Clinical Guidelines (Nursing)

Mouth Care – Oral Care of the paediatric oncology patient and haematopoieitic stem cell transplant patient

  • Note: This guideline is currently under review. 

    Introduction

    Aim

    Definition of Terms

    Assessment

    Management

    Dental Considerations

    Other Considerations

    Companion Documents

    Evidence Table

    References

    Document Control

     

    Introduction

     

    Oral mucositis is a common complication of chemotherapy and radiotherapy. Chemotherapy alters the integrity of the mucosa, the normal microbial flora of the oral cavity, salivary quantity and composition, as well as epithelial maturation. As a result, the child receiving chemotherapy may experience pain, dysphagia, alteration in nutritional status, and risk of infection.

    Severe mucositis can delay treatment and so limit the effectiveness of the child's cancer therapy. Not all chemotherapy-induced mucositis can be prevented but, with proper management, the severity and duration of oral complications can be minimised.

    Oral care and the promotion of good oral health can reduce the amount of microbial flora, reduce pain and bleeding, prevent infection and the risk of dental complications.

     

    Aim

    The aim of this guideline is to provide a comprehensive overview of the oral care of the paediatric oncology and haemopoietic stem cell transplant patient.

     

    Definition of Terms

    ALL –acute lymphoblastic leukemia

    Allogeneic donation not from self

    Gingivitis - inflammation of the gingivae (gums) caused by bacterial plaque accumulation

    GI tract gastrointestinal tract

    Haemopoietic stem cell transplant – transplantation of the blood forming components/cells of the body

    Mucositis - inflammation and/or ulceration of the mucous membranes and/or ulceration of the oral cavity (stomatitis), often involving the oesophagus (oesophagitis)

    NCA – nurse controlled analgesia

    OAG – oral assessment guide

    Oesophagitis - inflammation and/or ulceration of the mucous membranes involving the oesophagus

    PCA – patient controlled analgesia

    "Smear" – a "smear" or "pea sized" amount of chlorhexidine gel or toothpaste is equivalent to 0.1 to 0.2mls (or 5mm in length) of these products   

    Stomatitis - inflammation and/or ulceration of the mucous membranes in the oral cavity

    Xerostomia – a sensation of dryness in the mouth, can also be associated with the presence of thick, "ropey" saliva  

    Assessment

    Assessment by a dentist

    All children diagnosed with cancer or receiving a haemopoietic stem cell transplant should be screened by a paediatric dentist prior to the commencement of treatment.

    All children diagnosed with cancer or receiving a haemopoietic stem cell transplant should be reviewed by a paediatric dentist at least every 3-4 months during active treatment and then every 6-12 months after completion of treatment.

    The paediatric dentist will;

    • Identify current or potential sources of infection
    • Reduce or remove any food or plaque traps such as braces
    • Reduce the risk of future dental problems like cavities and bleeding gums
    • Review and provide advice on appropriate dental hygiene for the paediatric oncology patient
    • Liaise with other dental providers to provide guidance on the appropriate dental care for the paediatric oncology patient during active treatment and following completion of treatment

    Further information on dental management of the paediatric oncology and the haemopoietic stem cell transplant patient can be found at

     

    Daily assessment

     

    All patients being treated for childhood cancer or undergoing a haemopoietic stem cell transplant require daily assessment of the oral mucosa

    It is the responsibility of the clinician managing the patients care to assess the oral mucosa and decide on subsequent methods of oral hygiene

    The Oral Assessment Guide (OAG) can assist the clinician in determining oral health and function. 

    Each of the eight categories is scored 1, 2 or 3.  

    • An OAG score of 8 indicates a healthy oral cavity
    • An OAG score of 24 indicates severe mucositis  (warranting aggressive treatment)

    The OAG provides parameters for the assessment of each child's mouth and the implementation of a plan of care based on these findings.

    Results of the assessment should be clearly documented in the medical record. 

