1988). Development, testing, and application of the Oral Assessment Guide. Oncology Nursing Forum, 15, 325-330.
Eilers, J., & Million, R. (2007). Prevention and management of oral mucositis in patients with cancer. Seminars in Oncology Nursing, 23, 201-212.
Jaroneski, L.A. (2006). The importance of assessment rating scales for chemotherapy-induced oral mucositis. Oncology Nursing Forum, 33, 1085-1092.
Kwong, K.K. (2004). Prevention and treatment of oropharyngeal mucositis following cancer therapy: Are there new approaches? Cancer Nursing, 27, 183-205.
Lilleby, K., Garcia, P., Gooley, T., McDonnell, P., Taber, R., Holmberg, L., Bensinger, W. (2006). A prospective, randomized study of cryotherapy during administration of high-dose melphalan to decrease the severity and duration of oral mucositis in patients with multiple myeloma undergoing autologous peripheral blood stem cell transplantation. Bone Marrow Transplantation, 37, 1031-1035.
Mori, T., Aisa, Y., Yamazaki, R., Mihara, A., Ikeda, Y., & Okamoto, S. (2006). Cryotherapy for the prevention of high-dose melphalan-induced oral mucositis [Letter to the editor]. Bone Marrow Transplantation, 38, 637-638.
Multinational Association of Supportive Care in Cancer. (2005). Summary of evidence-based clinical practice guidelines for care of patients with oral and gastrointestinal mucositis (2005 update). Retrieved from http://www.mascc.org/media/Resource_centers/Guidelines_mucositis.doc
Rubenstein, E.B., Peterson, D.E., Schubert, M., Keefe, D., McGuire, D., Epstein, J., Sonis, S.T. (2004.) Clinical practice guidelines for the prevention and treatment of cancer therapy-induced oral and gastrointestinal mucositis. Cancer, 100(Suppl. 9), 2026-2046.
Scully, C., Sonis, S., & Diz, P.D. (2006). Oral mucositis. Oral Diseases, 12, 229-241.
Shih, A., Miaskowski, C., Dodd, M.J., Stotts, N.A., & MacPhail, L. (2002). A research review of the current treatments for radiation-induced oral mucositis in patients with head and neck cancer. Oncology Nursing Forum, 29, 1063-1078.
Spielberger, R., Stiff, P., Bensinger, W., Gentile, T., Weisdorf, D., Kewalramani, T., Emmanouilides, C. (2004). Palifermin for oral mucositis after intensive therapy for hematologic cancers. New England Journal of Medicine, 351, 2590-2598.