* School of Post Graduate Nursing,
University of Melbourne, Vic
** Victorian College of Pharmacy,
Monash University, Melbourne, Vic
*** Peter MacCallum Cancer Institute,
East Melbourne, Vic
Oral mucositis is a common and distressing complication for patients receiving treatment for cancer. Severe mucositis resulting in the delay or cessation of cancer treatments may jeopardise the intent for cure or control. An abundance of different interventions used to prevent and manage oral mucositis appear in the healthcare literature, with little scientific evidence of their effectiveness.
This paper reports on an evidence-based study at Peter MacCallum Cancer Institute (PMCI) to develop best practice guidelines aimed at prevention of oral mucositis in a cancer population. A literature review found that the systematic performance of good oral hygiene has been shown to be more effective in reducing oral mucositis than the use of any particular oral care regimen. Integral to successful oral mucositis prevention are mechanisms to improve patient compliance with oral care, including consistent nursing assessments and frequent reinforcement of oral care instruction. Education of nurses must focus on developing skills and confidence in undertaking oral assessments, educating patients about good oral hygiene and monitoring patient outcomes.
This paper describes the process taken by the Evidence Based Nursing Practice Group (EBNPG) at PMCI in the development of consensus guidelines for the prevention and early detection of complications of oral mucositis in the cancer patient. This process involved multidisciplinary participation in the evaluation of a literature review, the acquisition of a government grant to fund the project, the development of nurse and patient education programs, and the construction of oral mucositis prevention guidelines.
Clinical decision making in nursing is frequently based on experience, opinion, past practice and precedent resulting in the introduction of ineffective and sometimes harmful interventions and a reluctance to discontinue interventions found to be lacking1.
The EBNPG was developed at PMCI and consisted of four nurses, a dental oncologist and, in the later stages of the project, a pharmacist. The goals of this group were to develop guidelines for decision-making and to enhance clinical patient care by encouraging nurses to critically examine their practice through an evidence-based approach.
The group selected the research subject of oral mucositis, as it was considered a significant complication of cancer treatments and there was anecdotal evidence that prevention and management interventions were inconsistent. Findings of previous research have been somewhat equivocal, in part because issues of prevention and treatment of oral mucositis have not always been addressed separately. For example many of the aims of interventions have frequently confused prevention with that of treating symptoms of oral mucositis. Therefore the focus of this project was restricted to prevention as a starting point in the overall management of oral mucositis.
Mucositis is an inflammatory response of mucosal epithelial cells to the cytotoxic effects of chemotherapy as well as localised radiation therapy2. Epithelial cells lining the gastrointestinal tract mucosa renew rapidly, approximately every seven days. Mucositis results when mucosal cells are damaged and are unable to adequately repair and replace normal cell loss2. The primary function of the oral mucosa is to provide a first line of defence against infection and the oral cavity is a primary source in the development of septicaemia in immunosuppressed patients3.
Incidence and effects
Patients most affected by oral mucositis are those receiving radiotherapy to the head and neck, those with haematological malignancies and those having complex high doses of chemotherapy with blood cell transplantation2,4. The indirect effects of chemotherapy on the oral mucosa includes the suppression of bone marrow cells resulting in neutropenia and thrombocytopaenia, which promotes and exacerbates infection and bleeding. Changes in oral status correlate with the timing of myelosuppression as neutrophils and oral musosa have similar cell renewal rates2,5. Oral mucositis is often most severe at the nadir of the neutrophil count with resolution of mucositis as the count recovers2,5.
For many cancer patients the causes and exacerbation of mucositis are multifactorial. For example, multi-modality treatments for cancer are frequently given in the context of patients with a history of tobacco and/or alcohol abuse, or pre-existing poor oral hygiene6. Other factors known to increase risk include type of cancer and treatment, age, pre-existing oral disease, level of oral care and dental habits, nutritional status and numerous drugs that alter or dry the oral mucosa.
Oral mucositis is a major contributor to morbidity in the cancer patient, of which symptoms include mild discomfort, taste alterations, xerostomia, severe ulceration, pain, bleeding and infection5. These factors impede the patient’s capacity to eat, communicate and to adequately attend oral hygiene. Topical agents and systemic analgesia are often required for pain and intravenous hydration and parenteral or gastric feeding are often necessary to maintain nutrition. In particular, xerostomia plays a significant role in the incidence of oral mucositis where absence of saliva encourages heavy plaque to accumulate on the surfaces of teeth, resulting in an increase in bacterial volume in the mouth, leading to tooth decay, fungal infections and periodontal disease2,7.
The effectiveness of numerous oral care agents and regimens currently in use has not been established by reliable (Type I or II) research. In fact, much of the literature indicates that there is little consistency or agreement amongst practitioners in regard to assessment, prevention and treatment 5,7-11. For example a common nursing practice, not supported by evidence, is to discourage tooth brushing during treatment which evidence does suggest increases the risk of plaque, caries and oral infection.
