Oral Complications From

Best Practice Guidelines for the Management of
Oral Complications from

Cancer Therapy
- Best Practice Guidelines for the Management of Oral Complications from Cancer Therapy
Best Practice Guidelines for the Management of Oral Complications from Cancer Therapy -
Best Practice Guidelines for the Management of
Oral Complications from Cancer Therapy
Objective: circumstance. Guidelines do provide
This guideline will review assessment and evidence-based background
management of oral complications from information, consensus-based
treatment in cancer patients, including recommendations for similar problems,
those receiving surgery or radiotherapy and a context for each individual
to the head and neck, or decision.
chemotherapy-induced mucositis.
This guideline will be reviewed in three
Evidence will be reviewed and
years from publication date or earlier if
recommendations made for assessment,
important new evidence becomes
treatment and other management issues.
available. Current versions of this
A simplified discussion with flowcharts
guideline will be available on the Cancer
(practice pathways) will summarize the
Care Nova Scotia website
written contents. Through improved
(www.cancercare.ns.ca).
knowledge of health care professionals, it
is expected that management of oral These guidelines are designed for health
complications may be improved. care professionals, working in a variety of
settings. For front-line health care givers,
One specific objective for this guideline is
the Quick Reference Version of the
to standardize the assessment of oral
guidelines will be a useful reminder of
complications from cancer therapy
assessment and treatment. This Full
across Nova Scotia. By creating a
Version will be useful for those who prefer
common approach to assessment, the
to read a bit more about the
authors propose we can improve the
recommendations. The full evidence-
assessment and management of oral
based discussions of these guidelines are
complications for cancer patients.
located in the Appendices of the
Preamble Note: Comprehensive Version, available on
Practice guidelines are intended to assist request or at the Cancer Care Nova
health care professionals with decisions Scotia website. The development of
throughout the spectrum of the cancer these guidelines is described in Appendix
experience. This guideline is intended to XI.
assist health care professionals to care for
Patients, families and other non-health
cancer patients with oral complications
care professionals are recommended to
from their treatments. Management
review materials written for the lay
should be customized to meet the unique
public, such as the Living Well With
needs of individuals and their families.
Cancer information series.
Further information on oral complication
management for children with cancer Comment on Evidence:
may be obtained from the IWK Health There is a scarcity of clinical trial
Centre Hematology-Oncology Team. evidence on most aspects of oral
complication management in cancer
Guidelines should never replace specific
patients. When high-quality evidence
decisions for individual patients, and do
was not available, a ‘best practice’
not substitute for the shared decisions
approach was used to develop this
between any patient and health
guideline. Clinicians should continue to
professional which are unique to each
i - Best Practice Guidelines for the Management of Oral Complications from Cancer Therapy
provide the best possible care for cancer eligibility restrictions for each trial. Patients
patients, despite the absence of definitive are encouraged to discuss clinical
evidence. Best practices include research opportunities with their health
experience and sound clinical judgment, care providers. Other researchers may
aided by level III & IV evidence where also contact patients to offer participation
available, and should be given serious in relevant trials. Current clinical trials will
consideration for patient care and policy be listed on the Cancer Care Nova Scotia
decisions. website (www.cancercare.ns.ca).
Comment on Clinical Research: Acknowledgements:

An important component of treatment This guideline was written by a
decision-making for any patient is the collaborative effort of the Supportive
potential for enrollment in relevant Care Cancer Site Team, and was
clinical research. The Supportive Care sponsored by Cancer Care Nova Scotia.
Cancer Site Team is committed to Background research for the treatment
advancing patient care, through was performed by Sophie Goeury,
participation in clinical trials and other pharmacy student from Nancy, France.
clinical research projects. At any point in The guidelines also incorporate
time, there may be a clinical trial or other knowledge of current evidence by the
clinical research opportunity related to cancer experts in Nova Scotia.
any component of this guideline. As
specific trials or clinical research projects For further information on this, or any
become available, eligible patients may other Practice Guideline, please contact
be offered the opportunity to enroll in the CST Co-Chairs, or members of the
the relevant trial or research project. Guidelines Resource Team, Cancer Care
Every effort will be made to Nova Scotia.
accommodate patients for clinical Phone:1-866-599-2267
research participation, but there will be E-mail: info@ccns.nshealth.ca
Guideline Approvals:
• Supportive Care Cancer Site Team-
• Initial date approved- 10 May 2006
• Revision with Community Reviewer Input- 6 September 2006
• Cancer Care Nova Scotia, Interim Medical Advisor- 5 October 2006
Recommended citation:
Broadfield L, Hamilton J., Best Practice Guidelines for the Management of Oral Complications from
Cancer Therapy. Supportive Care Cancer Site Team, Cancer Care Nova Scotia, 2006
© Crown copyright, Province of Nova Scotia, 2006.

May be reprinted with permission from Cancer Care Nova Scotia
(1-866-599-2263).
Best Practice Guidelines for the Management of Oral Complications from Cancer Therapy - ii
Contents:
Part Title Page
Part 1. Introduction 1
Part 2. Anatomy and Pathophysiology of Oral Complications from 3
Cancer and Cancer Treatment
Part 3. Assessment of Oral Complications from Cancer Therapy 15
Part 4 Dental Assessment and Care of the Cancer Patient 22
Part 5 Referral Information 27
Part 6. Mouth Care for the Cancer Patient 29
Part 7. Treatment of Oral Complications Induced by Cancer or 38
Cancer Treatment
Figures Page
Figure 2.1 Anatomy of the Oral Cavity 3
Figure 2.2 Pathophysiology of Oral Mucositis 7
Figure 4.1 Dental Assessment & Interventions for Cancer Patients 24
Figure 7.1 Prevention & Management of Oral Complications in Low Risk Patients 43
Figure 7.2 Prevention & Management of Oral Complications in Intermediate Risk Patients 44
Figure 7.3 Prevention & Management of Oral Complications in Head & Neck Cancer (High Risk)
Patients 45
Figure 7.4 Prevention & Management of Oral Complications in Hematopoietic Stem Cell Transplant
(High Risk) Patients 46
Figure 7.5 Management of Specific Oral Complications in Cancer Patients 63
Tables
Table 2.1 Oral Complications of Cancer Treatment 4
Table 2.2 Pathophysiologic Phases in Development of Mucositis 5
Table 2.3 Oral Complications of Radiation Therapy 8
Table 2.4 Cancer Chemotherapy Agents Which Cause Mucositis 9
Table 2.5 Oral Complications of Cancer Chemotherapy 10
Table 2.6 Oral Complications of Hematopoietic Stem Cell Transplantation 11
Table 3.1 WCCNR Stomatitis Staging System 16
Table 3.2 Mouth Care Record for Cancer Patients 19
Table 3.3 Frequency and Tool Selection for Oral Screening and Assessment 20
Table 4.1 Communications with Dental Oncology Team 22
Table 6.1 Basic Mouth Care Plan 34
Table 6.2 Intensified Mouth Care Plan 35
Table 7.1 Agents for Mucositis Prevention 39
Table 7.2 Agents for Mucositis Management (Stepped Approach) 42
Table 7.3 Management of the Xerostomic Patient 49
Table 7.4 Pain Relief Mouthwash Formulations 53
Table 7.5 Chlorhexidine Mouth Rinse for Pediatric Oncology Patients 56
Table 7.6 Presentation and Treatment of Oral Infections in Cancer Patients 57-58
Table 7.7 Strategies to Treat Oral Hemorrhage 64
Table 7.8 Strategies to Maintain Nutrituion in Patients with Oral Complications 68
Table 7.9 Management of Osteoradionecrosis (ORN) 70
Table 7.10 Agents for Management of Oral Lesions in Chronic GVHD 71
iii - Best Practice Guidelines for the Management of Oral Complications from Cancer Therapy
Part 1. Introduction
1.1 Oral Complications of Cancer socially and emotionally. Eating is
The patient with cancer faces an assault integral to life, and is a key part of our
on oral health from both the disease and daily activities. Loss of eating ability
the treatment options. The development removes the various pleasures we enjoy
of oral complications can cause a from eating, including our socialization
variety of problems that have significant with family and friends.
impact on the individual.
1.2. Oral Complications Induced by
Cancers that invade the head and neck Cancer Treatment
area can cause physical barriers and Chemotherapy and radiotherapy can
disruption to the process of eating and both have devastating effects on the
swallowing. Neurological complications, oral cavity. The risk of oral complications
from cancers which affect the nervous is due to multiple factors. High turnover
system pathways (often caused by rates for cells lining the oral mucosa
compression of critical nerve pathways make this area susceptible to
by tumour masses) may result in reduced chemotherapy agents targeted to
or absent ability to swallow (dysphagia). rapidly dividing cells. There is a diverse
Dysphagia may be complicated by and complex natural microflora in the
ulcerous sores in the oral cavity oral cavity, which can lead to
(stomatitis) or through the opportunistic overgrowth by any of a
gastrointestinal tract (mucositis). large group of microbes. Normal
Treatment of head and neck cancers responses of sensitive tissues, such as
directly impacts upon oral health, and salivary gland dysfunction when
upon swallowing ability. Surgical exposed to radiotherapy, can become
resections, with or without progressively worse with continued
reconstruction, have direct impact upon treatments. Trauma to oral tissues,
oral functions, from full or partial removal which can occur during normal oral
of key anatomic areas associated with function, can exascerbate emergent
tumour masses. Radiotherapy, often problems from treatment toxicities. Also,
given as adjuvant therapy following anatomic and functional changes,
surgery, affects the tissues, with various resultant from cancers in the head and
effects depending upon anatomic neck area, can further contribute to oral
structures within the radiated field. complications from the cancer
therapies. Oral complications from
The resultant inability to eat has chemotherapy and radiotherapy are
significant consequences. Malnutrition listed in Tables 1 and 2.
and dehydration, from lack of intake of
foods and fluids, directly and indirectly Frequencies of oral complications from
impact upon a patient’s life. Reduced treatment may vary, depending on the
nutrients hamper many physiologic type of therapy given; some frequency
systems, and generally reduce a estimates include:
patient’s quality of life and perfomance • 10% adjunctive chemotherapy for solid
status. Patients with poor performance tumours (low risk)
status have a generally poorer prognosis • 40% primary chemotherapy (e.g. for
from cancer (and other diseases). hematologic malignancies)
Inability to eat also affects patients (intermediate risk)
Best Practice Guidelines for the Management of Oral Complications from Cancer Therapy - 1
• 80% hematopoietic stem cell transplant widely believed that the severity of oral
(HSCT) (high risk) complications will be less in those patients
• 100% head and neck radiation therapy who exercise good oral hygiene. As well,
to fields involving the oral cavity. there is some scientific rationale that strict
adherence to oral hygiene measures
The most common oral complications of
may actually prevent clinical
cancer therapy include mucositis,
presentation of some oral complications.
infection (local or systemic), salivary
Thus, active health care teaching and
gland dysfunction, taste alteration and
reinforcement of mouth care procedures
pain, which result directly or indirectly,
for patient self-administration is a key
from the side effects of therapy. These
component of patient teaching in the
complications can lead to secondary
health care institutions involved with
complications such as nutritional
cancer treatment.
disorder, xerostomia or haemorrhage
that may not be resolved with 1.3. Cost of Oral Complications
aggressive medical, nursing and dental Oral complications associated with
interventions. As much as possible, oral cancer therapy do not occur without a
complications should be prevented cost to the health care system. In a study
using good oral hygiene techniques. of patients with head and neck cancer1,
The severity of these conditions may be 61% of patients treated with radiotherapy
affected by patient- and therapy- alone and 75% of patients treated with
related variables. Examples of patient- radiotherapy and chemotherapy
related variables include the status of developed grade 3/4 oral mucositis .
the patient condition before and during These patients consumed ten-fold more
chemotherapy, and their compliance nutritional services and supplies (TPN and
with treatments. Therapy-related tube feeds), and spent an additional 7
variables include the type of days in hospital, when compared with
chemotherapy agent(s) used, dosage, patients who had no mucositis (or 3 extra
days for patients with low-grade
frequency of treatment, and the use of
mucositis). In this American centre, high-
combination chemotherapy.
grade oral mucositis was associated with
Understanding the circumstances in over $4,000 additional costs, above the
which oral complications can occur, and baseline treatment costs. In another
their clinical presentation enable study of chemotherapy patients who
healthcare professionals to implement experience myelosuppression, there were
interventions to prevent and resolve longer periods of hospitalization for those
them. But oral side effects remain a major patients with oral mucositis compared
source of illness despite the use of a with just neutropenia (6 vs. 4 days), and a
variety of approaches to prevent them. higher rate of infection2. Oral mucositis is
related to increased patient care costs in
In many cases, there is little clinical
all risk groups.
evidence of effect for the therapeutic
interventions employed to alleviate
References:
specific problems in the mouth. It is 1. Elting LS, Oral mucositis: epidemiology and
common wisdom that the best strategy implications. Proc MASCC, 2006
for mouth care is active prevention of 2. Elting LS, Cooksley C, Chambers M, et al. The
potential problems. Although stringent burdens of cancer therapy: clinical and
economic outcomes of chemotherapy-
prevention measures do not guarantee
induced mucositis. Cancer 2003; 98: 1531-9
that complications will not occur, it is
2 - Best Practice Guidelines for the Management of Oral Complications from Cancer Therapy
Part 2. Anatomy and Pathophysiology of Oral Complications from
Cancer and Cancer Treatment
2.1 Definitions Figure 2.1
Dental Plaques: A combination of food,
bacteria and bacteria by-products
creating acidic waste that can lead to
tooth decay
Denudation: The stripping or laying bare
of any part
Dysgeusia: The presence of a chronic
taste in the mouth (e.g. bitter, salty,
metallic)
Lesion: An abnormal change in structure
of an organ or part due to injury or
disease
Leukoplakia: Well localized firmly
attached white patches on the mucous
membranes . Commonly considered
precancerous
Mucositis: The pathologic effects of
cancer treatments on the mucosal tissues
lining the entire gastrointestinal tract
Non-keratinized: Tissue which does not
include keratin
Plaque: A patch or flat area, sometimes a
deposit of material May be duplicated for use in clinical practice. As appears
in: Broadfield L, Hamilton J. Best Practice Guidelines for the
Pseudomembrane: A thick tough film on Management of Oral Complications from Cancer Therapy.
a mucous membrane, characterized as © Cancer Care Nova Scotia, 2006
a false membrane Xerostomia: Abnormal dryness of the

Stomatitis: The pathologic effects of mouth due to insufficient secretions
cancer treatments on the mucosal tissues
lining the oral cavity, as well as 2.2 Anatomy of the Oral Cavity
complicating sequelae from the The oral cavity is composed of a mucosal
therapies. Sometimes this is referred to as lining of non-keratinized squamous
Oral mucositis, and often the terms are epithelium composed of 15-20 layers of
used interchangeably cells. These cells, and the underlying
Stomatotoxicity: Refers more specifically tissues, regenerate every 7-14 days.
to direct and indirect toxic effects of Salivary and sebaceous glands located
drugs and radiotherapy beneath the surface of the epithelium
Trismus: Spasm of the muscles of lubricate the oral cavity.
mastication resulting from any of various Oral complications often result from
abnormal conditions or diseases epithelial and glandular destruction and
Ulcer: A break in skin or mucous inflammation. Because most treatment
membrane with loss of surface tissue, modalities destroy normal cells as well as
necrosis and sloughing of epithelial tissue, cancer cells, normal tissues with high
and often pus rates of proliferation (e.g., hair follicles,
Vesicle: A membranous and usually fluid- gastrointestinal tract, oral cavity) can be
filled pouch (such as a cyst) damaged by these toxic treatments.
2.3 Pathophysiology of Oral Mucositis cells of the bone marrow, rather than the
Oral complications following cancer oral mucosa. Patients with hematologic
therapies result from one of two malignancies or those who have
mechanisms: a direct effect of the drug received intensive radiotherapy and
or radiation on the oral mucosa (direct chemotherapy are most likely to become
stomatotoxicity) or an indirect result of myelosuppressed. Reduced secretory
myelosuppression from drug or radiation IgA, a marker of immunosuppression, has
therapy (indirect stomatotoxicity). The been associated with stomatotoxicity.
clinical manifestations of direct and Infection and hemorrhage, worsened by
indirect stomatotoxicities are listed in neutropenia and thrombocytopenia
Table III.b. respectively, are the two most common
forms of indirect stomatotoxicity.
Direct stomatotoxicity results from the
nonspecific effect on cells undergoing The risk of developing oral complications
mitosis. It causes epithelial cells to cease is affected by a variety of factors for
replication, leading to mucosal atrophy each patient (e.g., type of malignancy,
and ulceration. Cell layers lost to abrasion age, status of oral health before and
during mastication are not replaced as during therapy), as well as for each
quickly as they are lost. treatment (e.g. chemotherapy agent[s],
dosage[s], schedule, radiotherapy dose,
Stomatitis may be seen 5-7 days after duration). Patients treated for
chemotherapy, and oral lesions often hematologic malignancies develop oral
heal in about 2-3 weeks. This can be complications more often than patients
complicated by repeated cycles of treated for solid tumors, perhaps because
chemotherapy. Radiotherapy to the oral these patients are functionally
cavity inevitably results in direct myelosuppressed as a consequence of
stomatotoxicity. Stomatitis may be further their malignancies, but also due to more
complicated by oral infections, which intensive chemotherapy regimens.
may exacerbate the mucositis and may Younger patients generally experience
progress to systemic infections. greater damage to the mucous
membrane. Cell membranes replicate
Indirect stomatotoxicity is the result of the
faster in younger people and these
effects of chemotherapy (or
patients are at greater risk of mucositis.
radiotherapy of bone marrow) on the
Table 2.1 Oral Complications of Cancer Treatment 4
Direct Toxicities Indirect Toxicities
Oral mucositis Myelosuppression
Salivary gland dysfunction • Neutropenia
Neurotoxicity • Immunosuppression
• Taste dysfunction • Anemia
• Dentinal hypersensitivity • Thrombocytopenia
Temporomandibular dysfunction Infection
Dental & skeletal growth and development • Viral (HSV,VZV,CMV,EBV,other)
(pediatric patients) • Fungal (Candida, aspergillus, other)
• Bacterial
Graft-vs.-Host Disease (GVHD) after allograft
Gastrointestinal mucositis
Nausea and vomiting
Concomitant diseases (e.g., diabetes, Cytokine release is the likely cause of
AIDS, cardiopulmonary disease, kidney local tissue damage, and subsequent
disease) may increase the risk. Treatment inflammation. Increased amounts of IL-1
with other drugs may exacerbate may also increase vascularity.
xerostomia, including antidepressants,
The second phase occurs a few days
opiates, antihypertensives, diuretics,
later. The direct cytotoxic effects of
antihistamines, and sedatives.
chemotherapy and radiotherapy
Complications can be acute (developing (especially on the cell-cycle of renewal
during therapy) or chronic (developing cells to maintain the tissue) result in
months to years after therapy). For reduced epithelial cell populations, and
protocol purposes, one can classify acute subsequent atrophy and ulceration.
effects as those appearing during Locally produced cytokines and
therapy and up to day 90 from initiation functional trauma (e.g. from mastication)
of therapy; those that extend beyond contribute to the clinical symptoms at this
day 90 or have their onset after that time phase. This phase also includes complex
can be classified as late effects or biologic changes in the submucosa,
complications. In general, cancer which may contribute more to the
chemotherapy causes acute toxicities mucositis than direct cellular depletion.
that resolve following discontinuation of
The third phase is more complex than the
therapy and recovery of damaged
first 2 phases. Local areas of erosion
tissues. In contrast, radiation protocols
become coated with a fibrinous
typically cause not only acute oral
pseudomembrane. Coincidentally, this
toxicities, but may induce permanent
period often occurs when the patient
tissue damage that results in life-long
reaches the nadir in neutrophil counts,
complications for the patient.
and is at maximal risk of febrile
neutropenia from infection. Secondary
2.2.1 Pathophysiologic and
bacterial colonization of the oral mucosa,
pathobiologic mechanisms
often involving gram-negative organisms,
Although the exact pathophysiologic
occurs. Some of the bacterial organisms
mechanism for mucositis is unknown, one
produce endotoxins, which further
hypothesis has been proposed from
stimulate cytokine release from
animal and clinical data.6 Mucositis is
surrounding connective tissue. In
proposed to be a complex process,
concert, the patient experiences
which occurs in sequential phases (Table
maximal ulceration, infection and toxic
2.2)
response to released cytokines.
In the first phase, cytotoxic
The fourth and final phase is healing. In
chemotherapy or radiotherapy causes
this phase the epithelium renews itself
the release of various cytokines, such as
through natural proliferation and
tumor necrosis factor-a, interleukin-1 (IL-1)
differentiation of cell populations, in
and interleukin-6 (IL-6) from epithelial
concert with normalization of circulating
tissue and adjacent connective tissue.
Table 2.2 Pathophysiologic Phases in Development of Mucositis 5

Phase 1 Inflammatory or vascular phase day 0
Phase 2 Epithelial phase days 4-5
Phase 3 Ulcerative or bacteriologic phase days 6-12
Phase 4 Healing phase days 12-16
white blood cells and the return of normal Other biologic events are involved in the
microbial flora to the oral cavity. This etiology of mucositis. Nuclear factor κB
phase occurs about 2 weeks after the (NF-κB) is one transcription factor that is
intial insult, but may be deferred if furthersuspected to be a key element in the
insults are incurred (e.g. more genesis of mucositis. NF-κB is activated by
radiotherapy or cycles of either radiotherapy or chemotherapy,
chemotherapy). As a rule, and it has the capacity to upregulate
chemotherapy is held for 1-2 weeks in several genes that can cause a range of
patients who experience significant tissue responses. Up-regulated genes are
stomatitis. This may not be the case for known to result in the production of the
patients with imminently life-threatening proinflammatory cytokines TNF-α, IL-1β,
cancers, such as acute leukemias. and IL-6 which leads to tissue injury and
apoptosis. Expression of adhesion
The pathophysiologic model has more
molecules, activation of the
recently been expanded to include
cyclooxgenase-2 pathway, and resulting
pathobiologic mechanisms. The complex
angiogenesis is associated with
pathobiology of mucosal barrier injury is
upregulation of other genes.
currently understood by a model with five
phases: initiation, upregulation with There are other pathways of normal tissue
generation of messengers, signaling and apoptosis induced by chemotherapy or
amplification, ulceration with radiotherapy. Chemotherapy can
inflammation, and finally healing7, as activate the ceramide pathway, which
illustrated in Figure 2.2 It is evident that may induce primary apoptosis.
mucositis is more than just an epithelial Fibronectin may break up during this
event. This five-phase model also serves phase of mucositis. Macrophages are
as a basis for understanding the rationale then activated, causing matrix
for therapeutic interventions as single metalloproteinases to induce tissue injury
agents or combination therapies. directly or to produce TNF-α. The up-
regulation and message-generation
Initiation
phase of mucositis involves tissue at all
The primary event leading to mucositis is
levels through several simultaneous
generation of oxidative stress and
events.
reactive oxygen species (ROS) by
chemotherapeutic agents or radiation. Signaling and amplification
ROS directly damage cells, tissues, and Proinflammatory cytokines (TNF-α, IL-1β,
blood vessels. The activation of ROS and and IL-6) are believed to not only cause
their subsequent stimulation of other direct damage to mucosal target cells
transcription factors mark the initiation but also to amplify radiation- and
phase of mucositis and lead to other chemotherapy-induced mucosal injury
biologic events. indirectly. TNF-α activates pathways that
can lead to tissue injury, such as the
Up-regulation and generation of
ceramide and caspase pathways and
messenger signals
the transcription pathway mediated by
In the second phase, there are multiple
NF-κB. These signals lead to further
simultaneous events. Clonogenic cell
production of these proinflammatory
death in the epithelial layer results from
cytokines. Activation of the ceramide
DNA damage caused by ROS. The direct
pathway can be an effector mechanism
death of basal epthelial cells is not the
for secondary TNF-α-mediated tissue
only cause for clinical mucositis, however.
damage. This phase results in tissue that is infiltrate during the early stages of
biologically altered, even though it may radiation-induced mucositis, but there is a
appear normal. robust infiltration of both round and
polymorphonuclear inflammatory cells
Ulceration
during the ulcerative phase.
Radiation-induced mucositis, and
perhaps chemotherapy-induced Bacterial colonization with gram-positive,
mucositis, involves an inflammatory gram-negative, and anaerobic
process. The significance of inflammation organisms occurs during the ulcerative
in mucosal barrier injury is uncertain, phase. It is not clear how oral
however. Since stomatitis occurs during environmental factors such as bacteria
the nadir of myeloablation in patients and their products is related to mucositis.
treated with chemotherapy, an acute Bacterial cell wall products can activate
inflammatory response would be minimal tissue macrophages and increase
with reduced availablity of neutrophils. production of the proinflammatory
There is no histologic inflammatory cytokines. Trials of bacterial load
Figure 2.2 Pathophysiology of Oral Mucositis
1. Initiation 2.Upregulation & generation of

3. Signaling and amplification
messenger signals
Cytokines Cytokines
Chemo Radiation NF-κB (TNF-α, IL-1β, IL-6) Ceramide TNF-α,IL-1β,IL-6
Cell death
Epithelium
Neutrophil
Macrophage
Aponeurosis I.
Blood vessel
4. Ulceration 5. Healing
Inflammation Cell Growth
Bacteria
May be duplicated for use in clinical practice. As appears in: Broadfield L, Hamilton J. Best Practice Guidelines for the
Management of Oral Complications from Cancer Therapy. © Cancer Care Nova Scotia, 2006
reduction have shown erratic effect on predetermined. Variations in susceptibility
the course of mucositis. Likewise, changes of individuals to chemotherapy-induced
in the composition and amount of saliva and radiotherapy-induced toxicities have
may influence tissue susceptibility to long been observed. Single nucleotide
cytotoxic agents and its ability to heal. polymorphisms that are associated with
Outcomes of mucositis studies are not the metabolism of certain
clear on the impact of abnormal salivary chemotherapeutic agents have been
function on mucositis. The consequences identified. Those individuals with a
of ulceration are further cytokine phenotypic deficiency of certain
amplification, inflammation, and pain. metabolic enzymes are less able to
Regardless of whether bacteria are metabolize these chemotherapy drugs,
involved in the etiology of mucositis, the and they are subsequently at greater risk
patient is at increased risk for bacteremia for toxicity. There are other findings that
and sepsis. suggest the risk of toxicity is determined in
part by gender or ethnicity, but these
Healing
require further study.
The healing phase of oral mucositis starts
with a signal from the extracellular matrix, 2.2.2 Radiation therapy
leading to renewed epithelial proliferation As radiation passes through a tissue, some
and differentiation. The local microbial of its energy is transferred to the cells
flora is re-established. Other associated causing ionization and producing highly
clinical events, such as leucocyte reactive, although short-lived, free radicals
recovery in stem cell transplantation within them. These, in turn, cause physical
patients, also return to normal. After the and chemical changes altering cellular
healing phase, the oral mucosa appears structure and function(s) through
normal, but the mucosal environment has interactions with deoxyribonucleic acid
been significantly changed. (DNA), ribonucleic acid (RNA) or
Angiogenesis continues after healing intracellular enzymes causing faulty
appears completed. The patient is at transcription, defective repair, metabolic
increased risk of future oral mucositis disturbance, accelerated ageing and
episodes with further anticancer therapy. mutations. Since radiation cannot
discriminate between normal and
Genetic risk and modulation of mucositis
malignant cells both cell populations are
Some aspects of mucositis risk are
vulnerable to damage. Its use in
hypothesized to be genetically
4
Table 2.3 Oral Complications of Radiation Therapy
Acute Chronic
Oral mucositis Mucosal fibrosis & atrophy
Infection Xerostomia
• Fungal Dental caries
• Bacterial Soft tissue necrosis
• Viral Osteoradionecrosis (ORN)
Salivary gland dysfunction Taste dysfunction
• Sialadenitis Dysgeusia
• Xerostomia Ageusia
Taste dysfunction Infections
Muscular/cutaneous fibrosis • Fungal, bacterial
eradication of tumour cells, therefore, The altered tissues are highly susceptible
depends on the differential sensitivity and to infection, especially fungal organisms
recovery potential between tumor cells such as Candida albicans or other
and normal tissues. 8-12 Candida subspecies. Bacterial and viral
infections may also occur.
The effects of irradiation on the oral
cavity and oropharyngeal normal tissues 2.2.3 Chemotherapy
(as listed in Table 2.3) depend on several Antineoplastic (cytotoxic) drugs play a
factors, including: dual role in cancer therapy both as the
• the type of radiation; primary treatment of choice for many
• the relative biologic efficiency (RBE) of widely disseminated malignancies or as
radiation; an adjunct to surgery or radiotherapy.
• the dose fraction; Treatment of cancer with chemotherapy
• the time between fractions; is becoming increasingly more effective
• the total irradiation dose (cumulative); but, like radiotherapy, is associated with
• the volume of the oral cavity which is short and long-term side effects. 12,14-7
irradiated (e.g. how much of the oral Common chemotherapy agents
tissue is exposed to radiation); associated with mucositis are listed in
• the introduction of rest periods during Table 2.4.
the treatment course;
• the overall treatment time (less effect Cancer chemotherapy agents are used
on toxicities); and in treatment to destroy, suppress, or
• the anatomic structure(s) exposed to prevent the spread of malignant cells,
the stated dose. which have a high proliferative rate.
With external irradiation, most or all theBecause chemotherapeutic agents are
anatomic structures are at risk. The not specifically targeted against cancer
incidence of necrosis increases with cells, they also adversely affect normal
irradiated volume and the magnitude of host cells that have a high mitotic index.
the dose. Normal cells that are susceptible to this
adverse affect include those of the oral
Radiation therapy often causes
and gastrointestinal (GI) mucosa, hair
extensive, permanent changes in salivary
follicles, the reproductive system, and the
glands, bones, or oral musculature, which
hemopoietic system.
may lead to xerostomia, loss of taste
sensation, infection, osteoradionecrosis,
trismus, and extensive dental caries.13
Table 2.4 Cancer Chemotherapy Agents Which Cause Mucositis 5,18
Amsacrine Docetaxel Mechlorethamine
Bleomycin Doxorubicin Mercaptopurine
Busulfan Epirubicin Methotrexate
Carboplatin Etoposide Mitoxantrone
Chlorambucil 5-Fluorouracil Mitomycin
Cisplatin Fludarabine Paclitaxel
Cyclophosphamide Gemcitabine Procarbazine
Cytarabine Idarubicin Vinblastine
Dacarbazine Irinotecan Vincristine
Dactinomycin Hydroxyurea Vinorelbine
Daunorubicin Lomustine
Note: Agents in bold print have higher likelihood of mucositis
Table 2.5 Oral Complications of Cancer Chemotherapy 18
Complication Direct Risk Factor Indirect Risk Factors
Oral mucositis Mucosal cytotoxicity Decreased local/systemic immunity
Physical/chemical trauma local infections
Re-activation of HSV
Oral infections
• Viral Decreased systemic immunity
• Fungal Decreased systemic immunity
Salivary gland dysfunction
Altered oral flora (decreased bacterial
flora)
• Bacterial Inadequate oral hygiene Decreased systemic immunity
Mucosal breakdown Salivary gland dysfunction
Acquired pathogens
Taste dysfunction Taste receptor toxicity
Xerostomia Salivary gland toxicity Anticholinergic drugs
Neuropathies Vinca alkaloid drug use
Gastrointestinal Nausea and vomiting
mucositis
Hemorrhage Oral mucositis Thrombocytopenia
Many chemotherapeutic agents exert maximum anti-tumour activity. Such

direct destructive effects on tissues in or combinations, although they may
around the oral cavity. The agents may enhance the response to therapy, may
also act indirectly by inducing increase the range and severity of side
myelosuppression and/or effects, particularly those which are not
immunosuppression. Frequency and the dose limiting toxicities of the individual
severity of oral complications are directly drugs.
related to extent and type of systemic Although oral tissue responses to
compromise. Complications are often chemotherapy show considerable
compounded by simultaneous or individual variation, their manifestations
sequential administration of mixtures of are usually related to the total dose and
chemotherapy drugs. Although these the drugs received. Patients who develop
factors are taken into account when oral toxicity during initial therapy are likely
planning individual treatment, it should to continue to exhibit toxic symptoms
be recognized that there is often only a throughout treatment, unless changes
narrow margin of safety between are made to the planned regimen.
tumoricidal and toxic doses. Because the Combination drug therapy or
aim of therapy is to maximize destruction chemoradiation therapy is more likely to
of malignant cells, the risk of at least some induce longer-lasting lesions.
toxicity should be accepted. By
Affected oral soft tissues are exposed to
combining agents with different
physical, chemical, thermal, and
mechanisms of action and different dose-
microbial injury. The oral cavity may
limiting toxicities, it is possible to optimize
become the focus of chemotherapeutic
the doses of individual drugs for
complications, especially if there is
concurrent bone marrow suppression. Xerostomia, dysphagia, and dysgueusia
Oral complications from chemotherapy are common problems, and are more
are similar to those induced by radiation, likely in patients with mucositis, soft tissue
although sometimes more transient in ulceration, or oral infection. Mucositis may
nature. be quite severe, with onset occurring
Table 2.6 Oral Complications of Hematopoietic Stem Cell Transplantation19

