5-Minute Inservice Mucositis Management

Patients who have experienced oral mucositis report it as the most bothersome side effect of cancer therapy. It can result in pain, infection, and nutritional defi cits, and can interfere with appropriate cancer treatment. Many patients with mucositis are opiate-naive, presenting clinical challenges.

A survey at Memorial Sloan- Kettering Cancer Center (MSKCC) uncovered discrepancies in mucositis assessment and management; the need for a practice change at MSKCC was identified. This was accomplished through comprehensive assessment of the medical literature and of current evidence-based guidelines on mucositis, focusing on prevention and management recommendations relevant to nursing.

A database was used to collect information from each citation detailing the size of the population assessed; the scientific rigor of the study; the assessment tool used; and specific recommendations regarding oral care, rinses, cryotherapy, and any other strategies for prevention or treatment. The multidisciplinary team from MSKCC that worked to develop the evidence-based nursing intervention for mucositis outlined in this article included nurses from both the inpatient and ambulatory areas, a nutritionist, a dentist, a pharmacist, and physicians (who reviewed the fi nal protocol).

OUTCOME GOALS

• Consistent oral mucositis assessment and patient education

• Patient understanding of oral cavity care

• Minimized discomfort and weight loss from mucositis

PATIENT ASSESSMENT Initial Assessment

• Assess the patient's risk for mucositis. Treatment-related factors that increase risk of mucositis include bone marrow or hematopoietic stem cell transplant, radiation to the head and neck (with risk increased further when radiation is concurrent with fl uorouracil), and chemotherapy/biologic agents that interfere with DNA synthesis. Patient-related factors include prolonged neutropenia, previous history of severe herpes simplex infection, poor nutritional status, poor oral hygiene, periodontal disease, dental caries, ill-fitting dentures, and continued use of alcohol or tobacco.

• Assess current oral hygiene and dental care measures (eg, use of mouthwash, dental floss, oral irrigation).

• Inspect all surfaces of the oral cavity using direct lighting and a tongue blade to ensure all areas are visualized.

• Use the Common Terminology Criteria for Adverse Events (CTCAE) v.3.0 scale (mucositis- clinical exam): 0 = None; 1 = Erythema of mucosa; 2 = Patchy ulcerations or pseudomembranes; 3 = Confluent ulcerations or pseudomembranes, bleeding with minor trauma; 4 = Tissue necrosis, significant spontaneous bleeding, life-threatening consequences.

• Observe for unhealed surgical incisions, evidence of poor oral hygiene, ill-fitting dental appliance, and signs or symptoms of infection.

• Assess ability to swallow solids, soft foods, and liquids. Use the CTCAE v.3.0 scale (mucositis-functional/symptomatic): 0 = No symptoms; 1 = Minimal symptoms, normal diet; 2 = Symptomatic but can eat and swallow modified diet; 3 = Symptomatic and unable to adequately aliment or hydrate orally; 4 = Symptoms associated with life-threatening consequences.

• Assess for presence and severity of mouth or throat pain using a numerical scale (0–10) or a categorical scale (none, mild, moderate, severe).

• Assess nutritional status (ie, oral intake, current weight, and amount of weight loss during previous 3 months).

On-Treatment Assessment 

• Inspect all surfaces of the oral cavity using the CTCAE v.3.0 scale (mucositis-clinical exam). • Assess ability to swallow solids, soft foods, and liquids using the CTCAE v.3.0 scale (mucositis- functional/symptomatic).

• Assess for presence and severity of mouth or throat pain using a numerical scale (0–10) or a categorical scale (none, mild, moderate, severe).

• Assess nutritional status (ie, oral/PEG intake, current weight, and change in weight).

• Assessment frequency: Inpatient: Once daily Outpatient transplant: At each clinic visit and as needed based on patient symptoms Patient receiving radiation therapy to head and neck: Weekly and as needed based on patient symptoms Chemotherapy/biologic therapy: At each visit and as needed 

PATIENT EDUCATION

• Describe the expected mucous membrane reactions to treatment and the signs and symptoms that should be reported to the doctor/nurse.

• Explain to patients and/or caregivers that patients need a dental evaluation before treatment with radiation therapy to the head and neck or before transplant. Encourage other patients receiving systemic chemotherapy to have a dental evaluation before beginning treatment. 

Brushing/Flossing

Instruct patients and/or caregivers on the importance of a systematic, consistent regimen to clean their mouths. The mucosa should be kept clean and moist. Plaque should be removed from teeth as follows: Brush teeth four times daily, after eating and at bedtime. Use a small soft-bristled toothbrush and fl uoride toothpaste. Regarding fl ossing, patients who have previously flossed their teeth can continue to floss daily. Patients who do not currently floss their teeth should not start fl ossing at this time.

Poor oral hygiene and plaque buildup may promote gingival bleeding; patients should not stop flossing unless they develop uncontrolled bleeding, their platelet count is < 20,000/mm3, or their absolute neutrophil count is < 1,000/mm³.

• Poor oral hygiene and plaque buildup may promote gingival bleeding, so patients should not stop brushing their teeth if they develop low platelets unless they also develop uncontrolled bleeding.

• Toothbrushes should be changed as needed to avoid harboring bacteria.

• Patients who develop pain should switch to a supersoft or an ultrasoft toothbrush. 

Rinsing

Patients should rinse their mouths every 4–6 hours, increasing to every 2 hours as needed for comfort. Adjust the temperature of the rinsing solution for comfort, but avoid extreme hot or cold temperatures.

