Mucositis and the Promotion of Oral Health in Children and Young People With Malignant Disease

Mucositis and the Promotion of Oral Health in Children and Young People With Malignant Disease - Management of

Publication: 27/04/2018

Next review: 01/05/2024

Clinical Guideline

CURRENT

ID: 5509

Approved By: Trust Clinical Guidelines Group

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

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

Ideally by a dentist or dental hygienist linked to the cancer centre.
Any treatment required should be undertaken or supervised by a consultant or specialist Paediatric Dentist.
Written and verbal oral hygiene advice should be provided for children and parents prior to commencing cancer treatment.

DURING ONCOLOGY TREATMENT

Dental assessment every 3 months

Ideally by a dentist linked to the cancer centre (retain registration and communication with usual dental provider).
Any treatment required should be undertaken ideally by dentist linked to the cancer centre.
If not available, then by usual dental provider with clear communication & guidance from the cancer centre.

POST TREATMENT

By usual dental provider with clear communication & guidance from the cancer centre.
Children should continue to be monitored during the period of growth and development.
Parents and children should be informed, at an appropriate time, of the possible long-term dental and orofacial effects of childhood cancer and cancer treatment.

2.2 BASIC ORAL CARE

AT DIAGNOSIS & DURING TREATMENT

Mini Mouth Care Matters (MMCM) Assessment Record within 24 hours of admission and documentation of risk level
Follow mouth care actions dictated by risk on Mini Mouth Care Record (including twice daily toothbrushing with fluoride toothpaste for all, nursing team to ensure children have a toothbrush and toothpaste)
Recording of all mouthcare on recording sheet each time it is given
Use of MMCM mascot markers to identify whether additional support needed for mouthcare
Whilst an inpatient, oral assessment using Mouth Care Assessment Record at a frequency determined by individual need (minimum of daily by nurse and/or medic)
For children undergoing active cancer treatment, WHO mucositis assessment daily whilst inpatient
Appropriate training in MMCM assessment should be available within the cancer centre, ideally in collaboration with the dental team
Use of additional aids e.g. floss, high fluoride/sodium lauryl sulphate free toothpaste by recommendation of the dental team.

2.3 ORAL COMPLICATIONS

	PREVENTION	TREATMENT
MUCOSITIS	Basic oral care (as above) Consider use of non-foaming, sodium lauryl sulphate (SLS) free toothpastes e.g. Sensodyne, Oranurse For those with prolonged inpatient stay and at very high risk of mucositis (e.g. children undergoing haemopoietic stem cell transplant, young people with osteosarcoma), use of photobiomodulation. See SOP. For those receiving short infusions of melphalan, methotrexate or 5FU consider cryotherapy (ice pops). See SOP.	Basic oral care (as above) Gelclair, Difflam, Chlorhexidine (to reduce risk of secondary infection) as needed Swab any ulcers that are present if suspect secondary infection Appropriate pain control as per recommendation on MMCM assessment
CANDIDIASIS	Basic oral care (as above)	Basic oral care (as above) Clinical decision required about which antifungal agent to use, choose one that is absorbed from the GI tract eg fluconazole as first line. Check treatment protocols. Nystatin is not recommended.
XEROSTOMIA	Basic oral care (as above)	Basic oral care (as above) Consider saliva stimulants/artificial saliva. Contact dental team regarding high fluoride toothpaste prescription for caries prevention.
HERPES	Basic oral care (as above) Aciclovir is only recommended as a preventative strategy for herpes simplex in patients undergoing high dose chemotherapy with stem cell transplant (“BMT”)	Basic oral care (as above) Assess need for aciclovir on individual basis considering age, severity, neutropenic status and febrile episodes For mild and/or non-progressive lip lesions prescribe topical aciclovir For moderate/severe and/or progressive lip lesions and for mild/moderate oral lesions prescribe oral aciclovir For severe oral lesions or if oral route cannot be tolerated prescribe IV aciclovir For doses see BNF - Children

Provenance

Record:	5509
Objective:	Aims To improve the management of oral health in children and young people with malignant disease. Objectives To provide recommendations for appropriate management of oral health in children and young people with malignant disease.
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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