In this section
Note: This guideline is currently under review.
Definition of Terms
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.
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.
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
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;
Further information on dental management of the paediatric oncology and the haemopoietic stem cell transplant patient can be found at
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.
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)
Method of Assessment
Normal no changes
Mild to Moderate change
Moderate to Severe change
Ask the child to swallow or observe the swallowing process.
Ask the parent if there are any notable changes
Difficulty in swallowing
Unable to swallow
Pooling or dribbling of secretions
Observe appearance of tissue
Smooth, pink and moist
Dry, cracked or swollen
Ulcerated or bleeding
Observe the appearance of the tongue using a pen torch to illuminate the oral cavity
Pink and moist with papillae present
Coated or loss of papillae with shiny appearance with or without redness
Ulcerated, sloughing or cracked
Observe consistency and quality of the saliva
Thin and watery
Excessive amount of saliva, drooling
Thick, ropey or absent
Observe the appearance of mucous membranes using a pen torch to illuminate the oral cavity
Pink and moist
Reddened or coated without ulcerations
Ulceration or sloughing, with or without bleeding
Observe the appearance of gingivae using a pen torch to illuminate the oral cavity
Pink and firm
Observe the appearance of teeth using a pen torch to illuminate the oral cavity
Clean and no debris
Plaque or debris in localized areas
Generalised plaque or debris along gum line
Talk and listen to the child
Ask parent if there are any notable changes
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)
Recommended management for oral hygiene in paediatric oncology and HSCT patients
Standard mouthcare for paediatric oncology & HSCT patients
-brush teeth, gums and tongue using soft toothbrush BD
¹Replace toothpaste in the morning with 0.5% chlorhexidine gel if child has dental decay (as verified by a dentist)
Mouthcare for paediatric oncology & HSCT patients at risk of oral complications²
-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
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.
Click here to view the Evidence Table.
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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