ORAL Mucositis in the cancer patient: A Tutorial

1. ORAL Mucositis in the cancer patient:A Tutorial By Monique Swiecichowski, BSN,RN,CCRC Alverno College Picture from Microsoft Clipart

2. Navigation Click on arrow to move back a slide Click on arrow to move forward a slide Click on underlined arrow to return to beginning slide Click on house to return to topic page TOPICS Click on desired topic to go directly to content Word Role over underlined words for definitions or explanations V Click on V to see video depiction on YouTube. Sound is recommended. Exiting out of or minimizing YouTube video will return you to the slide you were on. *** Hint: ‘finger pointing hand’ must be visible when clicking for commands to work

3. Objectives • Identify the five biological phases of mucositis • Identify at least three risk factors contributing to mucositis in cancer patients • Be able to assess those cancer patients at risk for and with mucositis • Identify at least three preventative measures and/or interventions of mucositis • Identify at least four implications of mucositis to the cancer patient

4. Case study • Mr. M is a 72 year old African American man with newly diagnosed Stage III squamous cell carcinoma of the hypopharnyx. His treatment plan includes concurrent radiation and cisplatin. He states that he has not been to a doctor in ‘years’ and admits to smoking half a pack of cigarettes and drinking 3 beers a day. He has never been to the dentist. You note that he has a history of not showing for his appointments. • Is Mr. M at risk for mucositis? What are his risk factors? • What interventions might you offer Mr. M? • If Mr. M experiences mucositis what are the five biological phases that will • occur? • You will be assessing Mr. M frequently, what will you be assessing and • how might you consider documenting it? • Why is it important to minimize Mr. M’s mucositis?

5. TOPICS REVIEW PATHOBIOLOGY CAUSES and RISK FACTORS GENETICS ASSESS and DOCUMENT IMPLICATIONS INTERVENTIONS REFERENCES

6. REVIEW layers of the oral mucosa Stratified squamous cells ---Oral epithelium ---Basement membrane--- Loose connective tissue under epithelium containing capillaries and gland ducts ----Lamina propia Minor salivary glands, striated muscle, fat, fibroblasts, endothelial cells, nerves, and inflammatory cells ------submucosa Muscle or bone

7. REVIEW Acute Inflammation Activation of macrophages, dendritic call, histocytes and mastocytes residing in endothelium Release of inflammatory mediators -Vasodilatation (rubor) -Heat (calor) -Permeability of blood vessels=exudation of plasma proteins/fluid into tissues (edema or tumor) -Sensitivity to pain (dolor) -Loss of function (functio laesa) necrotic loss of tissue=exposing lower layers=Ulcerative inflammation

8. REVIEW affects of stress Cancer as a stressor Immune cells (monocytes and lymphocytes) Cytokines (cross the blood-brain barrier) Corticosteroid releasing factor Stress hormone activation (catecholamines, corticosteroids, growth hormone, glucagon, and renin) Neuroendocrinological pathways: (sympathetic nervous system, renin angiotensin system, hypothalamic pituitary axis) Acute phase response Acute phase proteins (inflammatory mediators) Black, 2002; Porth, 2009

9. REVIEW Definition • Mucositis: refers to the inflammation of any • mucosal membrane • Stomatitis or oral mucositis: describes any • inflammatory condition of oral tissue • Not an inflammatory disorder

10. PATHOBIOLOGY Historical belief of mucositis in cancer patients cytotoxic treatments kills rapidly dividing cells; cancerous and normal Current belief of mucositis in cancer patients series of simultaneous events beginning in the epithelium or submucosa and progressing to other tissue layers Sonis et al., 2004 • Working model of mucositis=5 phases • Initiation • Upregulation • Signaling and Amplification • Ulceration • Healing

