Managing Oral Mucositis

Oral mucositis is an inflammatory process of the oral cavity caused by damage of the epithelium (Cawley, 2005, p.584). It is a common side effect that affects approximately 40%-100% of patients who undergo specific cancer treatments (Cawley, 2005, p.584; Eilers, 2004, p.13). Crystal Seto.

Oral mucositis may result in complications such as pain, infection, malnutrition, treatment delays and dosage reductions in cancer therapy, and decreased functional status and quality of life (Cawley & Benson, 2005, p. 584; Eilers, 2004, p. 13; Sadler et al., 2003, p. 28-29). Thus, proper management of oral mucositis is paramount in patients treated for specific cancer therapies. Nurses interact with patients during all phases of treatment, which gives them the advantage of playing a pivotal role in the proper management of oral mucositis. Cawley & Benson (2005) and Sadler et al. (2003) review the significance of nurse education and training, patient teaching, and the promotion of self-care by patients. In support, Eiliers (2004) points out that ongoing assessment and monitoring, and utilization of interventions with an evidence-based approach are efficacious and important in managing oral mucositis. Furthermore, Potting’s empirical study may prove to be a novel approach to assessing oral mucositis in daily nursing practice. Collectively, knowledge, proper and sufficient oral assessment skills and tools, and the delivery of adequate evidence-based palliative care by the nursing staff prove to be essential components of managing oral mucositis in cancer patients.
In order for nurses to properly manage oral mucositis they must first be knowledgeable about the pathophysiology. The oral mucosa is composed of rapidly-dividing epithelial cells, which are replaced approximately every two weeks from stem cells of the submucosa. Therefore, the integrity of the mucosa is dependent on the continuous reproduction of the submucosal stem cells (Cawley & Benson, 2005, p. 585).
Cawley and Benson (2005) use Sonis’ model to describe the five phases that occur with the process of oral mucositis. It begins with phase one (0-2 days), initiation, when epithelial cells are damaged by the effects of radiotherapy and chemotherapy. Next, phase two (2-3 days), upregulation and message generation, occurs. It involves increased tissue injury and cell death by inflammatory cytokines. Clinically, patients may begin to present with erythema as the mucosa starts to thin. Then, the third phase is signaling and amplification (2-10 days) in which there is cell damage below the mucosal layer. Next is ulceration (10-15 days), the fourth and most clinically observable phase. Ulcers appear deep (extends from epithelium into the submucosa) and are irregularly-shaped. The ulcers are often coated with a pseudomembrane of fibrinous exudate, which is ideal for bacterial colonization. Furthermore, nurses should recognize that nerve endings are exposed at this point. Thus, patients begin to experience pain during this phase. The final phase, phase five is healing (14-21 days). Cell proliferation begins and new tissue layers form. Although healing occurs, patients will continue to have an increased risk for developing oral mucositis because cells below the surface are permanently damaged.
Furthermore, nurses must be knowledgeable about the risk factors associated with the development of oral mucositis. This will help nurses identify high-risk patients, allow nurses to promote oral health care in high-risk patients, and assist nurses in prioritizing their care (Cawley & Benson, 2005, p. 585; Eilers, 2004, p. 15; Sadler et al., 2003, p. 30). There are treatment related risk factors including chemotherapy, radiotherapy, and bone marrow transplantation (Cawley & Benson, 2005, p. 585). In addition, patient-related risk factors include age, periodontal disease and oral health, diet, tobacco and alcohol use, medications, oxygen therapy, and changes in breathing (Eilers, 2004, p. 15). Young children are at risk due to their higher epithelial cell proliferation rate, and their higher rate of hematologic malignancies which produces prolonged and intensive myelosuppression; older individuals are at risk due to physiologic declines in renal function and healing capabilities (Eilers, 2004, p. 15). Periodontal disease and alterations in oral health impair the permeability of the oral mucosa, reduces oral pH, causes tooth decay and gingivitis, and increases infection rates (Eilers, 2004, p. 15). Nurses should encourage patients to complete a comprehensive dental evaluation prior to receiving their cancer treatment (Sadler et al., 2003, p. 30). Moreover, diet is another factor that places patients at risk. Excessive sugar consumption or inadequate protein and calories to the diet contribute to tooth decay and irritation of the oral mucosa, which prolongs healing time (Eilers, 2004, p. 15). Patients should be counseled about the effects of their diet so they can actively minimize their risk. Furthermore, tobacco and alcohol use exacerbates periodontal disease and irritates and alters the oral mucosa (Cawley & Benson, 2005, p. 585; Eilers, 2004, p. 15). Medications that may cause xerostomia (e.g. opioids, antidepressants, antihypertensives, antihistamines, diuretics, sedatives, phenothiazines) also promote periodontal disease and create a favorable environment for bacterial and fungal overgrowth (Eilers, 2004, p. 15). Lastly, patients who are subjected to oxygen therapy and/or have changes in their breathing (e.g. tachypnea and mouth breathing) are at an increased risk for developing mucositis because of the dry environment created in the oral cavity (Eilers, 2004, p. 15).
In addition to knowledge, nurses require proper assessment skills and tools to adequately manage oral mucositis. It is essential for nurses to incorporate thorough and ongoing assessment and monitoring throughout the treatment period so that interventions can be modified accordingly (Eilers, 2004, p. 14; Sadler et al., 2003, p. 31). Assessment of the oral cavity should begin before cancer treatment. Nurses play a key role in teaching patients the rationale and benefits of ongoing assessments. During nursing assessments, a thorough examination of the oral cavity should be implemented with appropriate lighting (Eilers, 2004, p. 17). Oral cavity assessments should include visualization of the lips, tongue, gingivae, and all other surfaces within the cavity; palpation of visible lesions; and evaluation of function (Eilers, 2004, p. 17). Interaction with patients for subjective assessment data is also important (Eilers, 2004, p. 17). Nurses should inquire about problems that patients may be experiencing, and they should also inquire about patients’ opinions about current interventions. If current interventions are dissatisfying to patients, or if patients do not understand how to adequately provide self-care, it can cause delays in the healing process and/or may cause the patient to discontinue treatment. Moreover, nurses must accurately document all observable findings gathered from each assessment. Observable findings in the oral cavity that could indicate impending complications include color changes, moisture changes, change in mucosal integrity, and edema of the lips and tongue (Eilers, 2004, p. 17).