Transplant Phase Oral Complication
Phase I: Oral infections: dental caries, endodontic infections, periodontal
Preconditioning disease (gingivitis, periodontitis), mucosal infections (i.e., viral,
fungal, bacterial).
Gingival leukemic infiltrates.
Metastatic cancer.
Oral bleeding.
Oral ulceration: aphthous ulcers, erythema multiforme.
Temporomandibular dysfunction.
Phase II: Oropharyngeal mucositis.
Conditioning Oral infections: mucosal infections, periodontal infections.
Neutropenic Pain in the mouth and/or lips.
Phase Reduced ability to eat, drink and talk.
Reduced ability to perform oral hygiene.
Hemorrhage.
Xerostomia.
Taste dysfunction.
Neurotoxicity: dental pain, muscle tremor (e.g., jaws, tongue).
Temporomandibular dysfunction: jaw pain, headache, joint pain.
Phase III: Oral infections: mucosal infections.
Engraftment Acute graft-versus-host-disease (GVHD).
Hematopoietic Pain in the mouth and/or lips.
Recovery Reduced ability to eat, drink and talk.
Reduced ability to perform oral hygiene.
Xerostomia.
Hemorrhage.
Neurotoxicity: dental pain, muscle tremor (e.g., jaws, tongue).
Temporomandibular dysfunction: jaw pain, headache, joint pain.
Granulomas/papillomas.
Phase IV: Immune Oral infections: mucosal infections.
Reconstitution Chronic GVHD.
Late Post- Dental/skeletal growth and development alterations (pediatric
transplant patients).
Pain in the mouth and/or lips.
Xerostomia.
Relapse-related oral lesions.
Second malignancies.
Phase V: Long- Ongoing chronic GVHD of the lips and mouth.
term Survival Pain in the mouth and/or lips.
Relapse or second malignancies.
Dental/skeletal growth and development alterations.
within 7 days of initiation of Phase II: Conditioning Neutropenic
chemotherapy and duration varying Phase
from several days to weeks. Gingival This phase is usually the period during
bleeding is found during nadir periods of which oral complications are most
maximum myelosuppression. common and most severe. Oral
Chemotherapy may also cause salivary complications are associated with high-
changes and sensory neuropathies. dose chemotherapy or
Many cytotoxic drugs will cause a chemoradiotherapy. Mucositis,
degree of myelosuppression secondary xerostomia, and lesions related to
to therapy. This usually occurs 7 to 14 myelosuppression, thrombocytopenia,
days after treatment. The resultant and anemia predominate.
neutropenia and thrombocytopenia will Oral mucositis usually begins 7 to 10 days
place the patient at increased risk from after cytotoxic chemotherapy or
infection and hemorrhage. chemoradiotherapy, and continues for
2.2.4 Hematopoietic Stem Cell approximately 2 weeks. Viral, fungal,
Transplantation (HSCT) and bacterial infections may occur
Patients undergoing hematopoietic stem during this time of greatest risk. Infections
cell transplantation experience more are dependent on oral status prior to
profound and severe oral complications chemotherapy, and duration/severity of
than those receiving less intensive doses neutropenia. Infections decline when
of chemotherapy and/or radiotherapy. mucositis is resolved and neutrophil
Conditioning regimens to partially or fully counts return to normal. Patients who
ablate the hematopoietic tissues have have poor immune system reconstitution
been reduced in myelotoxic intensity in may remain at risk, however.
more recent years, but these regimens Xerostomia and taste dysfunction may
are not necessarily less stomatotoxic. Oral begin in this phase. These toxicities
complications may change through the typically resolve within 2 to 3 months.
phases of HSCT, as noted in Table 2.6.
Phase III: Hematopoietic Recovery
Phase I: Preconditioning for HSCT Acute oral complications begin to resolve
Before conditioning chemotherapy, oral 2 to 4 weeks after the conditioning
complications are secondary to the regimen. As the bone marrow
underlying disease, and prior treatments regenerates, ulcerative oral mucositis will
for cancer (e.g. chemotherapy) or other begin to heal. Immune defenses in the
medical conditions. Pre-treatment oral mucosa will still take time to return to
problems with oral health including normal and patients remain at risk for
dental caries, periodontal disease, and certain types of infection, including
pulpal infection, should be addressed candida and herpes simplex virus.
and resolved (if possible). At this phase, Bacterial infections of the oral mucosa
dental screening should be performed are less common during this phase,
and patient education should begin, except in patients for whom engraftment
including information about potential oral is delayed, patients with acute graft-
complications, methods to manage the versus-host disease (GVHD- more
symptoms, and basic oral hygiene. common in allogeneic transplant
patients), or patients receiving GVHD
therapy.
Phase IV: Immune Reconstitution/
Recovery from Systemic Toxicity
Oral complications are among the
chronic toxicities experienced by many
hematopoietic stem cell transplant
patients. Late viral infections and
xerostomia are most common, and
bacterial infections are infrequent. The
hematopoietic stem cell transplant
patient may develop oral manifestations
of chronic GVHD during this period.
Phase V: Long-term Survival
There are few significant oral
complications in long-term survivors of
HSCT. Allogeneic transplant patients may
experience severe oral symptoms from
ongoing chronic GVHD of the lips and
mouth.
Patients treated with high-dose
radiotherapy (such as total body
irradiation- TBI) may have oral
complications associated with the total
dose and schedule of radiation therapy.
Xerostomia is the most common long-
term oral complication from Total Body
Irradiation.
References:
1. Dreizen S. Oral complications of cancer 14. Semba SE, Mealey BL, Hallmon WW. Dentistry
therapies. Description and incidence of oral and the cancer patient. Part 2. Oral health
complications. NCI Monogr 1990 ; 11-5. management of the chemotherapy patient.
2. Joyston-Bechal S. Prevention of dental dis- Compendium 1994; 15: 1378, 1380-78, 1387.
eases following radiotherapy and chemo- 15. Bissell TA, Doppalapudi VA. Oral medicine.
therapy [published erratum appears in Int Curr Opin Periodontal 1994: 54-63.
Dent J 1992 ; 42 : 122]. Int Dent J 1992 ; 42 : 16. Fayle SA, Curzon Me. Oral complications in
47-53. pediatric oncology patients. Pediatr Dent
3. Toth BB, Martin JW, Fleming TJ. Oral complica- 1991; 13:289-95.
tions associated with cancer therapy. An M. 17. Rosin-grget K, Lincir I. Dentist’s patient under
D. Anderson Cancer Center experience. J antineoplastic therapy. Acta Stomatologica
ischemia, and irritation. Croatica 1990; 24:133-8.
4. Peterson DE: Oral toxicity of 18. Kostler WJ, Hejna N, Wenzel C, Zielinski CC,
chemotherapeutic agents. Seminars in Oral mucositis complicating chemotherapy
Oncology 19(5):478-491, 1992. and/or radiotherapy: options for prevention
5. Zlotolow IM, Berger AM, Oral manifestations and treatment. Ca Cancer J CLin, 2001; 51:
and complications of cancer therapy. In: 290-315.
Berger AM, Portenoy RK, Weissman DE, Eds. 19. National Cancer Institute, Oral complications
Principles and Practice of Palliative Care and of chemotherapy and head/neck radiation
Supportive Oncology. Lippincott Williams & (PDQ®), Health Professional Version.
Wilkins, Philadelphia, 2002 http://www.cancer.gov/cancertopics/pdq/
6. Sonis ST: Mucositis as a biologic process: a supportivecare/oralcomplications/
new hypothesis for the development of healthprofessional, Download date- 26
chemotherapy-induced stomatotoxicity. Oral January 2006
Oncol 34(1):39, 1998.
7. Sonis ST, Elting LS, Keefe D, Peterson DE, et
al.,Perspectives on Cancer Therapy-Induced
Mucosal Injury- Pathogenesis, Measurement,
Epidemiology, and Consequences for
Patients. Cancer 2004; 100 (9 Suppl): 1995–
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8. Arcuri MR, Schneider RL. The physiological
effects of radiotherapy on oral tissue.
J Prosthodont 1992; 1 : 37-41.
9. Cacchillo D, Barker GJ, Barker BF. Late effects
of head and neck radiation therapy and
patient/dentist compliance with
recommended dental care.
Spec Care Dentist 1993 ; 13 : 159-62.
10. Cooper JS, Fu K, Marks J, Silverman S. Late
effects of radiation therapy in the head and
neck region. Int J Radiat Oncol Biol Phys
1995; 31 : 1141-64.
11. Parsons JT. The effect of radiation on normal
tissues of the head and neck. In : Million R,
Cassisi NJ, eds. Management of head and
neck cancer : a multidisciplinary approach.
Philadelphie : Lippincott, 1994.
12. Holmes S. Radiotherapy, Lisa Sainsbury
Foundation Series. Austen Cornish, London,
1988.
13. Dahllof G, Rozell B, Forsberg CM, Borgstrom
B. Histologic changes in dental morphology
induced by high dose chemotherapy and
total body irradiation. Oral Surg Oral Med
Oral Pathol 1994; 77:56-60.
Part 3. Assessment of Oral Complications from Cancer Therapy
3.1 Dental assessment stomatitis using the NCI Common Toxicity
Dental assessment and interventions Criteria, which has never been
should be arranged prior to the start of established as a reliable and valid tool.
chemotherapy or radiotherapy. See Part The Stomatitis Staging System (SSS) is a
4 for details about dental care of the simple, validated tool based on objective
oncology patient. observation by a health care
professional. Using a flashlight to
3.2 Screening for oral complications examine the oral cavity, the oral mucosa
Best Practice Statement: is rated for the number of visible lesions,
Ambulatory patients and hospital the tissue colour (erythema), and the
inpatients on chemotherapy should be amount of bleeding observed. The
screened on a regular basis with the scores for each criterion are added
Stomatitis Staging System scale for together and the sum is categorized as
evidence of oral complications. Normal, Mild, Intermediate, or Severe
Inspection of the oral cavity using a Stomatitis. Patients may be screened
flashlight should be included in the prior to the start of each chemotherapy
systematic screening of patients at each cycle, or weekly during radiotherapy
visit during chemotherapy treatment (or treatments, to identify emerging
daily for inpatients on chemotherapy). problems with oral complications.
If stomatitis or other oral complications Patients who are receiving treatment in
are identified and become a focus of hospital should be screened daily with
care, routine assessment should begin the Stomatitis Staging System and
(see Part 3.3). documented in the progress notes or
Patients at high risk of serious oral patient care flow sheet. If stomatitis or
complications (e.g. HSCT patients, or other complications develop, switch
patients receiving radiotherapy to the from screening to a routine assessment
oral cavity area) should not be screened, using the Mouth Care Record (MCR) for
but should begin with routine assessment documentation. When symptoms
(see Part 3.3) in anticipation of oral resolve, return to routine screening as
complications. above. Current therapy may need to
be altered if oral complications are
Since the risk of oral complications during identified or are becoming worse.
active treatment with chemotherapy is
not predictable, a regular screening 3.3 Oral assessment
process should be included with ongoing Best Practice Statement:
assessment of patients. Visual inspection When stomatitis or other oral
of the oral cavity and discussion of complications are identified from
possible symptoms with the patient are screening and become a focus of care,
necessary to properly assess the patient routine assessment should begin. For
for emerging oral complications. high-risk patients, routine assessment
should begin at the start of treatment.
The only validated tool for screening of
oral complications is the Stomatitis Assessment includes rating mucositis
Staging System- Table 3.1 (previously (using the Stomatitis Staging System
referred to as the WCCNR Stomatitis scale), and considers a range of oral
Staging System- see below). Historically, symptoms and response(s) to
common practice had been to screen for interventions over time. The MCR will be
Table 3.1 WCCNR STOMATITIS STAGING SYSTEM 17
Add the scores of the lesions, colour and bleeding to identify the stomatitis stage:
0 = Normal; 1-4 = Mild; 5-7 = Intermediate; 8-9 = Severe
SCORE LESIONS ERYTHEMA (COLOUR) BLEEDING
0 None More than 50% pink None
1 1-4 More than 50% slightly None
red
2 More than 4 More than 50% Bleeding with eating
moderately red or mouth care
3 50% or more More than 50% very red Spontaneous
denuded
Note: Denuded refers to the surface layer removed, and lesions spreading together
or coalescing. Reproduced with permission- ©2004 Olsen et al.
used for documentation of routine
In 1960, Greene and Vermillion
assessment until the oral complications
developed a numerical rating guide as a
are resolved.
method for classifying oral hygiene
Assessment should be incorporated into status4. In 1966, Passos and Brand did
both the Basic and Intensified Mouth further work with Greene and
Care Plans. Vermillion’s guide to evaluate the
effectiveness of three oral care agents.5
3.3.1 Development of oral assessment
Eight categories (saliva, tongue,
tools
palates, membranes/gums, teeth, odor,
Oral screening should take place at the
lips and nares) were given a rating from
first meeting with the patient1 because
1-normal to 3-severe, which were added
evidence suggests that screening prior
together to achieve a total score. There
to cancer treatment can reduce both
is no report of psychometric testing.
the incidence and severity of oral
complications for the patient.2 Oral Vandrimmelsen and Rollins adapted
assessment tends to be very subjective, Passos and Brand’s 8-item tool and
so valid comparisons of the oral cavity’s created an 11 item scale to examine the
actual state require the use of a well- effectiveness of lemon juice and
3
tested and validated tool. There are glycerine as an oral agent.6 The
many assessment tools in use today to investigators tried to increase reliability
systematically assess the oral cavity. of conducting the assessments, but
Most of these tools were adapted from there was no evidence that the
tools developed in the 1960’s and early assessment tool itself went through any
1970’s, when instruments were being psychometric testing.
developed to assess degrees of
Dewalt published results from work
stomatitis and the effects of
conducted using an adapted version of
interventions for the patient with mouth
Passos and Brand’s numerical rating
problems. Many instruments developed
guide.7 Dewalt’s work included how the
for research purposes have been
assessment was to be done and how it
adapted for use in day-to-day practice.
was to be measured. Inter-rater reliability
In cancer care, established centres use
was measured.
systemic mouth care assessment
instruments as a guide for assessment In 1975, Bruya and Madeira developed
and documentation. an assessment tool for assessing stomatitis
after the administration of In the late 1970’s and early 1980’s, the
chemotherapy.8 They used the previous term “grading system” was beginning to
work of Dewalt, Passos and Brant, be used in the descriptions of mouthcare
VanDrimmelsen and Rollins, to build their and in assessing stomatitis severity with
17-item scale. The 17 items included level cancer therapy.
of consciousness; breathing habits;
A well-known oral assessment guide is the
nutritional status; chewing ability; self-
Eiler’s oral assessment guide (OAG).10
care ability; the texture, colour and
Many assessment tools currently used in
moisture of the lips and tongue; mucous
practice today are based on Eiler’s OAG.
membranes, gingival tissue, teeth, saliva,
Eight items (lips, tongue, mucous
taste and voice. Items were rated
membranes, ginvia, teeth/dentures,
between 1 and 3. No psychometric
voice, swallow, saliva) are rated on a 1-3
tested was evident, however, it became
scale. Some reliability and validity testing
foundation work for future studies
was conducted. Users found the tool
because of the extensive review of
clinically useful.
normal and abnormal oral cavities.
The MacDibbs Mouth Assessment was
Beck developed three assessment tools –
specifically developed for use with
the oral examination guide – for use in
patients with stomatitis due to
her descriptive study to determine if
radiotherapy.11 Along with items in a
teaching nursing staff about stomatitis
physical examination, patients rate their
and an oral care protocol improved oral
pain, dryness, eating, talking, swallowing,
exam scores of patients receiving
tasting and saliva production on a scale
chemotherapy.9 Baseline evaluation was
from 0 to 3. A smear and culture are
conducted. The tools consisted of:
done to check for fungal and viral
1) An “Oral Exam Guide”, a
infection. There are 14 items in total to
combination and adaption of
be examined. Scoring is not well defined.
previously identified tools from a
Content validity was established by a
variety of disciplines. Sixteen
panel of experts. Unlike other tools, the
descriptions were identified to
MacDibbs Mouth Assessment is able to
numerically rate the condition of the
distinguish between radiotherapy-
patient’s mouth.
induced stomatitis and infection.
2) An Oral Perception Guide, in which
the nurse rated the patient’s sensory Difficulties have been identified with
perception of the mouth, teeth, tools that have numerous items that
taste, voice changes, and abililty to need to be evaluated. These tools can
eat. be time consuming for the health
3) Physical Condition Tool, which rated provider and the patient. With a
the patient’s general physical number of items, the same score can be
condition (self-care ability, diet, obtained in a variety of ways, so that
breathing habits and level of two different people can have different
consciousness). severities of stomatitis. As well, if items
are not specific or detailed enough, the
Each category was numerically scored
tool will not distinguish between stomatitis
between 1 and 4. Because Beck
and other oral health problems.
collected all of the data herself, variability
due to more than one rater was In 1981, the World Health Organization
eliminated, otherwise, no psychometric (WHO) held two meetings with
testing was evident.
representatives from the largely use with patients receiving cancer
recognized cancer organizations (the treatment.15 In the first phase of the tool
European Organization for Research on development, descriptors that were valid
Treatment of Cancer, The National indicators of stomatitis severity were
Cancer Institute, and The International identified. Each of 4 stages had
Union Against Cancer). The outcome of descriptors related to mucosal color,
these meetings was the WHO grading lesions, bleeding, moisture, edema,
toxicity scales.12 The grading system infection, ability to eat/drink, and
ranged from 0 (no side effects) to 4 discomfort. Testing was done on patients
(unable to eat or drink). A standardized with chemotherapy-induced stomatitis
assessment and reporting method for along with the Eiler’s Oral Assessment
mucositis became recognized and used Guide10 and the WHO Grading system.12
globally. No evidence of biometric or Correlation with these tools was 0.76 and
psychometric testing for this tool was 0.69 respectively. Discriminant analysis of
found. It is used by many groups the results revealed that using all 8
conducting co-operative clinical trials. predictors, 98% of patients were correctly
Despite the popularity of this grading staged. 96.4% of patients were correctly
system, there is criticism that the staged when using only the descriptors of
descriptors at each level are not specific color, lesions and bleeding. In further
enough. Level 4 (unable to eat or drink), study16, the 3 item staging system (the
for example, does not establish if the Stomatitis Staging System, or SSS) was
patient is not able to eat or drink because evaluated to establish reliability and
of the stomatitis or because of another concurrent validity in patients receiving
reason. chemotherapy, radiation therapy and a
combined chemotherapy and radiation
Scores from the expanded common
therapy. The MacDibbs Mouth
toxicity scale, developed by the
Assessment11 was used to establish
National Cancer Institute of Canada
validity with the radiation therapy
Clinical Trials Group, were compared
patients. Two hundred and thirty
with scores of the WHO grading toxicity
patients were staged. Results indicated
scale by Brundage et al.13 With poor
that the WCCNR SSS tool is a reliable
levels of agreement, the investigators
and valid tool for assessing stomatitis
concluded that varying conclusions
severity with these three populations of
could be drawn from the assessor, and
patients.
that neither scale demonstrated clear
superiority. The Common Toxicity The WCCNR SSS tool is the only tool for
Criteria, used by the NCIC, has further mouth assessment with validity and
evolved to be included in the CTEP reliability data for radiotherapy,
Common Toxicity Criteria for Adverse chemotherapy and combination
17
Events (CTCAE).14 Neither have been therapy , and is recommended in this
tested for reliability or validity, yet these guideline as the tool of choice for
have been adopted as the “gold assessing the mouth through treatment.
standard” for assessment and The Mouth Care Record incorporates the
evaluation in clinical trials. WCCNR stomatitis scales to ensure
consistency between screening and
The Western Consortium for Cancer
assessment of oral complications.
Nursing Research (WCCNR) was
interested in developing a tool for clinical
Table 3.2 ADDRESSOGRAPH
Mouth Care Record for Cancer Patients

Dental Assessment: Date Completed
STOMATITIS STAGING SYSTEM
Add the scores of the lesions, colour and bleeding to identify the stomatitis
stage:0 = Normal; 1-4 = Mild; 5-7 = Intermediate; 8-9 = Severe
SCORE LESIONS ERYTHEMA (COLOUR) BLEEDING
0 None More than 50% pink None
1 1-4 More than 50% slightly red None
2 More than 4 More than 50% moderately red Bleeding with eating or mouth care
3 50% or more denuded More than 50% very red Spontaneous
MOUTH ASSESSMENT DATE:

TIME:
Stomatitis Lesions
see Stomatitis Colour
Staging System Bleeding
above Total Score
Stomatitis Stage (N, M, I or S)
Pain Mouth Pain
(0-10 scale) Throat Pain
Pain on Swallowing
Function Xerostomia
(Yes or No) Taste Altered
Able to swallow
Eating Eating all foods
Check (9) Liquids only
Not eating or drinking
Suspected Infection (Y or N)
MOUTH CARE PLAN
Care Plan Basic
Check (9) Intensified
Stomatitis & Pain Coating Agent
Check (9) Lubricant
Pain Medication Needed (Y or N)
Topical Analgesic (ie. Benzydamine)
Anesthetic/Pain Relief Mouthwash
Systemic Analgesic
HSCT/BMT Parenteral (IV) Opioid
Patients Somnolence Score (1-4)
Infection Management
(Y or N) Systemic Antifungal(s)
Check (9) Topical Antifungal(s)
Other Antibiotic(s)
Care Provider Self
Check (9) Assisted
Totally by Other
Patient Teaching- Check (9)
Notes- (9)
Initials
3.3.2 The Mouth Care Record for Cancer the pain assessment section of the MCR
Patients for ongoing assessment. If pain is more
The Mouth Care Record for Cancer complicated than just the mouth, then
Patients (MCR- Table 3.2) is a tool use the standard pain assessment tools
developed for systematic assessment and (see Guidelines for the Management of
documentation of oral complications Cancer-Related Pain) concurrently with
when this has become a focus of care. the MCR. If infection is a focus of care,
Patients at high risk for oral complications assessment and management would be
will begin with assessment using the MCR documented as per usual practice in the
from the start of cancer treatment. health record.
The MCR form includes areas to rate and The frequency of oral assessment, and
document stomatitis, mouth pain, the tools to use, are outlined in Table 3.3.
function, ability to eat, and presence of
suspected infection. The MCR also
simplifies documentation of oral care
interventions (including the mouth care
plan). If oral pain is a focus of care, use
Table 3.3 - Frequency and Tool Selection for Oral Screening and Assessment
Low Risk (10-40%) Intermediate Risk High Risk (80%)
Adjuvant/Palliative (40%) Hematopoietic Stem
Chemotherapy for Chemotherapy for Cell Transplant AND
most Solid Tumours Hematologic (100%)-Radiotherapy
Malignancies, some for Head & Neck
Gastrointestinal Cancers
Cancers
Screening Ambulatory Patients:
Ambulatory Patients: Ambulatory Patients:
Through Rate with SSS at each
Rate with SSS at each Conduct assessment
Treatment visit visit at each visit
Inpatients: Rate with
Inpatients: Rate with Inpatients: Conduct
SSS once daily
SSS once daily each assessment at least
Documentation: On
morning once each shift
nursing flow sheet
Documentation: On Documentation: On
and/or progress notes
nursing flow sheet Mouth Care Record
and/or progress notes (MCR)
Assessment when Ambulatory Patients: Ambulatory Patients: Ambulatory Patients:
oral Assess all symptoms at Assess all symptoms at Assess all symptoms at
complications each visit until each visit until each visit until
become a focus resolved, then return resolved, then return resolved, then return
of care to screening to screening to screening
Inpatients: Assess all Inpatients: Assess all Inpatients: Assess all
symptoms at the start symptoms at least symptoms at least
of each shift once in each shift twice during the day
Documentation: On Documentation: On shift and once during
Mouth Care Record Mouth Care Record the night shift
(MCR) (MCR) Documentation: On
Mouth Care Record
(MCR)
3.4 Ongoing Assessment of Patients
When Oral Complications Are
Resolved
When oral complications have resolved,
ongoing assessment may cease and the
patient may continue to be screened
with CTC at follow up visits or once daily
in hospital. Some HSCT patients may
require long-term screening, due to
chronic oral complications from graft-
versus-host disease or other long term
effects.
References:
1. Krishnasamy M. Oral problems in advanced 11. Dibble, S; Shiha G; MacPhail, L & Dodd, J.
cancer. Eur J Cancer Care 1995; 4: 173-177. MacDibbs Mouth Assessment: A new tool to
2. Kenney SA. Effect of two oral protocols on evaluate mucositis in the radiation therapy
the incidence of stomatitis in haematology patient. Cancer Nursing, 1996; 4(3): 135-139
patients. Cancer Nurs 1990; 13: 345-353. 12. National Institutes of Health. National
3. Coleman S. An overview of oral Institutes of Health Consensus Development
complications of adult patients with Conference on Oral Complications of Cancer
malignant haematological conditions who Therapies: Diagnosis, Prevention and
have undergone radiotherapy or Treatment. National Cancer Institute
chemotherapy. J Adv Nurs 1995; 22: 1085-91. Monographs, 1990
4. Greene, J.C. & Vermillion, J.R. The oral 13. Brundage MD, Pater JL, Zee B. Assessing the
hygiene index. A method for classifying oral reliability of two toxicity scales: implications
hygiene status. Journal of Dental Assistant, for interpreting toxicity data. J Natl Cancer
1960; 61:172. Inst 1993 Jul 21;85(14):1138-48
5. Passos, JY & Brand,LM. Effects of agents used 14. CTC Version 2.0, Cancer Therapy Evaluation
for oral hygiene. Nursing Research, Program (CTEP), National Cancer Institute,
1966;15(3):196 April 30, 1999. http://ctep.cancer.gov/forms/
6. VanDrimmelsen,J & Rollins, H. Evaluation of a CTCv20_4-30-992.pdf
commonly used oral hygiene agent. Nursing 15. Western Consortium for Cancer Nursing
Research, 1969;18(4): 327 Research. Development of a staging system
7. Dewalt E. Effect of timed hygienic measures for chemotherapy-induced stomatitis. Cancer
on oral mucosa in a group of elderly subjects. Nursing, 1991; 14 (1), 6-12.
Nursing Research, 1975; 24 104-108 16. Western Consortium for Cancer Nursing
8. Bruya,M & Madeira N. Stomatitis after Research. Assessing stomatitis: Refinement of
chemotherapy. American Journal of Nursing, the Western Consortium for Cancer Nursing
1975; 75(8): 1349-1352 Research (WCCNR) stomatitis staging system.
9. Beck, S. Impact of a systemic oral care Canadian Oncology Nursing Journal,1998; 8
protocol on stomatitis after chemotherapy. (3), 160-165.
Cancer Nursing, 1979; 2(3): 185-199 17. Olson K, Hanson J, Hamilton J, Stacey D, et al.
10. Eilers J; Berger A & Petersen M. Development Assessing the reliability and validity of the
testing and application of the oral assessment revised WCCNR stomatitis staging system for
guide. Oncology Nursing Forum, 1988; 15(3): cancer therapy-induced stomatitis.
325-330 Can Oncol Nurs J. 2004 Summer;14(3):168-74,
176-82
Part 4. Dental Assessment and Care of the Cancer Patient
4.1 Dental Assessment before cancer treatrment is started.
Best Practice Statement: Dental exams may be repeated during
Patients who are scheduled to receive active therapy on the advice of the
chemotherapy of any kind should be oncology team.
assessed by a dentist prior to the cancer Prior to the start of chemotherapy or
treatment. Patients who will receive radiotherapy, it is advisable for patients to
radiotherapy to the head and neck, or visit their dentist (or oncology dental
hematopoietic stem cell transplant must specialist, where available) for a
be assessed by a dentist prior to thorough physical inspection of the oral
treatment. For these patients at high risk cavity, and dentition. If there are pre-
for oral complications, the dental existing problems with oral health, these
assessment should be done by a dental should be considered for rapid resolution,
team experienced with oral oncology. if possible8.
Other dental assessments may be done
by the patient’s community dentist in Patients scheduled to receive
consultation with the oncology radiotherapy to the head and neck
specialist(s). The dental examination and require dental assessment (and, when
assessment should be done as soon as indicated, a maxillofacial prosthodontic
possible, to allow time for any dental examination) before radiotherapy, to
procedures and adequate healing prior address factors which can predispose the
to the cancer treatment. If dental work is patient to osteoradionecrosis (ORN-
indicated, this should be carried out section 5.19) and other radiation-induced
Table 4.1 Communications with Dental Oncology Team