11. Phase I: Initiation • Chemotherapy (CT) or radiation (RT) exposure: • Begins day 1 of treatment • Begins in the submucosal endothelium Radiation will stimulate nuclear factor-kappaB NF-kB RT or CT causes direct damage to DNA resulting in cell death Chemotherapy will stimulate Ceramidesynthase RT and CT generate reactive oxygen species (ROS) that damage lipids, DNA, connective tissue and cell membranes [stress response] Sonis et al., 2004; Sonis, 2007 Diagram used with permission by John Wiley and Sons

12. Phase II: Upregulation • days 1-3 • Occurs in the epithelium and submucosa • Multiple pathways resulting in damage NF-kB regulates the pro-inflammatory cytokines-that lead to an inflammatory response And promotes apoptosis direct damage to DNA by ROS Diagram used with permission by John Wiley and Sons Sonis et al., 2004; Sonis, 2007

13. Phase II: Upregulation (cont’d) • Additional pathways resulting in damage Do you remember the previous Phase? Click for a reminder. Initiation Damaged cell membranes stimulate sphingomyelinase fibronectin break-up leads to increased macrophages, and tissue damage or eventual apoptosis Ceramide pathway signals cells to enter apoptosis (V1 ) Excessive apoptosis and/or decreased clearance of apoptotic cells induce secretion of other pro-inflammatory cytokines Gupta, 2006 Diagram used with permission by John Wiley and Sons Sonis et al., 2004; Sonis, 2007 V1: Alberts et al, 2002

14. Phase III: Signaling and Amplification • Day 4-8 • Pro-inflammatory cytokines= positive feedback loops re-initiating the damage response pathways • Mucosal surface still appears clinically normal Initiation Upregulation Do you remember the previous Phases? Click for a reminder. NF-kB activates cyclooxygenase-2 (Cox-2) and produces prostaglandins resulting in inflammatory mediation and angiogenesis (V2) TNF-Alpha activates NF- kB which activates more TNF **RT induced FEEDBACK LOOP** PROCESS (cont’d) MMPdegrades the extracellular matrix (ECM); ECM begins to swell with fluid (inflammatory response) Tumor Necrosis Factor (TNF)-alpha stimulates apoptosis and sphingomelinase **Chemo induced FEEDBACK LOOP** Diagram used with permission by John Wiley and Sons Sonis et al., 2004; Sonis, 2007 V2: Alberts et al., 2009

15. Phase IV: Ulceration • Day 8-12 • Cell death, reduced epithelial regeneration, and apoptosis thin the epithelium • Characterized by inflammation and ulceration Do you remember the previous Phases? Click for a reminder. I. Initiation II. Upregulation III. Signaling & amplification Breakdown of mucosa=ulcers Bacteria penetrate the submucosa and stimulate macrophages to produce and release additional pro-inflammatory cytokines. Pro-inflammatory cytokines Stimulate inflammatory responses. Bacteria and debris are removed and factors are released to promote proliferation V3/ V4 Diagram used with permission by John Wiley and Sons Sonis et al., 2004; Sonis, 2007 V3: http://www.youtube.com/watch?v=CmbWE3jLUgM V4: http://www.youtube.com/watch?v=uNG-jZxvhcg

16. Do you remember the previous phases? Click for a reminder. • -Initiation • -Upregulation • -Signaling • &amplification • -Ulceration • Phase V: Healing • Day 12-21 • Downregulation of the inflammatory response • Signaling from extracellular matrix = epithelial proliferation and • differentiation • Epithelial cells multiply and migrate to close the ulcers • Submucosal cells regenerate • Increased risk of future injury with subsequent therapy Wound repair V5 V5: Alberts, 2009 Sonis et al., 2004; Sonis, 2007

17. Testing your knowledge Click on the letter box in each section below that corresponds to the correct phase of mucositis listed at the bottom. A B A B C D C D A B C A B C A B C A B C E F E F D E F D E F D E F D E F Pre treatment Phase I Phase II Phase III Phase IV Phase V A.Upregulation B. Healing C. Signaling and Amplification D. Initiation E. Ulceration F. Normal Diagram used with permission by Sonis, 2007

