Mucositis and the Promotion of Oral Health in Children and Young People With Malignant Disease - Management of |
Publication: 27/04/2018 -- |
Last review: 05/05/2021 |
Next review: 01/05/2024 |
Clinical Guideline |
CURRENT |
ID: 5509 |
Approved By: Trust Clinical Guidelines Group |
Copyright© Leeds Teaching Hospitals NHS Trust 2021 |
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated. |
Please check the patients allergy status, as they may be allergic to Chlorhexidine, and alternative ( Providine iodine) solution will be required. Be aware: Chlorhexidine is considered an environmental allergen. Refer to the asepsis guidance. |
Management of Mucositis and the Promotion of Oral Health in Children and Young People With Malignant Disease
- Background
- Diagnosis/Assessment
- Treatment / Management
- Appendix 1: Mini Mouth Care Matters
- Appendix 2: Mouthcare For Children and Young People With Cancer: At A Glance
- Photobiomodulation for prevention of oral mucositis in children and young people undergoing chemotherapy
Background
One of the most common side effects of cancer treatment is mucositis, a painful inflammation and ulceration of the mucous membranes. The rapidly dividing cells of the oral mucosa are especially susceptible to the damaging effects of cytotoxic therapy. Oral complications during chemotherapy and radiotherapy can arise from direct injury to the oral mucosa but they also result from cytotoxic induced myelosuppression which can produce profound neutropenia. In around 50% of patients with mucositis, lesions can be severe causing significant pain and can interfere with normal nutritional intake. Mucositis can also predispose the child / young person to fungal, viral and bacterial infections.
In 2006 Evidence based guidelines for Mouth Care for Children and Young People with Cancer were published by the UKCCSG (now CCLG) – PONF (now CYPCN) Mouth Care Group. They are comprehensive evidence-based guidelines on oral care for children and young people who have undergone or are receiving chemotherapy and/or radiotherapy for a malignancy (including head and neck cancers), or stem cell transplant (including bone marrow and peripheral blood stem cell transplants).
This work was advanced by the development of Mini Mouth Care Matters (MMCM), and recent clinical practice guidelines from the Canadian POGO group with international input.
Diagnosis/Assessment
An oral assessment guide should be used for all patients at risk of mucositis. The frequency and nature of assessment are dictated by the risk of complications (see appendix 1)
Treatment / Management
The management of oral health consists of general prevention (with appropriate toothpastes, floss and other aids as directed by the dental team), specific prevention (such as cryotherapy - see SOP and photobiomodulation when indicated), and management of complications.
The summary document (appendix 2) outlines the essentials of both prevention and treatment and should be used in all clinical areas where oncology patients are cared for.
In the setting of mucositis, appropriate analgesia is important, and the following topical treatments should be considered:
‘Difflam’ (analgesic oral rinse or spray)
Oral rinse 12- 18 years only: Rinse or gargle 15ml every 1.5 to 3 hours as required. Not more than 7 times a day.
Spray: < 6yrs: 1 puff per 4kg to max of 4 puffs onto effected area every 1.5 to 3 hours.
6 to 12 years; 4 puffs frequency same
12 to 18 years: 4 to 8 puffs same frequency.
‘Gelclair’ (coats the mouth and acts as a barrier)
Dissolve one sachet in approximately 40ml water and use as a mouthwash three times per day or as needed. Can also be used undiluted directly onto ulcers using a pink mouth sponge. Can commence use prophylactically before chemotherapy.
If systemic analgesia is required local pain protocols should be followed. It should be noted that mucositis can cause considerable distress. Assessment for analgesia should include previous assessments for analgesia response, and look for behavioural indicators of oral pain such as dribbling secretions, and abnormal voice. Consideration of how to deliver the analgesia should include preference of route of enteral therapy (NG/PEG, or by mouth) and children may need early escalation to NCAS/PCAS.
Nutritional assessment for patients with mucositis should be undertaken as reduced intake is very common and nutritional support may be needed.
Appendix 1: Mini Mouth Care Matters
Daily assessments:
These vary depending on the location.
The BMT unit uses the „OAG“ scale
Category |
Method of observation |
Rating .1. |
Rating .2. |
Rating .3. |
Voice |
Converse with patient. Listen to crying. |
Normal |
Deeper or raspy |
Difficulty talking or crying, or painful. |
Ability to swallow |
Ask patient to swallow. |
Normal swallow |
Some pain on swallowing |
Unable to swallow |
Lips |
Observe and feel tissue. |
Smooth, pink and moist |
Dry or cracked |
Ulcerated or bleeding |
Saliva |
Insert depressor into mouth, touching centre of tongue and the floor of the mouth. |
Watery |
Thick or ropy. Excess salivation due to teething. |
Absent |
Tongue |
Observe appearance of tissue. |
Pink, moist and papillae present |
Coated or loss of papillae with a shiny appearance with or without redness. Fungal infection. |
Blistered or cracked |
Mucous membrane |
Observe appearance of tissue. |
Pink and moist |
Reddened or coated without ulceration. Fungal infection. |
Ulceration with or without bleeding |
Gingiva |
Gently press tissue. |
Pink and firm |
Oedematous with or without redness, smooth. Oedema due to teething. |
Spontaneous bleeding or bleeding with pressure |
Teeth (if no teeth, score 1) |
Visual. Observe appearance of teeth. |
Clean and no debris |
Plaque or debris in localised areas (between teeth). |
Plaque or debris generalised along gum line |
Other areas use the simpler WHO scale
Grade |
Description |
0 (none) |
None |
I (mild) |
Oral soreness, erythema |
II (moderate) |
Oral erythema, ulcers, solid diet tolerated |
III (severe) |
Oral ulcers, liquid diet only |
IV (life-threatening) |
Oral alimentation impossible |
Appendix 2: Mouthcare For Children and Young People With Cancer: At A Glance
2.1 DENTAL CARE / TREATMENT
AT DIAGNOSIS Oral & dental assessment |
|
DURING ONCOLOGY TREATMENT Dental assessment every 3 months |
|
POST TREATMENT |
|
2.2 BASIC ORAL CARE
AT DIAGNOSIS & DURING TREATMENT |
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2.3 ORAL COMPLICATIONS
|
PREVENTION |
TREATMENT |
MUCOSITIS |
|
|
CANDIDIASIS |
|
Clinical decision required about which antifungal agent to use, choose one that is absorbed from the GI tract eg fluconazole as first line.
|
XEROSTOMIA |
|
|
HERPES |
|
|
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Provenance
Record: | 5509 |
Objective: | Aims Objectives |
Clinical condition: | Mucositis and prevention of poor oral health |
Target patient group: | Adult Patients receiving systemic anti‐cancer therapy, haematopoietic stem cell transplantation or radiotherapy in adult patients |
Target professional group(s): | Secondary Care Doctors Secondary Care Nurses |
Adapted from: |
Evidence base
Taken from the Children’s Cancer Network Guideline (approved) 26/03/2018 reviews with the dental, nursing, and medical oncology teams
Evidence Base:
References and Evidence levels:
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. (where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other)
Further Information and References
2006 Evidence based guidelines for Mouth Care for Children and Young People with Cancer (cclg.org.uk -> Members Area)
MiniMouthCareMatters https://mouthcarematters.hee.nhs.uk/links-resources/mini-mcm-resources-2/
iPOG / POGO Guidelines https://www.pogo.ca/healthcare/practiceguidelines/
Approved By
Trust Clinical Guidelines Group
Document history
LHP version 2.0
Related information
Not supplied
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