Clinical Guidelines (Nursing)

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

  • Introduction

    Aim

    Definition of Terms

    Assessment

    Management

    Dental Considerations

    Other Considerations

    Companion Documents

    Evidence Table

    References

    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
    • COPADM – chemotherapy regimen involving the agents cyclophosphamide, vincristine (oncovin), prednisolone, doxorubicin (adriamycin) and methotrexate 
    • Cryotherapy – the application of ice or ice chips to the mouth  
    • Gingivitis - inflammation of the gingivae (gums) caused by bacterial plaque accumulation
    • GI tract - gastrointestinal tract
    • Haemopoietic stem cell transplant (HSCT)– transplantation of the blood forming components/cells of the body
    • Low Level Laser/Light Therapy (LLLT) – the application of low level/low power/low energy density laser or light emitting diodes (LED) to the oral mucosa 
    • 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
    • TBI – total body irradiation; radiation of the entire body used as pre conditioning regimen for HSCT 
    • 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 HSCT require daily assessment of the oral mucosa.
    It is the responsibility of the nurse managing the patient’s care to assess the oral mucosa and decide on subsequent methods of oral hygiene in consultation with the medical team.
    The Oral Assessment Guide (OAG) can assist in determining the patient’s 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 

    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 Electronic Medical Record.  The OAG Assessment tool should be added for all paediatric oncology and HSCT patients under the ENT assessment in the Focused Assessment flowsheet. 

    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 et al (1988) by the mouth care working party, Great Ormond Street Hospital for Children NHS Trust (2005)

    Management

     Recommended management for oral hygiene in paediatric oncology and HSCT patients

    Level 1

     

    Standard mouthcare for paediatric oncology & HSCT patients


    Patients in this group should;
     - 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)









    ¹  Replace 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

    Risk groups includes;

    - febrile neutropenia

    - patients with mucositis

    - ALL induction phase

    - ALL delayed intensification phase

    - allogeneic HSCT (preconditioning to Day =+100) 

     Patients in this group should; 

    - 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

     

    The management plan should be clearly documented in the Electronic Medical Record. 

    Toothbrushing

    • Use a toothbrush to clean teeth, this is the most effective way to reduce gingivitis and remove plaque and debris   
    • Teeth should be brushed for a minimum of two minutes to ensure good oral care
    • After use, allow the toothbrush to air dry
    • Change toothbrushes every three months to ensure effective brushing and minimize infection
    • 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 should be used as a temporary alternative if the patient has significant mucositis, bleeding or pain in the oral cavity (a foam brush is ineffective at removing plaque and should not be used on an ongoing basis to brush teeth) 
    • Parents may need to assist children under 6 to 8 years of age with tooth brushing (children under this age may not have the fine motor skills needed to brush teeth effectively)

    Toothpaste

    • The use of fluoride toothpaste strengthens tooth enamel and decreases the risk of dental cavities
    • It is recommended that adult strength fluoride toothpaste (0.22% fluoride) be used when brushing teeth
    • Children who are very young (between 18 months to 6 years) 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;
      • a patient should spit out excess toothpaste (infants may swallow very small amounts of toothpaste)
      • a patient should not rinse out their mouth or eat and drink for 30 minutes post using toothpaste (rinsing or eating and drinking after using toothpaste may remove it from the mouth and teeth and decrease effectiveness)
    • 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 antiviral properties.
    • Chlorhexidine based gels and mouth rinses can also inhibit plaque formation on the teeth and decrease the risk of dental caries and long term dental complications 
    • 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;
      • a patient should spit out excess gel or mouthrinse (do not swallow the gel or mouth rinse)
      • a patient should not rinse out their mouth or eat and drink for 30 minutes post using the gel or mouth rinse (rinsing after using the chlorhexidine gel may remove it from the mouth and teeth and decrease effectiveness)
    • Chlorhexidine based gels and mouth rinses need to be prescribed 
    • If chlorhexidine 0.5% gel is unavailable, chlorhexidine 0.2% mouth rinse may be used; moisten the toothbrush with the chlorhexidine 0.2% mouth rinse and clean teeth as normal (a foam brush or super soft toothbrush may be used as a temporary alternative if the patient has significant mucositis, bleeding or pain in the oral cavity)  
    • Rinsing the mouth with chlorhexidine 0.2% mouth rinse should not be used as a substitute for tooth brushing 

      Flossing and interdental brushes 

      • 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
      • Interdental brushes may be used as an alternative
      • Flossing or the use of interdental brushes should be discontinued if mucositis is present

      Pain management

      • Non adherence to mouth care by the paediatric oncology or HSCT patient may be related to oral mucosa pain
      • Indications of pain associated 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
      • A regular pain assessment is required using a validated tool as per the Pain Assessment and Measurement clinical guidelines (nursing)
      • Effective analgesia should be provided prior to performing mouth care where there is evidence of mucositis. Time analgesia administration to have maximum efficacy during mouth care procedures
      • Xylocaine 2% Viscous applied topically may be of use prior to mouth care. Onset of action occurs 3-5 minutes following the application to the oral mucosa. Anaesthetic effect lasts approximately 5-10 minutes. It is best gargled and spat out rather than swallowed, or may be applied with a swab directly to painful areas. Overuse of Xylocaine 2% Viscous has the potential to decrease a patient’s gag reflex if swallowed. Consult the AMH Children’s Dosing Companion for further information on dosage and frequency
      • Systemic analgesics (as examples paracetamol or opioids) 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. Consult the Pain Management clinical practice guidelines for further information on opioid or PCA infusions

      Low Level Laser/Light Therapy (LLLT)