Patients should swish and gargle thoroughly for 15–30 seconds, then spit out the rinsing solution. Commercial mouthwashes containing alcohol should not be used. Any of the solutions listed below may be used.

• 1 quart water mixed with 1 teaspoon salt and 1 teaspoon baking soda (or 1 quart normal saline with one teaspoon baking soda)

• 1 quart water mixed with 1 teaspoon salt

• 1 quart water mixed with 1 teaspoon baking soda

• Plain water

• Nonalcoholic unsweetened mouthwash (eg, Biotene) 

Dental Appliances

Dental appliances should be removed and cleaned each time the patient's oral care is addressed. Once patients' mucous membranes become irritated, they should wear their dental appliances only for brief periods during the day. It is important to apply moisturizer to lips four to six times a day (eg, Aquaphor, A&D ointment). Patients receiving radiation therapy to the head and neck should not apply the moisturizer less than 4 hours before treatment. 

Irritating Substances

Patients should be advised to avoid the following substances, which may irritate the mucous membranes during treatment.

• Chemical irritants: Tobacco, alcohol, commercial mouthwash containing alcohol, spices (eg, pepper, chili powder, horseradish, curry powder, Tabasco sauce), citrus fruits and juices (eg, orange, lemon, lime, grapefruit, pineapple), and tomatoes

• Physical irritants: Loose or illfi tting dentures (should be realigned by dentist or worn only when necessary); hard, dry, or coarse foods (eg, toast, crackers, raw vegetables, potato chips, pretzels)

• Thermal irritants: Very hot foods or liquids 

PATIENT CARE

Topical anesthetics or coatings can be used for mouth/throat pain. Consult with doctor or nurse regarding initiation of medication, and instruct patients as follows:

• For mild pain localized to specific areas in the mouth, consider a topical anesthetic.

• For mild pain generalized in the mouth and throat, consider a coating agent (eg, Gelclair [adults only], Carrington Oral Wound Rinse), to be used as directed on the package; or a topical anesthetic (eg, viscous lidocaine 2%). There is no evidence to support the use of multiagent solutions such as magic mouthwash.

• Topical anesthetics can decrease the gag reflex and sensation.

• For mild pain not relieved by above measures or for moderate or severe pain, consider systemic analgesia using the guidelines described in this article. 

Difficulty or pain on swallowing

Suggest dietary modifications as follows to make swallowing easier and maintain an adequate nutritional intake.

• Soft, moist, bland foods taken in small bites and chewed well

• Use of sauces and gravies

• Moistening foods with pasteurized yogurt, milk, soy milk, water

• "Dunking" dry foods in liquids

• Blending or pureeing food or taking nutritional supplements

• Altering the temperature and consistency of foods to individual tolerance

• Avoidance of irritants: alcoholic beverages, tart or acidic fruits and juices, spicy foods, pickled foods, tobacco

• Sipping fluids throughout the day to assure adequate fluid intake. Well-tolerated fluids include: warm or cool beverages, nonacidic fruit juices or nectars (diluted as necessary)

• Fortifying broth, soups, cereals, and beverages with protein powders (diluted as necessary) 

Other symptoms

• Patients unable to maintain their weight should be referred to a nutritionist and consult with a physician regarding PEG placement.

• Patients receiving radiation to the head and neck who become symptomatic should undergo daily (Monday through Friday) nursing assessments and receive saline oral sprays for comfort and cleansing.

• Patients with signs of thrush or infection should consult with a doctor or nurse regarding initiation of antibiotics/antifungals.

• Patients with mouth dryness should be instructed to take frequent sips of water or other liquids throughout the day. Other strategies that are helpful for some patients are using a spray bottle with water to moisten the mouth, applying commercial mouth moisturizers (eg, Biotene Oralbalance) or using artificial saliva, chewing Biotene gum, and installing a humidifier at home. 

PHARMACOLOGIC MANAGEMENT OF PAIN Determine Opioid History

• Patients on opioids = 2 weeks are considered opioid-naive.

• Patients on opioids = 2 weeks are considered opioid-tolerant.

• Patients with a history of substance abuse commonly require higher doses of opioids and closer monitoring. They should be referred to either the pain service or the pain and palliative care service for pain management. 

Determine Optimal Route of Administration

• Oral route: Indicated for patients with mild to moderate pain who are able to swallow medication.

• Transdermal route: Indicated for patients with mild to moderate pain who are having difficulty swallowing oral medication.

• Intravenous patient-controlled analgesia (IV PCA)-Indicated for patients with moderate to severe pain (> 5/10) and/or patients who cannot tolerate oral opioids.

• If patient is presently on opioids, consider a pain consult when converting to parenteral opioids for IV PCA.

• Titration of opioids is based on pain severity, presence of side effects, and use of prn dosing/number of prn doses.

• Tapering of opioids should begin as the mucositis begins to resolve and there is a decrease in the use of prn rescue doses.

Disclosures:

Megan Dunne participated in a speaker program for EKR Therapeutics (manufacturers of Gelclair) in 2007. Elizabeth Rodriguez has no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.

 

The author wishes to acknowledge the exceptional dedication of the group who developed the mucositis standard at Memorial Sloan-Kettering Cancer Center: Joanne Frankel Kelvin, RN, MSN, AOCN, for her mentorship in this project, and Kristin Cawley, RN, MSN, OCN; Susan Derby, RN, MA, CGNP, ACHPN; Jody Gilman, MS, RD; Cathy Hydzik, RN, MS, AOCN; and Mary Montefusco, RN, MPA, OCN.

References:

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