18. Now let’s apply it! Remember Mr. M? He is a 72 year old African American man with newly diagnosed Stage III squamous cell carcinoma of the hypopharnyx. His treatment plan includes concurrent radiation and cisplatin. Click on the right answer. Mr. M began his chemotherapy and radiation today. You don’t need to worry because it is too early for any pathobiological process to have begun. On Day 3 of Mr. M’s treatment, you suspect that there will be multiple damage response pathways resulting in damage. On Day 6, due to all the activity of TNF-alpha and the feedback loops in Phase III, you anticipate Mr. M will have sign of mucositis. When you see Mr. M on day 11 he might complain of a sore mouth. When you assess him chances are there might be signs of biological phase IV mucositis. If Mr. M develops mucositis, once it resolves. You expect that he will not be a risk with further therapy. True False True False True False True False True False

19. RISK FACTORS • #1 Causative risk is the cancer therapy being administered • RADIATION-to the head and neck • Conventional external beam (once a day) • Hyperfractionated (twice a day) • CHEMOTHERAPY- of any cancer type • Thymide synthetase inhibitors: methotrexate • Topoisomerase II inhibitors: Etoposide, irinotecan • Pyrmidine analogs: cytarabine, 5-FU • Alkylating agents: busulfan, melphalan, cytoxan, cisplatin • Purine analogs: 6-MP • Intercalating drugs: idarubicin, doxorubicin, daunorubicin • Pictures from Microsoft Clipart • BOTH or COMBINED MODALITIES-to the head and neck • Chemosensitizer • Niscola et al., 2007; Sonis, 2004

20. RISK FACTORS (cont’d) • #2 Patient-related variables • AGE • 1.Csiszar ,2008; 2. Niscola et al.,2007; 3.Sonis , 1998; 4. Treister & Woo, 2010; 5.Zalcberg , Kerr, Seymour, & Palmer, 1998 • Younger age is associated with more severe mucositis 3 • higher basal cell proliferation rate4 • greater epidermal growth factor receptors • Older age may be at risk due to other factors • Decreases salivary flow & increased prevalence of gingivitis • poor oral health at baseline 2 • Very old age (>70 year old) has also been associated with increased mucositis • Diminished organ function 5 • chronic inflammation process=elevated • proinflammatory cytokines 1 • Oxidative stress of aging=NF-kB activation 1 • Elevated NF-kB=programmed cell death 1

21. RISK FACTORS (cont’d) • #2 Patient-related variables • Barasch & Peterson, 2003 • SALIVARY FUNCTION • xerostomia predicts mucositis • hyposalivation can be caused by anxiety/stress,medications, alcohol, depression, endocrine disorders, nerve damage from surgery, oxygen, dehydration, tobacco • Obstructive nasal disease • ORAL HEALTH • Poor baseline oral status exacerbates mucositis • ill-fitting prostheses or faulty restorations • Pre-existing oral infections (viral or fungal) • Dental disease

22. RISK FACTORS • GENETICS • Microsoft ClipArt • May explain why patients of the same age, treatment regimens, • and equivalent oral health status vary in the incidence of mucositis • deficiencies of enzymes due to polymorphisms = greater risk of mucositis • variations in the metabolism of chemotherapy= different rates of mucositis • variations in apoptotic activity = variations in risk • Mice with deficiency in the acidic sphingomyelase gene= increased resistance • to mucositis • Sonis et al., 2004 • Example: • psoriasis patients lack apoptosis of the skin; • when treated for cancer= lower incidence of mucositis • Addison’s disease patients have excess apoptosis; • cancer treatments= higher incidence of mucositis • Sonis,2007

23. Testing your knowledge What are the risk actors associated with mucositis? • Across • 2. conventional external beam or hyperfractionated • 4. young or old • 5. ill-fitting dentures, gingivitis, caries, broken teeth • 6. may cause variations in drug metabolizing enzymes and • deficiencies in metabolizing enzymes • Down • 1. radiation with chemotherapy (chemosensitizer) • 3. caused by medications, alcohol, tobacco, nerve damage from • surgery, dehydration • antimetabolites, antitumor antibiotics, alkylating agents  CLICK WHEN READY TO SEE ANSWERS