      LLLT has been shown to improve therapeutic outcomes and reduce the prevalence and severity of oral mucositis in oncology patients by promoting healing, reducing inflammation and increasing cell metabolism. Studies have shown that LLLT may:

      • prevent the development of oral mucositis
      • decrease the severity of established oral mucositis
      • be well tolerated by children
      • provide an analgesic effect (patients have reported a ‘tingling’ sensation with the therapy; several adolescent patients have reported an immediate analgesia)

      All patients undergoing a HSCT or patients receiving high doses of chemotherapy agents such as COPADM should be referred by the treating team to the Dentistry department for LLLT prior to commencing chemotherapy. Other patients should also be referred 
      - if it is anticipated there is a high risk of the development of mucositis OR
      - if a patient develops significant mucositis

      Cryotherapy

      • Cryotherapy involves applying ice or ice chips to the mouth to cause vasoconstriction (ice-cold water, ice cream or icy poles may also be used). This reduces blood flow to the mouth and therefore decreases the amount of chemotherapy agent that reaches the oral mucosa 
      • Cryotherapy may be offered to cooperative children and adolescent patients receiving chemotherapy or HSCT preconditioning with regimens associated with a high incidence of mucositis. This technique is dependent on the patient being able to tolerate and manage the cryotherapy safely.  
      • Cryotherapy is most effective in regimens with chemotherapy with a short infusion time and short plasma half-life;
        • patients receiving the chemotherapy melphalan in the HSCT preconditioning phase, or a bolus of 5-fluorouracil chemotherapy may apply ice cubes/ice chips in their mouth for 5 minutes prior the infusion and continuing for a total of 30 – 45 mins if able to be tolerated. 

      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 prophylaxis doses of oral candida
      • Antifungal agents that are not absorbed by the GI tract, such as nystatin, are NO longer recommended as preventative anti-fungal agents for oral candida
      • Antifungal prophylaxis agents (oral or intravenous as tolerated) are recommended for paediatric oncology and HSCT patients at risk of invasive fungal infection (IFI). An azole antifungal agent, such as fluconazole, may be prescribed
      • 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, comorbidities 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
      • Antifungal agents that are not absorbed by the GI tract, such as nystatin, are NO longer recommended for the treatment of oral candida in the immunocompromised patient
      • 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  
      • 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, comorbidities and concomitant medications.

      Further information on the prevention and management of fungal infections in the paediatric oncology and the HSCT patient can be found at:
      Clinical Practice Guidelines (RCH): Antifungal prophylaxis for children with cancer or undergoing haematopoietic stem cell transplant
      Clinical Practice Guidelines (RCH): Fever and suspected or confirmed neutropenia  
      Guideline (CCC): Infection: Prophylaxis and Treatment in Haematopoietic Progenitor Cell Transplantation

      Anti-viral agents

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

      Further information on the prevention and treatment of viral infections in the HSCT patient can be found at 

      Guideline (CCC): Infection: Prophylaxis and Treatment in Haematopoietic Progenitor Cell Transplantation

      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 pathogenesis of oral mucositis

      • Chemotherapy agents such as methotrexate, cytarabine, doxorubicin, etoposide, bleomycin, mercaptopurine and fluorouracil (5FU) are particularly associated with the development of mucositis. Symptoms usually start 5 to 10 days after chemotherapy and may resolve within a few days following completion of the chemotherapy (however this is dependent on various therapy and patient specific factors)
      • Patients receiving targeted therapy agents such as epidermal growth factor receptor inhibitors or tyrosine kinase inhibitors (imatinib, dastanib, dabrafenib, trametinib, sorafenib) are more susceptible to the development of oral mucositis. This is more common when used in combination with other treatments such as chemotherapy 
      • Radiotherapy to the head and neck or total body irradiation (TBI) before HSCT are particularly associated with the development of oral mucositis. Symptoms usually start 14 days after radiotherapy; the duration of radiotherapy associated mucositis may last for several weeks 

      Further points to consider;

      • Encourage patients to rinse the mouth after vomiting with water (this will remove any stomach acid in the mouth; left in contact with the teeth, stomach acid can contribute to tooth decay and irritate the mouth)
      • Sodium bicarbonate mouth rinses may be useful and effective in dissolving mucus and loosening debris, raising pH and preventing overgrowth of aciduric bacteria
      • Rantidine or a proton pump inhibitor such as omeprazole or pantoprazole may be useful for the prevention of epigastric pain after treatment with cyclophosphamide, methotrexate and 5-FU
      • The use of hydrogen peroxide is not recommended as it increases dryness, contributes to the breakdown of newly formed tissue, disrupts normal oral flora and may increase the risk of aspiration and foaming
      • 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 a moisturising cream to the lips is recommended. Avoid petroleum based lubricants such as vaseline that can increase dryness of the tissues, preferably use water, lanolin or aloe based products. Paraffin based lubricants should be used with caution with oxygen therapy or babies with phototherapy as it is highly flammable

      Companion Documents

      Information for Parents

      Parent Information Sheet; Mouthcare – Taking care of your child's TEETH and MOUTH after chemotherapy or a bone marrow transplant

      Other parent information:

      Information for Health Professionals

      Evidence Table

      The evidence table for the Mouth Care – Oral Care of the paediatric oncology patient and haematopoieitic stem cell transplant patient can be found here. 

      References


      Please remember to read the disclaimer. 

       

      The development of this nursing guideline was coordinated by  Lisa Barrow, Clinical Nurse Educator, Children's Cancer Centre and approved by the Nursing Clinical Effectiveness Committee. Updated December 2018.