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).
• Consistent oral mucositis assessment and patient education
• Patient understanding of oral cavity care
• Minimized discomfort and weight loss from mucositis
• 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).
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.
1.Clarkson JE, Worthington HV, and Eden OB: Interventions for preventing oral mucositis for patients with cancer receiving treatment (Review). The Cochrane Database of Systematic Reviews, Issue 1, 2000.
2.Eilers JE: Nursing interventions and supportive care for the prevention and treatment of oral mucositis associated with cancer treatment. Oncol Nurs Forum 31(4):13-23, 2004.
3.Epstein JB, Schubert MM: Oropharyngeal mucositis in cancer therapy: Review of pathogenesis, diagnosis, and management. Oncology (Williston Park) 17(12):1767-1779, 2003.
4.Hita-Iglesias P, Torres-Lagares D, Gutiérrez-Pérez JL, et al: Evaluation of the clinical behaviour of a polyvinylpyrrolidone and sodium hyalonurate gel (Gelclair) in patients subjected to surgical treatment with CO2 laser. Int J Oral Maxillofac Surg 35:514-517, 2006.
5.Innocenti M, Moscatelli G, Lopez S, et al: Efficacy of Gelclair in reducing pain in palliative patients with oral lesions: Preliminary fi ndings from an open pilot study. J Pain Manage 24:456-457, 2002.
6.Joanna Briggs Institute. Prevention and treatment of oral mucositis in cancer patients. Best Practice: Evidence Based Practice Information Sheets for Health Professionals. 2(3):1998. Available at: http://www.joannabriggs.edu.au/best_practice/bp5.php. 7.Accessed January 29, 2008.
Kostler WJ, Hejna M, Wenzel C, et al: Oral mucositis complicating chemotherapy and/or radiotherapy: Options for prevention and treatment. CA Cancer J Clin 51(5):290-315, 2001.
8.McGuire DB: Barriers and strategies in implementation of oral care standards for cancer patients. Support Care Cancer 11:435-441, 2003.
9.Miller M, Kearney N: Oral care for patients with cancer: A review of the literature. Cancer Nursing 24(4):241- 254, 2001.
10.National Cancer Institute. Oral complications of chemotherapy and head/neck radiation (PDQ) (2005). Available at: http://www.cancer.gov/cancertopics/pdq/supportivecare/oralcomplications/hea lthprofessional. Accessed January 29, 2008.
11.National Institute of Dental and Craniofacial Research. Oral Complications of Cancer Treatment: What the Oncology Team Can Do (2002). Available at: http://www.nidcr.nih.gov/NR/rdonlyres/015DE57E-92CC-427C-A084-0222 45B5D4F5/0/OncologyTeamCan-Do.pdf. Accessed January 29, 2008.
12.National Institute of Dental and Craniofacial Research Oncology Reference Guide to Oral Health. Available at: http://www.nidcr.nih.gov/NR/rdonlyres/AA5DF3DD-5DB7-47D4-9 F09-461F242C471F/0/OncologyRefGuideOralHealth.pdf. Accessed January 29, 2008.
13.Oncology Nursing Society. Measuring Oncology Nursing-Sensitive Patient Outcomes: Evidence-Based Summary Review (Mucositis) (2005). Available at: http://onsopcontent.ons.org/toolkits/evidence/Clinical/pdf/MucositisSummary.pdf. Accessed January 29, 2008.
14.Plevova P: Prevention and treatment of chemotherapy- and radiotherapy-induced oral mucositis: A review. Oral Oncol 35(5):453-470, 1999.
15.Rubenstein EB, Peterson DE, Schubert MM, et al: Clinical practice guidelines for the prevention and treatment of cancer therapy-induced oral and gastrointestinal mucositis. Cancer 100(suppl 9):2026- 2046, 2004.
16.Shih A, Miaskowski C, Dodd MJ, et al: A research review of the current treatments for radiation-induced oral mucositis in patients with head and neck cancer. Oncol Nurs Forum 29(7):1063- 1078, 2002.
17.Sonis ST, Elting LS, Keefe D, et al: Perspectives on cancer therapy-induced mucosal injury: Pathogenesis, measurement, epidemiology, and consequences for patients. Cancer 100(suppl 9):1995- 2025, 2004.
18.Stricker CT, Sullivan J: Evidence-based oncology oral care clinical practice guidelines: Development, implementation, and evaluation. Clin J Oncol Nurs 7(2):222- 227, 2003.
19.Sutherland SE, Browman GP: Prophylaxis of oral mucositis in irradiated head and neck cancer patients: A proposed classifi cation scheme of interventions and meta-analysis of randomized controlled trials. Int J Radiation Oncology Biol Phys 49(4):917-930, 2001.
20.Worthington HV, Clarkson JE, Eden OB: Interventions for treating oral mucositis for patients with cancer receiving treatment. The Cochrane Database of Systematic Reviews, Issue 2, 2004.