• 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
• 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.
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.
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(Drug information on 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 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.
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
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(Drug information on 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)
• 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.