     

    Oral Assessment Guide (OAG)

    Category

    Method of Assessment

    Normal no changes

    1

    Mild to Moderate change

    2

    Moderate to Severe change

    3

    Swallow

    Ask the child to swallow or observe the swallowing process.

    Ask the parent if there are any notable changes

    Normal

    Without difficulty

    Difficulty in swallowing

    Unable to swallow

    Pooling or dribbling of secretions

    Lips

    Observe appearance of tissue

    Normal

    Smooth, pink and moist

    Dry, cracked or swollen

    Ulcerated or bleeding

    Tongue

    Observe the appearance of the tongue using a pen torch to illuminate the oral cavity

    Normal

    Pink and moist with papillae present 

    Coated or loss of papillae with shiny appearance with or without redness

    Ulcerated, sloughing or cracked

     Saliva

    Observe consistency and quality of the saliva

    Normal

    Thin and watery

    Excessive amount of saliva, drooling

    Thick, ropey or absent

    Mucous membranes

    Observe the appearance of mucous membranes using a pen torch to illuminate the oral cavity

    Normal

    Pink and moist 

    Reddened or coated without ulcerations 

    Ulceration or sloughing, with or without bleeding

    Gingivae

    Observe the appearance of gingivae using a pen torch to illuminate the oral cavity

    Normal

    Pink and firm

    Oedematous

     Spontaneous bleeding

    Teeth

    Observe the appearance of teeth using a pen torch to illuminate the oral cavity

    Normal

    Clean and  no debris 

    Plaque or debris in localized areas 

    Generalised plaque or debris along gum line

    Voice

    Talk and listen to the child

    Ask parent if there are any notable changes

    Normal

    Deeper or raspy 

    Difficult or unable to talk or cry

    *Oral Assessment Guide- adapted from Eilers, A. & Peterson, M. (1998), and from the GOSH Oral Care Working Party (2004)

     

    Management

     Recommended management for oral hygiene in paediatric oncology and HSCT patients

     

    Level 1

     

    Standard mouthcare for paediatric oncology & HSCT patients

     -brush teeth, gums and tongue using  soft toothbrush BD

    • with a smear of toothpaste in the morning (after breakfast)¹
    • with a smear of toothpaste in the evening (before bedtime)

     

    ¹Replace toothpaste in the morning with 0.5% chlorhexidine gel if child has dental decay (as verified by a dentist) 

    Level 2

     

    Mouthcare for paediatric oncology & HSCT patients at risk of oral complications²

    Includes;

    -febrile neutropenia

    -patients with mucositis

    -ALL induction phase

    -ALL delayed intensification phase

    -allogeneic HSCT (preconditioning to Day =+100) 

      

    -brush teeth, gums and tongue using soft toothbrush TDS

    • with a smear of 0.5% chlorhexidine gel in the morning (after breakfast)
    • with a smear of 0.5% chlorhexidine gel in the afternoon (after lunch)
    • with a smear of toothpaste in the evening (before bedtime)

     

    ² Once the patient is no longer at risk of oral complications, mouthcare should continue as outlined in Level 1

     

    Management plan should be clearly documented in the medical record. 

     

    Toothbrushing

    • Change toothbrushes every three months to ensure effective brushing and minimize infection
    • Allow toothbrush to air dry after use
    • A cotton swab or foam brush should be used in babies who have no teeth instead of a tooth brush
    • A foam brush or super soft toothbrush may be used as an alternative if the patient has significant mucositis, bleeding or pain in the oral cavity
    • Parents should assist children under 6 years of age with tooth brushing

     