24. Now let’s apply it! Mr. M’s treatment plan includes concurrent radiation and cisplatin. He states that he has never been to a dentist and admits to smoking half a pack of cigarettes and drinking 3 beers a day. Since his last visit he has established a primary care physician, was found to have hypertension and depression, and was placed on corresponding medications. What are Mr. M’s risk factors? (Click on the right answer) True False The radiation and cisplatin will put Mr. M at risk. True False Geneticswill play a role in mucositis. True False Mr. M likely has excellent oral health so is not a risk for mucositis. True False Mr. M is too old to be at risk. True False Mr. M does not evidence any behaviors to be concerned about xerostomia.

25. ASSESSMENT • Pretreatment-stratify risk based on: • Each visit: during treatment • treatment plan • level of xerostomia • list of prescribed and over-the-counter medications • baseline oral hygiene • Examine the lips, tongue, and oral mucosa (after removing dental appliances): Color, moisture, integrity, cleanliness • *Adequate illumination; halogen light sources provide consistent intensity and color • Sonis et al., 2004 • Assess for changes: in taste, voice, ability to swallow • Examine the saliva: for amount and quality • Assess oral pain (0-10 scale) • Document all of the above MicrosoftClipArt • Polovich , Whitford, & Olsen , 2009

26. DOCUMENTATION A wide variety of scales have been developed focusing on symptomatic and functional outcomes: World Health Organization (WHO)-Oral Mucositis National Cancer Institute Common Toxicity Criteria (NCI-CTC)-Oral Mucositis Microsoft ClipArt

27. DOCUMENTATION (cont’d) Another all inclusive Oral Assessment Guide The key is for all caregivers to consistently use an accepted grading scale throughout all patient’s treatments. Microsoft ClipArt Modified from the Oral Assessment Guide with permission by J. Eilers RN,MSN, UNIVERSITY OF NEBRASKA MEDICAL CENTER, 83 Rev 2-84, 5-84, 4-85, 11-85, 4-86 jeilers@nebraskamed.com Click here to see original Oral Assessment Guide with pictures

28. ASSESSMENT AND DOCUMENTATION Let’s focus on the NCI-CTC version 3.0 Microsoft ClipArt This scale is the most used in documenting the assessment of a patient’s lips, tongue and oral mucosa. But what else should be assessed and documented? (Click to find out.) Changes in taste and voice, amount and quality of saliva, oral pain. As well as vital signs for signs of infection and dehydration.

29. ASSESSMENT AND DOCUMENTATION Grade 0 Grade 1 Erythema/minimalsymptoms, normal diet Normal/No symptoms Grade 2 Grade 3 Patchy ulcerations or pseudomembranes/ symptomatic but can eat and swallow modified diet Confluent ulcerations or pseudomembranes (contiguous patches > 1.5 cm in diameter)/Symptomatic and unable to adequately ailment or hydrate orally G 0 from Microsoft ClipArt/ G1-4 photos used with permission from EUSA Pharma @ www.caphosol.com/patients/oral-mucosiis/index.php

30. ASSESSMENT AND DOCUMENTATION (cont’d) Grade 4 Grade 5 DEATH (indirectly from mucositis: sepsis and other treatment related side effects) Tissues necrosis; significantspontaneous bleeding/symptoms associated with life-threatening consequences

31. Testing your knowledge Grade 3 Pseudomembranes; bleeding with minor trauma Grade 2 or 3 Depending on extent and intake ability Grade 4 Tissue necrosis and spontaneous bleeding; life-threatening especially for bone marrow transplant patients and other immunosupressed patients Grade 0 Not mucositis- Hairy tongue: decreased salivary flow causes debris that is normally washed away by saliva builds up in the oral cavity. Grade 2 Can eat a modified diet Grade 1 Erythema: Eating a normal diet • Click on the picture of a: • Grade 0 mucositis • Grade 1 mucositis • Grade 2 mucositis • Grade 3 mucositis • Grade 4 mucositis Images reprinted with permission from Medscape.com, 2011. Available at: http//emedicine.medscape.com/article/1079570-overview