It is critical for all nurses involved with a patient to use an assessment tool that is effective, to use the same assessment tool, and to be properly trained in using the assessment tool (Cawley & Benson, 2005, p. 587; Potting et al., 2005, p. 233). An ideal tool for evaluating the oral cavity should be: reliable, valid, objective, and usable in all clinical and research situations (Cawley & Benson, 2005, p. 586; Potting, Blijlevens, Donnelly, Feuth, & Van Achterberg, 2005, p. 229). Some of the instruments utilized in practice for scoring oral mucositis include the Oral Assessment Guide (OAG), Oral Mucositis Assessment Scale, Oral Exam Guide, World Health Organization Scale, and the National Cancer Institute Common Toxicity Criteria Scale for Mucositis and Stomatitis (Cawley & Benson, 2005, p. 587; Potting et al.; 2005, p. 229). Potting et al. (2005) argue that current instruments lack inter-rater reliability, practicality, and usability in daily nursing practice. Thus, Potting et al. (2005) developed a new instrument called the Nijmegen Nursing Mucositis Scoring System (NNMSS), which was tested and found to have favorable results. The goal of developing the NNMSS was to create an assessment instrument that was reliable, valid, and usable in daily nursing practice (Potting et al., 2005, p. 233). The NNMSS measures both objective (erythema, oedema, lesions) and subjective (pain, dryness of mouth, viscosity of saliva) characteristics of the oral cavity (Potting et al., 2005, p. 232). The NNMSS is still a newly developed instrument that needs further testing, but proves to be a promising assessment tool for the future.
The final component nurses should incorporate in their management of oral mucositis is the delivery of adequate evidence-based care. Nursing implementation of an oral care protocol is the key to preventing or minimizing oral mucositis and its complications (Cawley & Benson, 2005, p. 588; Eilers, 2004, p. 15). For patients who undergo cancer therapies, good oral hygiene is the most basic element in the oral care protocol (Cawley & Benson, 2005, p. 588; Eilers, 2004, p. 16). Nurses should always include patient teaching of how and when to care for the mouth to promote self-care. Nurses need to educate patients on topics such as toothbrushes (use soft-bristled/foam brushes, brush at lease twice daily, when to replace ); daily flossing; mouth rinses (avoid alcohol-based mouthwash); foods to avoid (coarse, spicy, acidic, alcohol, extremely hot or cold); ways to deal with dry mouth (rinses, sugar-free candy/gum, increase fluid intake); denture-care instructions (remove when performing oral care, avoid use except when eating, importance of regular cleaning); products to use for dry lips (water-based moisturizers); and how to examine and note changes in their oral cavity (Cawley & Benson, 2005, p. 589; Eilers, 2004, p. 16).
In addition to oral care protocol, there are various treatment therapies to manage oral mucositis (Cawley & Benson, 2005, p. 589; Eilers, 2004, p. 18). A common therapy to prevent and treat oral mucositis is mouth rinses (Cawley & Benson, 2005, p. 589; Eilers, 2004, p. 18). It helps to clean the debris, keep the oral cavity soft and moist, and offers pain relief (Cawley & Benson, 2005, p. 589; Eilers, 2004, p. 18). Recommended rinsing solutions include 0.9% saline solution, sodium bicarbonate, and a 0.9%/sodium bicarbonate mixture (Eilers, 2004, p. 18). There are also some rinses that can offer pain relief such as Magic mouthwash (lidocaine, diphenhydramine, magnesium or aluminum hydroxide), and Gelcair Bioadherent Oral Gel (polyvinylpyrrolidone, sodium hyaluronate, and glycyrrhetinic acid) (Cawley & Benson, 2005, p. 589). Nurses must teach patients about various rinses and instruct patients on its proper use.
Another treatment for oral mucositis is cryotherapy (Eilers, 2004, p. 18; Nikoletti, Hyde, Shaw, Myers, Kristjanson, 2005, p. 751). Cryotherapy is based on the principle of vasoconstriction, which reduces epithelial exposure (Eilers, 2004, p. 18). It is an ideal treatment for patients who receive a bolus of chemotherapy (especially with 5-fluorouracil), but it is not practical for those receiving prolonged chemotherapy infusions (Eilers, 2004, p. 18). Nikoletti et al. (2005) conducted a study of cryotherapy, using ice chips, and found that it significantly reduces the effects of oral mucositis.
Furthermore, there are various other agents that patients can use including mucosal protectants like sucralfate suspension and hydroxypropyl cellulose film; antiseptic agents; anti-inflammatory agents; topical analgesics; and growth factors (Cawley & Benson, 2005, p. 589; Eilers, 2004, p. 19-20). Mucosal protectants promote mucosal healing and cell regeneration (Eilers, 2004, p. 18). According to Eilers (2004), growth factors assist with the regeneration and healing of the oral mucosa (p. 21). In addition, recombinant human keratinocyte growth factor is instrumental in treating mucositis because, it stimulates the replication and maturation of epithelial cells (Cawley & Benson, 2005, p. 589).
To conclude, it is crucial for nurses to be self-directed in seeking knowledge deficits, updating their knowledge base and skills, and utilizing evidence-based interventions to provide optimal patient care and effective management of oral mucositis. Knowledge enables nurses to anticipate the occurrence of oral mucositis and be proactive in the management of its process (Cawley & Benson, 2005, p. 585). Although visual signs of mucositis typically only appear after seven to ten days of treatment initiation, damage begins the day of treatment (Cawley & Benson, 2005, p. 585-586). Initiating patient care prior to therapeutic cancer regimens will minimize the debilitating effects of oral mucositis. Furthermore, adequately maintaining or minimizing oral mucositis will increase the likelihood for completion of therapy and improve patient outcome.

