Oral Complications from Cancer Therapy
An Overview of Cancer Care IntroductionClinicians are often challenged with the management of oral complications as their patients undergo cancer treatments. In 2006, Cancer Care Nova Scotia published a "Best Practice Guideline for the Management of Oral Complications from Cancer Therapy" (Broadfield & Hamilton, 2006). More recently these guidelines have been summarized (Broadfield, 2007). This article will provide an overview of the recommendations put forth as they pertain to the adult population. The full Cancer Care Nova Scotia document is available on line at www.cancercare.ns.ca . A print version can be obtained by emailing info@ccns.nshealth.ca or by calling 1 800 599 2267. Risk FactorsThe risk of oral complications varies based on the type of cancer and the type of treatment. At highest risk are patients receiving hematopoietic stem cell transplant and all patients receiving radiotherapy to the oral cavity. Those at intermediate risk are patients receiving chemo as the primary cancer treatment, and chemo targeted to tumors of the head and neck or GI tract. The lowest risk is for patients receiving chemo after surgical removal of a solid tumor (Broadfield, 2007). (Table 1) Table 1:
The most common complications are oral mucositis (or stomatitis), salivary gland dysfunction (or xerostomia), oral pain and oral infection (Broadfield, 2007). Other more serious complications (oral hemorrhage, systemic infections) may occur as a result and are often difficult to manage. PreventionPrevention is key, especially for those at intermediate or high risk.
The guideline reviews a detailed mouth care plan with recommendations for flossing, brushing, rinsing, denture care, care of necrotic tissue, lip care and eating. Rinsing of the mouth should be encouraged. "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" (Broadfield & Hamilton, 2006). There are several recommended rinsing solutions:
DO NOT USE:
Of the recommended solutions, there is no one solution found to be better than another. Finding the solution that the patient prefers is important, as the diligence in rinsing is a key factor. The Guideline also recommends that each patient visit their dentist or oral surgeon for a complete examination prior to beginning chemo or radiation to the oral cavity. "The organization of a pre chemotherapy dental visit is a change in common practice, and will require collaboration between the physician referring patients for chemotherapy, (often surgeon), the oncologist receiving the referral, and action by an informed patient" (Broadfield, 2007). In some cases there is a delay between surgery and the start of chemotherapy allowing for an opportunity to undergo the dental exam/intervention. It is understood that for some this recommendation may not be practical, and urgent chemotherapy should not be delayed to accommodate the dental visit. Clear communication between providers is key. The Guideline outlines other preventative measures utilized during the treatment process as well as measures that have been proven to be ineffective, or for which there is insufficient evidence of their effectiveness. (See the full version for further information.) ManagementMucositisDue to the lack of definitive evidence, a stepwise approach to management is proposed in the guidelines. (Table 2) The approach progresses from the least aggressive treatment for minor mucositis symptoms to more aggressive treatment for more significant symptoms. Note: the use of local anesthetics is not the first step but is reserved for significant oral pain when coating agents alone and non steroidal anti inflammatories/analgesics are not effective (Broadfield, 2007). "There is evidence that chlorhexidine should not be used to treat established oral mucositis" (Broadfield, 2007). If it has been advised by a dentist for prevention of dental cavities, it should be held if there is mucositis. Table 2
Oral Pain Oral pain can often accompany oral mucositis. The severity of pain can change over time and can differ based on treatments. The guideline suggests the following:
For pain that persists despite the above interventions, local anesthetics, alone or compounded in a pain relief mouthwash may be used. Eliminate any formulations that include antibiotic agents (e.g. nystatin). There are three suggested formulations which are listed on Page 7 of the Guideline (refer to previous web site information). Currently at Saint Martha's Regional Hospital, when 'Magic Mouthwash' is ordered by a physician, the formula used is as follows:
The Saint Martha's hospital pharmacy is currently making a change to the formula to reflect the guideline recommendation of Diphenhydramine 6.25mg/5ml (pediatric elixir). The current formulation being used is the adult elixir and contains alcohol, which may in fact cause irritation and drying. Patients may notice the 'bubble-gum' flavor of the pediatric elixir when the change is instituted. It is important for Clinicians to note that the components of the 'Magic Mouthwash' can be specified in the prescription if specific components may better suit their patient's needs. For example, Maalox could be substituted for the Kaopectate as it has more balanced effect on the bowels. When using Magic Mouthwash, patients should be instructed to swish 10-15ml for up to 2 minutes (after brushing teeth and rinsing mouth). Then spit out or swallow slowly. Repeat TID QID prn. "Patients on these agents need to be properly educated about avoidance of aspiration from foods and liquids when the anesthetic numbs the gag reflex" (Broadfield, 2007). In many cases, it is the pain relief provided by the mouthwash that allows the person the ability to eat. "Systemic absorption of swallowed lidocaine may be contraindicated in patients with impaired cardiovascular function." (Broadfield & Hamilton 2006). Very severe pain: is most likely to occur with hematopoietic stem cell transplant patients and often requires hospitalization and parenteral opioids. Oral InfectionsOral candidiasis (or Thrush) is a very common type of oral infection and is particularly associated with mouth ulcers. The Best Practice statement in the guideline is as follows: Patients who are at risk or who have been diagnosed with candidiasis (thrush) should be treated with oral fluconazole 100mg qd (or another azole antifungal agent). Oral nystatin suspension or alternate forms of nystatin delivery may be considered if fluconazole is contraindicated. "Despite established empiric practice, the evidence to date suggests that absorbable antifungal agents, such as fluconazole, are effective for both prevention and treatment, whereas non-absorbable agents, such as nystatin, are not effective. It is recommended that nystatin not be used for routine prevention or treatment, and this agent is not included in any mouthwash formulations" (Broadfield, 2007). What is not clear in the evidence is the recommendation for the appropriate duration of treatment with systemic antifungal agents. Daily, long-term treatment would be contraindicated for many, and for some, a single dose would be sufficient. It is a clinical judgment on the part of the clinician with regards to the duration of treatment. The guideline includes a table outlining appropriate treatment of bacterial, herpes simplex, varicella zoster, CMV and non herpes virus infections. The only recommended prophylaxis for oral infection is fluconazole; otherwise infections are only treated as they occur. ConclusionThe oral complications from cancer treatment can add discomfort and distress to patients already facing challenging medical situations. Clinicians can assist by offering education about preventative mouth care (often one measure that patients can control), communicating with providers about pre treatment dental assessments, and following a stepwise approach to management of oral complications as they arise. - Heather Brander RN, CHPCN(C) Thanks to Dr. Michael MacKenzie, Director of the Palliative Care Department at St. Martha's Regional Hospital, for reviewing the draft copy of this article. References:
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