32. Now let’s apply it! • Mr. M comes in and you assess him. He states that his mouth is sore. When asked about • what he is eating he admits that he is not eating his usual fried chicken dinners due to pain • but is able to eat the mashed potatoes, grits and apple sauce. He admits that they don’t taste • the same. You notice that his voice is a bit raspy. • When you check his oral mucosa you find this: • Furthermore, you note that his lips are without • erythema or lesions, his saliva is thick, there is food • at his gum line, it takes a lot of effort for him to swallow, • and when asked his pain level he ranks it at a 4/10. • You would document: level of xerostomia ? oral hygiene?, taste ?, voice?, • color of oral mucosa ? • You would also indicate the grade of mucositis so as to gage his mucositis compared to • past assessments and to aid in future assessments. Using the NCI-CTC Oral Mucosa Scale. What grade would you assess his mucositis to be? Oops this is not normal! Try again. 0 There is erythema, but there is more, Try again. 1 YES!! There is patchy pseudomembranes and symptoms: soreness, and soft diet 2 Try again. He could bleed with trauma, but he is able to eat 3 No, not yet. The tissue is not necrotic and his symptoms are not life-threatening 4 He is still alive!!! 5 photo used with permission from EUSA Pharma @ www.caphosol.com/patients/oral-mucosiis/index.php

33. WHY IS IT IMPORTANT? • AFFECTS PATIENT OUTCOMES • Decreases the efficacy of RT, chemotherapy, and chemo/RT • Studies indicate this is due to: • Rosenthal, 2007 • Studies have shown: • -treatment breaks in RT were predictive of local recurrence and overall survival in locally advanced head and neck patients. • -treatment breaks were associated with higher rates of first relapse, rate of failure in the chest, and rate of failure in the brain for limited small-cell lung cancer patients • -chemotherapy dose reductions in breast cancer patients result in a higher recurrence rate • -Tumor growth during the breaks • -a dose-response threshold; increases in the dose are needed for tumor control

34. IMPLICATIONS • PAIN • “…reported as the most distressing symptom by patients receiving treatment for head and neck cancer...” Harris (2006, p.252) • Domino affect: • Fatigue • PAIN Reduced oral intake Weight Loss/Malnutrition • Death • If severe enough requires opiods • Keefe et al., 2007

35. IMPLICATIONS (cont’d) • INFECTION • Ulceration • Compromise of mucosal barrier • Local invasion of colonizing microorganisms • Local infection: Streptococcal/candida/reactivation of HSV-1 • Systemic infection: sepsis, bacteremia, and systemic fungal infection

36. IMPLICATIONS (cont’d) • ECONOMIC IMPACT • Ulceration • Local infection Reduced oral intake • Systemic infection Pain Malnutrition/dehydration • IV antibiotics IV opiods TPN/feeding tube • ?Hospitalization?

37. ECONOMIC IMPACT • Study of 75 patients treated for head and neck cancer • 78% of opiods prescribed were for pain of the mouth and throat • 51% had a feeding tube placed • 30% were hospitalized due to mucositis (length of stay= 4.9 days) • Average cost for a 5-day hospitalization=$23,000 • Isitt et al., 2007 • Study of bone marrow transplant patients in US, Canada, and Europe • + correlation between severity of mucositis, # days of injectable narcotics, TPN, and injectable antibiotics • Hospital costs were $43,000 higher for patients with ulcerations than those without • Papas et al., 2003

38. IMPLICATIONS (cont’d) • NUTRITION/HYDRATION • Mucositis • Oral intake • Malnutrition/dehydration • DECREASED QUALITY OF LIFE • NON-COMPLIANCE to THERAPY • may not show for treatments • may not take oral chemotherapeutics

39. Testing your knowledge Which of the following implications of severe mucositis could affect our patient Mr. M? (Click on the best answer.) True False Severe mucositis would not affect M. M’s quality of life. True False Treatment breaks due to toxicity might affect his cancer outcomes and compliance to therapy. True False Infections are a very real issue with severe mucositis. True False Severe mucositis would not have any nutritional implications. True False Severe mucositis could place significant financial burden on Mr. M.