a. Intervention 1- Proper Oral Assessment

i. Disadvantage 1- Current assessment tools lack inter-rater reliability, practicality, and usability in daily nursing practice.
Some of the common scoring instruments used for the assessment of the oral cavity in cancer patients lack validity, reliability, and/or usability (Cawley & Benson, 2005, p. 586; Potting et al., 2005, p.228). A few current scoring instruments used in practice include the Oral Cavity Assessment Form (OCAF), the Oral Assessment Guide (OAG), the Oral Mucositis Index (OMI), and the Western Consortium for Cancer Nursing Research Stomatitis Staging System (WCCNR). Potting et al. (2005) revealed that some instruments base their validity on consensus statements from cooperative groups or a small number of experts in the field, and that only a few instruments were evaluated for reliability during the study of the instrument. In addition, Potting et al. (2005) state that some instruments require the assessment of several items or symptoms on specific locations in the oral cavity, which require patients with severe pain to open their mouths for prolonged periods. Various instruments require different tools to correctly inspect the oral cavity, which can be too complicated for daily nursing practice and requires a significant amount of training to be used accurately (Potting et al., 2005, p. 231). Moreover, some of the scoring instruments were developed for various purposes and from the perspective of a specialized field (e.g., dentistry, radiotherapy, oncology) (Jaroneski, 2006, p. 1086; Potting et al., 2005, p. 229). Most of these instruments focused on evaluating a particular intervention and were not developed with an emphasis on inter-rater reliability because they were only used by a few researchers (Potting et al., 2005, p.229). The lack of inter-rater reliability in these instruments is incompatible with daily nursing practice, which requires a reliable and validated instrument that offers consistency with the changing of staff during every shift (Potting et al., 2005, p. 229).