    Toothpaste

    • Adult strength fluoride toothpaste should be used (0.22% fluoride)
    • Children who are very young (between 18 months to 6yrs) or having chemotherapy may not tolerate adult strength fluoride toothpaste.
      •  A recommended alternative is a toothpaste marketed  for use from 6+ years of age (adult strength toothpaste with a mild taste that is suitable for young children)  or
      • A low fluoride toothpaste (0.11% fluoride) marketed for use below 6 years of age
    • After using toothpaste the patient should be instructed as follows;
      • patient may spit out excess toothpaste (infants may swallow very small amounts of toothpaste)
      • do not rinse for 30 minutes post using toothpaste
      • do not eat or drink for 30 mins after using toothpaste
    • Normal saline or water should be used in babies who have no teeth instead of a toothpaste

     

    Chlorhexidine based gels or mouth rinses

    • Chlorhexidine based gels and  mouth rinses have a broad antimicrobial activity, with some antifungal and anti viral properties
    • If chlorhexidine 0.5% gel is unavailable, chlorhexidine 0.2% mouth rinse may be used.
    • It is recommended to use chlorhexidine based gels and mouth rinses that are alcohol free as the presence of alcohol may contribute to mouth dryness, irritation and brown staining to the teeth
    • After using a chlorhexidine based gel or mouth rinse the patient should be instructed as follows;
      • do not swallow the gel or mouth rinse
      • patient may spit out excess gel or mouth rinse
      • do not rinse for 30 minutes post using the gel or mouth rinse
      • do not eat or drink for 30 minutes after using the gel or mouth rinse
    • Chlorhexidine based gels or mouth rinses need to be prescribed
      •  

    Flossing

    • Flossing should be encouraged once daily if the child is older than 12 years of age, is used to regular flossing and it can be managed atraumatically
    • Flossing should be discontinued if mucositis is present

     

    Pain management

    • Non compliance by the paediatric oncology or HSCT patient in attending to mouthcare may be related to oral mucosa pain
    • Regular pain assessment is required using a validated tool as per pain management clinical practice guidelines
    • Indications of pain associate with mucositis may include; difficulty swallowing, refusal to swallow, difficulty/refusal to talk, difficulty/refusal in opening mouth, drooling saliva, difficulty/refusal to attend to mouthcare and epigastric chest pain as examples
    • Xylocaine Viscous 2% applied topically may be of use prior to eating. Xylocaine Viscous 2% should not be used more than 4 hourly. It is best gargled and spat out rather than swallowed, or may be applied with a swab directly to painful areas
    • Time analgesia administration to have maximum efficacy during mouth care procedures
    • Systemic analgesics (as examples paracetamol or morphine) may be required, and should be administered according to the degree of pain (as stated by the child), the presence of drooling, and/or difficulty in swallowing, talking, eating or opening the mouth

     

    Anti-fungal agents

    Prophylaxis of Oral Candida

    • Discussion with the paediatric oncology/HSCT fellow or consultant is required prior to prescribing anti-fungal agents for treatment doses of oral candida
    • Anti-fungal agents that are not absorbed by the GI tract, such as nystatin, are no longer recommended as preventative anti-fungal agents for oral candida
    • Anti-fungal agents (oral or intravenous as tolerated) should be used for the prophylaxis of patients undergoing haemopoietic stem cell supported therapy. An azole antifungal agent, such as fluclonazole  may be prescribed as per the
    • Prophylaxis for fungal infections will be based on sensitivities of the proven or suspected organism, consideration of medication toxicity and consideration of the patient's clinical status, co morbidities and concomitant medications.

     

    Treatment of Oral Candida

    • Discussion with the paediatric oncology/HSCT fellow or consultant is required prior to prescribing anti-fungal agents for treatment doses of oral candida
    • Oral anti-fungal agents (intravenous if not tolerated) should be used for the treatment of visible oral candidia. An azole antifungal agent such as fluclonazole may be prescribed  

    Recommended dosages

    • For recommended dosages for children undergoing Haemopoietic Progenitor Cell Transplantation refer to
    • Treatment for fungal infections will be based on sensitivities of the proven or suspected organism, consideration of medication toxicity and consideration of the patient's clinical status, co morbidities and concomitant medications.