Pre-treatment Dental Exam
The dentist should receive key information about the cancer patient prior to the
assessment, including:
• Cancer diagnosis, such as type, stage, prognosis
• Current CBC and other relevant bloodwork results; hematologic and immunologic
status
• Treatment planned for the patient, including planned date for first treatment
• If radiation is planned, field and dose of radiation
• If the patient is to receive a stem cell transplant, type of transplant, planned
transplant date, conditioning regimen to be given
• Other medical considerations, such as splenectomy, cardiopulmonary disease,
indwelling venous access line
Assess as early as possible- one month before cancer treatment if invasive oral
procedure(s) needed
Information to Send Back to Oncology Team:
• Amount & severity of dental caries
• Number of teeth requiring restoration or extraction
• Teeth requiring endodontic treatment, or other endodontic disease issues
• Periodontal disease status
• Teeth with pupal infection
• Any other urgent dental care required
• Time needed to stabilize any oral disease
oral toxicities. A dental team oral disease management before,
experienced with oral oncology may during, and after cancer therapy.
reduce the risk of oral complications If not consulted before hospital admission,
through direct examination and the Capital Health Department of Oral
interventions for the cancer patient prior and Maxillofacial Surgery may be
to cancer therapy, especially treatments consulted for patients treated in the
with intermediate to high risk of CDHA district; for other districts patients
stomatotoxicity. The oncology dental may speak with their oncology specialists
team, or the oncologist may also work in for local consultation options.
consultation with the patient’s
community-based dentist. The oncologist When chemotherapy is planned,
or oral oncology team should be in particularly for hematologic
contact with the community dentist, to malignancies, the patient may be
determine how best to schedule an referred for dental consult before
assessment and any necessary dental treatment, and dental care may be
work in context of the planned cancer provided by the patient’s own dentist
therapy. In some circumstances, the either before or after cancer treatment.
dental assessment and subsequent 4.2 Dental Management Before
intervention(s) may be done by the Chemotherapy and/or Radiotherapy
hospital dental team. Patients scheduled Upon completion of a thorough dental
for a hematopoietic stem cell transplant assessment, the dental team may opt to
procedure should also be referred for a perform appropriate and necessary
pre-treatment dental assessment by the procedures, to establish optimal oral
oncology dental team. health prior to cancer treatment (see
The assessment and resolution of any pre- Figure 4.1). The community dentist may
existing dental problems should occur as opt to refer the patient to an oral surgeon
early as possible prior to treatment.1-3 The or oral pathologist for certain procedures.
dental examination allows the dentist to Specific dental interventions prior to
initiate necessary interventions that may cancer treatment may be directed to (as
reduce oral complications during and necessary):
after the cancer therapy. The • Mucosal lesions
examination should be performed at • Dental caries and endodontic disease
least 1 month prior to cancer treatment to • Periodontal disease
permit adequate healing from any • Ill-fitting dentures
invasive procedures. • Orthodontic appliances
• Temporomandibular dysfunction
To facilitate the dental assessment, the • Salivary abnormalities
oncology team or oncologist should
Guidelines for dental extractions,
provide relevant information to the
endodontic management, and related
dentist3 , as listed in Table 2.1. At the
interventions can be utilized as
dental assessment visit, an oral hygiene
appropriate.4,5 Antibiotic prophylaxis prior
program for the duration of the cancer
to invasive oral procedures may be
therapy should be started. The dental
needed, particularly if the patient is
team should communicate back to the
neutropenic. The following guidelines
oncology team on the dental assessment
may help the dental team to determine
and interventions conducted. The dental
the need for antibiotics or transfusions in
team may also develop a care plan for
Figure 4.1 Dental Assessment & Interventions for Cancer Patients
LOW RISK (10%) Pre-treatment Dental Exam
Adjuvant/Palliative The dentist should receive key information about the cancer
Chemotherapy patient prior to the assessment, including:
Patients • Cancer diagnosis, such as type, stage, prognosis
• Current CBC and other relevant bloodwork results;
hematologic and immunologic status
• Treatment planned for the patient, including planned date for
first treamtent
• If radiation is planned, field and dose of radiation
Assess as early as possible- one month before cancer treatment if
invasive oral procedure(s) needed
Pre-treatment Interventions
May be directed to (as necessary):
• Mucosal lesions
• Dental caries and endodontic disease
• Periodontal disease
• Poorly-fitting dentures, orthodontic appliances
• Temporomandibular dysfunction
• Salivary abnormalities
• Patient education on oral hygiene plan
By community dentist or on referral to oral surgeon or oral pathologist
Information to Send Back to Oncology Team:
• Amount & severity of dental caries
• Number of teeth requiring restoration or extraction
• Teeth requiring endodontic treatment, or other endodontic disease
issues (or recommendation for chlorhexidine use)
• Periodontal disease status
• Any other urgent dental care required
• Time needed to stabilize any oral disease
Post Chemotherapy:
• Avoid dental work during periods of chemotherapy-induced
neutropenia and/or thrombocytopenia
• Regular dentist and dental hygienist visits (annual or more often as
needed) after chemotherapy is complete
• Watch for evidence of osteonecrosis of the jaw (ONJ) in patients
given injectable bisphosphonates e.g. Pamidronate, Zoledronic Acid;
if there is evidence of risk of ONJ, avoid dental extractions and
consider concomitant topical and systemic antiobiotics.
INTERMEDIATE RISK (40%)

Same as Low Risk, plus
Primary Chemotherapy (e.g.
• Pre-treatment dental exam and interventions may
Hematologic Malignancy) &
be performed by oral oncology team/hospital
some Gastrointestinal Cancer
dentist or referred to community dentist
Chemotherapy Patients
Post Chemotherapy:
• Same as Low Risk
Figure 4.1 Dental Assessment & Interventions for Cancer Patients (continued)
• Comprehensive pre-treatment dental exam and interventions
may be performed by oral oncology team/hospital dentist or
referred to community dentist, oral surgeon or oral
HIGH RISK (80-100%) pathologist
Head & Neck • Fabrication of custom flouride trays or PrevDent for radiation
Cancer Patients on patients
Radiotherapy • Pre-treatment assessment by prosthodontist prior to any
radiotherapy to the head and neck; preparation and fitting
for prosthodontic appliances as required
• Eliminate oral disease before treatment (e.g. dental
extraction of high-risk dentition) for radiotherapy patients
Post Radiotherapy:
• Annual follow-up visits with prosthodontist and regular visits to
dentist (every 4 months) for cleaning and assessment (dental
caries prevention)- for 2 years after radiotherapy.
• Then annual dentist visits (or more often as needed)
• Daily oral fluoride tablets (e.g. Prevident) may be used to
avoid ongoing superficial fluoride applications.

• Comprehensive pre-treatment dental exam and interventions
HIGH RISK (80-100%)
may be performed by oral oncology team/hospital dentist or
Bone Marrow/Stem
referred to community dentist, oral surgeon or oral
Cell Transplant
pathologist
Patients
• Eliminate oral disease before treatment (e.g. dental
extraction of high-risk dentition)
Post Transplant:
• Caution with any oral treatments or interventions (including
dental scaling & polishing) for at least one year after
transplant, even if hematology parameters return to normal
and graft-versus-host disease has resolved; patient immune
systems do not return to normal for at least one year post-
transplant
the cancer patient population (adapted before surgery; OR