Cawley, M., & Benson, L. (2005, October). Current trends in managing oral mucositis. Clinical Journal of Oncology Nursing, 9(5), 584-592. Retrieved October 18, 2007 from CINAHL database.
Jaroneski, L.A. (2006, November). The importance of assessment rating scales for chemotherapy-induced oral mucositis. Oncology Nursing Forum, 33(6), 1085-1090. Retrieved February 4, 2008 from CINAHL database.
Potting, C.M.J., Blijevens, N.A.M., Donnelly, J.P., Feuth, T., & Van Achterberg, T. (2006, July). A scoring system for the assessment of oral mucositis in daily nursing practice. European Journal of Cancer Care 15(3), 228-234. Retrieved October 18, 2007 from CINAHL database.

ii. Disadvantage 2- Lack of universal standards of practice regarding oral care for cancer patients.
According to Jaroneski (2006) there are no universal standards of oral care for patients with cancer. Moreover, Eilers (2004) notes that not only are standards of oral care used inconsistently in patients who undergo cancer therapy, but standards of oral care do not even exist in many institutions. Literature regarding the frequency of performing oral assessment is inconsistent, and experts fail to agree upon the use of assessment tools in the management of oral mucositis (Jaroneski, 2006, p. 1089). Current clinical guidelines, and evidence-based guidelines developed by organizations such as the Multinational Association of Supportive Care in Cancer and the International Society for Oral Oncology, for the prevention and treatment of cancer therapy fail to address the use of grading scales in the assessment phase (Jaroneski, 2006, p. 1089). Chemotherapy and biotherapy guidelines and recommendations by the Oncology Nursing Society addresses the use of an assessment tool, but does not provide a specific protocol for its use (Jaroneski, 2006, p. 1089). The lack of standards of practice in the use of assessment tools and in the frequency of performing oral assessments lead to the use of inconsistent assessment tools, inadequate documentation, and absent or inconsistent oral evaluations. Adequate and proper assessment of oral mucositis is necessary to guide clinical practice for positive outcomes.

Eilers, J. (2004, April). Nursing interventions and supportive care for the prevention and treatment of oral mucositis associated with cancer treatment. Oncology Nursing Forum, 31(4), 13-23. Retrieved October 18, 2007 from CINAHL database.
Jaroneski, L.A. (2006, November). The importance of assessment rating scales for chemotherapy-induced oral mucositis. Oncology Nursing Forum, 33(6), 1085-1090. Retrieved February 4, 2008 from CINAHL database.

b. Intervention 2- Delivery of adequate evidenced-based care.

