Fast Facts for the Frontline: Oral Care and Mucositis During Cancer Treatment

Melissa A. Grier, MSN, APRN, ACNS-BC

Melissa A. Grier, MSN, APRN, ACNS-BC

Understandably, patients have a lot of anxiety about starting anticancer therapy. Oncology nurses play a major role in alleviating some of this anxiety by providing education about management of possible side effects. Much of this education focuses on prevention of nausea and vomiting, and other common side effects, but one often overlooked topic deserves special attention: oral care.

WHY IS ORAL CARE DURING CHEMOTHERAPY SO IMPORTANT?

Many immunotherapy and chemotherapy agents cause mucositis, an inflammatory process within the gastrointestinal (GI) tract that can affect mucosal epithelial cells from the oral cavity to the rectum. Inflammation associated with severe mucositis can lead to breakdown of the protective mucosal barrier that lines the GI tract, increasing the likelihood of systemic infection caused by GI microorganisms entering the bloodstream.

Severe pain associated with mucositis often results in decreased oral intake and malnutrition, leading to dose reduction or delays in treatment. These complications negatively impact quality of life and often require lengthy hospitalizations. Beginning oral care early and maintaining a routine throughout treatment can reduce the severity of mucositis and prevent associated complications from getting out of hand.

“Discussing oral care with patients

before starting anticancer therapy is crucial.”

WHY IS THE FOCUS ON ORAL CARE WHEN MUCOSITIS CAN AFFECT THE ENTIRE GI TRACT?

Because the oral cavity can be easily assessed without costly invasive diagnostic studies, it has become the focus of much of the research surrounding prevention and treatment of mucositis. Patients also tend to report complications related to oral mucositis because of pain management issues and malnutrition that negatively impact their quality of life. In other words, the risk of infection related to mucosal barrier injury in the colon isn’t as readily apparent to patients as painful mouth sores that prevent them from eating.

WHAT INTERVENTIONS SHOULD BE INCLUDED IN AN ORAL CARE ROUTINE?

Research has shown that some interventions definitively decrease the severity and duration of mucositis. These interventions are recommended for practice:

• Cryotherapy or topical application of ice chips, ice water, or ice lollipops can help reduce the symptoms and pain associated with mucositis when used during administration of chemotherapy agents with short half-lives.
• Sodium bicarbonate (baking soda) mouth rinses have been shown to be effective, although the exact mechanism of action isn’t fully understood.
• Oral care protocols that consist of routine oral hygiene (brushing and flossing, as allowed by hemodynamic status), oral rinses, and early detection through regular assessment are also highly recommended.
• Low-level laser therapy and IV palifermin administration have only been studied in certain populations — primarily patients with head and neck cancer receiving radiation therapy and patients undergoing hematopoietic cell transplantation. Both have shown great effectiveness in reducing duration and, in some cases, preventing the incidence of oral mucositis.

Further research is needed in order to recommend several other oral care interventions, but enough evidence is available to suggest that the following are likely to be effective:

• In a study examining mucositis among patients receiving radiation and chemotherapy, use of lactobacillus lozenges reduced the incidence of oral mucositis when compared with placebo.
• Prophylactic chlorhexidine oral rinses reduced the incidence of mucositis and associated pain in several studies. However, these rinses are not recommended for treatment of existing mucositis as they can intensify pain and irritation.
• Benzydamine rinses shown to reduce pain and severity of oral mucositis in a few studies are recommended by international oncology associations for patients with head and neck cancer, but additional research is necessary among larger sample sizes and other patient populations.

WHAT'S THE MOST IMPORTANT TAKE-AWAY FOR NURSES INVOLVED IN DIRECT PATIENT CARE?

Having the initial conversation about oral care with patients starting chemotherapy and immunotherapy is crucial. However, helping your patients adopt an oral care routine and performing frequent assessments for early detection of oral mucositis can greatly decrease the incidence, severity, and duration of this side effect.

• Eilers J, Harris D, Henry K, Johnson L. Evidence-based interventions for cancer treatment-related mucositis: putting evidence into practice. Clin J Oncol Nurs. 2014; 8(6):80-96. doi: 10.1188/14.CJON.S3.80-96.
• Lalla RV, Bowen J, Barasch A, et al. The Mucositis Guidelines Leadership Group of MASCC/ISOO: Clinical practice guidelines for the management of mucositis secondary to cancer therapy. Cancer. 2014;120(10):1453-1461. doi: 10.1002/cncr.28592.
• McGuire DB, Fulton JS, Park J, et al. Systematic review of basic oral care for the management of oral mucositis in cancer patients. Support Care Cancer. 2013;21(11):3165-3177. doi: 10.1007/s00520-013-1942-0.