from the American Heart Association • Ampicillin 2 G IM/IV given 30 minutes
(AHA) protocol for infective endocarditis before surgery
and oral procedures6,7): If allergy to penicillin:
• Patients with chronic indwelling venous • Clindamycin 600 mg PO/IV given 1
access lines (e.g., Hickman). - Consider hour before surgery PO or 30 minutes
empiric prophylactic antibiotics (low before IV; if parenteral dose used,
risk). follow with 150 mg PO/IV 6 hours
• Neutrophils 1.0-2.0 x 109/L - Consider later; OR
empiric prophylactic antibiotics (low • Azithromycin or Clarithromycin 500
risk). mg PO given 1 hour before surgery;
• Amoxicillin 2 g PO given 1 hour OR
• Cephalexin 2 g PO given 1 hour
before surgery; OR One issue of concern to dentistry is the
• Cefazolin 1 g IV given 30 minutes development of osteonecrosis of the jaw
before surgery (see Part 7.20) in some patients under
• Neutrophils <1.0 x 109/L - treatment with bisphosphonate agents,
• Give Meropenum 500 mg IV q6h, such as Pamidronate. The dental team
starting 30 minutes before surgery must be aware if a patient has received or
and continuing until afebrile continues to receive these drugs before
• Platelets 40 - 75 x 109/L - Platelet planning any major dental surgery, such
transfusions are optional; consider as a tooth extraction.
administering preoperatively and 24
Planning may need to be altered based
hours later. Additional transfusions are
on individual patient outcomes from
based on clinical course.
cancer treatment. This may continue to
• Platelets < 40 x 109/L - Platelets should
be an issue for the remainder of some
be transfused 1 hour before
patients’ lives.
procedure, immediately obtain
platelet count, transfuse regularly to
maintain counts above 30-40 x 109/L References:
until initial healing has occurred. 1. Woo SB, Matin K: Off-site dental evaluation
program for prospective bone marrow
During the period of dental work and transplant recipients. J Am Dent Assoc 128
upon completion, the dental team must (2): 189-93, 1997. [PUBMED Abstract]
stay in close communication with the 2. Schubert MM, Epstein JB, Peterson DE: Oral
oncology team, to properly and safely complications of cancer therapy. In: Yagiela
JA, Neidle EA, Dowd FJ: Pharmacology and
coordinate the overall plan for patient Therapeutics for Dentistry. 4th ed. St. Louis,
care. See Table 4.1. Mo: Mosby-Year Book Inc, 1998, pp 644-55
3. Schubert MM, Peterson DE, Lloid ME: Oral
4.3 Dental Management Following complications. In: Thomas ED, Blume KG,
Chemotherapy and/or Radiotherapy Forman SJ, eds.: Hematopoietic Cell
Upon completion of the cancer Transplantation. 2nd ed. Malden, Mass:
treatment, the patient may require Blackwell Science Inc, 1999, pp 751-63
further dental work. Dental work may 4. Williford SK, Salisbury PL 3rd, Peacock JE Jr, et
al.: The safety of dental extractions in patients
or may not be related to the cancer or with hematologic malignancies. J Clin Oncol,
cancer treatment. The dental team 1989; 7 (6): 798-802,
must continue to communicate with the 5. Overholser CD, Peterson DE, Bergman SA, et
oncology team, to ensure that all al.: Dental extractions in patients with acute
relevant clinical information is nonlymphocytic leukemia. J Oral Maxillofac
Surg, 1982; 40 (5): 296-8.
considered prior to future dental work. 6. Dajani AS, Taubert KA, W. Wilson W, Bolger A,
Patients treated for head and neck et al. Prevention of bacterial endocarditis.
Recommendations by the American Heart
cancers should visit their dentist every 4 Association. JAMA 1997; 227 (22): 1794-1801
months over the 2 years following 7. Slayter K, Chevalier B, Lummis H, and the
radiotherapy, for regular cleaning and Antibiotic Utilizational Committee.
assessement. These patients will also Antimicrobial Handbook. Queen Elizabeth
have follow-up care annually by the Health Sciences Centre, 2005, Halifax, pp 22,
36
prosthodontist. After 2 years post- 8. Keefe DM, Schubert MM, Elting LS, et al.
radiotherapy, patients may return to Updated clinical practice guidelines for the
annual dentist visits or as needed. prevention and treatment of mucositis.
Patients should be on daily oral fluoride Cancer, 2007; 109: 820-31
tablets.
Part 5. Referral Information
5.1 Community Dentist 5.2 Hematopoietic Stem Cell Transplant
Patients who are scheduled to receive Patients
cancer treatment with a low risk of oral Once it has been established that the
complications may be assessed by their patient will undergo a transplant, the
family dentist, preferably well in advance BMT/HSCT coordinators send a referral to
of the planned first treatment date. the CDHA Department of OMF Surgery.
Community dentists may also be An appointment time is sent back to the
contacted by the patient’s oncologist or coordinator who in turn phones the
the hospital-based dentist for an patient with the date and time. The
assessment referral. Some patients may coordinators attempt to organize other
require referral to an oral surgeon or oral activities (ie. tests and appointments) on
pathologist. the same day as the dental appointment
(VG Site) to decrease the number of visits.
General dental care and maintenance is
not covered under MSI, although cancer
After the patient is seen, a written
treatments (especially radiation therapy)
consultation from OMF Surgery is sent
can have a significant effect on a
back to the HSCT physician with
patient’s dentition. Cost for these services
recommendations. For uncomplicated
are the responsibility of the patient
oral care issues, the patient is generally
through their own means or through
referred back to their own dentist and
private dental insurance. These services
has the dental work completed before
are provided by the patient’s own
transplant. If there are complicated
community dentist. Unfortunately, many
issues, the CDHA OMF surgeon will
patients are unable to afford proper
contact the patient’s dentist for further
dental care.
discussion. Some complicated dental
work may be performed in the
There is coverage under provincial health
Department of Oral and Maxillofacial
insurance (MSI) for oncologic dental
(OMF) Surgery at QEII.
prostheses and for extraction of teeth
prior to cancer treatment (radiotherapy, Occasionally a patient does not have a
chemotherapy or HSCT) through the dentist. The Department of OMF Surgery
cancer team’s Maxillofacial clinic does not have the personnel (i.e.
Prosthodontist. Coverage for patients general dentists) or equipment to provide
from other provinces must be arranged in general dental care to these patients. The
advance, and may not be available. In Department of OMF Surgery will attempt
some circumstances, the dental care to find a dentist for the patient in their
may be provided by the oral own community (or near the VG Site if
maxillofacial (OMF) surgeon at CDHA they are from a different location, but
dentist at no cost to the patient (on a they are awaiting treatment). If the
case-by-case basis). patient is unable to afford dental care,
provincial health insurance (MSI) will
occasionally cover some basic dental
services but a predetermination is
required and can take up to several
weeks to obtain (which is unrealistic for
the HSCT population).
There are general dentists who are willing 5.3 Hematology/Medical Oncology
to provide the necessary immediate oral Patients
care at no cost to pre-transplant patients Physicians may consult the Department
who have no means of paying. The of OMF Surgery as required, or the
Department can sometimes arrange this patient may be referred to their
on a per case basis. The HSCT co- community dentist.
ordinators occasionally have access to
5.4 Head & Neck Cancer Patients
some funds for the necessary dental
Before a head & neck cancer patient
care. The Department of OMF Surgery
receives radiation treatment , they must
may recommend tooth extraction for
have a dental assessment prior to
HSCT patients (and selected
radiotherapy. These patients are referred
radiotherapy or chemotherapy patients),
to a Maxillofacial Prosthodontist in the
to ensure that all potential sources of
Otolaryngology Department (fax: 423-
odontogenic infection are removed
5001) for a thorough dental assessment.
regardless of a patient’s ability to pay.
Appliances and other interventions may
be recommended and produced by the
The initial consultation in the Department
Maxillofacial Prosthodontists. If extraction
of OMF Surgery at QEII is a MSI insured
is necessary prior to treatment, extractions
benefit as are necessary extractions in
may be performed in the Department of
selected cancer patients. There is no
OMF Surgery at the QEII, or the patient
remuneration for consulting on or
may be referred to their community
providing dental treatment for pre-
dentist as appropriate.
transplant patients from New Brunswick or
Prince Edward Island. These patients are
not billed for the initial consultation. NB
and PEI patients are billed for treatment
rendered but the ability to pay is never a
determinant in treating these patients.
Patients who indicate that they are
unable to pay are not billed.
Part 6. Mouth Care for the Cancer Patient
6.1 Oral Hygiene 5) Prevent halitosis and freshen the
Guideline Suggestion: mouth
Use of a uniform, systematic plan for oral
Effective oral hygiene is important
care, along with standard educational
throughout cancer treatment and
approaches to help patients understand
recovery, with emphasis on oral hygiene
and cope with the symptoms of oral
beginning prior to initiation of that
complications, is suggested. The
treatment. 6-8 Primary preventive measures
comprehensive management plan(s)
such as well-balanced nutritional intake,
may reduce the severity of mucositis
adequate oral hygiene, and early
caused by chemotherapy or
detection of oral problems are important
radiotherapy.
pre-treatment interventions.
Level of Evidence: III
Grade of Recommendation: B Mouth care should be planned daily on
the basis of individual patient
A systematic approach for mouth care is
assessment.9 Patients on active
outlined in the Mouth Care Plans (Basic
chemotherapy or radiotherapy should
and Intensified), described in Appendix
be educated on appropriate mouth care
III.
practice (including oral hygiene
Guideline Suggestion: procedures) and encouraged to follow
Patients on active chemotherapy or the practices during active treatment.
radiotherapy should be educated on (Appendix VI- Patient Education
appropriate mouth care practices1 and Materials).
encouraged to follow these practices
The patient should be informed of the
during active treatment and recovery.
rationale for the oral hygiene program as
Basic oral hygiene is particularly
well as the potential side effects of
important for any patient who is
cancer chemotherapy and radiation
immunocompromised.
therapy.
Grade of Recommendation: B The provision of regular, organized oral
care is extremely important in reducing
Strict oral hygiene is important for
the incidence and severity of oral
patients with cancer.2
complications from cancer treatment.
The major purposes of oral care are to
maintain normal function of the oral 6.1.1 Frequency of oral care
tissues, to maintain comfort, and to The vital factors in oral care are the
reduce the risk of local and systemic frequency, thoroughness and
infection.3,4 The aims of care are well consistency with which it is performed. To
summarized by Daeffler5 prevent complications, the frequency of
1) Keep oral mucosa clean, soft, moist care is more important than the agents
and intact thus preventing infection employed.
2) Keep the lips clean, soft, moist and
On the basis of evidence from Howarth10,
intact
Beck11, and Dudjack12, and in the
3) Remove food debris/dental plaque
absence of more recent research,
without damaging the gingiva/
Krishnasamy13 proposed various
periodontum
frequencies of oral care delivery
4) Alleviate pain/discomfort thus
according to the patient’s condition:
enhancing oral intake
• Care every 4 to 6 hours may reduce gingiva. To improve patient compliance
the patient’s potential for infection however, the type of floss used by the
from microorganisms. patient prior to their cancer should be
• Care every 2 hours may reduce continued. Using dental floss daily rather
mouth care problems and may than twice a day minimizes trauma to
enhance patient comfort by keeping the gingiva. Flossing should be performed
membranes moist. before bedtime brushing for optimal
• Care every hour (or more frequently) effectiveness.15,16
is appropriate for patients requiring
6.1.2.2 Brushing
oxygen therapy, patients who
A small, soft-headed, rounded-end, bristle
breathe through their mouths, patients
toothbrush is the best tool for cleaning the
with oral infections, unconscious
teeth, even in the dependent patient.5,12,16
patients, and patients with severe
Brushing should be performed four times
mucositis.
a day with techniques that specifically
6.1.2 Flossing, Brushing and Rinsing maintain the gingival portion of the tooth
A basic regimen of oral care, including and periodontal sulcus keeping them
flossing, teeth brushing, and rinsing, is free of bacterial plaque. Rinsing the
essential to minimize the risk of toothbrush in clean, hot water for 15 to 30
developing oral complications. seconds before brushing will soften the
brush and reduce risk for trauma. Brushes
Flossing and brushing are two of the most
should be air-dried between uses.
effective ways to remove dental plaque.
Plaque is the buildup of debris on tooth The ease of tooth brushing may be
enamel. Accumulated dental plaque influenced by various factors including
contributes significantly to inflammation gingival status, alignment of the teeth,
of the gingiva.14 personal motivation, patient fatigue,
pain, and manual dexterity.16
6.1.2.1 Flossing
Toothbrushing is considered the most
Flossing is important for oral hygiene as it
effective means of plaque removal, but it
allows a patient to clean the surfaces
is not well tolerated in severe mucositis.
between the teeth. Many people do not
floss because the technique is difficult to If the gingival tissue bleeds for more than
master, time-consuming, and, if 2 minutes, brushing may be discontinued
improperly performed, can cause and the teeth cleaned with moist gauze
trauma to the tissues. If flossing causes wrapped around the finger or a foam
bleeding of the gums which does not swab. If this is too painful (even with
stop after 2 minutes, it should be analgesia) or if it causes the gingival
discontinued until the platelet count tissues to bleed, attempt rigorous rinsing.
increases to 20 x 109/L. Because of Once the platelets are >20 x 109/L,
possible trauma to the gums, patients brushing may be resumed.
who have not flossed routinely before
Although toothbrushing is undoubtedly
cancer treatment should not begin
better at removing plaque when used
flossing at this time, unless suggested by
appropriately, a foam swab is able to
the dentist or dental hygeinist.
remove some plaque from some oral
Waxed and unwaxed floss are equally areas.17,18 Using a foam swab may
effective, but waxed floss may be easier reduce plaque and control gingivitis as
to use and minimize trauma to the an alternative when toothbrushing
cannot be performed. Additionally, 6.1.2.3 Fluoridated toothpastes and gels.
foam swabs have the potential to Since the flavoring agents in toothpaste
stimulate saliva production and improve can irritate oral soft tissues, a toothpaste
vascularity through gentle massage. with relatively neutral taste should be
Even if they may be useful in cleansing considered. Toothpaste requires three
soft tissues, foam swabs are ineffective at key ingredients to be effective: a
cleansing tooth surfaces. detergent to lower surface tension and
loosen surface debris which is then more
Clearly it is essential that debris and
easily removed, a fine abrasive to
plaque are removed. The tooth cleaning
cleanse the teeth, and fluoride to prevent
process should not, however, cause
cavities. Fluoride is incorporated in
further damage. Irrigation of the oral
hydroxyapatite reducing its solubility in
cavity can be useful in removing large
acid and also enhancing
food particles and debris although,
remineralization when pH rises, this is
alone, it will not remove all plaque from
probably the single most important
the gingival sulci. While irrigation may be
intervention in the prevention of
useful in healthy individuals its value/
radiation-induced damage. Furthermore,
effectiveness in cancer patients is
fluoride inhibits bacterial metabolism thus
unknown. Some authors have identified
lowering acid production and so can
possible harmful effects including
almost eliminate dental caries and tooth
formation of periodontal abscess and
loss following irradiation of the head and
possible penetration of the oral tissue by
neck.
bacteria and other particle matter.
Irrigation may cause further damage to Patients with receding gums should
friable mucosa; care must also be taken choose a low- or moderately-abrasive
to prevent the spread of infection. toothpaste to avoid abrading the
exposed roots of their teeth. If the teeth
Electric toothbrushes were developed in
are sensitive, patients can use a
an attempt to make daily oral hygiene
desensitizing toothpaste, such as
easier to perform, thereby improving
Sensodyne.
patient compliance. They are popular
and widely available with several 6.1.2.4 Rinsing
different types of brushing motion, head Rinsing the oral cavity after flossing and
design and bristles. The head design and brushing helps to maintain the moisture in
hard bristles of most electric toothbrushes the mouth, removes the remaining debris
are manufactured to make the head last and toothpaste, and reduces the
longer but are rarely of the ideal shape/ accumulation of plaque and infection.
texture for thorough cleaning of the teeth The patient should rinse, swish and spit at
and gums. They may be more effective least 1 tablespoon (15mL), of rinse solution
in removing plaque and decreasing several times after each brushing.
gingivitis than regular toothbrushes. Rinsing without brushing can be
Electric toothbrushes cover more area repeated as often as necessary to
faster, but they may also increase the maintain oral comfort. The patient should
19-20
potential for gum injury and bleeding. rinse mouth thoroughly using an
The use of electric toothbrushes is alternative ballooning and sucking cheek
generally not recommended for patients motion to force mouth rinse solution
at high risk of oral complications of between the teeth. If unable to do this,
cancer therapy. patients can tilt or rock the head from
side to side prior to expectorating.
6.1.3 Mouth Rinse Solutions Mixing this as a stronger solution is not
Best Practice Statement: recommended, since it may harm
Patients should be encouraged to mucosal tissue. Saline can be
thoroughly rinse out their mouths using a administered at room or refrigerated
mouth rinse solution. Water, club soda, temperatures, depending on patient
normal saline or sodium bicarbonate preference. Sodium chloride rinse solution
solution may be considered as should be prepared fresh at least once
reasonable options for mouth rinse daily. The patient should rinse and swish
solutions. Commercial solutions with approximately 1 tablespoon (15mL),
hydroalcoholic base or astringent followed by expectoration; this can be
properties should be discouraged for repeated as often as necessary to
routine mouth rinse during active cancer maintain oral comfort. Saline solution can
therapy. enhance oral lubrication directly as well
as by stimulating salivary glands to
To date, no research has demonstated
increase salivary flow.
the benefit of one rinsing solution over
another and therefore they will all be Sodium bicarbonate (NaHCO3) is a non-
discussed. It is recommended that irritating compound that reduces the
patients be given their choice of rinse viscosity of saliva. Sodium bicarbonate
solution, to optimize patient compliance (baking soda) neutralizes the acidic oral
with oral hygiene practice. environment. The alkaline environment
from sodium bicarbonate allows bacteria
Mouth rinse solutions should be
to multiply, which may have detrimental
nondehydrating to promote the safe
effects on the mucosa. This solution is
removal of loose debris and to moisten
prepared by adding ½ teaspoon of
and soften the oral mucosa. Suggested
baking soda to 8 ounces of lukewarm
rinse solutions include tap water (or
water. Stronger solutions may be irritating
bottled water in areas where tap water
to the oral mucosa and are not
may be contaminated), saline and
recommended. Patients sometimes
sodium bicarbonate mouthwash.
report an unpleasant taste with sodium
Carbonated soda water may be used as
bicarbonate preparations, which may
a simple, commercially-available
impact on subsequent compliance.21
substitute for other mouth rinse solutions.
Sodium bicarbonate rinse solutions should
Club soda is inexpensive, and simple for
be prepared fresh at least once daily
patient use, making this alternative an
and can be used cold or room
attractive option for routine patient
temperature.
mouth care. A new can or bottle should
be opened at least once every 24 hours, The mouth rinse solution should be
to avoid oral infection from a mouth rinse prepared at least once daily (to avoid
which has been open for possible the risk of contamination). If a
contamination for more than a day. commercial product is used, a new bottle
should be used every 24 hours.
Sodium chloride 0.9% (saline or NaCl) is
not an irritant. Use of saline as a mouth The use of hydrogen peroxide as a
rinse may be more effective than a mouth rinse has no scientific or clinical
regimen using a more astringent base, and controversy surrounds its use as
mouthwash. This solution is prepared by it impedes granulation of new tissue.
adding approximately ½ teaspoon Hydrogen peroxide solution should only
(2.5mL) of table salt to 8 oz. of water.
be used for 1 to 2 days if absolutely hydrogen peroxide (3%)and water (or
necessary to remove necrotic material. normal saline) may be considered.
More extended use may impair timely
6.3 Lip Care
healing of mucosal lesions. It is both
Dry lips may be coated with either an oil-
bacteriostatic and hemostatic, but its
based lubricant or a water-based
antibacterial properties may promote
lubricant to keep the lips moist. Dry lips
fungal overgrowth and may inhibit
can become cracked and
mucosal tissue granulation in patients
uncomfortable, and this condition may
with oral lesions.22-24 Patients find it highly
inhibit proper oral hygiene and eating.
astringent, exacerbating a dry mouth,
Oil-based lubricants such as petroleum
and unpleasant tasting.22 Hydrogen
jelly, mineral oil, and cocoa butter are
peroxide should not be used as a mouth
effective on the lips but should be
rinse.
avoided on the inside of the mouth
Commercial mouthwashes with because of the danger of aspiration.
hydroalcoholic base or astringent Lanolin-based creams and ointments
properties are not recommended for may be more effective in protecting the
patients with oral problems because they lips against trauma (e.g. from heat or
have the potential to cause irritation and cold, hard foods, etc.)26, but are
hypersensitivity stomatitis through contraindicated in patients allergic to
erythema, ulceration, and epithelial wool products.
sloughing.25 These clinical reactions may
Patients should be encouraged not to
be caused by oils, astringents, alcohol,
touch their lip lesions. Water-soluble
and antiseptics, as contents of
lubricants can be used inside and outside
commercial products. These products
of the mouth. These lubricants can be
may be sweetened with saccharin and
used during oxygen therapy, without risk
may contain coloring agents. They may
of aspiration. They should be applied
also contain other aromatic substances.25
more frequently, before meals, after
Lemon leads to tooth decalcification and cleaning and at bedtime. Examples of
overstimulation of salivary glands resulting water-soluble lip lubricants are products
in rebound xerostomia. Lemon-based compounded with Glaxal Base or Derma
products should not be used for mouth Base (eg. K-Y Jelly, Dermasone).
care. Examples of non-soluble lubricants are
lanolin, petroleum jelly, mineral oil and
6.2 Debriding
cocoa butter.
Tissue should not be debrided unless
absolutely necessary (ie. loose tissue 6.4 Eating
causing gagging or choking). Do not Patients should be discouraged from
remove tissue that is still attached or eating foods which are abrasive, rough,
hanging unless it is posing a risk. If after spicy, acidic, or very hot. Alcohol and
cleaning and rinsing, debris is not tobacco can be irritating to the oral
removed, rinse vigorously with soda water tissues; patients should be encouraged to
or the preferred mouth rinse solution. limit or stop the use of these substances
and others which irritate the mouth. High-
Hydrogen peroxide is NOT
density and high-fibre foods help to clean
recommended. If ongoing crusting and
teeth and massage the gums. Patients
hemorrhagic debris does not dislodge
may be encouraged to eat these foods,
after repeated use, the benefits of 1:1
as well as foods high in protein and
vitamins B and C. Adequate fluid intake Staging System scale for screening),
is important to maintain good oral returning to the Basic Mouth Care Plan
hygiene. Patients should be encouraged when stomatitis and other symptoms
to drink plenty of fluids, with a target have resolved. These Mouth Care Plans
intake of 2 liters /day. should be integrated into hospital
nursing care plans for cancer patients
If a patient experiences oral
and used as a basis for health
complications, bland foods are
education of ambulatory patients.
recommended. TPN (total parenteral
nutrition) or G-tube (gastrostomy tube) 6.5.1 BASIC MOUTH CARE PLAN
feeding may be needed for patients who A basic regimen of oral care, for patients
are unable to eat or swallow. Topical without oral complications, is essential to
anesthetics, applied 20 to 30 minutes minimize the risk of developing future
before eating, (or topical analgesics complications. The interventions
applied 1 hour before eating) may described for basic mouth care should
provide enough comfort for the patient be considered for all patients who have
to be able to eat or drink. The numbing cancer. They should be initiated before
effect of the anesthetic commonly lasts 1- treatment begins and continued until the
2 hours after the application. The gag risk of side effects or oral complications is
reflex should be checked prior to eating over. Basic mouth care practices are for
or drinking, in case the patient swallows the patient with Grade 0-1 stomatitis
the anesthetic, by accident or instead of (rated by the CTC) . Key points are listed
spitting it out. in Table 6.1.
6.5 Management Plans 6.5.2 INTENSIFIED MOUTH CARE PLAN
Guideline Suggestion: Intensified mouth care practices are for
Use of a uniform, systematic plan for oral the patients who have been graded on
care, along with standard educational the CTC as 2 or greater. These practices
approaches to help patients understand build on those of basic mouth care
and cope with the symptoms of oral practices. Key points are listed in Table
complications, is suggested. The protocol 6.2.
should be multidisciplinary. One
Patient Education
component of the protocol should be the
Patients who are to receive
use of a soft toothbrush that is replaced
chemotherapy or radiotherapy should
on a regular basis. The comprehensive
begin their education about possible oral
management plan(s) may reduce the
complications and preventive mouth
severity of mucositis caused by
care practices as they begin their
chemotherapy or radiotherapy.
treatment teaching.
Grade of Recommendation: B The importance of brushing, even with
discomfort should be normalized and
Best Practice Statement:
emphasized so that patients have the
For routine care, the oral complication
expectation of continuing the brushing
treatment components are compiled into
with pain should it occur.
Mouth Care Plans. The Basic Mouth Care
Plan is used for most patients. The
Intensified Mouth Care Plan is used for
patients as they develop intermediate to
severe stomatitis (on the Stomatitis
Table 6.1 Basic Mouth Care Plan
Flossing •
Flossing with dental floss allows a patient to clean surfaces between the
teeth
• Flossing is usually done before brushing, and before going to bed.
• The patient should continue their flossing practices, using the same type of
dental floss as they have done in the past.
• If flossing causes bleeding of the gums which does not stop after 2 minutes, it
should be discontinued. Flossing may be restarted when the platelet count is
> 20 x 109/L, or as instructed by their cancer care team.
• Patients who have not flossed routinely before cancer treatment should not
begin flossing at this time
• Patients with cancers in the mouth may not be able to floss
Brushing • Use a small, soft-headed, rounded-end, bristle toothbrush (electric
toothbrushes are not preferred), and a fluoridated toothpaste or gel
(preferably with a neutral taste)
• Brush teeth 4 times daily, within 30 minutes after eating and before bed.
Brush after flossing
• Rinse toothbrush in hot water to soften it before using
• Brush tongue gently from back to front
• Rinse brush after using in hot water. Air dry.
• Change toothbrush when bristles are not standing up straight (about once
per month)
Patients with Head & Neck Cancers
• Brushing may not be appropriate because of tumor involvement. Patient
may attempt to clean teeth with a moist gauze wrapped around the finger
or a foam swab soaked in rinsing solution, if able. Otherwise patient should
rinse mouth several times with rinsing solution.
Dentures
• Remove dentures, plates and prostheses before beginning mouth care.
• Rinse mouth thoroughly with rinse solution.
• Brush and rinse dentures after meals and at bedtime. Rinse with rinsing
solution before placing in mouth. Remove from mouth for long periods (at
least 8 hours/24). Soak in rinsing solution.
Rinsing • Rinsing the oral cavity helps to maintain the moisture in the mouth, removes
the remaining debris and toothpaste, and reduces the accumulation of
plaque and infection
• Rinse vigorously several times after brushing and flossing, using one of the
rinsing solutions
Lip Care • Coat lips with an oil-based or water soluble lubricant to keep them moist.
Water soluble lubricants may be used inside and outside the mouth, and
can be used with oxygen, since there is no risk of aspiration.
• Apply the lubricant after each cleaning,at bedtime, and as needed.
Water-based lubricant needs to be applied more frequently.
Eating Avoid abrasive, rough, spicy, acidic and hot foods. All irritants should be
avoided, especially alcohol and tobacco. Eat soft foods. Avoid foods
containing a lot of sugar, and really cold foods. Encourage high-density and
high-fibre foods to clean teeth and massage gums. Encourage a well-
balanced diet, high in protein, vitamins B & C. Encourage a fluid intake of at
least 2 litres per day to keep mucous membranes moist.
Table 6.2 Intensified Mouth Care Plan
Flossing • Continue until discomfort becomes too great
• Discontinue flossing if gums bleed for longer than 2 minutes. Advise patient to
try to begin again when platelet count rises >20 x 109 cells/mL.
Brushing • Use ultra soft toothbrush (Butler 435 stocked on some inpatient units)
• Encourage patient to continue brushing through treatment even when it
causes discomfort. If unable to tolerate brushing after benefits are reinforced
and weighed against the detriments, try to clean teeth with a moist gauze
wrapped around finger or a foam swab soaked in rinsing solution.
• Consider the use of a topical analgesic q 4-6 hours to promote more
thorough tooth brushing when continuous pain is present. Oral analgesics
(opioids) should be given 60 minutes before brushing.
• Consider a topical anesthetic before brushing to minimize pain.
• If bleeding does occur, encourage more gentle brushing. If bleeding does
not stop after 2 minutes, consider cleaning with gauze, toothette or vigorous
9
rinsing (with rinsing solution). Restart brushing when platelet count > 20 x 10
• If the gingival tissue bleeds, clean teeth with a moist gauze wrapped around
the finger or a foam swab
• If there has been an oral infection, use a new toothbrush after infection is
resolved.
• Dentures Keep out of mouth as much as possible
Rinsing • Perform in place of brushing if patient absolutely unable to brush.
• As well as after meals, encourage rinsing every 1-2 hours while awake, and
every 4 hours through the night if awake (to minimize complications of
decreased saliva).
• If unable to clean using toothette or gauze or swishing (or tilting head),
syringe rinsing solution into different areas of mouth if platelet level is not too
low.
References: 19. Bader H. Review of currently available
1. Shieh SH, Wang ST, Tsai ST, Tseng CC. Mouth battery-operated toothbrushes.
care for nasopharyngeal cancer patients Compendium of Continuing Education
undergoing radiotherapy. Oral Oncol, 1997; Dentistry; 13: 1162-69.
33: 36-41 20. Barnes C, Weatherford T, Menaker L. A
2. Watson R. Care of the mouth. Nursing 1989; comparison of the Braun Oral-B Plaque
3: 20-4. Remover (D5) Electric and a manual
3. McElroy TH. Infection in the patient receiving toothbrush in affecting gingivitis. J Clin Dent
chemotherapy for cancer: oral (1993); 4(2): 48-51.
considerations. JADA 1984; 109(3): 454-56. 21. Beck, S Yasko J. Guidelines for oral care (2nd
4. Carl W. Oral complications in cancer ed.) Crystal Lake, IL. 1993: Sage.
patients. Am Fam Phys 27: 161-170. 22. Davis R. Mouth care in oral cancer treatment:
5. Daeffler R. Oral hygiene measures for a nursing protocol. Macmillan Nurs 1998;
patients with cancer III. Cancer Nurs 1981; 7(suppl): 1-7.
4(1): 29-35. 23. Daeffler R. Oral hygiene measures for patients
6. Ezzone S, Jolly D, Replogie K et al. Survey of with cancer II. Cancer Nurs; 1980: 3(6): 427-
oral hygiene regimens among bone marrow 32.
transplant centres. Oncology Nursing Forum 24. Tombes MB, Gallucci B. The effects of
20(9): 1375-1381, 1993. hydrogen peroxide rinses on the normal oral
7. Schubert MM, Peterson DE, Lloid ME: Oral mucosa. Nurs Res 42; 332-7.
complications. In:Thomas ED, Blume KG, 25. Kostler WJ, Hejna N, Wenzel C, Zielinski CC,
Forman SJ eds: Hematopoietic Cell Oral mucositis complicating chemotherapy
Transplantation. 2nd ed. Malden, Mass: and/or radiotherapy: options for prevention
Blackwell Science Inc.1999, pp 751-63. and treatment. Ca Cancer J Clin, 2001; 51:
8. Jansma J, Vissink A, Spijkervet FK, et al. 290-315
Protocol for the prevention and treatment of 26. Richards RME, McCague GJ. In vivo
oral sequelae resulting from head and neck estimation of the antimicrobial activity of
radiation therapy. Cancer 1992; 70(8): 2171- proprietary mouthwashes. Pharm J 1988;
80. 12(26): 1226.
9. Jenkins D. Oral care in the ICU: an important
nursing role. Nurs Standard 1989; 8: 24-28.
10. Howarth H. Mouth care procedures for the
very ill. Nurs Times 1977; 73(10): 345-55.
11. Beck S. Impact of a systemic oral care
protocol in stomatitis after chemotherapy.
Cancer Nurs 1979; 10:185-89.
12. Dudjak L. Mouth care for mucositis due to
radiation therapy. Cancer Nurs 1987; 10: 131-
40.
13. Krishnasamy M. Oral problems in advanced
cancer. Eur J Cancer Care 1995; 4: 173-177.
14. Galgut PN. The need for interdental cleaning.
Dental Health 1991;30(5): 8-11.
15. Floss: encourage compliance. J Amer Den
Assoc (1991); 9: 6-8.
16. Roth PT, Creason NS. Nurse administered oral
hygiene: is there a scientific base? J Adv Nurs
1986; 11: 323-31.
17. Ransier A, Epstein JB, Lunn R, Spinelli J. A
combined analysis of a toothbrush, foam
brush and a chlorhexidine-soaked foam
brush in maintaining oral hygiene. Cancer
Nurs 1995; 18: 393-96.
18. Pearson L. A comparison of the ability of
swabs and toothbrushes to remove dental
plaque: implications for nursing practice. J
Adv Nurs 1996; 23: 62-9.
Part 7. Clinical Manifestations and Management of Oral
Complications from Cancer and Cancer Treatment
7.1 Introduction
Initially patients may complain of a
Mouth care practices, as described in
mucosal tenderness, a burning sensation
Part 6, should be continued through the
in their mouth. This commonly progresses
period of cancer treatment and
to increased sensitivity to heat and cold,
recovery, as appropriate to the level of
and to spicy and salty food. The
oral complications experienced by the
ulcerations are usually painful, causing
patient. In addition to the mouth care
restrictions in oral intake and, importantly,
practices, patients may require symptom
act as sites of secondary infection and
management and treatment of different
portals of entry for the endogenous oral
problems. Treatment of the problems
flora.
may require different approaches for
different patients. Often more than one Mucositis appears clinically as
problem occurs concurrently, and erythematous or diffuse ulcerative lesions.
management may be complicated and These lesions develop primarily on the
may require careful integration. non-keratinized tissues such as the buccal
and labial mucosa, the ventrolateral
7.2 Mucositis
surface of the tongue and the floor of the
The terms “oral mucositis” and “stomatitis”
mouth. The hard palate, attached
are often used interchangeably at the
gingiva, and the dorsal surface of the
clinical level, but do not reflect identical
tongue are rarely subject to mucositis but
processes. Oral mucositis describes
may become painful. 4
inflammation of oral mucosa resulting
from chemotherapeutic agents or The overall frequency of mucositis varies
ionizing radiation. Mucositis typically and is influenced by the patient’s
manifests as erythema or ulcerations. It diagnosis, age, level of oral health, the
may be exacerbated by local factors. type, dose, and frequency of drug
Stomatitis refers to any inflammatory administration and/or the dose and field
condition of oral tissue, including mucosa, of radiation therapy. The presence of
dentition/periapices and periodontium. dental appliances has the potential to
Stomatitis thus includes infections of oral irritate the oral mucosa and produce
tissues, as well as mucositis as defined breaks in the integrity of the mucosa.
above. 1-3 Increases in the use of alcohol and
tobacco have also been implicated in
Oral mucositis is a major cause of
increasing the incidence of mucositis.
morbidity in cancer patients and results
from the exposure of the underlying Oral mucositis is a distressing toxic effect
connective tissue to the oral environment of systemic chemotherapy with many
and the tissue’s reaction to the insult. commonly utilized drugs and of head
Cancer therapy-induced tissue damage and neck irradiation in patients with
leading to mucositis can occur through cancer. 5-11 Chemotherapy alters the
either direct or indirect stomatotoxicity. integrity of the mucosa. Mucositis can be
Since cellular replication is inhibited, the major dose-limiting toxicity during the
inadequate numbers of cells are administration of certain types of
available to maintain mucosal integrity. chemotherapy, especially 5-fluorouracil,
The mucosa becomes thin, inflamed and methotrexate and doxorubicin.
eroded, as outlined in Part 2.
Chemotherapy-induced mucositis begins 7.2.1Mucositis Prevention
shortly after therapy, reaching a peak Best Practice Statement:
within 1 to 2 weeks after treatment and Patients with oral mucositis require
slowly receding unless complicated by appropriate therapeutic intervention(s) to
infection, hemorrhage or repeat drug prevent symptoms.
administration.
Prevention is the most effective strategy
The origin of radiation-induced mucosal for mucositis. Oral care protocols
lesions is iatrogenic in nature, although generally include procedures for
further development of mucositis is cleansing the oral mucosa (with minimal
essentially influenced by infection. trauma), maintaining lubrication of the
Mucositis is the result of these atrophic lips and oral tissues, and relieving pain
changes in the epithelium related to the and inflammation (Appendix III). It should
decreased cell renewal. Mucosal be noted that some agents for
reactions in patients receiving radiation prevention of mucositis may continue to
treatment for head and neck cancer are be used during treatment if mucositis
regarded as unavoidable side effects, occurs.
and generally occur 5 to 7 days after 7.2.1.1 Benzydamine
initiation of radiation therapy. The degree Guideline Recommendation:
of mucositis experienced is determined Benzydamine is recommended for
by the treatment dose, radiation field size prevention of radiation-induced mucositis
and fractionation schedules prescribed in patients with head and neck cancer
for individual patients. It occurs after a receiving moderate-dose radiotherapy.
dose of approximately 10 Gray Level of evidence: I
(1000cGy). Mucositis usually resolves two Grade of recommendation: A
to three weeks after the termination of
radiation therapy if infection and Benzydamine hydrochloride is a topical
additional trauma are avoided .
12-16 nonsteroidal drug, with anti-inflammatory,
analgesic, anesthetic and antimicrobial
Oral mucositis in cancer patients properties. It has also been shown to
produces clinically significant toxicities inhibit proinflammatory cytokines, such as
that require multiprofessional TNF-α. Clinical trials have shown that
interventions. 17-24 The lesion can increase benzydamine can reduce the severity
risk for systemic infection, produce and frequency of oral mucosal ulcers
clinically significant pain, and promote and decreases pain associated with
oral hemorrhage. Local infections may radiation-induced oral mucositis25-28.
become systemic and life-threatening,
especially in immunocompromised 7.2.1.2 Radiotherapy Delivery
patients such as HSCT patients. Once Guideline Recommendation: Midline
mucositis has developed, its severity and radiation blocks and three-dimensional
the patient’s hematologic status govern radiation treatment to the oral cavity
appropriate oral management. 17,22 should be used where possible, to reduce
Meticulous oral hygiene and mucosal injury.
management of symptoms are essential. Level of evidence: II
Grade of recommendation: B
The prevention and management of
mucositis are illustrated in Figures 7.1, 7.2 Although clinical trials addressing the
and 7.3 for low, intermediate and high risk effect of radiotherapy planning have not
patients respectively.
Table 7.1: Agents for Mucositis Prevention
Cryotherapy Oral Cryotherapy (sucking ice chips) with 5FU bolus chemotherapy, high
dose Melphalan used in HSCT conditioning regimen
Biological Response Keratinocyte Growth Factor 1 (KGF-1)- Palifermin (Kepivance)
Modifiers Keratinocyte Growth Factor 2 (KGF-2)
Interleukin-11
Transforming Growth Factor Beta-3
Topical Analgesics Benzydamine HCl topical rinse (e.g. Tantum™)- to prevent radiation-induced
mucositis
Other Agents Under Amifostine
Investigation Topical Vitamin E, Topical Betacarotene
Prostaglandin E (PGE2) Lozenge
Kamillosan liquidum oral rinse
Glutamine
Granulocyte Colony Stimulating Factor (GCSF)
Sodium Alginate
Misoprostol (topical)
Low Energy Laser Therapy
Radiation Shields
Protegrins/Defensins
Lysofiline
been large, it has been shown that the replicating oral epithelium. In addition,
use of midline radiation blocks and the use of cold packs or frozen ice bags has
use of three-dimensional treatment successfully relieved fluorouracil-related
delivery (which reduces irradiation to a side effects occurring at other sites
larger volume of mucosa) may reduce including lips, skin, and groin area.
oral mucosal injury29,30. Patients are instructed to swish ice chips in
their mouths for 30 minutes, beginning 5
7.2.1.3 Cryotherapy
minutes prior to bolus 5-FU administration.
Guideline Recommendation:
It is not practical to consider cryotherapy
Patients receiving 5-fluorouracil-based
with infusional 5-FU, however. (Note: an
chemotherapy should be treated with
exception is cryotherapy for regimens
oral cryotherapy (ice chips in the mouth
containing both 5-FU and Oxaliplatin.
for 30 minutes starting 5 minutes before
Cold-induced dysaesthesia from
chemotherapy administration) to prevent
Oxaliplatin is a common and
stomatitis. This recommendation should
preventable toxicity of this
be suspended if oxaliplatin is included in
chemotherapy agent)
the chemotherapy regimen.
Level of Evidence: II Guideline Suggestion:
Grade of Recommendation: B Patients receiving high-dose melphalan
as part of a conditioning regimen for
Although mucositis continues to be one of
stem cell transplant should be treated
the dose-limiting toxicities of fluorouracil
with oral cryotherapy to prevent oral
(5-FU), cryotherapy may be an option in 231
31-34 mucositis.
prevention of oral mucositis. It may
Level of Evidence: II
ameliorate mucositis caused by agents
Grade of Recommendation: A
such as 5-Fluorouracil (5-FU) by reducing
vascular delivery of these toxic agents to
In the 2005 update to the Multinational palifermin has been approved for use in
Association of Supportive Care in Canada. There was no change in survival
Cancer (MASCC) guidelines, emergent between the groups (indicating that
evidence was reviewed to suggest that palifermin did not reduce the
cryotherapy may also be an effective effectiveness of the transplant
strategy for oral mucositis prevention in intervention). Adverse effects from
stem cell transplantation patients palifermin included increased skin
receiving high-dose melphalan as part erythema, pruritus, edema, tongue
of their conditioning regimen. It is not “feeling thick,” taste disturbances (26% vs
known if cryotherapy is effective 3%), and transient asymptomatic
preventive therapy with other increases of serum lipase (77% vs 67%)
conditioning regimens. and serum amylase (32% vs 25%).
7.2.1.4 Human Keratinocyte Growth In another multicenter, randomized,
Factors double-blind, placebo-controlled Phase II
Guideline Recommendation: trial36, palifermin was studied in patients
In patients with hematological with head and neck cancer who
malignancies receiving high dose received standard or hyperfractionated
chemotherapy and total body radiotherapy with concomitant
irradiation with stem cell transplant, chemotherapy. The palifermin-treated
Keratinocyte Growth Factor-1 group had a lower incidence and shorter
(Palifermin) in a dose of 60 µg/kg/day duration of mucositis compared with the
for 3 days prior to conditioning group that received placebo.
treatment and for 3 days post-transplant
Human keratinocyte growth factor 2
is recommended for the prevention of
(KGF-2; repifermin) was evaluated in a
oral mucositis. 231
Phase II trial37 with 42 patients who
Level of Evidence: I
received conditioning regimens with
chemotherapy before undergoing
Recombinant human keratinocyte autologous stem cell transplant. This trial
growth factor 1 (rHuKGF-1; palifermin) was withdrawn due to poor performance
was evaluated in a randomized double- of the new agent231.
blind placebo-controlled trial involving
7.2.1.5 Agents Which Have Not Proven
patients undergoing autologous
to be Effective for Prevention of
transplantation for a variety of
Mucositis
hematologic malignancies, palifermin
Many agents and protocols have been
60 mcg/Kg/day was given for 3 days
promoted for management or
before conditioning and 3 days after
prevention of mucositis. Several of these
transplant35. Results showed a reduction
have been tested and proven to be
in duration of severe mucositis (3.7 vs
ineffective in trials conducted to date.
10.4 days; P < 0.001), reduced incidence
These are identified in a series of guideline
of grade 4 mucositis (20% vs 62%; P <
recommendations below, adapted from
0.001), and reduced use of opioid
the MASCC guidelines38, updated in
analgesics (212 vs 535 mg morphine
2007231.
equivalents median usage per patient;
P < 0.001. 7 vs 11 days median duration
of opioid use per patient; P < 0.001).
Based on this pivotal trial in 212 patients,
Chlorhexidine Acyclovir
Guideline Recommendation: Guideline Recommendation:
Chlorhexidine should not be used to Acyclovir and its analogues should not
prevent oral mucositis in patients with solid be used routinely to prevent mucositis.
tumors of the head and neck who are Level of evidence: II
undergoing radiotherapy. Grade of recommendation: B
Level of Evidence: II While acyclovir has not proven to be
Grade of Recommendation: B useful for prevention of mucositis, it may
If tolerated by the patient, chlorhexidine be considered as a treatment option for
may be used as part of an oral care plan systemic viral infection.
to help prevent dental caries (usually on Systemic Glutamine
the advice of a dentist). Several clinical Guideline Recommendation:
trials have failed, however, to Glutamine should not be used routinely to
demonstrate that chlorhexidine is prevent mucositis. 231
39-41 42,43
effective in preventing or treating Level of evidence: II
oral mucositis (see section 7.5.1.1). Grade of recommendation: C
Sucralfate GM-CSF Mouthwashes
Guideline Recommendation: Guideline Recommendation:
Sucralfate should not be used for the Granulocyte-Macrophage Colony
prevention of radiation-induced oral Stimulating Factor (GM-CSF) mouthwash
mucositis. 231 formulations are not recommended for
Level of Evidence: II prevention of mucositis in patients
Grade of Recommendation: A undergoing hematopoietic stem cell
Sucralfate, an anti-ulcer drug, binds to transplant. 231
ulcerated tissue. Oral sucralfate forms an Level of evidence: II
adhesive, paste-like substance and Grade of recommendation: C
attaches to proteins in the damaged Pentoxifylline
mucosa, forming a protective coating Guideline Recommendation:
that prevents further mucosal damage. Pentoxifylline is not recommended for
Sucralfate is available in tablet form and prevention of mucositis in patients
must be dissolved in water to make an undergoing hematopoietic stem cell
oral rinse that is swished and transplant.
expectorated or swallowed. The mixture Level of evidence: II
must be refrigerated and shaken well Grade of recommendation: B
prior to use.
7.2.1.6 Other Agents for Prevention of
Even though sucralfate has been used as Mucositis (Insufficient Evidence)
a mucosal coating agent, it has not been Although not adequately supported by
found to have any effect on mucositis controlled clinical trials, allopurinol
prevention or treatment.44-51 mouthwash52 and vitamin E53 have been
Antimicrobial Lozenges cited as agents that improve mucositis.
Guideline Recommendation: Topical application of phytochemicals
Antimicrobial lozenges should not be such as betacarotene54 also may protect
used for the prevention of radiation- the oral mucosa. A single trial of Saforis
induced oral mucositis. 231 (L-glutamine) showed reduced mucositis;
Level of Evidence: II further trials are underway231. Another
Grade of Recommendation: B
trial of N-acetylcysteine mouth rinse (RK- breakdown by protecting the DNA. It has
0202) demonstrated reduced mucositis in less systemic effect by topical application
head and neck cancer patients231. and has been noted to reduce the
amount of desquamation in some cases.
Kamillosan liquidum oral rinse is also used
It has also been claimed to reduce the
in preventing or reducing the intensity of
pain and the inflammation, and to heal
mucositis in patients with head and neck
the ulcer within 5-15 days.
cancer receiving radiation and
chemotherapy. Kamillosan liquidum Usage of granulocyte colony-stimulating
solution is prepared from the flower of the factor (G-CSF) 58-63, a hematopoietic
chamomile plant. Kamillosan solution has growth factor, reduces the severity and
an anti-inflammatory action and duration of chemotherapy-induced
appears to accelerate re-epithelialization neutropenia. It has been suggested that
of desquamated tissue. reduced neutropenia is associated with
less severe mucositis, but research results
Prostaglandin E (PGE2) 55-57 also has been
have been conflicting on the value of G-
given to patients in lozenge form to
CSF for treatment or prevention of oral
protect the oral mucosa from injury. It is
mucositis.
proposed that PGE2 reduces cell
Table 7.2: Agents for Mucositis Management (Stepped Approach)