i. Disadvantage 1- Knowledge gaps in the pathophysiology of oral mucositis, and identification of at-risk patients.
Oncology nurses must be aware of and become familiar with the current five-stage model of mucositis developed by Sonis. Before Sonis’ research, mucositis was believed to be a result of epithelial damage caused by radiotherapy and chemotherapy (Cawley & Benson, 2005, p. 585). Sonis’ research has helped us better understand the process of oral mucositis, which targets the submucosa, as opposed to the previously believed epithelium (Cawley & Benson, 2005, p. 585).
A review of Sonis’ five-stage model is included above. An understanding of this model can help guide clinical practice for more positive outcomes (Cawley & Benson, 2005, p. 586; Jaroneski, 2006, p. 1089). Nurses who are knowledgeable about the five stages can better anticipate the occurrence of oral mucositis and therefore, can better manage oral mucositis. An understanding of the occurrence and stages of events involved with the process of oral mucositis allows nurses to be proactive with their interventions. In addition to being knowledgeable about the pathophysiology, nurses should also be able to identify at-risk populations. This knowledge will help nurses reduce patients’ risk, implement early interventions, and provide supportive care to patients who are at-risk from suffering the effects of cancer therapy (Cawley & Benson, 2005, p. 584). Cawley & Benson (2005) acknowledge differing views based on age as a risk factor, which includes both the older populations and the younger populations. Other risk factors that nurses should be aware of include gender (women more likely than men to develop oral mucositis), certain chemotherapeutic agents (5-FU, etoposide, methotraxate, antimetabolites, cyclophosphamide, bulsulfan), medications (opioids, antidepressants, phenothiazines, antihypertensives, antihistamines, diuretics, sedative), tobacco and alcohol use/abuse, oxygen therapy, poor oral health or periodontal disease, diet (high sugar intake, protein/calorie malnutrition), and changes in breathing (tachypnea, mouth breathing) (Cawley & Benson, 2005, p. 585; Eilers, 2004, p. 15).

Cawley, M., & Benson, L. (2005, October). Current trends in managing oral mucositis. Clinical Journal of Oncology Nursing, 9(5), 584-592. Retrieved October 18, 2007 from CINAHL database.

Eilers, J. (2004, April). Nursing interventions and supportive care for the prevention and treatment of oral mucositis associated with cancer treatment. Oncology Nursing Forum, 31(4), 13-23. Retrieved October 18, 2007 from CINAHL database.
Jaroneski, L.A. (2006, November). The importance of assessment rating scales for chemotherapy-induced oral mucositis. Oncology Nursing Forum, 33(6), 1085-1090. Retrieved February 4, 2008 from CINAHL database.

ii. Disadvantage 2- Lack of an efficacious management strategy.
According to Eilers (2004) there is a widespread interest in the prevention and treatment of mucositis, but limited progress toward finding an efficacious management strategy. Eilers (2004) states that there are few well-designed studies demonstrating the effectiveness of various treatments, but the studies are inconsistent. Thus, different institutions are using diverse regimens and are forced to make incomplete informed treatment decisions (Eilers, 2004, p. 17). In addition, although there are a variety of agents available for reducing the severity of mucositis, oral complications remain a significant source of morbidity for patients who undergo cancer therapy (Eilers, 2004, p. 17). Current treatment strategies are targeted at providing symptomatic relief, reducing the severity of mucositis, and using systemic agents that work against multiple targets (Cawley & Benson, 2005, p. 589; Eilers, 2004, p. 18).

Cawley, M., & Benson, L. (2005, October). Current trends in managing oral mucositis. Clinical Journal of Oncology Nursing, 9(5), 584-592. Retrieved October 18, 2007 from CINAHL database.
Eilers, J. (2004, April). Nursing interventions and supportive care for the prevention and treatment of oral mucositis associated with cancer treatment. Oncology Nursing Forum, 31(4), 13-23. Retrieved October 18, 2007 from CINAHL database.

References
Cawley, M., & Benson, L. (2005, October). Current trends in managing oral mucositis. Clinical Journal of Oncology Nursing, 9(5), 584-592. Retrieved October 18, 2007 from CINAHL database.
Eilers, J. (2004, April). Nursing interventions and supportive care for the prevention and treatment of oral mucositis associated with cancer treatment. Oncology Nursing Forum, 31(4), 13-23. Retrieved October 18, 2007 from CINAHL database.
Nikoletti, S., Hyde, S., Shaw, T., Myers, H., & Kristjanson, L. (2005, July). Comparison of plain ice and flavoured ice for preventing oral mucositis associated with the use of 5 fluorouracil. Journal of Clinical Nursing14(6), 750-753. Retrieved October 18, 2007 from CINAHL database.
Potting, C.M.J., Blijevens, N.A.M., Donnelly, J.P., Feuth, T., & Van Achterberg, T. (2006 July). A scoring system for the assessment of oral mucositis in daily nursing practice. European Journal of Cancer Care 15(3), 228-234. Retrieved October 18, 2007 from CINAHL database.
Sadler, G., Stoudt, A., Fullerton, J., Oberle-Edwards, L., Nguyen, Q., & Epstein, J. (2003, February). Managing the oral sequelae of cancer therapy. MEDSURG Nursing, 12(1), 28-36. Retrieved October 18, 2007 from CINAHL database.