A number of researchers have shown that the systematic performance of good oral hygiene has been shown to be more effective in reducing oral mucositis than the use of a particular oral care regimen11-15.
In addition, the maintenance of oral cleanliness in the form of tooth and gum brushing and flossing is considered the most reliable means of controlling bacterial plaque, which has a direct causative link to the development of caries, gingivitis and periodontal disease16. These findings are of particular relevance as studies have shown that patients who have had dental evaluation, preventative care and treatment of pre-existing dental disease prior to chemotherapy and radiotherapy experience a reduced incidence of oral mucositis7,11. Studies comparing mouth wash interventions have also co-incidentally found that when nurses performed consistent oral assessments and frequently reinforced oral care instructions, patient compliance with oral care improved9,11,13.
The literature suggests that preventing or reducing the incidence and/or severity of oral mucositis not only has positive outcomes for patients by decreasing complications and length of hospital stay but additionally reduces staff time and costs associated with care5.
A review and evaluation of the literature has resulted in the formulation of consensus guidelines: Prevention and Early Detection of Oral Complications of Mucositis PMCI Consensus Guidelines©*. These guidelines have been formulated with multidisciplinary representation including dental oncologists, radiation and medical oncologists, a general practitioner, pharmacist, dietitian, and academic and clinical nurses from within and outside PMCI.
An Oral Health Promotion Grant from the Department of Human Services Victoria was acquired to partially fund the costs involved in the project. As a result of progress to date the development and implementation of consensus guidelines and a program of education for all staff and patients has now become possible.
The guidelines for selected patients receiving chemotherapy and radiotherapy include:
* Available from the CNSA in June 2001.
Questions surrounding the best practice in the prevention and treatment of oral mucositis are left unanswered due to poor quality and insufficient research. Even so there are considerable incidental findings from the literature in regard to factors, which facilitate prevention to warrant further evaluation. These findings have formed the basis on which the EBNPG have developed the enclosed guidelines.
Maintaining good oral hygiene is a first principle in the prevention of oral mucositis for patients undergoing chemotherapy and radiotherapy. The role of dental examination and treatment of pre-existing oral disease is significant in reducing the risk of complications associated with oral mucositis. Oncology nurses caring for patients undergoing treatment for cancer require education about the effects of treatment on the oral mucosa, the effectiveness of regular mouth care and how to perform an oral assessment. Patient education about self-care measures for oral care including demonstration and reinforcement of oral care instruction by nursing staff is advocated. As the regular observation and assessment of the oral status of patients undergoing cancer treatments is recorded and communicated by nurses, early and appropriate intervention for the management of degrees of severity of oral mucositis can be instituted3,17.
The outcomes of an improved oral health program such as that introduced at PMCI are to standardise care and assessment interventions. In addition the project aims to improve patient outcomes relating to incidence and severity of oral mucositis and to enhance quality of life and self-care ability by acquiring new knowledge and skills. For nurses the benefits are a continued growth of knowledge, clinical expertise and a commitment to improving the care given to their patients with cancer. In addition the implementation and evaluation of these guidelines for the prevention and early detection of oral mucositis at PMCI will create the best environment to generate future research on the management of oral mucositis in the future.
2. M Goodman, L Hilderley and S Pur. “Integumentory and mucous membrane alteration”. In: S Groenwald, M Goodman, M Hansen-Frogge and C Yarbro (Eds). Cancer Nursing: Principles & Practice (4th ed.) Jones and Bartlett, Boston, 1997.
8. S Coleman. “An overview of the oral complications of adult patients with malignant haematological conditions who have undergone radiotherapy or chemotherapy”. Journal of Advanced Nursing, 22 (1995), 1085-1091.
9. P J Larson, C Miaskowski, L MacPhail, M J Dodd, D Greenspan, S L Dibble, S M Paul and R Ignoffo. “The pro-self mouth aware program: An effective approach for reducing chemotherapy-induced mucositis”. Cancer Nursing, 21, 4 (1998), 263-368.
10. The Joanna Briggs Institute for Evidence Based Nursing and Midwifery. Systematic review of the effectiveness of strategies for preventing and treating chemotherapy and radiation induced oral mucositis in patients with cancer. Margaret Graham Building, Royal Adelaide Hospital SA, 1998.
14. M Dodd, P Larson, S Dibble, C Miaskowski, D Greenspan, L MacPhail, W Hauck, S Paul, R Ignoffo and G Shiba. “Randomised clinical trial of chlorhexidine versus placebo for prevention of oral mucositis in patients receiving chemotherapy”. Oncology Nursing Forum, 23, 6 (1996), 921-927.
15. B Borowski, E Benhamou, J L Pico, A Laplanche, J P Margainaud and M Hayat. “Prevention of oral mucositis in patients treated with high-dose chemotherapy and bone marrow transplantation: a randomised controlled trial comparing two protocols of dental care”. Oral Oncology, European Journal of Cancer, 30, 2 (1994), 93-97.