     

    Anti-viral agents

    • Aciclovir is recommended as a prophylactic and treatment measure for herpes simplex virus in patients undergoing haemopoietic stem cell supported therapy
    • For recommended dosages refer to

     

    Dental Considerations

    • Elective dental treatment should be delayed until the child is either in remission or on maintenance chemotherapy
    • During immunosuppression all elective dental procedures should be avoided
    • Fixed orthodontic appliances and space maintainers should be removed if the patient has poor oral hygiene or the treatment protocol carries a risk of developing moderate to severe mucositis

     

    Other considerations

    • A multidisciplinary approach to oral care (nurse, medical officer, dentist, pain management team, procedural pain management team, dietician, pharmacist and others) will assist in providing appropriate supportive care to the paediatric oncology patient
    • Several therapy and patient specific factors, including the chemotherapy drug, the type of malignancy, age, neutrophil count and level of oral care are important in the aetiology of oral mucositis
    • Chemotherapy agents such as methotrexate, cytarabine, doxorubicin, etoposide, bleomycin, mercaptopurine and fluorouracil (5FU) are particularly associated with the development of mucositis
    • Rinse mouth after vomiting with water
    • Sodium bicarbonate may be effective in dissolving mucus and loosen debris, raising pH and preventing  overgrowth of aciduric bacteria
    • Rantidine or omeprazole may be useful for the prevention of epigastric pain after treatment with cyclophosphamide, methotrexate and 5-FU
    • Chewing sugarless gum or lozenges has been shown to increase saliva flow and thus reduce discomfort.  It can however, cause irritation and may be unacceptable for some patients.
    • Application of moisturising cream to the lips is recommended.  Avoid petroleum-based lubricants such as Vaseline that can increase dryness of the tissues, preferably use water based or aloe based lip balm.

     

    Companion Documents

     

    Evidence Table

    Click here to view the Evidence Table.

     

    References

    • American Academy of Pediatric Dentistry (2009) Guideline on dental management of pediatric patients receiving chemotherapy, hematopoietic cell transplantation, and/or radiation. Pediatric Dentistry, 31(6), 232-238.
    • Great Ormond Street Hospital for Children, NHS (2010) Clinical Guideline Mouth Care, http://www.gosh.nhs.uk/clincial_information/clinical-guidelines/cpg_guideline_00116 Retrieved 26/09/2011
    • Oral and Dental Expert Group (2012) Therapeutic Guidelines: Oral and Dental, Version 2, Therapeutic Guidelines Limited
    • UKCCSG-PONF Mouth Care Group (2006) Mouth Care for Children and Young People with Cancer: Evidence-based Guidelines Guideline Report, Version 1, February 2002, 1-65.
    • Kumar, N., Brooke, A., Burke, M., John, R., O'Donnell, A. & Soldani, F. (2012) The Oral Management of Oncology Patients Requiring Radiotherapy, Chemotherapy and/or Bone Marrow Transplantation: Clinical Guidelines. The Royal College of Surgeons of England / The British Society for Disability and Oral Health
      http://www.rcseng.ac.uk/fds/publications-clinical-guidelines/clinical_guidelines/documents/clinical-guidelines-for-the-oral-management-of-oncology-patients-requiring-radiotherapy-chemotherapy-and-or-bone-marrow-transplantationRetrieved 14/05/13

    Document Control

    The development of this nursing guideline was coordinated by Charmaine Hall, Dental Fellow, Dentistry, Dr. Kerrod Hallett, Director, Dentistry, Lisa Barrow, Clinical Nurse Educator, Children's Cancer Centre, Sarah Egan, Clinical Support Nurse, Children's Cancer Centre and Tracy Shields, Pharmacist, Oncology Pharmacy, and approved by the Nursing Clinical Effectiveness Committee. Updated December 2013.  


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