1. Mucosal Coating Alumina suspension (AmphojelTM)- constipating effects
Agents Magnesia Suspension (Milk of MagnesiaTM)- laxative effects
Alumina and Magnesia Suspension (MaaloxTM)- balanced bowel effects
Attapulgite suspension (KaopectateTM)- mild constipating effects
• May use 5-10mL 4-6 times daily to coat the mucosal surfaces
2. Water-Soluble Artificial Saliva (e.g. Moi-Stir™, Salivart™)- 1-2 mL PRN
Lubricating Agents OraBase™
3. Topical Analgesics/ Benzydamine topical rinse (e.g. Tantum™)- No effect on gag reflex
Anti-inflammatory • Rinse mouth with 10-15 mL q 4-6 hours; swish around mouth and spit out
Agents • May have a drying effect (from alcohol in formulation)
May consider systemic analgesics (e.g. Acetaminophen) or non-steroidal
anti-inflammatories (e.g. ibuprofen, naproxen)- unless contraindicated for
patients at risk of febrile neutropenia
4. Topical Anesthetics/ Lidocaine: Viscous, Ointment, Sprays (e.g. Xylocaine™)- Xylocaine Viscous is
Pain Relief a thick paste, most patients dislike the sensation of this viscous product
Mouthwash • Swish and swallow slowly or spit out of mouth 5-10 mL q4h PRN; may inhibit
Formulations gag reflex- do not eat or drink for at least 30 minutes after dose
• Anesthetic effects occur in 5 minutes and last 20-30 minutes
Diphenhydramine liquid (e.g. Benadryl™)- may cause sensitization of the
mucosal tissue; used in patients who cannot tolerate other anesthetics
• Swish and swallow 5-10 mL q4h PRN; Use non-alcoholic liquid formulation
• Lidocaine and/or Diphenhydramine are components of the Pain Relief
Mouthwash formulations
5. Systemic Opioid Drugs: Oral, IV Bolus Morphine or Hydromorphone
Analgesics Continuous infusion, PCA dosing of Morphine or Hydromorphone for severe
pain- Use according to institutional policy
TM
6. Cellulose Film- Film-forming Agents (e.g. Film-forming Hydroxypropylcellulose [Gelclair ],
forming Agents when available in Canada; or other available products)
Figure 7.1 Prevention & Management of Oral Complications
in Low Risk Patients
LOW RISK (10%)
Patients treated with Adjuvant/Palliative Chemotherapy
SCREENING
Screen each patient with Stomatitis Staging System (SSS) scale
Pre-treatment Dental Exam recommended
PREVENTION
Prevention Use Basic Mouth Care Plan: (See Table 6.1)
Oral cryotherapy (ice chips) • Drink plenty of fluids (2L/day)
for 30 minutes, beginning 5 Follow oral care Recommendations of Dentist
minutes prior to 5-Fluorouracil • Dentist may order Chlorhexidine for dental caries
administration prevention when there is no mucositis
Patient Education on mouth care and how to manage oral complications from
cancer therapy
ASSESSMENT
If mucositis or other oral complications are identified from routine
screening, and become a focus of care, assess with the SSS scale and
other sections on the Mouth Care Record until symptoms resolved
MANAGEMENT
Stepped Approach for Management
1. Mucosal coating agent (i.e. attapulgite [KaopectateTM] May add oral
antacid suspensions)- to provide a temporary physical Fluconazole for
barrier prevention or
• Do NOT use Chlorhexidine if there is mucositis treatment of oral
fungal infection
2. Water-soluble lubricating agents (e.g. artificial saliva, KY
Jelly, OraBase)- to moisten the mucosa
3. Topical analgesic (i.e. benzydamine)- to reduce pain by
anti-inflammatory effect
4. Topical anesthetics (e.g. lidocaine)- to reduce pain by
numbing the mouth
• May use Pain Relief Mouthwash if needed for oral pain
(combination of mucosal coating agent and topical
anesthetic) See Table 7.4
5. Systemic analgesics (oral, IV bolus morphine or
hydromorphone) for severe pain
Oral Infection Oral Hemorrhage:

• See Table 7.6 • Treat with ice water and local pressure
in Intermediate Risk Patients
INTERMEDIATE RISK (40%)
Patients treated with primary chemotherapy (e.g. Hematologic
Malignancies) and some Gastrointestinal Cancer Chemotherapy
SCREENING
Screen each patient with Stomatitis Staging System (SSS) scale
Pre-treatment Dental Exam required
PREVENTION
Prevention Basic Mouth Care Plan: (Table 6.1)
Oral cryotherapy (ice chips) for 30
• Drink plenty of fluids (2L/day)
minutes, beginning 5 minutes prior to 5-
Follow oral care Recommendations of
Fluorouracil administration (unless
Dentist
Oxaliplatin will also be given)
• Dentist may order Chlorhexidine for
Patient Education on mouth care and
dental caries prevention when there is
how to manage oral complications from
no mucositis
cancer therapy
ASSESSMENT
If mucositis or other oral complications are identified from routine screening,
and become a focus of care, assess with the SSS scale and other sections on
the Mouth Care Record until symptoms resolved
MANAGEMENT
• Increase to Intensified Mouth Care Plan if stomatitis worsens
• Continue flossing unless bleeding (> 2 minutes)
• Brush teeth gently with ultra soft toothbrush
• Use mouth rinse solution q1-2hr (q4h during the night)
• Referral to dietitian for any nutritional problems
• Add antibiotics or other treatments as needed for additional symptoms
Stepped Approach for Management – below (see Low Risk)
1. Mucosal coating agent (i.e. attapulgite [KaopectateTM]
antacid suspensions)
• Do NOT use Chlorhexidine if there is mucositis
2. Water-soluble lubricating agents (e.g. artificial saliva, KY
Jelly, OraBase)
3. Topical analgesic (i.e. benzydamine)
4. Topical anesthetic (i.e. lidocaine)
• May use Pain Relief Mouthwash if needed for oral pain (Table 7.4)
5. Systemic opioid analgesics (oral, IV bolus morphine or
hydromorphone) for severe pain
May add oral Fluconazole for prevention

or treatment of oral fungal infection
in Head & Neck Cancer (High Risk) Patients
SCREENING
Assess each patient with M outh Care Record from beginning of
treatm ent until all sym ptom s are resolved (no longer a focus of care)
Com prehensive dental exam before treatm ent
• Prosthodontic care prior to radiotherapy to oral cavity
• Elim inate oral disease before treatm ent (e.g. dental extraction of high-
risk dentition) for radiotherapy patients
PREVENTION
Prevention- Patients on Radiotherapy
• Topical application of benzydam ine Use Intensified M outh Care Plan: (Table 6.2)
solution • Drink plenty of fluids (2L/day)
• Consider use of m idline radiation blocks/ • Oral Fluconazole for prevention of
3-D radiotherapy treatm ent candidiasis
• Do NOT use acyclovir for m ucositis Follow oral care Recom m endations of
prevention Dentist
• Do NOT use chlorhexidine , sucralfate, • Dentist m ay order Chlorhexidine for dental
acyclovir, or antim icrobial lozenges to caries prevention when there is no
prevent m ucositis m ucositis
Patient Education on m outh care and how to m anage oral com plications from cancer
therapy
M ANAGEM ENT
Stepped Approach for M anagem ent
1. M ucosal coating agent (i.e. attapulgite [Kaopectate TM ] antacid suspensions)
• Do NOT use Chlorhexidine if there is m ucositis
2. W ater-soluble lubricating agents (e.g. artificial saliva, KY Jelly, OraBase)
3. Topical analgesic (i.e. benzydam ine)
4. Topical anesthetics (e.g. lidocaine)
• M ay use Pain Relief M outhwash if needed for oral pain (Table 7.4)
5. System ic opioid analgesics (oral, IV bolus m orphine or
hydrom orphone) for severe pain
Xerostom ia M anagem ent for Head & Neck Radiotherapy Patients:

• Frequent sips of water • Ice chips
• Oral pilocarpine (5m g BID to TID) • Artificial saliva, as tolerated
Oral Hem orrhage:
• Treat with ice water and local pressure
Oral Infection
• Use appropriate antibiotic
• For candida use oral Fluconazole (or another azole antifungal agent) for
prevention or treatm ent
• If Nystatin suspension used for treatm ent, give this after topical analgesic or
anesthetic for treatm ent of oral fungal infection- Swish and swallow
• See Table 7.6
May be duplicated for use in clinical practice. As appears in: Broadfield L, Hamilton J., Best Practice Guidelines for the
in Hematopoietic Stem Cell Transplant (High Risk) Patients
SCREENING
Assess each patient w ith M outh C are Record from beginning of
treatm ent until all sym ptom s are resolved (no longer a focus of care)
Com prehensive dental exam before treatm ent
• Prosthodontic care prior to radiotherapy to oral cavity (i.e. TBI patients)
• Elim inate oral disease before treatm ent (e.g. dental extraction of high-
risk dentition)
PREVENTIO N
Prevention- Stem C ell Transplant Patients
• O ral cryotherapy (ice chips) for 30
Use Intensified M outh C are Plan: (Table 6.2)
m inutes beginning 5 m inutes prior to high
dose M elphalan chem otherapy (if this is • Drink plenty of fluids (2L/day)
part of the HSC T conditioning regim en) • O ral Fluconazole for prevention of
• Paliferm in 60 m cg/Kg daily for 3 days candidiasis
prior to and 3 days follow ing stem cell Follow oral care Recom m endations of
transplantation (w hen available in Dentist
C anada ) • Dentist m ay order C hlorhexidine for dental
• Do NO T use pentoxyfylline or acyclovir to caries prevention w hen there is no
prevent m ucositis m ucositis
Patient Education on m outh care and how to m anage oral com plications from cancer
therapy
M ANAG EM ENT
Stepped Approach for M anagem ent
1. M ucosal coating agent (i.e. attapulgite [Kaopectate TM ] antacid suspensions)
• Do NOT use Chlorhexidine if there is m ucositis
2. W ater-soluble lubricating agents (e.g. artificial saliva , KY Jelly, O raBase)
3. Topical analgesic (benzydam ine)
4. Topical anesthetics (i.e. lidocaine)
• M ay use Pain Relief M outhw ash if needed for oral pain (Table 7.4)
5. System ic opioid analgesics (oral, IV bolus, continuous IV infusion or
PC A m orphine or hydrom orphone) for severe pain
O ral Hem orrhage:

• Treat w ith ice w ater and local pressure
O ral Infection
• Use appropriate antibiotic
• For candida m ay use oral Fluconazole for prevention or treatm ent
• If oral azole antifungals are contraindicated , Nystatin suspension m ay be used for
treatm ent, give this at least 30 m inutes after topical analgesic or anesthetic for
treatm ent of oral fungal infection- Sw ish and sw allow
• See Table 7.6
7.2.2 Management of Mucositis provide a more permanent barrier for
Symptoms severe mucositis
Products used for the “stepped”
Patients with oral mucositis require
approach, and other agents used for
appropriate therapeutic intervention(s) to
management of mucositis are listed in
manage the symptoms and prevent
Table 7.2. It may be better to manage
symptom progression. It is suggested to
mucositis using the “stepped” approach
use the “stepped” approach for mucositis
than to begin with a compounded
management, adding agents as
therapeutic mouthwash, holding the
symptoms present.
topical anesthetic until there is pain.
If patients develop oral mucositis, they will
7.2.3.2 Chlorhexidine
require appropriate therapeutic
intervention(s) to manage the symptoms
Chlorhexidine should not be used to
and prevent symptom progression. Once
treat established oral mucositis.
mucositis has developed, its severity and
Level of Evidence: II
the degree of myelosuppression govern
appropriate oral management.
7.2.3.2 Management of Severe Mucositis
Meticulous oral hygiene and treatment of
Symptoms
symptoms are essential. A stepped
Oral mucositis may be much more severe
approach may be used, with progression
for high-risk treatment patients, and they
from one level to the next as follows:
may be admitted to hospital for
1. Mucosal coating agents (e.g., antacid
management of pain and other toxicities.
solutions, kaolin solutions)- to provide a
If oral mucositis becomes severe, there is
temporary physical barrier
an increased risk of aspiration of saliva. To
2. Water-soluble lubricating agents,
prevent aspiration, a simple precaution is
including artificial saliva for
to raise the head of the bed to at least 30
xerostomia- to moisten the mucosa
degrees. Keep an emergency airway at
(Note. Oral Pilocarpine may also be
the bedside. Keep tonsil suction at the
indicated to stimulate residual salivary
bedside for suctioning saliva, if the patient
function after radiation therapy)
is unable to swallow easily (if patient is not
3. Topical analgesics (e.g. benzydamine
TM thrombocytopenic or neutropenic). If
[Tantum ] solution- to reduce pain by
unable to use suction, put the patient on
anti-inflammatory effect)
their side so that saliva can drain out of
4. Topical anesthetics (e.g., viscous
the mouth. Ensure adequate humidity.
lidocaine, benzocaine sprays/gels,
Involve respiratory experts as soon as
diphenhydramine solutions)- to
possible.
reduce pain by numbing the mouth
• In common practice, therapeutic
(anesthetic) mouthwashes (section
7.4.2) are often added to the mouth
care regimen when the oral mucosa
becomes painful.
5. Systemic analgesics for severe pain
6. Cellulose film-forming agents for
covering localized ulcerative lesions
(e.g., hydroxylpropyl cellulose)- to
7.3 Xerostomia saliva barrier. Discomfort, difficulty in
swallowing, mastication and speaking,
7.3.1Salivary Gland Dysfunction and
loss or alteration of taste sensation, may
Xerostomia
lead to anorexia, loss of weight, and
The mouth is lubricated by exocrine
cachexia.
secretions from the major salivary glands
(the parotid, submandibular and Xerostomia promotes the accumulation
sublingual glands) together with of bacteria, plaque, and materia alba,
secretions from numerous smaller glands which increases the patient susceptibility
spread over the surface of the palate to caries and periodontal disease.
and tongue, and inside the lips. The Xerostomia is one of the most frequent
smaller glands secrete saliva in response side effects of cancer therapy.70 It results
to local mechanical stimuli and, unlike from inflammatory and degenerative
the major glands, are not under effects of ionizing radiation on salivary
parasympathetic control. The major gland parenchyma, especially serous
glands are stimulated by a conditioned acinar cells. Salivary flow decreases
reflex fired by the thought, sight or smell within 1 week after starting radiation
of food. Saliva contains two major treatment and diminishes progressively
secretions- a serous fluid, containing with continued treatment. The degree of
bacteriocidal components dysfunction is related to the radiation
(e.g.thiocyanate), proteolytic enzymes dose and volume of glandular tissue in
(e.g.lysosyme) and antibodies, notably the radiation field. Parotid glands may be
IgA, together with alpha-amylase, an more susceptible to radiation effects than
enzyme acting on starch; and mucus, submandibular, sublingual, and other
which functions as a lubricant. minor salivary glandular tissues. Salivary
gland tissues that have been excluded
Saliva is important for maintaining oral
from the radiation portal may become
health and function. It dilutes food,
hyperplastic, partially compensating for
lubricates the oral cavity, buffers and
the nonfunctional glands at other oral
dilutes acids produced by fermentation
sites.
and continuously washes food particles
and organisms from the oral cavity. When Cancer chemotherapy can cause
salivary function is reduced or even changes in salivation, but the changes
destroyed, the quantity of saliva is are usually much less severe and only
decreased and its chemical composition transient. Although only a small number
altered.64-67 The saliva becomes viscous of chemotherapeutic agents cause
losing its lubricating qualities. It adheres to xerostomia (doxorubicin in particular), its
the membranes and teeth and the effect may be devastating when it
mouth becomes dehydrated. occurs in conjunction with existing
mucositis.
Xerostomia, which is caused by changes
in the salivary glands, is the subjective Some psychotropic and sedative drugs
sensation of dryness in the mouth. 68,69 It induce xerostomia through
may cause an oral burning sensation, parasympatolytic effects. Treatment with
ulceration, or soreness. The corners of the antidepressants and phenothiazines, for
mouth can become fissured, and the example, has been associated with
tongue may become red and smooth. xerostomia complicated by oral
These consequences are due to both the moniliasis.71
diminished lubrication and the lack of
76
Table 7.3 Management of the Xerostomic Patient
Plaque Removal Tooth Brushing
Flossing
Other Oral Hygiene Aids
Remineralization Topical High Concentration Fluorides
Children: Topical and Systemic
Adults: Topical
Remineralizing Solutions
Antimicrobials Chlorhexidine Solutions (rinses)
Povidone Iodine Oral Rinses
Tetracycline Oral Rinses
Sialogogues Pilocarpine
Bethanechol
Antholetrithione (SialorTM)
7.3.2 Xerostomia Management line with those of Regnard et al.,75 who

Guideline Statement: Patients at risk of supported the use of semifrozen tonic
xerostomia may be managed by water and gin, semifrozen juice, frequent
preventative measures. If xerostomia sips of cold water, or sprays and
occurs in patients receiving radiotherapy petroleum jelly. No scientific rationale is
to the head and neck, oral pilocarpine given for these recommendations, but
should be considered for systemic most are reasonable strategies. it may
therapy. If the xerostomia is caused by also help to eat puddings or foods with
chemotherapy or other toxic stimuli, oral sauces and gravies. Patients should
pilocarpine may be considered. Artificial avoid tobacco and alcohol (e.g. gin)
saliva products may also be considered, because of their potential to dry and
for a brief course to determine irritate the oral mucosa.
effectiveness and patient acceptability,
Patients who experience xerostomia
followed by continuing therapy when
should maintain excellent oral hygiene to
warranted.
minimize risk for oral lesions. Periodontal
Xerostomia may be temporarily relieved disease can be accelerated and caries
by rinsing with a mouth rinsing solution can become rampant unless preventive
(e.g. normal saline) or by using an measures are instituted. Multiple
artificial saliva substitute. 72,73 These preventive strategies should be
solutions are helpful in keeping the oral considered (Table 7.3); an example of a
mucosa moist and free of debris and in protocol is listed below.
thining secretions. Frequent sips of water, • Perform systematic oral hygiene at
and the use of an air humidifier may also least 4 times per day (after meals and
help to minimize dry oral mucosa. before retiring at night).
• Use a fluoridated toothpaste when
On the basis of clinical practice,
brushing.
Krishnasamy74 recommended sucking or
• Apply a prescription-strength fluoride
chewing small pieces of fresh pineapple
gel daily at bedtime to cleaned teeth
cubes, sugar-free chewing gum, jelly,
(fluoride is ineffective on plaque-
hard candies or popsicles for the
coated teeth).
treatment of a dry mouth in advanced
• If provided through the dentist, a
cancer. These recommendations are in
custom fitted flouride tray may be properties, and they also attack enamel
used. and decalcify teeth. 83
• Avoid foods and liquids with a high
7.3.4.4 Saliva stimulants
sugar content.
Guideline Recommendation: Patients
7.3.3 Saliva substitutes with radiation-induced xerostomia should
The discomfort of xerostomia may be be considered for treatment with oral
treated by indirect and simple measures, pilocarpine.
using saliva substitutes, for example. The Level of Evidence: II
84
use of saliva substitute before meals and Grade of Recommendation: B
conversations may help to reduce the
Saliva stimulants can be used to reduce
embarrassment caused by associated
the discomfort of xerostomia. These
speech and eating problems.
agents fall into two categories:
These artificial substances physically 1) Agents which stimulate the
resemble saliva but do not provide the proprioceptive receptors within and
antibacterial and immunological around the oral cavity (eg, organic
protection of saliva.76 acids or chewing gum),
2) Agents which act directly on
“Artificial” salivas can maintain oral
parasympathetic nerves (eg,
comfort and may be used as often as
pilocarpine)83
necessary. The volume used should be
the minimum needed to maintain internal Saliva stimulants include citric acid 78;
lubrication; excessive quantities simply malic acid, which occurs in fruit or vitamin
serve to enhance discomfort. One to two C which is often used in palliative care
millilitres will often maintain lubrication up settings,78 although little evidence exists to
to 12 hours. support its use. 75,78
Artificial salivas usually are not associated Pilocarpine is the only drug approved for
with systemic side effects.77 These use as a sialogogue (5 mg tablets of
products’ effects are of limited duration, pilocarpine hydrochloride). It is a
may have an unpleasant taste, may parasympathomimetic agent used as a
irritate the mucosa and are expensive. systemic agent to stimulate remaining
salivary gland function in patients
Artificial salivas 78 most commonly
following radiation therapy. A number of
prescribed are based on either mucin or
79 studies have supported its use in the
carboxymethylcellulose. Mucin-based
treatment of both non-radiation- and
artificial salivas are reported to be better
radiation-induced xerostomia. 80-85 The
tolerated, because mucin is a natural
response to pilocarpine appears to be
component of saliva.77
better for non-radiation-induced
Lemon and glycerine have been xerostomia, in which its action is almost
recommended historically as saliva always immediate,81 It may take as long
substitutes. 80 Lemon juice increases as 12 weeks to detect a response in
salivation, and glycerine absorbs water, radiation-induced xerostomia.82 As
so their combination actually acts to dry compared with artificial saliva,
the mouth.81 Although their use offers pilocarpine is found to be more effective
initial stimulation of saliva, this quickly in patients with radiation-induced
results in reflex exhaustion. 82 They xerostomia.86
demonstrate no mechanical or cleaning
Treatment is initiated at 5 mg orally, 3 7.4 Oral Pain
times daily; dose is then titrated up to 10 Many oral complications are associated
mg TID to achieve optimal clinical with pain, both local and systemic. The
response and minimize adverse effects. underlying mechanisms of mucositis (see
Some patients may experience increased Part 2.2) include ulceration, inflammation
benefit at higher daily doses; however, and the release of various cytokines, all of
incidence of adverse effects increases which are associated with local pain. In
proportionally with dose. The patient’s addition, pain may also be associated
evening dose may be increased to 10 with the cancer. Pain can be a serious
mg within 1 week after starting impediment to proper mouth care,
pilocarpine. Subsequently, morning and eating and drinking, and quality of life for
afternoon doses may also be increased the patient. Pain sensations may range
to a maximum 10 mg/dose (30 mg/day). from mild to severe, with debilitating pain
in many patients who receive bone
Patient tolerance of the side effects is
marrow/stem cell transplantation
improved by allowing 7 days between
procedures or radiation therapy to the
increments. Side effects are associated
head and neck.
with generalized parasympathetic
stimulation such as sweating, headache, Pain management may be local,
increased lacrimation, rhinorrhea, systemic, or both. Severe pain may
bradycardia, hypertension and urinary require parenteral opioid therapy during
frequency, and incidence appears to be the maximum period of mouth pain. Pain
dose-related. Sweating is the most may be managed by the use of topical
common side effect, and the most analgesics to reduce somatic pain, or
frequent reason given for discontinuing topical anesthetics to numb the painful
treatment. tissues. Other patients require less strong
measures. In addition to mucositis, pain is
Pilocarpine usually increases salivary flow
exacerbated by oral infections,
within 30 minutes after ingestion. Maximal
xerostomia or pre-existing oral disease.
response may occur only after continual
Management of the infection or other co-
use. Pilocarpine may exert a
morbid condition may reduce pain for
radioprotective effect on salivary glands
many patients.
if given during radiation therapy to the
head and neck. Oral pain may be associated with
malnutrition. Patients are usually unwilling
Another agent used to treat xerostomia is
or unable to eat or drink when they have
antholetrithione. Antholetrithione, a
severe mouth pain. Nutrition deficits can
sialogogue, may act directly on the
further exacerbate oral complications
secretory cells of the salivary glands,
and result in a series of problems, which
resulting in increased salivary secretion.
further compound each other.
Interestingly, studies considering patient
7.4.1 Oral Pain Management
preference in relation to saliva substitutes
and stimulants have established that
Patients who experience oral pain, alone
patients prefer saliva stimulants. 87,88
or in combination with other oral
complications, may be treated with
coating suspensions, topical analgesic
solutions, topical anesthetics or pain relief
mouthwash suspensions, and systemic
analgesics (for increasing severity of the reasons:
pain). Clinicians should only use the • Topical non-absorbable antifungals
institutional standard(s) for pain relief (e.g. Nystatin) are not effective for
mouthwash formulations. prevention and less effective than oral
absorbable antifungals (e.g.
For patients with localized areas of oral
fluconazole) for treatment of
pain, focal application of a topical
candidiasis
anesthetic agent is preferred. If the pain
• The mucositis symptoms may not occur
is throughout the oral cavity, the patient
over the same time interval as any oral
may require more widespread
infection
application. These agents have a 5-
• Addition of several agents may result
minute onset of action and a duration of
in an unstable compound
less than one hour. Products such as 2%
• Usually, it is important to manage the
viscous lidocaine, diphenhydramine
oral pain before any other product is
solution may be absorbed systemically
used in the mouth, so analgesia or
and cause adverse side effects including
anesthesia should be achieved first.
hypertension, hypotension, bradycardia,
Then the nystatin suspension may be
tachycardia, electrocardiographic
held in the oral cavity for a longer
changes, and central nervous system
exposure time and swallowed to coat
depression.
the entire throat (anesthetic
Some commercial products are used as compounds must be spit out- not
topical analgesics (e.g. benzydamine swallowed)
89-91
solution ) or topical anesthetics (e.g.
Mixtures of topical anesthetics, analgesic
diphenhydramine suspension). These
agents, and antacids also are used to
may reduce inflammation or cause mild
decrease oral pain and discomfort.
numbing effect, without suppression of
Systemic nonsteroidal anti-inflammatory
the gag reflex.
drugs that effect platelet adhesion and
Many extemporaneously prepared damage gastric mucosa should not be
mixtures incorporate a coating agent used if thrombocytopenia is present.
such as milk of magnesia, attapulgite
Capsaicin preparations may be effective
(kaolin with pectin) suspension, mixtures
in controlling oral mucositis pain.92-95
of aluminum, and/or magnesium
Capsaicin and its analogues are the
hydroxide suspensions (many antacids)
active ingredients in chili peppers that
combined with a topical anesthetic
produce burning pain by stimulating
agent to provide relief. (See Pain Relief
polymodal nociceptors, the predominant
Mouthwashes, Part 7.4.2). The choice of
pain receptors found in skin and mucous
coating agent should take into
membranes. It has been demonstrated
consideration the laxative or constipating
experimentally that after ingesting
effects of different antacids. The purpose
capsaicin-containing foods or after
of a combined product is to simplify
capsaicin application to the oral mucosa,
administration when multiple agents are
severity of pain is directly proportional to
needed in the ‘stepped approach’ for
concentration of capsaicin present.
managing oral stomatitis symptoms (see
Capsaicin’s clinical potential derives from
Part 7.2.2). Other agents, such as nystatin
the fact that it elevates the threshold for
for oral candidiasis are NOT
pain in areas to which it is applied. The
recommended for inclusion in
pain threshold can be further elevated
compounded products, for a number of
Table 7.4 Pain Relief Mouthwash Formulations 99
Pain Relief Mouthwash with Attapulgite (Kaopectate™) Mild constipating effect
• Diphenhydramine 6.25mg/5 mL (Benadryl™) liquid 50 mL
• Lidocaine (Xylocaine™) viscous 2% 25 mL
• Attapulgite (Kaopectate™) suspension 25 mL
TOTAL VOLUME 100 mL
• After brushing teeth and rinsing mouth, swish 10-15mL for up to 2 minutes, then spit out
or swallow slowly. Repeat TID-QID PRN. Avoid putting anything in the mouth
(including medications) for 30 minutes, especially if mouthwash swallowed.
• Lidocaine may inhibit gag reflex. Systemic absorption of swallowed lidocaine may
be contraindicated in patients with impaired cardiovascular function. Do not give
more than 6 times daily. If this is a problem, order Pain Relief without Lidocaine.
• Duration of action of lidocaine about 30-60 minutes.
• In Capital Health: If the order reads “Magic Mouthwash”, Pharmacy will
automatically substitute Pain Relief Mouthwash with Attapulgite.
Pain Relief Mouthwash with Antacid Balanced effect on the bowels
• Lidocaine (Xylocaine™) viscous 2% 25 mL
• Magnesia-Alumina Concentrate Suspension (Maalox TC™) 75 mL
TOTAL VOLUME 150 mL
• After brushing teeth and rinsing mouth, swish 10-15mL for up to 2 minutes, then spit out
or swallow slowly. Repeat TID-QID PRN. Avoid putting anything in the mouth
(including medications) for 30 minutes, especially if mouthwash swallowed.
• Lidocaine may inhibit gag reflex. Systemic absorption of swallowed lidocaine may
be contraindicated in patients with impaired cardiovascular function. Do not give
more than 6 times daily. If this is a problem, order Pain Relief without Lidocaine.
• Duration of action of lidocaine about 30-60 minutes.
Pain Relief Mouthwash without Lidocaine Mild constipating effect
• Attapulgite (Kaopectate™) suspension 50 mL
TOTAL VOLUME 100 mL
• After brushing teeth and rinsing mouth, swish 10-15 mL for 2 minutes, then swallow.
Repeat TID-QID PRN. Do not put anything (except water) in the mouth for 30 minutes
after treatment.
• Administer Pain Relief Mouthwash before any other medications and wait 30 minutes
before administering.
• Used for patients who cannot tolerate lidocaine anesthetic.
• Diphenhydramine may cause sensitization of the oral tissues.
NOTE: Oral fluconazole is recommended as first choice for prevention or treatment of
oral candidiasis. Mouthwash formulations that include Nystatin suspension are not
covered by public prescription insurance plans (e.g. Pharmacare). If oral azole
antifungal agents are contraindicated and Nystatin is needed for oral candidiasis, it
may be given 30 minutes AFTER the appropriate Pain Relief Mouthwash has been
used, both to reduce pain from active swishing of Nystatin around the mouth, and to
allow the Nystatin to be swallowed (to coat the back of the throat)
96-98
by gradually increasing the capsaicin anesthetic agent . Mucosal coating
concentration in a series of repeated agents may help to thicken the
applications. This approach to mucositis formulation so that anaesthetic agents
pain control is not convenient and some adhere more effectively to mucous
patients are clearly not candidates for its membranes. They also improve
use. Thus far, evidence that capsaicin palatability.
produces symptomatic relief for mucositis
Since each prescriber may have unique
pain is encouraging but limited to
personal preferences, the number of
anecdotal reports and a small case
formulations may become confusing at
series. It is not yet known what effects
institutions with major oncology programs.
capsaicin may have on compromised
Many of these formulations are
human gastrointestinal mucosa at doses
euphemistically titled as “Magic
and durations that may be useful in
Mouthwash”, “Miracle Mouthwash” or
treating mucositis. Further evaluation is
similar names. It is not uncommon to
warranted.
have several “Magic Mouthwash”
Pain associated with clenching or bruxism formulations on record at the same time,
(i.e. grinding the teeth) may be leading to confusion by many health
eliminated by calling it to the attention of care professionals. Often the empiric
the patient and by the use of a bite formulation may include Nystatin, other
guard fabricated by a dental antibiotics or other ingredients. These
professional. agents are not recommended for
mucositis prevention (Section 7.2.1.5) or
7.4.2 Pain Relief Mouthwashes
infection prophylaxis (Section 7.5.1), so
these agents should not be included in
An analgesic or anesthetic mouthwash
mouthwash formulations.
should be considered for management
of patients with oral pain. For ease of To eliminate the potential confusion, it is
administration, multiple components may advised for institutions to limit the number
be compounded together into a pain of formulations, and to use descriptive
relief mouthwash preparation. The names rather than fanciful titles.
appropriate compounded mouthwash Formulations should not contain more
preparation should be incorporated into than one drug from the same
the oral care procedures. therapeutic classification, and should
keep the ingredient list to the minimum of
Compounded preparations should not
items specifically needed to manage oral
include more than one agent from the
stomatitis and pain.
same therapeutic classification. An
institution should limit the selection of At the QEII Health Sciences Centre, 3
compounded pain relief mouthwash standard formulations have been
preparations to two or three standard developed for pain relief mouthwashes.99
formulae. Additional formulations are discouraged,
to avoid excessive formulation
In many institutions, a variety of empiric
complications and confusion. The
preparations have been formulated to
standard formulations are described in
prevent and/or treat symptoms of
Table 7.4.
stomatitis. Formulations vary, but typically
include a coating agent with a topical
7.4.3 Management of Severe Oral Pain Infections of the oral cavity may arise
Guideline Recommendation: from previous commensal organisms or
Hematopoietic stem cell transplant (HSCT) from introduced pathogens. The major
patients should be offered patient- pathogens involved in infections
controlled analgesia with morphine (or occurring in the mouth include gram-
other strong opiate) to manage severe negative bacteria, candida and herpes
oral pain. viruses. These organisms acquire the
Level of Evidence: I ability to cause both oral and systemic
Grade of Recommendation: A infection because of disruptions of the
skin and mucosa. 109
Systemic analgesics such as
acetaminophen and codeine may be Factors that influence the initiation,
administered when topical anesthetic development, and severity of an
strategies are not sufficient for clinical infection include the host’s primary
relief. Acetaminophen elixir can be physical barriers against invasions, the
swished in the mouth and then swallowed ability of the organism to destroy the
for local and systemic relief of pain. Oral host’s defenses 110, the manner in which
medications should be administered 60 to the organisms spread and causes
90 minutes before meals to maximize pain disease, and the ability of the body to
relief. When pain is severe, opioids may be control and eliminate invading
needed. Opiates such as morphine have organisms. Adherence to a prospective
been effective in relieving severe and mouth care plan (see below) is believed
transient pain associated with oral to reduce the potential for infections in
complications.100 The combination of the oral cavity.
tunnelled indwelling venous catheters and
Neutrophils are an important factor
computerized drug administration pumps
associated with infection in the
to provide patient-controlled analgesia
immunocompromised patient and act as
(PCA) has significantly increased the
the body’s first line of defense once
effectiveness of controlling severe
microbial invasion has occurred. In
mucositis pain while lowering the dose
patients with cancer, the signs and
and side effects of opioid analgesics (see
symptoms of infection may be less
Appendix IV).101 For some patient
pronounced if the patient is neutropenic.
populations, where there is intense oral
pain for a relatively short period of time, Factors increasing the risk of infection in
and the patients are dealing with a cancer patients
variety of complex care needs (i.e. • Intrinsic immune deficiencies
hematopoietic stem cell transplant), it • Malignancy-induced hemopoietic
may be more appropriate to provide and immune deficiencies
continuous intravenous or subcutaneous • Chemotherapy-induced
infusion of opioid. myelosuppression or
immunosuppression
7.5 Oral Infection 102-106
• Other immunosuppressant drugs (e.g.
Following cytotoxic therapy, the
prednisone)
pathogenicity of the oral flora is likely to
• Obstruction of the lymphatic system
increase. Generally, more intense
• Drug therapy which encourages
cytotoxic therapy is associated with more
growth of resistant pathogens
common oral infection complications.107-109
• Tumour necrosis
• Generalized physical debilitation
• Nosocomial infection 0.12% oral rinse may be used alone or in
• Inadequate hygiene conjunction with other prophylactic
• Nutritional deficiency topical and systemic antibiotics in the
high-risk patient populations. Several
7.5.1 Infection Prevention
studies have found products containing
chlorhexidine 111-115 to have antibacterial
Treatment with prophylactic antibiotic
effects,116 which may exert an
therapy may be considered for patients
antibacterial effect for as long as 12
who are seriously myelosuppressed and/
hours.116 Chlorhexidene is effective
or who have poor oral hygiene, to
against gram-positive and gram-
prevent oral infections. Antibiotic
negative infections, yeast, and fungi, and
prophylaxis may be topical or systemic.
it prevents dental plaque formation. It
Prophylactic use of chlorhexidine to also has the desirable properties of
prevent serious oral infections is not sustained binding to oral surfaces and
recommended for adults. Potential minimal gastrointestinal absorption,
antimicrobial effects are offset by other thereby limiting adverse systemic effects.
adverse effects in patients with oral
Chlorhexidine has been successfully
mucositis. Chlorhexidine may be used for
included in oral care plans for several
prevention of dental caries and plaque,
years. Chlorhexidine is not well tolerated
but should not be used during
by many patients, however, with an
symptomatic episodes of mucositis.
unpleasant taste due to an alcohol
7.5.1.1 Chlorhexidine content of 9.6%.112 Chlorhexidine can
Despite early enthusiasm for the use of cause burning and stinging. Brown
chlorhexidine as prevention or treatment staining of the teeth occurs commonly
of oral mucositis, subsequent clinical trials but can be removed with oxidizing
failed to support initial observations. The agents.116 Chlorhexidine oral rinse may be
detrimental effects of chlorhexidine in used as a mouthwash and gargle, but
treating radiation-induced mucositis, are should not be ingested. Chlorhexidine
exacerbation of pain and irritation as a may exacerbate mouth pain and
result of its astringency. Chlorhexidine is irritation when used to treat radiation-
NOT recommended for prevention or induced mucositis.
treatment of mucositis in adults (see
117 For children, the Atlantic Provinces
section 7.2.1.5). Evidence is lacking to
Pediatric Hematology/Oncology Network
support a recommendation to use
(APPHON)119 recommends the use of an
chlorhexidine specifically for
alcohol-free chlorhexidine solution as a
antimicrobial prophylaxis.
standard antibacterial mouth rinse for
Chlorhexidine is a quaternary ammonium pediatric patients receiving cancer
118
compound with topical antimicrobial treatment . However, the use of some
properties. Chlorhexidine gluconate commercial preparations (e.g. Peridex™,
Table 7.5 Chlorhexidine Mouth Rinse for Pediatric Oncology Patients