40. INTERVENTIONS • Before therapy begins • Evidenced-based • Comprehensive oral/dental consult • Oral cleaning • Removal of excess plaque • Treatment of all dental caries • Extraction of teeth with poor prognosis • Check prosthesis fit • Consider a fluoride tray Microsoft clipart Bhatt et al., 2010; Bensinger, 2008

41. Patient education • Mouth care • Floss once a day • Brush w/soft-bristle toothbrush for 90 seconds 3 times a day • Use fluoride toothpaste • Rinse w/bland (non-alcohol based) rinse • Keep lips lubricated Harris, 2006 • Recommended intake • Drink 1-3 liters of fluid a day • Maintain nutrition; emphasize intake of high protein foods • Eat non-acidic fruits (banana, mango, melon, peach) • Avoid • Smoking • Rough hard foods • Acidic foods (grapefruit, lemon, orange, tomatoes) • Alcohol • Alcohol-containing and highly flavored oral products Microsoft clipart Strohl & Camp-Sorrell , 2006

42. INTERVENTIONS: cont’d During therapy Evidenced-based • Nursing interventions Microsoftclipart • Likely to be effective • Cryotherapy: ice chips 30 minutes prior and during melphalan and • bolus 5-FU (agents with short half-life); local vasoconstriction • Normal saline (with or without baking soda) mouthwash: • 30 ml swish 30 seconds and spit after meals and bedtime; removes • debris without compromising healing • Eaton, 2009; Besinger, 2008 • Effectiveness not established • Raw honey: 20ml honey applied 15 min before and 15 min after • radiation & 6 hrs later; active enzymes have antimicrobial properties • Eaton, 2009; Khanal et al, 2010; Rashad et al, 2008 • Fluoride chewing gum: chew 5 pieces x 20 minutes each every day; • increases salivary flow • Eaton, 2009

43. Patient Education • Change tooth brush q month or with each chemo cycle • (Plt <50K and WBC <1,000 use moistened gauze sponge) • Rinse w/saline mouthwash after meals and a bedtime • Salt/sodium bicarbonate: 1 part salt/1-2 parts baking soda • mix ½-1 tsp dry mix in 1 cup water • Use fluoride mouth rinse, tray, or toothpaste daily • Re-enforce what to avoid and recommendations for intake • NOTIFY PROVIDER WITH ANY SIGNS AND SYMPTOMS Polovich, Whitford & Olsen, 2009 Per NCCN Guidelines: “Adequate patient education and communication between the patient and all members of the cancer care team are critical, particularly since nursing staff…interact with the patient more frequently than the physician” Besinger, (2008, p. 17). Microsoft clipart

44. INTERVENTIONS During therapy • Prevention/reduce severity • Likely to be effective (medical interventions) • Palifermin- IV bolus (for high dose chemotherapy/Bone Marrow Transplant) • Mid-line radiation blocks and conformal radiotherapy(CRT) or (3D) CRT • Benzydamine- mouhwash for head and neck radiation patients (In the NCCN guidelines but not available in the US) • Gelclair (EKR Therapeutics, Inc)-mix product w/2-3 T water, swish for 1 minute and spit, 3x a day. Recommended to not eat or drink or 1 hour after use. (Approved as a medical device for oral mucositis; Not a NCCN recommended treatment and conflicting ONS recommendations) Eaton, 2009 & Polovich, Whitford & Olsen, 2009 • Low-level laser therapy (LLLT); not generally used due to cost Bensinger, 2008