Age Volume of Mouth Rinse Interval Options
< 6 years 5 mL Swab mouth or rinse soother or
swish and spit out up to QID
> 6 years 10 mL Swab mouth or swish and spit out
up to QID
Table 7.6 Presentation and Treatment of Oral Infections in Cancer Patients
Oral Infection Appearance and Characteristics Treatment
Fungal Candidiasis Systemic antifungals are usually the drug of choice for
infections Oral candidiasis may have one of several prevention and/or treatment of candidiasis in patients with
including different clinical appearances normal immune function.
• Pseudomembranous candidiasis, also known • Fluconazole 100 mg daily is equal or more effective
as thrush, is the most common form of oral against oropharyngeal candidiasis in cancer patients
candidiasis. It typically appears as white than nystatin or clotrimazole. Prophylactic fluconazole
patches on the surface of the oral mucosa, 100 mg PO daily (400 mg PO daily for HSCT patients) may
and/or tongue, that develop into confluent be considered for prevention of oral candidiasis in
plaques that resemble milk curds and can cancer patients. Maintenance therapy to prevent
be wiped off to reveal a raw erythematous relapse after initial treatment- 50 mg (up to 400 mg) daily.
and sometimes bleeding base which may be • Nystatin suspension 100,000U/mL- Use in patients who
tender. cannot tolerate Fluconazole (or other azole antifungals);
• Chronic hyperplastic candidiasis (or Swish around and hold in the mouth for at least one
candidal leukoplakia) is a less common, minute, then swallow; use 5 mL qid for 7-14 days (works by
asymptomatic form of candidiasis, that direct contact)
appears as a dense, white plaque that is • For children, use 2mL for infants, or 4 to 6 mL for children-
hard and rough to the touch (plaquelike Swish and swallow or swab mouth QID
lesion). Homogeneous or speckled areas, • Nystatin cream to treat dentures
which do not rub off (nodular lesions), can • Nystatin popsicles (for cooling relief)
be seen, usually on the inside surface of one • Clotrimazole oral suspension 1mg/mL- Swish around the
or both cheeks. mouth for one minute and then swallow; use 10 mL qid
• Angular cheilitis (perleche) is a type of • For children, use 3mL if < 1 year, 5mL if 1-3 years, , or
candidiasis that appears as red, eroded, 10mL if > 3 years- Swish and swallow or swab mouth
fissured lesions which occur bilaterally in the
• Clotrimazole troche 10 mg 5 times per day
commissures of the lips and are frequently
irritated and painful.
Periodontitis or gingivitis (oral infections)
Bacterial Eliminate oral sources of bacteremia before
infection usually appear as reddened gums which chemotherapy (consult dentist)
bleed easily on probing. • Assessment and interventions for advanced periodontal
When the natural flora is affected by cancer disease, periapical pathosis
therapy, some of the bacteria may proliferate Broad-spectrum systemic antibiotic therapy (e.g.
and invade the gastrointestinal,
Cloxacillin or cephalexin)
cardiovascular, renal, or respiratory systems,
resulting in systemic infections (such as
bacterial endocarditis or glomerulonephritis). May be duplicated for use in clinical practice. As appears in: Broadfield L,
Hamilton J., Best Practice Guidelines for the Management of Oral
Local infections in the oral cavity may provide Complications from Cancer Therapy. © Cancer Care Nova Scotia, 2006
foci for systemic infection.
Table 7.6 Presentation and Treatment of Oral Infections in Cancer Patients (continued)
Oral Infection Appearance and Characteristics Treatment
Herpes simplex Symptomatic primary infection, with multiple, small, Topical acyclovir- Apply to affected area q3-4h,
clustered vesicles in numerous locations, can occur for a total of 6 times/d, for 7 d; apply a
anywhere in the oral cavity, on the perioral skin, on the sufficient quantity to adequately cover all
lips, or on the pharynx, and can be severe. Extensive lesions
ulceration can make eating painful. Headache, fever, Systemic acyclovir for larger lesions
painful lymphadenopathy, and malaise are common. • Primary HSV: 200 mg q4h PO 5 times/day for 10
Recurrent herpes lesions (or cold sores) occur on days or 500 mg tid PO for 7-10 days (In
keratinized mucosa (usually the lips, attached gingiva, immunocompromised patients, consider 400
and/or the hard palate). Vesicles often break quickly, so mg q4h PO 5 times/day for 10 days)
the lesions may appear as small clustered ulcers. • Recurrent HSV: 200 mg q4h PO 5 times/d for 5 d
Valacyclovir 500 mg BID PO
Varicella-zoster Recurrent varicella (also known as herpes zoster or Acyclovir 400 mg 5 times/day PO for 7-10 days;
shingles) results in a vesicular rash that usually affects a for severe infection, 5 mg (base) per kg body
single dermatome. Inside the oral cavity, this may be weight q8h IV for 5-7 days (administer over at
observed as vesicles or ulcerations that stop sharply at least 1 h); patients with acute or chronic renal
the midline. A prodrome of pain, burning, or itching that impairment may require dose reduction (200
mimics a toothache may occur. After the resolution of mg q12h PO when CrCl 0-10 mL/min)
the rash, postherpetic neuralgia may linger for a month or Valacyclovir 1000 mg TID PO for 7 days (superior
longer, especially in patients who are immunosuppressed. to acyclovir for post-herpetic infections)
Cytomegalovirus CMV infection may cause esophagitis, which is Ganciclovir (individualized dosing)
occasionally accompanied by oral ulcerations or
erythema. Oral ulcerations are clinically nonspecific; a
biopsy is required for definitive diagnosis.
Non-herpes Verruca vulgaris (common warts) in the oral cavity are Laser surgery or cryotherapy to remove oral
virus infections usually sharp-tipped, verrucous, white and elevated with HPV lesions
discrete borders. The lesions most commonly occur on Intralesional injections of Imiquimod (AldaraTM)
the lips, hard palate, or gingiva. Verruca plana is similar may be used for recurrent lesions
but less elevated. Warts are commonly observed on the May be surgically excised
digits of patients with oral infection.
Condyloma acuminata, or genital warts may also affect
May be duplicated for use in clinical practice. As appears in:
the oral mucosa. These lesions are usually cerebriform, Broadfield L, Hamilton J. Best Practice Guidelines for the
pink, and sessile; they occur more commonly on non- Management of Oral Complications from Cancer Therapy. ©
keratinized mucosa than on keratinized mucosa. Cancer Care Nova Scotia, 2006
Pericleanse™) is not recommended, 7.5.3 Fungal infection
121
since these contain local anesthetic Guideline Recommendation :
agents or alcohol. The mouth rinse Patients who are at risk, or who have
solution is dosed as outlined in Table 7.4. been diagnosed with candidiasis (thrush)
should be treated with oral fluconazole
7.5.2 Infection Management
100mg qd (or another oral azole
antifungal agent).
Treatment with appropriate antibiotic
Level of Evidence: I
agents should be considered for patients
with an active oral infection, especially in
patients who are immunosuppressed. Best Practice Statement:
Antibiotic treatment is usually systemic, Oral nystatin suspension or alternate
and the treatment plan should consider forms of nystatin delivery may be
fungal, bacterial and viral opportunistic considered if fluconazole (and other
superinfections. If topical antibiotics are azole antifungal agents) is
used, they must be given in conjunction contraindicated.
with proper oral hygiene as part of the
Fungi can exist in the oral mucosa when
mouth care plan.
the integrity of the mucosa is
Patients with clinically-diagnosed uninterupted and protected by rapid
infections should be treated with the cellular renewal. Disruption in the
appropriate antibiotics for the empiric or integumentary and mucosal barrier,
pathologically-confirmed diagnosis. disease, and immunosupression can lead
Treatments are listed in Table 7.6. For to invasive fungal infections. Candida
patients using a number of oral albicans, which is part of the normal
medications, timing for each agent is gastrointestinal and oral flora in 20 to 50%
important. As a rule, mouth cleansing of the population, is the primary cause of
should be performed first, to remove any opportunistic fungal disease in patients
debris. If a topical anesthetic or who are immuno-compromised. In
analgesic is required (for pain relief), this healthy subjects, candida is typically
should be used next, and no further present as a blastopore; when
applications for about 30 minutes (until pathogenic, it can also exist in a hyphal
pain relief is achieved). The topical form.
antibiotics should be applied last. Since
Under normal conditions, its growth is
these agents work by topical exposure, it
inhibited by other microorganisms
is important to leave the mouth alone for
(Lactilobacillus acidophilus, in particular)
at least 30 minutes, for maximal antibiotic
and by an intact immune system.
effect. The patient should avoid putting
However, in cancer patients, humoral
anything in the mouth, including fluids, for
and cell-mediated immunity, the lines of
this time. It is also important to remove
defense against this infectious organism,
any dentures or other oral prostheses
are depleted.120 There is evidence to
before each session of mouth care, and
support prophylatic antifungal treatment
to disinfect these devices at the same
for HSCT patients, however prophylaxis is
time as the mouth. The patient could
suggested for all patients at high risk of
otherwise re-introduce microbes after
mucositis and may be considered for
topical disinfection of the mouth.
intermediate mucositis risk patients.
7.5.3.1 Candidiasis dyspnea. Azoles act by interfering with
A candida infection is often the cytochrome P 450 (CYP450) enzymes
characterized by white, curd-like in the fungi, so Fluconazole (and other
elevations with a peripheral zone of azoles) interacts with several other drugs
erythema over an inflamed mucosa. through the human CYP450 hepatic
There are other clinical presentations. enzyme system.
Overgrowth of candida causes several
types of lesions, including Ketoconazole is an alternative azole
pseudomembranous candidiasis antifungal agent to consider127-129 ,
(removable white plaques), chronic however, it is rarely used in routine clinical
hyperplastic candidiasis (leukoplekia-like practice. Patients on ketoconazole may
white plaques that do not rub off), and develop nausea and vomiting or
chronic erythematous candidiasis increase in transminase levels (rarely
(patchy or diffuse mucosal erythema). hepatitis).108,136
The variable presentation of this infection Clotrimazole
may complicate diagnosis. Clotrimazole is an effective alternative
122,136-140
The tongue, mucosa, and commissures of antifungal agent. The lozenges are
the lips are most frequently affected. taken five times a day and should be
Once established, C albicans may allowed to dissolve slowly in the mouth.
spread to the esophagus or lungs via Clotrimazole can both prevent and treat
deglutition or droplet aspiration, or candidiasis in the oropharyngeal area
through the hematologic route, and all and taste more pleasant if used in the
organs systems may be affected. Oral same way as the nystatin suppository.
119
candidiasis can occasionally be For pediatric oncology patients ,
refractory to treatment and potentially clotrimazole extemporaneous suspension
lethal. is recommended as the treatment of first
Azole Antifungals choice for uncomplicated oral thrush.
There is clear evidence that prophylactic The IWK uses a suspension formulation
systemic azole antifungals can effectively with 1 mg/ mL, that may be prepared at
reduce overall oral fungal colonization the community pharmacy (if not
levels and reduce the risk of oral available, nystatin suspension may be
candidiasis, with fluconazole being the used). Pediatric dosing guidelines are
agent of choice.121-126 Fluconazole has age-based:
been studied in a range of doses, from 50 • Clotrimazole 3 mg/ 3 mL if < 1 year
mg to 400 mg daily in adults (or 6 mg/Kg • Clotrimazole 5 mg/ 5 mL if 1-3 years
loading dose, then 3 mg/Kg for 2 weeks in • Clotrimazole 10 mg/ 10 mL if > 3 years
children). The indicated dose in adults is Clotrimazole (or Nystatin) suspension
100 mg PO daily. Higher doses (400 mf should be given before Chlorhexidine
PO daily) are used for prophylaxis during mouth rinse.
HSCT and for immunocompromised Side effects may be less frequent than
patients. The drug is available as oral Nystatin, with nausea and anorexia
capsules, oral suspension and injectible reported in 5% to 10% of cases. With
solution. Serious adverse effects include prolonged use, induction of hepatic
some cardiac arrhythmias and enzymes can occur, leading to reduced
hepatotoxicity; less serious adverse effects efficacy. This outcome may be avoided
include headache, rash, nausea, by the use of an intermittent dosing
diarrhea, myelosuppression and schedule.
Nystatin Administration of Topical Antifungals
Research studies utilizing topical non- Patients with superficial candidiasis
absorbable oral antifungal agents should be instructed to:
appear to have variable but low efficacy 1. Remove dentures so there is direct
in treating fungal infection in tissue contact with the medication(s).
immunocompromised patients. Nystatin, 2. Clean the oral cavity prior to
in particular, has been shown to be administering topical antifungal
121
ineffective in prevention of candidiasis . medication; irrigation and plaque
The historic treatment of oral candidiasis removal by tooth brushing may be
was nystatin in the form of a vaginal necessary prior to drug dosing. Rinse
suppository used as a lozenge four times well with rinse solution.
daily. Prolonged contact between the 3. If there is pain, use the topical pain
medication and the infected surface relief analgesic or anesthetic
increases the local effect of the mouthwash and wait 30 minutes
medication. Nystatin suspension130, if before using antifungal.
used, should be swished around the 4. Do not rinse mouth or put anything in
mouth for one minute and then the mouth for 30 minutes after each
swallowed. The nystatin oral suspension dose of topical antifungal.
may be frozen in the form of ice cubes, 5. Clean and disinfect any dentures or
which provide prolonged mucosal dental prosthesis, using the same
contact and taste better. The elevated mouth rinse and topical antifungal as
sugar level contained in this product may used in the mouth. Coat surfaces of
adversely affect the teeth, and the taste denture and contact mouth tissues
is not always well accepted by with antifungal suspension (or cream)
patients.131,132 Several studies have using a sterile swab. If no topical
demonstrated the inability of nystatin antifungal is used, simply clean
suspension to effectively reduce thoroughly and rinse. Store dentures
incidence of either oropharyngeal or or prosthesis in a fresh solution daily.
systemic Candida infections in 6. If xerostomia is present, use a
immunocompromised patients receiving suspension instead of a lozenge/
chemotherapy or radiation. Although vaginal suppository (if a lozenge is
topical antifungal prophylaxis and preferred, the patient should rinse or
treatment may clear superficial drink water prior to dosing).
oropharyngeal infections, topical agents
are not well absorbed through the GI 7.5.3.2 Noncandidal Fungal Infections
tract and are ineffective against more An increasing number of different fungal
deeply invasive fungal infections. The organisms are being associated with oral
practice continues in many centers.133-135 infection in immunocompromised cancer
patients in recent years, and includes
Amphotericin B infection by species of Aspergillus,
In carefully selected and evaluated Mucormycosis, and Rhizopus.146 The
patients in whom the risk/benefit ratio clinical presentation is not athognomonic;
favors the use of a potential toxicity, IV lesions may appear similar to other oral
amphotericin B can be used. It is the toxicities.
preferred drug for treating serious
systemic infections
141-144
; however this Microbiologic documentation is essential.
medication may compromise renal and Systemic antimicrobial therapy must be
liver function, and is associated with instituted promptly due to high risk for
many adverse effects.127,145 morbidity and mortality.
7.5.4 Viral infection 147,148 treated with topical acyclovir. 149,150 With
Herpes group viruses can be associated progressive or larger lesions, measures to
with important oral disease in patients prevent suprainfection and treatment
receiving cancer therapy. 149-152 In most with systemic acyclovir are
instances, herpes simplex virus (HSV), recommended. This drug has few side
varicella zoster virus (VZV), and Epstein effects. Patients should be well-hydrated
Barr virus (EBV) infections result from and the dose may need to be diminished
reactivation of latent virus, while if the creatinine clearance is low.152-155
cytomegalovirus (CMV) infections can Acyclovir reduces viral shedding, pain,
result from either reactivation of latent and healing time. Antiviral therapy
virus, or via a newly acquired virus. should be initiated as soon as possible
following the onset of the symptoms and
Herpes simplex
may be taken for 7-10 days. Care should
Herpes simplex, a recurrent viral infection,
be taken to avoid transmission of the
is characterized by single or multiple
infection to other body sites when
clusters of small vesicles filled with clear
applying the ointment. True resistance to
fluid on a raised inflammatory base that
anti-virals may develop, clinical infection
appears on the skin or mucous
is likely due to insufficient dosing or
membranes. Recurrent herpetic eruptions
compromised gastrointestinal absorption
can be precipitated by febrile illnesses,
of oral acyclovir. Topical therapy alone is
physical or emotional stress, overexposure
generally not efficacious in the
to sunlight, or certain foods and drugs.
immunocompromised patient.
The lesions may appear anywhere on the
mucosa, but oral lesions are seen most Topical, oral, and systemic acyclovir may
frequently on the lips or in the mouth. be used prophylactically to minimize the
Following a short prodrom period of recurrence of HSV in the patient who is
tingling or itching, small vesicles appear severely myelosuppressed. Extraoral HSV
on an erythematous base. The vesicles infections characteristically become
persist for a few days, then begin to dry, infected secondarily.
forming a thin, yellowish crust, that is
Bacitracin (neosporin) ointment helps
easily removed from the mucosa and is
keep viral lesions lubricated and free of
extremely painful. Healing begins 7-10
secondary infections.
days after onset, with lesions varying in
size from 0.5-1.5 cm. Reccurrent lesions at Herpes zoster virus
the same site may cause atrophy and Herpes zoster 149 (or varicella zoster) is a
scarring. painful, unilateral vesiculation that may
follow the distribution of a branch of the
Patients with prior HSV infection have HSV
trigeminal nerve. The lesions coalesce into
antibodies. In the presence of
large ulcerations and may linger for
immunosuppression, the latent virus can
weeks before remission occurs. Recurrent
be reactivated, causing oral or
infections frequently affect patients who
disseminated infection. In patients who
are myelosuppresed. The lesion is
are immunocompromised, the mucositis
typically observed several weeks after
associated with HSV may be more
cessation of chemotherapy. This is in
painful, severe, and prolonged. HSV
contrast to HSV, which often occurs within
ulcerations may act as portals of entry for
two to three weeks after chemotherapy is
bacterial and fungal pathogens.
discontinued. Herpetic infection can give
Small lesions of herpes simplex may be noticeable morbidity and can have a
Figure 7.5 Management of Specific Oral Complications
in Cancer Patients
Oral Infection (see Table 7.6)
Topical &/or systemic
Herpes Simplex
Acyclovir
Systemic Acyclovir or
Viral Infection Varicella zoster
Valacyclovir
Cytomegalovirus
Systemic Ganciclovir
Oral (CMV)
Infection
Resistant Other Azole or
Fungal Infection Oral Fluconazole
Infection Clotrimazole
Broad-Spectrum Blood Specific Oral

Bacterial Infection
Oral Antibiotic Culture Antibiotic
Xerostomia
Frequent sips of water, Oral Pilocarpine

Artificial Saliva
Xerostomia suck on ice chips, (if there is residual
(if tolerated)
increase fluid intake salivary gland function)
Hemorrhage
Ice Water & Consider platelet

Hemorrhage
Local Pressure transfusion
Oral Pain
Topical Topical Anesthetic/Pain Consider Topical

Oral Pain
Analgesic Relief Mouthwash Capsaicin
Pain Not Pain Not Systemic Analgesics