45. INTERVENTIONS During therapy • Prevention • Unlikely to be effective • Oral aloe vera • Pilocarpine • Oral povidone-iodine • Iseganan • Misopostol • Topical vitamin E • Flurbiprofen tooth patch • G-CSF • IM Immunoglobulin • Wobe-mugos E • Amifostine for mucositis • has not been determined • Prevention • Not recommended for • Practice • GM-CSF mouthwash • Sucralfate • Antimicrobial lozenges • Hydrogen peroxide • Chlorhexidine Eaton, 2009 & Bensinger, 2008

46. INTERVENTIONS Review (click on box to review) DENTAL CARE Oral cleaning Removal of excess plaque Treatment of cavities Pull teeth as needed Check fit of dentures and partials PATIENT EDUCATION Mouth care Recommended intake Food, behaviors, and products to avoid NURSING INTERVENTIONS EDUCATION Cryotherapy Mouth rinses Honey? MEDICAL INTERVENTIONS Palifermin CRT or 3D-CRT LLLT Gelclair?

47. Pain Management • Nociceptive pain: • -mediated by C fibers • relieved w/opioids • Other strategies-Cox-2 inhibitors, NSAIDS, gabapentin • Harris, 2006 Microsoft clipart • Incidental pain: • -caused by movement and contact • -mediated by A-8 fibers • Only effective treatment is “functional exclusion of the anatomic parts” Niscola et al. (2007, p.226) • Temporary relief strategies • Magic mouthwash: 15ml swish and spit QID (however, little evidence to support) Eaton, 2009 • Various lidocaine/xylocaine rinses (not recommended due to compromise of the gag reflex and possibility of incidental injury when numb) • Besinger, 2008

48. Xerostomia Management • Frequent fluid intake • Artificial saliva (i.e. Biotene, Oasis) • Sucrose-free lemon drops • Caphosol mouthwash (EUSA Pharma, Inc): prescription ‘supersaturated’ (with calcium and phosphate ions) mouthwash • Not listed in current ONS or NCCN guidelines Microsoft clipart Eaton, 2009 & Strohl, 2006

49. Testing your knowledge Which of the following is the most important nursing intervention for a patient at high risk for mucositis? Click on the correct response. Indeed, this is very important as therapy will affect salivary function and it’s role in mucosal protection. But what else? Xerostomia management Yes, oral hygiene is extremely important before and during therapy. What else? Re-enforce oral hygiene Although there are non-prescriptive therapies that nurses can offer such as cryotherapy, normal saline mouthwash, pushing fluids is there anything that encompasses more? Preventative therapies Right, patients at significant risk, such as head and neck cancer patients should be assessed and treated by a dental professional prior to initiating cancer therapy. What else? Dentalexam YES!!!!! Patients and families need to understand the importance of oral hygiene , ways to reduce their risk of xerostomia and mucositis, s/s oral inflammation, and the importance of notifying providers of s/s Patient education Very important for quality of life and although nursing is important for assessing pain at onset most treatments involve prescribe medications. Anything else? Pain management

50. Now let’s apply it! Let’s review. Mr. M is your 72 year old patient with head and neck cancer. His treatment included concurrent radiation and cisplatin. At treatment onset, he admitted to smoking half a pack of cigarettes and drinking 3 beers a day. He had never been to the dentist. During treatment he was placed on hypertensive and antidepressant medications. You assessed him with a Grade 2 mucositis. What have been your interventions? YES NO • Assisted Mr. M in making a dental appointment? YES NO • Educated Mr. M on oral hygiene, foods to avoid and those to try, tobacco cessation, alcohol avoidance? YES NO • Activated the preventative measures of normal Saline mouthwash, honey, cryotherapy and GM-CSF mouthwash? YES NO • Xerostomia management including oral fluids, oral moisturizers, and sugar free lemon drops? YES NO • Pain assessment and management such as • topical swish and spit medications?