Controlled Controlled (Opioids)- PO, IV, SC
Severe
Pain
Continuous IV Infusion/
PCA Opioids
Osteoradionecrosis
Comprehensive Dental Management:
Osteoradionecrosis
Reduce trauma, avoid dental prostheses,
(ORN)
avoid alcohol & tobacco
chronic course. Systemic spread, which
can have great consequences, is Laser surgery, cryotherapy or surgical
fortunately infrequent. excision are typically utilized to remove
oral HPV lesions; intralesional injections of
Acyclovir and valacyclovir are currently TM
Imiquimod (Aldara ) may prove effective
the primary drugs used for treatment of
for recurrent lesions. These lesions may
varicella-zoster infections. 156
also be surgically excised.
Cytomegalovirus
7.5.5 Bacterial infection
Oral lesions associated with
Bacterial infection may present with small
Cytomegalovirus (CMV) have been
hemorrhages, pain localized in the
documented in recent years. 157,158
periodontum, and fever. Other signs of
Appearance is not pathognomonic and
inflammation are often missing. Clinical
is characterized by multiple mild-
presentation may vary depending on the
moderate ulcerations with irregular
bacterial source and immune status of the
margins. The lesions initially present during
patient. Evidence of secondary infection
early periods of marrow regeneration
in nearby structures may be present.
(e.g., 3 weeks after chemotherapy is
These often contribute to morbidity in
discontinued).
cancer patients, and occasionally to
Ganciclovir for treatment of acute mortality. Bacterial infections in the mouth
systemic CMV infection should be may originate from an odontogenic
considered.157,158 source, or in the mucosa or salivary
glands.
Epstein-Barr Virus
Oral hairy leukoplakia has been The Gram-positive microorganisms
attributed to EBV infection in (staphylococci and streptococci)
immunocompromised patients. The lesion normally inhabit the mouth but are
does not appear to be clinically potentially opportunistic. Gram-negative
significant in chemotherapy recipients. infections are also commonly seen in oral
cavities of cancer patients. As a result of
Non-herpes virus infections
myelosuppression, the mouth may be
Infections caused by non-herpes viruses
inoculated by enteric Gram-negative
are less common in
microorganisms such as Klebsiella,
immunocompromised chemotherapy
Pseudomonas 159, Proteus, Serratia, and
patients. Oral lesions caused by
Escherichia coli.
adenovirus and oral human papilloma
virus (HPV) have been described.
Table 7.7 Strategies to Treat Oral Hemorrhage
• A sponge-tipped applicator or a piece of gauze saturated with ice water
• Applying pressure with a frozen, wet tea bag
• Irrigating the oral cavity with cold water
• Gauze soaked in topical thrombin solution (when available), applied to the
affected area with pressure
• Do not remove any clots that form
• Microcrystalline collagen applied to a dry site for several minutes (see product
instructions)
• Platelet transfusions may be considered for thrombocytopenic patients
Myeloablated cancer patients with 7.6 Hemorrhage
chronic periodontal disease may Hemorrhage may be present clinically as
develop acute periodontal infections with gingival bleeding, submucosal bleeding
associated systemic sequelae. Pulpal/ with hematoma formation, or
periapical infections of dental origin can disseminated intravascular coagulation
complicate the course of the (DIC). Bleeding usually results from
chemotherapy patient. These lesions trauma or pre-existing periodontal
should be eliminated prior to initiation of disease and usually is intermittent with
chemotherapy. soft, fragile clots that form and break
away. The most common oral bleeding
Oral sources of bacteremia should be
sites include the lips, tongue, and gingiva.
eliminated before onset of
Bleeding from the oral cavity may occur
chemotherapy. Such sources particularly
in the presence of thrombocytopenia.
include areas of advanced periodontal
The potential for spontaneous bleeding
disease, teeth with soft tissue coverage
exists when a patient’s platelet count falls
and periapical pathosis. Antibiotic
below 20x109/L.
prophylaxis must be considered before
dental treatment. 160,161 Local etiological factors, such as
mucositis, plaque and mucosal dryness,
The treatment of bacterial infection
due to mouth breathing, oxygen therapy
depends first on adequate hygiene. In
or varying degrees of xerostomia, may
acute periodontal infection, broad-
increase the hemorrhagic tendency.
spectrum antibiotic therapy is usually
initiated. Typical empiric antibiotic 7.6.1 Hemorrhage Management
therapy may be penicillin (with or without Prevention is the most effective technique
metronidazole) for odontogenic used to avoid hemorrhage. Eliminating
infections. Clindamycin may be potential areas of trauma (sharp
substituted for penicillin-allergic patients. restorations, fractured teeth) and pre-
If bacterial cultures can be obtained, the existing intraoral disease before
antibiotic therapy may be modified to chemotherapy will prevent hemorrhage.
match the bacterial sensitivity profile. Oral care must be performed very gently
to reduce risk of hemorrhage. It is
The Gram-positive microorganisms
important in decreasing hemorrhagic
(Staphylococcus-streptococcus) are
tendencies in patients with
usually treated with cloxacillin or
thrombocytopenia who are receiving
cephalexin.
chemotherapy.
Focal bacterial infections of the mouth
A sponge-tipped applicator or a piece of
are often suspected as the source for
gauze saturated with ice water may help
infections of other organs, such as the
to control bleeding. Applying pressure
heart (bacterial endocarditis), kidneys
with a frozen, wet tea bag or irrigating
(glomerulonephritis), gastrointestinal and
the oral cavity with cold water or saline
respiratory systems. in addition, bacterial
also may decrease bleeding by causing
infections of the mouth may coexist with
vasoconstriction.
viral and/or fungal infections. Careful
diagnosis is required whenever an oral Gauze soaked in topical thrombin
infection is suspected or observed. solution (when available) and applied to
the affected area with pressure also can
help to minimize bleeding. Clots that form
should not be removed to avoid 7.8 Dental caries
repeated bleeding. Microcrystalline Dental caries are often a consequence
collagen applied to a dry site for several of radiation-induced xerostomia. Caries
minutes also may decrease hemorrhage. susceptibility is not limited to teeth within
the radiation field. The harmful impact on
Depending on the hematologic status of
post-radiation caries is as follows. 64,174,177-179
the patient, platelet transfusions may also
be required. The gradual fall of salivary pH, the
reduced volume and altered
7.7 Dental growth
composition of saliva, combined with its
The developing tooth, and to a lesser
reduced lubricating and cleansing
extent the adult tooth, both present
activity, result in adherence and
constituent cells that exhibit proliferation,
stagnation of both saliva and food debris
maturation, and secretion. Both the
around the teeth and the emergence of
developing tooth and the mature tooth
a highly cariogenic microflora
have a complex interrelationship with the
(Streptococcus mutans and Lactobacillus
supporting mandible. 162-168
species), increasing the vulnerability to
Altered dental growth and development decay.
is a frequent complication for long term
7.8.1 Dental Caries Management
cancer survivors who received high dose
Treatment strategies should be directed
chemotherapy and/or head/neck
to each component of the caries
radiation for childhood malignancies.169-
176 process.180 Optimal oral hygiene should
Developmental disturbances in
be maintained. Caries resistance can be
children treated at ages less than 12
enhanced via use of topical fluorides 180
years generally affect size, shape, and
and/or remineralizing agents. Use of
eruption of teeth as well as craniofacial
topical fluoride has demonstrable benefit
development. Abnormal tooth formation
in minimizing caries formation. Daily
manifests as decreased crown size,
application of fluoride is recommended.181-184
shortened and conical shaped roots, and
Efficacy of topical products may be
microdontia; on occasion, complete
enhanced by increased contact time on
agenesis may occur. Eruption of teeth
the teeth by application using custom
can be delayed, including increased
trays. Fluoride mouth trays should be used
frequency of impacted maxillary
judiciously to avoid exacerbation of pre-
canines. Shortened root length is
existing mucositis. Patients not able to
associated with diminished alveolar
effectively comply with use of fluoride
processes, which in turn leads to
trays should be instructed to use brush-on
decreased occlusal vertical dimension.
gels and rinses.
Additionally, conditioning-induced injury
to maxillary and mandibular growth Cultural data can be useful in defining
centers can compromise full maturation level of risk in relation to colonization
of the craniofacial complex. Because the patterns. Topical fluorides or chlorhexidine
changes tend to be symmetric, the effect rinses may lead to reduced levels of
may not be clinically obvious; Streptococcus mutans but not
cephalometric analysis may be used to Lactobacilli.185,186
delineate the extent of the condition.
Remineralizing agents which are high in
calcium phosphate and fluoride have
demonstrated salutary in vitro and
187
clinical effects. The intervention may 7.11 Fatigue and Frustration
be enhanced by delivering the drug via Cancer patients undergoing high dose
customized vinyl carriers. This approach chemotherapy and/or radiation can
extends the contact time of active drug experience fatigue related to either
with tooth structure which leads to disease or its treatment.189 These processes
increased uptake into enamel. can produce sleep deprivation or
metabolic disorders, which collectively
7.9 Periodontal disease
contribute to compromised oral status. In
Dental plaque is the primary etiological
addition, patients receiving intensive
agent in the development of periodontal
treatments may become tired, frustrated
disease. Plaque accumulates on the
with the treatment, or run out of
teeth, then initiates an inflammatory
motivation. The fatigued and/or
response causing erythema and
frustrated patient may have difficulty
edema.188
complying with mouthcare protocols.
Periodontal tissues directly in the radiation Biochemical abnormalities may also be
field may be significantly damaged present. It is still important that the patient
displaying disorganization of ligamentous makes every reasonable effort to
fibres, thickening of membranes, and loss continue their mouth care, despite the
of vascularity reducing the capacity for concurrent fatigue.
repair and regeneration and probably
It is important to support the patient
accounting for the resultant mobility and/
during the periods of fatigue and
or loss of teeth. Periodontal disease
frustration. Reassurance that the feelings
involves inflammation but is not painful,
are normal and that it will improve in time
unless the patient develops an acute
should be balanced with gentle but firm
periodontal abscess.
encouragement to continue the mouth
7.10 Neurologic disorders care practices even when the patient
Chemotherapeutic agents may have a seems to have no energy. Involvement
toxic effect on peripheral and autonomic of the family to help perform mouth care
nerves and, on occasion, cranial nerves practices may be particularly important
are affected. Such complications include during periods of fatigue (and pain).
pain, which mimics that of dental or
7.12 Taste Alteration
periodontal origin and paresthesia to the
Taste alteration comprises a reduction in
head and neck region. Plant alkaloids
taste sensitivity (hypogueusia), an
such as vincristine or vinblastine are most
absence of taste sensation (ageusia), or
commonly associated with these
a distortion of normal taste (dysgueusia).
neurotoxic effects. Dental hypersensitivity
These symptoms are usually transient, but
in patients may occasionally arise weeks
may be permanent and can lead to
or months following discontinuation of
food aversion, nausea, and vomiting.190-196
chemotherapy.
Taste is mediated through organs known
Selected patients may experience
as taste buds, which are essentially found
spontaneous or induced pain of the
on the tongue (in papillae) and are
temporomandibular joint. This condition is
continuously renewed. The number of
not unique to cancer patients, and may
papillae and taste buds diminish with
be associated with stress and
age. Free nerve endings in the
dysfunctional habits including bruxism
epithelium of the mouth also mediate
and clenching of the jaws.
taste sensation.
Attenuation or loss of the sense of taste •Malnutrition
and smell is commonly associated with •Metabolic disturbances
radiation therapy. Radiation affects taste •Ionizing radiation
by damaging the taste buds and by •Medications
modifying saliva. The taste buds alone •Endocrine factors (thyroidectomy,
are relatively resistant to radiation hypophysectomy, adranalectomy)
damage. However, the changes in saliva • Viral infections
and oral mucosa seriously modify the • Reduced saliva
patient’s ability to taste even though 5. Modification in the receptor cells due
taste buds are nearly normal. The to alteration of saliva by metabolic
perception of sour and bitter are agents, medicine, and/or radiation
suppressed more than that of sweet and 6. Dental pathology
salty. 7. Poor dental hygiene
Alteration in taste in cancer patients may 7.13 Dysgueusia

be correlated with the location or extent Dysgeusia is the presence of a chronic
of the tumor, independent of the taste in the mouth (often bitter, salty or
histological type. There is an association metallic). This very unpleasant taste
between advanced disease and an sensation may be an adverse effect from
abnormality in the recognition of sugar some cancer treatment medications,
and urea for example. and it may affect eating and nutrition.
Causes of taste alteration The reduced taste threshold for bitter
1. Local disease of the mouth and taste often results in cancer patients
tongue caused by cancer removing meat from their diet (source of
2. Partial glossectomy urea, which produces a bitter taste).
3. Damage to the nervous structure Patients may also have a raised threshold
following surgery or cerebral lesions for sweet taste (i.e. less ability to taste
4. Alteration of the cell renewal, or cell sweet foods). A common report is an
regeneration cycle unpleasant metallic taste associated with
Table 7.8 Strategies to Maintain Nutrition in Patients with Oral Complications

• Inform patients of possibility of food aversion before starting treatment
• Avoid eating for up to 4 hours before and after chemotherapy or irradiation of
the bowel
• Modify the texture and consistency of the diet
• Add between-meal snacks to increase protein and caloric intake
• Vitamin, mineral, and caloric supplements
• If tolerated, fruit juice before meals may stimulate the appetite
• Avoid rough, irritating food, citrus fruits, and extremes in food temperature- if
stomatitis present
• Frozen confections can numb oral discomfort
• Determine what the patient is capable of swallowing- if dysphagia is present
• Soft, bland diet or liquids may be better tolerated than solid foods
• Increase fluid intake, unless contraindicated
• Provide continuing support to patient that their situation will improve over time
chemotherapy, which may be worsened patients with dysgeusia. If stomatitis is
by placing metal in the mouth (e.g. present, patients should avoid rough,
metallic cutlery). irritating food, citrus fruits, and extremes in
food temperature. Eating frozen
Zinc supplementation (zinc sulfate 220
confections can numb oral discomfort. If
mg, twice a day) has been reported to
dysphagia is present, determine what the
be useful in some patients, the overall
patient is capable of swallowing. A soft,
benefit of this treatment remains unclear.
bland diet or liquids may be better
7.15 Nutrition tolerated than solid foods. Using creams
197
7.15.1 Nutritional deficiencies and gravies also can make eating easier
Nutritional deficiencies may develop as a when pain is present. Patients may wish to
result of oral discomfort associated with avoid favorite foods during treatment, to
chemotherapy and/or radiation therapy avoid development of food aversions
complicated by mucositis, xerostomia, which may last beyond the treatment
taste loss, dysphagia, nausea, vomiting, period. Increasing fluid intake, unless
or anorexia. contraindicated, also can enhance
taste.198
Quality of life is compromised as eating
becomes more problematic. Oral pain Nutritional counseling may be required
upon eating may lead to selection of during and following therapy with
foods that do not aggravate the oral emphasis on maintenance of
tissues, often at the expense of adequate appropriate caloric and nutrient intake.
nutrition. Nasogastric (NG) or percutaneous
esophageal gastrostomy (PEG) feeding
7.15.2 Nutrition Management
tubes may be required when swallowing
is significantly impaired.
Maintenance of adequate nutrition may
be compromised in patients with oral When nutrition is seriously compromised
complications to cancer treatment. A due to mucositis or nausea, and NG or
referral to a dietitian should be PEG tubes cannot be used, the physician
considered for patients experiencing may consider initiating IV
difficulties with eating during and after hyperalimentation (TPN or total
cancer treatment. parenteral nutrition), which has been
beneficial in many cases.
Nutritional deficiencies can be minimized
However, the hazards associated with this
by modifying the texture and consistency
type of therapy (e.g. risk of infection from
of the diet. If tolerated, patients can be
continuous indwelling IV line in an
encouraged to add between-meal
immunosuppressed patient) reinforce the
snacks to increase protein and caloric
importance of preventing mucositis,
intake. Dietary caloric supplements, with
infection and hemorrhage in the patient
additional minerals and vitamins, may be
receiving chemotherapy for cancer.199
added to the diet according to patient
tastes, to further improve nutritional status. 7.17 Neutropenic ulcers
If tolerated, fruit juice before meals may Mouth ulcers are a characteristic
stimulate the appetite. If patients can complication of severe neutropenia,
tolerate meats, sweet marinades or soy usually occurring with neutrophil counts
sauce can enhance their flavor. of less than 0.1 x 109/L 182-184. Neutropenic
Increasing the use of spices, seasoning, ulcers typically presents as one or more
and garlic can enhance taste, except for lesions characterized by regular margins,
a yellow/white background that is not the number of viable osteoclasts and
easily removed, and few signs of osteoblasts and a gradual development
inflammation. The clinical appearance of of obliterative endarteritis, compromising
an ulcer corresponds with the breakdown blood supply to the bone. Thus, the
in the continuity of the cell to neighboring radiated tissue becomes hypovascular,
epithelial cells. All regions of the oral hypocellular and hypoxic and the ability
cavity can be involved, whether to replace even normal cellular loss is
keratinized or not. impaired. Spontaneous
osteoradionecrosis (ORN) is not, therefore,
7.18 Tissue necrosis
unlikely and appears related to higher
Ideal management of the head/neck
therapeutic radiation doses.
radiation patient is centered in
prevention, based on comprehensive Although ORN may develop in the
oral care pre-radiation. The dentition, absence of any readily identifiable
periodontium, periapices, and mucosa triggering factors, it may be exacerbated
should be thoroughly examined by a in the presence of caries, oral/systemic
dentist in order to identify oral disease, infection or xerostomia. It can arise from
which should be eliminated prior to one month to many years after therapy.
cancer therapy. Dentition exhibiting poor Susceptibility to ORN may continue
prognosis and which lie within high dose throughout the lifetime of the patient,
fields should be extracted prior to and performance of dental extractions,
radiation therapy. Ideally, at least 7 to 14 invasive periodontal procedures or other
days should be allowed for healing prior surgical procedures in irradiated areas
to initiation of radiation, though some should be avoided whenever possible.
have suggested up to 21 days. Surgical
Patients who develop osteoradionecrosis
technique should be as atraumatic as
(ORN) should be comprehensively
possible and utilize primary wound
managed including elimination of
closure.200-202
trauma, avoidance of removable dental
7.19 Osteoradionecrosis prosthesis if the denture bearing area is
Patients at high risk for necrosis of the within the ORN field, assuring adequate
bone (osteoradionecrosis 201-217) include nutritional intake, and discontinuation of
alcoholics, heavy smokers, and patients tobacco and alcohol use. Topical
with chronically poor nutrition or poor oral antibiotics (e.g., tetracycline) or
hygiene. Radiation induces reductions in antiseptics (e.g., chlorhexidine) may
Table 7.9 Management of Osteoradionecrosis (ORN)
• Elimination of trauma
• Avoidance of removable dental prosthesis if the denture bearing area is within the
ORN field
• Adequate nutritional intake
• Discontinue tobacco and alcohol use
• Topical antibiotics (e.g. tetracycline) or antiseptics (e.g. chlorhexidine) may
contribute to wound resolution.
• Hyperbaric oxygen therapy (HBO).
• Surgical debridement of necrotic bone, as required.
• Partial mandibulectomy for severe cases of ORN
Table 7.10 Agents for Management of Oral Lesions in Chronic GVHD
Topical Steroids Rinses: dexamethasone elixir (Decadron®, generics).
Gels, creams:
• fluocinonide (Lyderm®, Tiamol®)
• clobetasol
• halobetasol (UltravateTM)
• betamethasone (Lotriderm®, Diprosone®, Valisone-G®, others)
Powders: beclomethasone (Beclovent®, QvarTM) (inhalers applied to
mucosa)
Topical Immuno- • azathioprine rinse (Imuran®; 5-8 mg/ml)
suppressants • cyclosporin (Neoral®)
Antifungals Systemic agents:
• fluconazole (Diflucan®, generics)
• itraconazole (Sporanox®)
Topical preparations:
• clotrimazole (Canesten®, others)
• nystatin (Mycostatin®, generics)
• amphotericin (Fungizone®)
PUVA Psoralen and ultraviolet irradiation
Sialogogues • pilocarpine (Salagen®)
• bethanechol (Duvoid®)
Topical Anesthetics • lidocaine (Xylocaine®, generics)
• diphenhydramine (Benadryl®, generics OTC)
• doxepin (Sinequan®, generics)
contribute to wound resolution. Wherever mandible can be reconstructed to

possible, coverage of the exposed bone provide continuity for esthetics and
with mucosa should be achieved; function. In most cases, ORN is primarily
necrotic bone must be debrided before managed by OMF surgery. A
any attempt to cover the area with soft multidisciplinary cancer team including
tissue, however. Analgesics for pain oncologists, oncology nurses,
control are often effective. Surgical maxillofacial prosthodontists, general
debridement of bone sequestrae may be dentists, hygienists, and physical
necessary. therapists may be involved in continuing
management of these patients.
Hyperbaric oxygen therapy (HBO)218,219 is
generally recommended for 7.20 Mandibular dysfunction
management of ORN in that it increases Trismus of the muscles of mastication is a
oxygenation of irradiated tissue, relatively common occurrence after
promotes angiogenesis, and enhances head and neck radiation, due to
osteoblast repopulation and fibroblast induced hypovascularity and soft tissue
function. HBO is usually prescribed as 20 fibrosis and scarring.
to 30 dives at 100% oxygen and 2 to 2.5
Patients can be instructed in physical
atmospheres of pressure. If surgery is
therapy interventions including
needed, 10 dives of postsurgical HBO are
mandibular stretching exercises as well as
recommended. Unfortunately, HBO
use of prosthetic aids designed to reduce
technology is not always accessible to
severity of fibrosis. It is important that these
patients who might otherwise benefit.
approaches be instituted prior to trismus
Partial mandibulectomy may be development. If clinically significant
necessary in severe cases of ORN. The changes develop, several approaches
including stabilization of occlusion, trigger will help, although it may be helpful to
point injection and other pain plan routine oral examinations by the
management strategies, muscle community dentist for patients prescribed
relaxants, and/or tricyclic medications bisphosphonate therapy221.
can be considered.218
7.22 Graft-versus-Host Disease
Allogeneic hematopoietic stem cell
7.21 Osteonecrosis of the Jaw (ONJ)
transplantation patients (receiving stem
It has been recognized in recent years
cells from a donor) are at risk for graft-
that a syndrome of jaw osteonecrosis is
versus-host disease (GVHD).222-224 GVHD
associated with the use of
may begin with engraftment (usually 14
bisphosphonates. Osteonecrosis of the
days after transplant). Mucosal
jaw is not clearly defined, but may be
erythema and erosion/ulceration are
described as an area of exposed bone
typical symptoms of acute GVHD.
that persists for 6 weeks or longer.
Chronic GVHD, which begins day 100 of
Symptoms may range from none to
the transplant, may include long-term
severe jaw pain. ONJ is uncommon with
oral complications.225 Oral lesions in
low dose bisphosphonate therapy (used
chronic GVHD are similar to those in
for osteoporosis prevention) but is more
acute GVHD, but may also include raised
common with the intravenous
white plaques and striae, increased
bisphosphonates (e.g. pamidronate,
involvement of the lips, and persistent
zoledronic acid) used in cancer
reduced salivary function. Oral
therapy220.
symptoms of GVHD, both acute and
ONJ can complicate regular dental chronic, may include xerostomia and
procedures. Dentists should include increased sensitivity and pain with spices,
questions to screen for bisphosphonate alcohols, and flavoring agents (especially
use in cancer patients seen for any mint flavors in toothpaste and oral care
dental care. If a patient is receiving a products). Oral GVHD has also been
bisphosphonate agent, dental linked with oral precancerous and
extractions should be avoided. If dental malignant lesions.226
surgery is indicated, endodontic
Diagnosis of oral GVHD may be
procedures, such as root filling treatment
established by biopsy of the oral mucosa
should be considered instead of
(including surface epithelium and minor
extraction. If extraction is not avoidable,
labial salivary glands).227-229 Presence of a
this procedure must include minimal
lymphocytic infiltrate (grade I) with
trauma to the bone and soft tissue flap
epithelial cell necrosis (grade II) provides
raising220.
the diagnostic basis for oral GVHD.
There are no guidelines to date on Clinical criteria for oral signs and
management of ONJ, but management symptoms of GVHD may also be used for
recommendations include consideration diagnosis, which may eliminate the need
of topical (e.g. chlorhexidine, for a diagnostic oral biopsy unless the
tetracycline) and systemic broad- clinical examination is not sufficient for
spectrum antibiotics, good oral hygiene, diagnosis.
surgical management of exposed bone
Systemic therapy with steroids,
(if possible) and protection of exposed
cyclosporine and other
bone. There is no evidence whether
immunosuppressive agents remains the
discontinuation of the bisphosphonate
foundation for treatment of oral GVHD
symptoms. Patients with clinically
significant xerostomia may benefit from
pilocarpine (5 mg 3 or 4 times a day) if
salivary gland function remains at least
partially intact. Topical management of
oral mucosal lesions in graft-versus-host
disease (GVHD) may include steroids,
azathioprine, and/or oral psoralen and
ultraviolet A (PUVA) (see Table 5.7).226,230
Topical cyclosporin has been used for
management of oral lesions, but it has
proven to be less effective and much
more expensive than other options.
Likewise, topical use of other drugs used
for reduction of graft rejection, such as
tacrolimus and mycophenolate mofetil,
have not proven to be efficacious.
A related condition referred to as
pseudo-GVHD may also occur with
autologous hematopoietic stem cell
transplant patients. The oral lesion often
mimics naturally occurring autoimmune
diseases such as erosive lichen planus,
lupus erythematosus, scleroderma and
Sjögren’s syndrome.
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Guidelines for the Management of
Oral Complications from Cancer Therapy
Appendices:
Contents:
Title Page
Appendix I Supportive Care Cancer Site Team Members A2
Appendix II Summary of Guideline Recommendations/Statements and A3
Best Practice Statements
Appendix III Management Plans for Oral Health Care A7
Appendix IV Guideline Development Process A17
Appendix V Guidelines for the Initiation and Discontinuation of To
Continuous Intravenous Infusion of Opioids (CIVIO) for Follow
Mouth Pain
Appendix VI Patient Education Materials To
Follow
A1 - Best Practice Guidelines for the Management of Oral Complications from Cancer Therapy
Comprehensive Version
APPENDIX I- Supportive Care Cancer Site Team Members
Guideline Writing Team: Supportive Care CST Executive:
Larry Broadfield, Systemic Therapy Program Mark Dorreen, Medical Oncologist, CDHA -
Manager, CCNS Co-Chair
Joan Hamilton, Clinical Nurse Specialist, Debbie MacLeod, Clinical Scientist, CDHA-
CDHA Co-Chair
Sophie Gouery, Pharmacy Student (2002)
Christine Algee, Dietitian, CDHA
Guideline Reviewing Team: Ann Bereziuk, Patient Representative,
Clinical Practice Committee, Nova Scotia CDHA
Dental Association Barbara Bird, Canadian Cancer Society
Chad Robertson, Faculty of Dentistry Mark Blumberg, Psychologist, IWK
Violet Cameron, Palliative Care Nurse, Larry Broadfield, Systemic Therapy Program
CDHA Manager, CCNS
Mark Dorreen, Bruce Colwell, Medical Violet Cameron, Palliative Care Nurse,
Oncologist, CDHA CDHA
Carol Digout, APPHON Sandra Cook, Patient Navigation Project
Barb McCully, Pharmacist, IWK Manager, CCNS
Joy Tarasuk, Nurse Educator, CDHA Lynn Coulter, Expanded Role Nurse, CDHA
Carol Digout, APPHON Coordinator
No conflicts of interest have been Jill Flinn, Health Services Manager, CDHA
identified by members of the Guideline Lyn Frankton, Family Care Co-ordinator,
Writing Team or the Guideline IWK
Donna Grant, Oncology Nurse Educator,
Reviewing Team that could have
CDHA
compromised the recommendations of Joan Hamilton, Clinical Nurse Specialist,
this guideline. CDHA
Andrew Harris, Psychiatrist, CDHA
Note: Robert Horton, Palliative Care Physician,
APPHON = Atlantic Provinces Pediatiric CDHA
Hematology Oncology Network Janice Howes, Clinical Psychologist, CDHA
CBDHA = Cape Breton District Health Emmie Luther-Hiltz, Cancer Patient and
Authority Family Network Coordinator, CCNS
CDHA = Capital Health Heather MacKenzie, Recording Secretary
CCNS = Cancer Care Nova Scotia David Maginley, Spiritual Care, CDHA
Meg McCallum, Canadian Cancer Society
Jane Palmer, Health Services Manager,
CDHA
Mary Lou Roberston, Social Work, CDHA
Judy Simpson, Palliative Care Coordinator,
CCNS
Janice Spencer, Social Work, CDHA
Joy Tarasuk, Nurse Educator, CDHA
Derek Wilke, Radiation Oncology, CDHA
Effective September 2005
Best Practice Guidelines for the Management of Oral Complications from Cancer Therapy -A2
APPENDIX II- Summary of Guideline Recommendations/Suggestions
and Best Practice Statements
Note: For this guideline, a literature review was conducted to identify all guidelines or meta-analyses
listed in PubMed or the National Guidelines Clearinghouse (NGC). There were 2 listings in the NGC
under the search heading “mucositis” and the disease state “cancer” and 25 listings under the search
heading “oral infection” and the disease state “cancer”, of which the only citation (common to both
searches) that clearly addressed the issues in this guideline was limited to pediatric patients1. In
PubMed, there were 11 articles identified (meta-analysis or guideline, English language) under the
search heading “oral mucositis cancer”, and 8 articles under the search heading “oral infection
cancer”. Additionally, a search of the Program for Evidence-Based Care (Cancer Care Ontario) and
the Cochrane Database was conducted. Through abstract review, articles and guidelines were
assessed for relevance to this guideline. Due to the poor quality or absence of published research,
the meta-analyses illustrate that there are very few aspects of the prevention2 or management3 of oral
mucositis where the evidence is sufficient to make an EBR. There is, however, convincing evidence
on the optimal prevention of oral candidiasis in cancer patients4. The 2004 guideline publication by
the Multinational Association of Supportive Care in Cancer (MASCC)5, which was updated at the
2005 MASCC meeting (proceedings unpublished to date) is the only paper that provides evidence-
based recommendations (EBRs) across a similar scope as this guideline.
The MASCC recommendations (and one PEBC guideline5) are adapted for local use in this guideline,
based upon the most current update. If there is strong supporting evidence for a practice, this will be
indicated as a “Guideline Recommendation”; if the supportive evidence is weak, this will be indicated
as a “Guideline Suggestion”. All guideline statements will be followed by the Level of Evidence and
Grade of the Recommendation (as assigned by the MASCC Expert Panel). A practice for which there
is little or inconclusive evidence but which is commonly supported in the literature will be indicated as
a “Best Practice Statement”, in order to provide direction in the absence of supporting evidence.
Screening for Oral Complications Assessment of Oral Complications:

Best Practice Statement: Best Practice Statement:
Ambulatory patients and hospital inpatients When stomatitis or other oral complications
on chemotherapy should be screened on are identified from screening and become
a regular basis with the Stomatitis Staging a focus of care, routine assessment should
System scale for evidence of oral begin. For high-risk patients, routine
complications. Inspection of the oral cavity assessment should begin at the start of
using a flashlight should be included in the treatment.
systematic screening of patients at each
visit during chemotherapy treatment (or Assessment includes rating mucositis (using
daily for inpatients on chemotherapy). the Stomatitis Staging System scale), and
considers a range of oral symptoms and
If stomatitis or other oral complications are response(s) to interventions over time. The
identified and become a focus of care, MCR will be used for documentation of
routine assessment should begin (see Part routine assessment until the oral
3.3). complications are resolved.
Patients at high risk of serious oral Assessment should be incorporated into

complications (e.g. HSCT patients, or both the Basic and Intensified Mouth Care
patients receiving radiotherapy to the oral Plans.
cavity area) should not be screened, but
should begin with routine assessment (see
Part 3.3) in anticipation of oral
complications.
Dental Assessment and Care • Mouth Rinse Solutions
Best Practice Statement: Best Practice Statement:
Patients who are scheduled to receive Patients should be encouraged to
chemotherapy of any kind, or radiotherapy thoroughly rinse out their mouths using a
to the head and neck, or hematopoietic mouth rinse solution. Water, normal saline
stem cell transplant should be assessed by or sodium bicarbonate solution may be
a dentist prior to the cancer treatment. If considered as reasonable options for
the cancer treatment is intermediate or mouth rinse solutions. Commercial solutions
high risk, the dental assessment should be with hydroalcoholic base or astringent
done by a dental team experienced with properties should be discouraged for
oral oncology. Other dental assessments routine mouth rinse during active cancer
may be done by the patient’s community therapy.
dentist in consultation with the oncology
specialist(s). The dental examination and Management Plans
assessment should be done as soon as Guideline Suggestion: Use of a uniform,
possible, to allow time for any dental systematic plan for oral care, along with
procedures and adequate healing prior to standard educational approaches to help
the cancer treatment. If dental work is patients understand and cope with the
indicated, this should be carried out before symptoms of oral complications, is
cancer treatrment is started. Dental exams suggested. The protocol should be
may be repeated during active therapy on multidisciplinary. One component of the
the advice of the oncology team. protocol should be the use of a soft
toothbrush that is replaced on a regular
Oral Hygiene basis. The comprehensive management
Guideline Suggestion: plan(s) may reduce the severity of
Use of a uniform, systematic plan for oral mucositis caused by chemotherapy or
care, along with standard educational radiotherapy.
approaches to help patients understand Level of Evidence: III
and cope with the symptoms of oral Grade of Recommendation: B
complications, is suggested. The Best Practice Statement:
comprehensive management plan(s) may For routine care, the oral complication
reduce the severity of mucositis caused by treatment components are compiled into
chemotherapy or radiotherapy. Mouth Care Plans. The Basic Mouth Care
Level of Evidence: III Plan is used for most patients. The
Grade of Recommendation: B Intensified Mouth Care Plan is used for
Guideline Suggestion: patients as they develop intermediate to
Patients on chemotherapy or radiotherapy severe stomatitis (on the Stomatitis Staging
should be educated on appropriate mouth System scale for screening), returning to
care practice (including oral hygiene the Basic Mouth Care Plan when stomatitis
procedures) and encouraged to follow the and other symptoms have resolved. These
practice(s) during active treatment. Basic Mouth Care Plans should be integrated
oral hygiene is particularly important for into hospital nursing care plans for cancer
any patient who is immunocompromised. patients and used as a basis for health
Level of Evidence: III education of ambulatory patients.
Best Practice Guidelines for the Management of Oral Complications from Cancer Therapy - A4
Prevention and Management of Oral Human Keratinocyte Growth Factors
Complications: Guideline Recommendation:
In patients with hematological
• Mucositis Prevention
malignancies receiving high dose
chemotherapy and total body irradiation
Patients with oral mucositis require
with autologous stem cell transplant,
appropriate therapeutic intervention(s) to
Keratinocyte Growth Factor-1 (Palifermin)
prevent symptoms.
in a dose of 60 µg/kg/day for 3 days prior
Benzydamine to conditioning treatment and for 3 days
Guideline Recommendation: post-transplant is recommended for the
Benzydamine is recommended for prevention of oral mucositis.6
prevention of radiation-induced mucositis Level of Evidence: I
in patients with head and neck cancer Grade of Recommendation: A
receiving moderate-dose radiotherapy.
Level of evidence: I • Agents Which Have Not Proven to be
Grade of recommendation: A Effective for Prevention of Mucositis
Radiotherapy Delivery Chlorhexidine should not be used to
Guideline Recommendation: prevent oral mucositis in patients with solid
Midline radiation blocks and three- tumors of the head and neck who are
dimensional radiation treatment to the oral undergoing radiotherapy.
cavity should be used where possible, to Level of Evidence: II
reduce mucosal injury. Grade of Recommendation: B
Level of evidence: II
Grade of recommendation: B Guideline Recommendation:
Sucralfate should not be used for the
Cryotherapy prevention of radiation-induced oral
Guideline Recommendation: mucositis.6
Patients receiving 5-fluorouracil-based Level of Evidence: II
chemotherapy should be treated with oral Grade of Recommendation: A
cryotherapy (ice chips in the mouth for 30
minutes starting 5 minutes before Guideline Recommendation:
chemotherapy administration) to prevent Antimicrobial lozenges should not be used
stomatitis. This recommendation may be for the prevention of radiation-induced
suspended if oxaliplatin is included in the oral mucositis.6
chemotherapy regimen. Level of Evidence: II
Level of Evidence: II Grade of Recommendation: B
Guideline Suggestion:
Acyclovir and its analogues should not be
Patients receiving high-dose melphalan as
used routinely to prevent mucositis.
part of a conditioning regimen for stem cell
transplant should be treated with oral
Grade of recommendation: B
cryotherapy to prevent oral mucositis. 6
Level of Evidence: II Guideline Recommendation:
Grade of Recommendation: A Glutamine should not be used routinely to
prevent mucositis. 6
Grade of recommendation: C
GM-CSF Mouthwashes • Saliva stimulants
7
Guideline Recommendation: Guideline Recommendation :
Granulocyte-Macrophage Colony Patients with radiation-induced xerostomia
Stimulating Factor (GM-CSF) mouthwash should be considered for treatment with
formulations are not recommended for oral pilocarpine.
prevention of mucositis in patients Level of Evidence: I
undergoing hematopoietic stem cell Grade of Recommendation: A
transplant. 6 • Oral Pain Management
Level of evidence: II Best Practice Statement:
Grade of recommendation: C Patients who experience oral pain, alone
Guideline Recommendation: or in combination with other oral
Pentoxifylline is not recommended for complications, may be treated with
prevention of mucositis in patients coating suspensions, topical analgesic
undergoing hematopoietic stem cell solutions, topical anesthetics or pain relief
transplant. mouthwash suspensions, and systemic
Level of evidence: II analgesics (for increasing severity of the
Grade of recommendation: B pain). Clinicians should only use the
institutional standard(s) for pain relief
mouthwash formulations.
• Management of Mucositis Symptoms
Best Practice Statement: • Pain Relief Mouthwashes
Patients with oral mucositis require Best Practice Statement:
appropriate therapeutic intervention(s) to An analgesic or anesthetic mouthwash
manage the symptoms and prevent should be considered for management of
symptom progression. It is suggested to use patients with oral pain. For ease of
the “stepped” approach for mucositis administration, multiple components may
management, adding agents as symptoms be compounded together into a pain
present. relief mouthwash preparation. The
appropriate compounded pain relief
Chlorhexidine
mouthwash preparation should be
incorporated into the oral care
Chlorhexidine should not be used to treat
procedures.
established oral mucositis.
Level of Evidence: II Compounded preparations should not
Grade of Recommendation: A include more than one agent from the
same therapeutic classification. An
• Xerostomia Management
institution should limit the selection of
Guideline Statement:
compounded pain relief mouthwash
Patients at risk of xerostomia may be
preparations to two or three standard
managed by preventative measures. If
formulae.
xerostomia occurs in patients receiving
radiotherapy to the head and neck, oral • Management of Severe Oral Pain
pilocarpine should be considered for Guideline Recommendation:
systemic therapy. If the xerostomia is Hematopoietic stem cell transplant (HSCT)
caused by chemotherapy or other toxic patients should be offered patient-
stimuli, oral pilocarpine may be considered. controlled analgesia with morphine (or
Artificial saliva products may also be other strong opiate) to manage severe
considered, for a brief course to determine oral pain.
effectiveness and patient acceptability, Level of Evidence: I
followed by continuing therapy when Grade of Recommendation: A
warranted.
• Infection Prevention References:
Best Practice Statement: 1. American Academy of Pediatric Dentistry.
Treatment with prophylactic antibiotic Clinical guideline on dental management of
therapy may be considered for patients pediatric patients receiving chemotherapy,
who are seriously myelosuppressed and/or hematopoietic cell transplantation, and/or
radiation. Chicago (IL): American Academy
who have poor oral hygeine, to prevent
of Pediatric Dentistry; 2004. 6 p.
oral infections. Antibiotic prophylaxis may 2. Worthington HV, Clarkson JE, Eden OB.
be topical or systemic. Interventions for preventing oral mucositis for
Prophylactic use of chlorhexidine to patients with cancer receiving treatment.
Cochrane Database of Systematic Reviews
prevent oral infections is not
2006, Issue 2. Art. No.: CD000978. DOI: 10.1002/
recommended for adults. Potential 14651858.CD000978.pub2.
antimicrobial effects are offset by other 3. WorthingtonHV,Clarkson JE, EdenOB.
adverse effects in patients with oral Interventions for treating oralmucositis for
mucositis. patientswith cancer receiving treatment.
Cochrane Database of Systematic Reviews
• Infection Management 2004, Issue 2. Art. No.: CD001973. DOI: 10.1002/
Best Practice Statement: 14651858.CD001973.pub2.
Treatment with appropriate antibiotic 4. Worthington HV, Eden OB, Clarkson JE.
agents should be considered for patients Interventions for preventing oral candidiasis
with an active oral infection, especially in for patients with cancer receiving treatment.
patients who are immunosuppressed. Cochrane Database of Systematic Reviews
Antibiotic treatment may be topical or 2004, Issue 4. Art. No.: CD003807. DOI: 10.1002/
systemic, and the treatment plan should 14651858.CD003807.pub2.
5. Rubenstein EB, Peterson DE, Schubert M, Keefe
consider fungal, bacterial and viral
D, et al. for the Mucositis Study Section of the
opportunistic superinfections. If topical Multinational Association of Supportive Care
antibiotics are used, they must be given in in Cancer and the International Society for
conjunction with proper oral hygiene as Oral Oncology. Clinical Practice Guidelines
part of the mouth care plan. for the Prevention and Treatment of Cancer
4 Therapy–Induced Oral and Gastrointestinal
Guideline Recommendation : Mucositis. Cancer 2004; 100 (9 Suppl): 2026–
Patients who are at risk, or who have been 2046.
diagnosed with candidiasis (thrush) should 6. Keefe DM, Schubert MM, Elting LS, et al.
be treated with oral fluconazole 100mg qd Updated clinical practice guidelines for the
(or another oral azole antifungal agent). prevention and treatment of mucositis.
Oral nystatin suspension or alternate forms Cancer, 2007; 109: 820-31
of nystatin delivery may be considered if 7. Head and Neck Cancer Disease Site Group.
Hodson DI, Haines T, Berry M. Symptomatic
fluconazole is contraindicated.
treatment of radiation-induced xerostomia in
Level of Evidence: I head and neck cancer patients [full report].
Grade of Recommendation: A Toronto (ON): Cancer Care Ontario (CCO);
2004.
• Nutrition
Best Practice Statement: Maintenance of
adequate nutrition may be compromised
in patients with oral complications to
cancer treatment. A referral to a dietitian
should be considered for patients
experiencing difficulties with eating during
and after cancer treatment.
Appendix III.
Management Plans for Oral Health Care
IIiI.a Management Plans Taking all of the above issues into
Guideline Suggestion: consideration, comprehensive plans have
Use of a uniform, systematic plan for oral been determined for oral health care in
care, along with standard educational Capital Health . These Oral Health Care
approaches to help patients understand Plans are separated into a Basic Mouth Care
and cope with the symptoms of oral Plan and an Intensified Mouth Care Plan.
complications, is suggested. The The Intensified plan is intended for use in
comprehensive management plan(s) may patients with stomatitis assessed as
reduce the severity of mucositis caused by intermediate to severe in the Stomatitis
chemotherapy or radiotherapy. Staging System, used in the Mouth Care
Level of Evidence: III Grade of Record (Table 2.2). Ambulatory patients
Recommendation: B screened for stomatitis during
chemotherapy or radiotherapy to the head
Best Practice Statement: and neck, should move to this care level
For routine care, the oral complication once the threshold is reached. While these
treatment components are compiled into Oral Health Care Plans are designed for
Mouth Care Plans. The Basic Mouth Care nursing services for hospital inpatients, they
Plan is used for most patients. The may be applied to ambulatory patients
Intensified Mouth Care Plan is used for through health education and periodic
patients as they develop intermediate to reinforcement by health caregivers.
severe stomatitis (on the Stomatitis Staging
System scale for screening), returning to
the Basic Mouth Care Plan when stomatitis
and other symptoms have resolved. These
Mouth Care Plans should be integrated into
hospital nursing care plans for cancer
patients and used as a basis for health
education of ambulatory patients.
Basic Mouth Care Plan
Patient Education:
• All patients should be taught on oral care at commencement of chemotherapy,
immunosuprresant drugs, any disease which causes immunosuppression , or
radiotherapy to the head & neck
• Use appropriate patient information material(s) to supplement verbal education on
all aspects of this care plan
• Patients should be aware that they will be reminded and enoucraged frequently to
perform their mouth care even when they feel sick or tired.
• Encourage family participation in mouth care when appropriate.
Flossing:
• If patient has flossed regularly, encourage patient to continue flossing as per ususal
habit (at least once daily, preferably at bedtime).
• Continue to use the same floss as before (e.g. waxed, unwaxed, denotape, dental
floss, fine, regular).
• If patient has not flossed routinely to date, do not initiate just before treatment begins.
• Discontinue flossing if gums bleed for more than 2 minutes. Advise patient to restart
flossing when the platelet count rises above 20 x 109/L
Head and Neck cancer patients: Flossing may not be appropriate because of
tumour involvement and location.
Brushing:
• If flossing, floss before brushing.
• Brush teeth 4 times daily, within 30 minutes after eating, and before going to bed.
• Use an ultrasoft toothbrush (e.g. Butler 449).
• Rinse brush with hot water to soften it just before brushing.
• Brush surface of tongue gently from back to front.
• Use non-abrasive toothpaste with fluoride. Gel paste can be less abrasive.
• Clean brush after each use with hot water. Air dry.
• Change toothbrush often (e.g. once per month, on average) or when bristles are not
standing up straight.
Head and Neck cancer patients: Brushing may not be appropriate because of
tumour involvement and location.
Dentures or Bridges:
Brush and rinse dentures after meals and at bedtime. Rinse dentures with the mouth rinse
solution (see below) before placing them in the mouth. Remove dentures from the mouth
for long periods, at least 8 hours per day. Soak them in the denture cleaning solution,
mouth rinse solution or water (patient choice).
Rinsing:
• After flossing and brushing, the mouth should be rinsed with a mouth rinse to remove
remaining debris and toothpaste (which may irritate the tissue). Rinse as vigorously as
able after each brushing (4 times daily).
• Rinse BEFORE applying topical agents, since any therapeutic agent will penetrate
oral tissue more effectively when the mouth is free of debris and saliva.
• Rinse the oral cavity thoroughly without dentures in place.
• Offer the patient the following options for rinse solutions:
• Soda Water (Club Soda) • Normal Saline
• Sodium Bicarbonate Solution
• Tap water (or bottled water, especially where water is contaminated)
• DO NOT USE – Commercial mouthwash products, glycerin products, or hydrogen
peroxide.
Basic Mouth Care Plan (continued)
Debriding:
Tissue should not be debrided. Do not remove tissue that is still attached or hanging
unless it is creating an obstruction for the patient.
Debris:
If debris (i.e. blood, necrotic tissue) is not removed with regular brushing, or with a
toothette, rinse vigorously with carbonated soda water. Because hydrogen peroxide
impedes granulation of new tissue, it should not be used (even if diluted) unless
absolutely necessary.
Lip Care:
• Coat lips with an oil-based or water soluble lubricant to keep them moist. Water
soluble lubricants may be used inside and outside the mouth, and can be used with
oxygen, since there is no risk of aspiration.
• Apply the lubricant after each cleaning,at bedtime, and as needed. Water-based
lubricants needs to be applied more frequently.
• Some water soluble lip lubricants to consider include:
• Glaxal Base cream
• Derma Base (K-Y Jelly & Dermasone)
• Eucerin/glycerine/water cream (from QEII HSC stores)
• Examples of oil-based lubricants include lanolin, petroleum jelly, mineral oil and
cocoa butter.
• Encourage patients not to touch their lip lesions.
Eating:
Avoid abrasive, rough, spicy, acidic and hot foods. All irritants should be avoided,
especially alcohol and tobacco. Eat soft foods. Avoid foods containing a lot of sugar,
and really cold foods. Encourage high-density and high-fibre foods to clean teeth and
massage gums. Encourage a well-balanced diet, high in protein, vitamins B & C.
Encourage a fluid intake of at least 2 litres per day.
Taste Alterations:
• Increase the palatability of foods (e.g. with seasonings, sugar to balance against
bitterness)
• Refresh the mouth. Regular frequent mouth care, before and after meals.
• Try eating meats cold
• Hard, sugarless candies; soft mints; sugarless gum.
• Take small bites and chew food thoroughly to stimulate taste sensations.
• Use plastic cutlery to reduce potential metallic taste from the metal utensils.
Special Considerations for Children: (See APPHON Guidelines)
• Certain changes or additions are recommended for children with cancer:
• Use a soft toothbrush after each meal and at bedtime. If gums are bleeding, or
platelet count < 20 x 109/L, do not use toothbrush or floss; clean teeth with cotton
swab, damp gauze, or Q-tips
• Rinse mouth with 0.12% Chlorhexidine mouthwash (e.g. Oro-X with Chlorhexidine
0.12% MIC) after mouth care (30 minutes after brushing with gel toothpaste)
during intensive chemotherapy or when dental disease is present
• Do not use mouthwashes which contain alcohol or local anesthetics
• Wait 30 minutes after mouth care before eating
Best Practice Guidelines for the Management of Oral Complications from Cancer Therapy -A10
Intensified Mouth Care Plan
Patient Education:
• In addition to eduction in the Basic Mouth Care Plan:
• Patients should be informed ahead of treatment that their mouths may become
uncomfortable, especially when brushing, but that it is very important to continue
brushing even with soreness and lesions. Brushing is the most effective method to keep
the mouth clean.
• Patients should be made aware that there are a variety of pain management
options
• Family members can encourage the patient to perform mouth care, or they may
assist their loved one with mouth care, when appropriate.
Flossing:
• If patient has flossed regularly, encourage patient to continue flossing.
• Discontinue flossing if gums bleed for more than 2 minutes. Advise patient to restart
flossing when the platelet count rises above 20 x 109/L
Brushing:
• Continue brushing teeth 4 times daily, within 30 minutes after eating, and before going
to bed, unless the patient refuses due to discomfort.
• Patients should be told that even with soreness, they should continue using a
toothbrush to clean their mouths
• If patient unable to tolerate brushing, patient can attempt to wipe mouth out with
gauze soaked in rinsing solution, or by using a foam brush.
• Encourage brushing and rinsing throughout treatment and recovery regardless of
platelet count (unless patient refuses).
• Patient responses to reduced platelet counts should be continually monitored. If
bleeding occurs, brush more gently. If bleeding does not stop after 2 minutes,
consider a toothbrush alternative, such as a toothette, or vigorous rinsing with
cleansing solution. Try using a toothbrush again, when platelets rise above 20 x 109/L.
Dentures:
• Keep out of the mouth as much as possible.
Debriding & Debris:
As stated in Basic Mouth Care Plan
Rinsing:
• Continue to rinse after each brushing
• Rinse every 1 to 2 hours while awake, and every 4 hours through the night if awake.
(Performing oral hygiene during the night is believed to minimize the effects of a
decrease in saliva).
• If unable to swish rinse around in the mouth, consider one of the following:
• Use toothette or gauze saturated in rinsing solution, to apply rinse over all
surfaces.
• Wrap gauze around gloved finger or tilt patient’s head back and forth and from
side to side with rinse solution in mouth.
• Rinse mouth by syringing solution into different areas of mouth (this should not be
performed by the patient if platelets are low, since they may cause trauma to
themselves.
Special Considerations for Children:
TM
• May rinse mouth with 0.12% Chlorhexidine mouthwash (e.g. Oro-X with
Chlorhexidine 0.12% MIC) after mouth care (30 minutes after brushing with gel
toothpaste) during intensive chemotherapy or when dental disease is present
Intensified Mouth Care Plan
Lip Care:
• Increase applications lip lubricants to before meals, before and after cleaning, and
as often as needed by the patient.
• Water-soluble lip lubricants may need to be applied more frequently than oil-based
lubricants.
• Oli-based lip lubricants cannot be put in the mouth.
• Oil-based lip lubricants may be less desirable, since these products can cause
aspiration if ingested.
Eating:
May need to introduce bland foods. If patient unable to swallow, may need to start TPN
or g-tube feedings. Consider rinsing with topical anesthetic mouthwash 1-5 minutes
before eating, to allow for onset of anesthetic action.
Taste Alterations:
• Increase the palatability of foods (e.g. with seasonings, sugar to balance against
bitterness).
• Refresh the mouth. Regular frequent mouth care, before and after meals.
• Take small bites and chew food thoroughly to stimulate taste sensations.
Airway Concerns:
• HOB at 300C as stomatitis progresses.
• Keep emergency airway at bedside.
• Keep tonsil suction at bedside (yanker suction 92) if platelet or WBC counts are high
enough to allow for this type of intervention. If it is inappropriate to use suction, put the
patient on his/her side with the head of the bed slightly lowered (so the saliva can
drain out of the mouth).
• Ensure adequate humidity.
• Involve respiratory experts as soon as the problem is identified.
Appendix IV. Guideline Development Process
This guideline was written by a guideline discussions, where appropriate. Other
writing team, comprised of members of areas for consideration, not discussed by
the Supportive Care Cancer Site Team the MASCC guideline, were identified,
expertise in the content areas. The and a full literature search was
guideline was written for an audience of conducted by content area experts for
general practitioners, dentists and other these areas. New material was written
health care professionals (HCPs), not and discussed by the writing team. This
necessarily oral oncology specialists. As effort continued on the advice of the
such, it is a synthesis of knowledge and corresponding team and other reviewers
evidence, and reflects the common through the development process.
practice policies of the Supportive Care
Once the draft guideline was completed,
Cancer Site Team in Nova Scotia. The
it was approved by the CST for expert
written text on management is supported
and user reviews. The draft was
by the graphic flowcharts in the ‘Practice
distributed to a large group of
Pathways’ section. These flowcharts are
community reviewers across Atlantic
reproduced in a stand-alone short version
Canada, including members of the
of the guideline, called the Quick
Faculty of Dentistry and the Clinical
Reference Version.
Practice Committee of the Nova Scotia
This guideline is constructed in three Dental Association (NSDA) for critical
versions: the writien guideline document appraisal. Reviewers included identified
(Full Version- FV), detailed appendices oncologists, hematologists, oncology
with evidence-based recommendations nurses, palliative care physicians and
(Comprehensive Version- CV), and an nurses, clinical and academic dentists,
abbreviated version with minimal text family physicians, hospital pharmacists,
and flowcharts of the major points (Quick and other interested individuals. Non-
Reference Version- QRV). The intent of specialist physicians and other HCPs were
these three versions is to provide sent the QRV (7 pages) and those who
consistent information at different levels of specialize in palliative care, oncology, or
detail for different target audiences of clinical dentistry were sent the FV (124
health care professionals. By design, the pages), although either group could
short QRV is intended for widespread request the other version to review.
distribution to primary health caregivers, Approximately 120 review packages
whereas the FV distribution is intended for were distributed across all 4 Atlantic
oncology and palliative care specialists, Canada provinces, and some elsewhere.
as well as refernce copies in health All responses were anonymous, but there
sciences libraries. The detailed CV will be was not confirmation that all copies were
available on the CCNS website for received by reviewers. Responses to the
individuals who wish a more thorough draft review were collected on a
review of the literature. standard guideline review questionnaire.
Results are presented below.
The guideline was based upon an
evidence-based guideline on mucositis,
developed by the Multinational
Association of Supportive Care in Cancer
(MASCC). New papers were obtained
and new information was edited into the
There were 27 responses to the draft Some recommended treatment practices are
guideline. The NSDA committee unlikely to be accepted by your patients = 2
responded as a group and did not Other Comments = 1
complete the questionnaire. By discipline It is clear in this feedback that the
and province, there were: guidelines were felt to be useful by
4 Physicians 18 Nova Scotia clinicians, and would be used in clinical
16 Nurses 3 New Brunswick
4 Pharmacists 0 PEI practice. The guidelines woulld be useful
1 Unanswered 5 Newfoundland as decision aids, aids for teaching other
1 Other health care professionals and patients,
and would help practitioners to better
The Guideline Review Questionnaire was
understand cancer pain management.
structured to solicit feedback on:
However, some respondents noted that
Usefulness, Format, Content and
some treatments discussed in the
Dissemination. There were category
guideline might not be available locally,
questions and open-ended questions in
or may not be acceptable to some
all areas, collected on a standard
patients. It was also noted by one
guideline review questionnaire. Five
respondent that it needed to be rewritten
reviewers looked at the FV, 16 reviewed
and another did not find it useful (both
the QRV and 5 reviewed both. Results are
persons reviewed the FV and were
presented below. There were 4 questions
looking for the QRV)
on usefulness, 3 on format, 2 on content,
and 3 on dissemination. Guideline Format:
The format of the guideline is easy to use.
Usefulness of the Guideline
Strongly Agree = 4 Agrees 19
A guideline on this topic will be useful to Agree = 15 Disagrees 3
clinicians. Neither Agree/Disagree = 1 No Answer = 3
Strongly Agree = 14 Agrees 23 Disagree = 3 Comments = 1
Agree = 9 Disagrees 1 Strongly Disagree = 0
Neither Agree/Disagree= 0 No Answer = 2
Disagree = 1 The Practice Pathways (flowcharts/
Strongly Disagree = 0 algorithms) are easy to understand.
Strongly Agree = 6 Agrees 18
Would you use this guideline in your own
Agree = 12 Disagrees 0
practice? Neither Agree/Disagree = 6 No Answer = 2
Yes = 20 No = 3 Unsure = 3 Disagree = 0 Comments = 0
How do you think this Guideline would be Strongly Disagree = 0
useful to you and other Health In which other format(s) should this CCNS
Professionals? guideline be developed once it is
Decision aid when caring for a patient= 19 approved?
Better understanding about how cancer pain is Pocketbook copy mailed to all appropriate
detected and managed = 19 clinicians (approx. 4"x7") = 14
Aid for teaching health care professional Pocketbook copy available on request = 9
students about cancer pain = 18 Comprehensive version on request = 9
Aid for patient education on cancer pain = 20 Multiple versions on CCNS website = 18
Other Comments = 2 Downloadable for Palm Pilot or other PDA = 11
In what ways do you think this Guideline Presentations in conjunction with Continuing
Education activities = 13
might not be useful?
Other Comments = 2
Some recommended treatment practices are
not practical or available in your setting = 8 Format Comments = 5
Of 25 respondents, most agreed that the Guideline Dissemination:
format was easy to use; only 2 disagreed This guideline should be disseminated to
(and they may have reviewed the Full all appropriate practitioners in:
Version- there were some comments that Nova Scotia = 9 No Answer = 2
the FV was too long for routine clinical Atlantic Canada = 15 Other = 1 (nation-wide)
practice, which was not the intent of the Comments = 1
FV in the first place). The results were
similar when asked if the flowcharts were In your opinion, should this guideline be
easy to understand. On the question of disseminated to appropriate health care
other formats, there was strong support for practitioners:
Once it is approved, and periodically
a pocketbook version (approx 4” by 7”) afterwards as new versions are approved = 17
and also a downloadable PDA version. It Only in response to a patient referral for
is the practice of CCNS to post all versions specialist care (e.g. to a cancer centre) = 0
of each guideline on the website and to Practitioners should be notified when it is
send any guideline version on request, so available on the website, and they can get it
themselves as they choose = 9
these options are already in place.
Other = 1
Guideline Content: Comments = 1
Overall, you agree with the content and If you do not think this guideline should be
recommendations of this guideline. disseminated, please check ALL the
Strongly Agree = 6 Agrees 19 reasons below:
Agree = 13 Disagrees 0 Other provinces have their own guideline
Neither Agree/Disagree = 1 No Answer = 6 development processes = 0
Disagree = 0 Not the mandate of Cancer Care Nova Scotia
Strongly Disagree = 0 to distribute guidelines outside Nova Scotia = 3
Comments: Other Dissemination Suggestions = 20
Additions to the guideline = 6
Deletions from the guideline = 1
Seventeen respondents felt that CCNS
should send the guideline to health care
Changes to the guideline = 4
practitioners once approved and when
Does the Quick Reference Version contain new versions are approved. Others thought
the appropriate information? that practitioners should ge the guidelines
Yes = 8 themselves from the website. The plan is to
No = 0 distribute the QRV to a large group of
Comments = 2 health care professionals and to suggest
the website for access to the FV and to the
None of the 25 respondents disagreed Comprehensive Version.
with the content or recommendations.
Twelve respondents answered the Reconciliation of Guideline with
question about the content in the Quick Feedback Results
Reference Version; of these, 2 did not see Upon feedback from the reviewers, the
the QRV, and 8 agreed with the amount document was modified. Format issues
of content. Two made suggestions for were resolved in collaboration with the
improvements. From these results, it would Guidelines Resource Team of Cancer
appear that the content is correct and Care Nova Scotia.
that right amount is included in the QRV. Once the draft document was
completed, with modifications from the
reviewers, it was approved by the CST.
The approved guideline will be circulated
in hard copy to all cancer care and
palliative care specialists (from multiple
disciplines), to practicing dentists (through
the NSDA), to the cancer chemotherapy
clinics and regional hospital pharmacies
in Nova Scotia, and to health sciences
libraries in hospitals and universities.
Copies will also be made available to
health care professionals in Prince Edward
Island and New Brunswick. Others who
are interested may request hard copies
by contacting Cancer Care Nova Scotia
at 1-866-599-2267. All versions of the
approved guideline will also be available
on the CCNS Web Site
(www.cancercare.ns.ca).
The guideline will be reviewed three years
after approval or revised as necessary
before then as new evidence becomes
available. The most recent version of this
guideline will always be available on the
CCNS Web Site.
The development of this guideline was
funded indirectly by CCNS via a stipend
for the Supportive Care Cancer Site
Team’s operations. CCNS staff also
support the guideline development
process. CCNS directly funded the design,
printing and dissemination of the
guideline survey as well as the approved
guideline. The views and interests of CCNS
have not influenced the Supportive Care
Cancer Site Team’s recommendations in
this guideline.

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Comment on Clinical Research: Acknowledgements:

© Crown copyright, Province of Nova Scotia, 2006.

a false membrane Xerostomia: Abnormal dryness of the

Table 2.2 Pathophysiologic Phases in Development of Mucositis 5

Figure 2.2 Pathophysiology of Oral Mucositis

1. Initiation 2.Upregulation & generation of

Inflammation Cell Growth

Many chemotherapeutic agents exert maximum anti-tumour activity. Such

Table 2.6 Oral Complications of Hematopoietic Stem Cell Transplantation19

Mouth Care Record for Cancer Patients

MOUTH ASSESSMENT DATE:

Table 4.1 Communications with Dental Oncology Team

INTERMEDIATE RISK (40%)

Same as Low Risk, plus

the cancer patient population (adapted before surgery; OR

Table 7.2: Agents for Mucositis Management (Stepped Approach)

Oral Infection Oral Hemorrhage:

May add oral Fluconazole for prevention

Xerostom ia M anagem ent for Head & Neck Radiotherapy Patients:

O ral Hem orrhage:

7.3.2 Xerostomia Management line with those of Regnard et al.,75 who

Table 7.5 Chlorhexidine Mouth Rinse for Pediatric Oncology Patients

Broad-Spectrum Blood Specific Oral

Frequent sips of water, Oral Pilocarpine

Ice Water & Consider platelet

Topical Topical Anesthetic/Pain Consider Topical

Pain Not Pain Not Systemic Analgesics

Alteration in taste in cancer patients may 7.13 Dysgueusia

Table 7.8 Strategies to Maintain Nutrition in Patients with Oral Complications

contribute to wound resolution. Wherever mandible can be reconstructed to

Effective September 2005

Screening for Oral Complications Assessment of Oral Complications:

Patients at high risk of serious oral Assessment should be incorporated into

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