Mucositis - diagnosis and treatment

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1. Introduction

The purpose of this document is to provide guidance for the management of mucositis in children and young people with cancer receiving chemotherapy/radiotherapy.  

Oral complications occur commonly during and/or following cancer treatment, particularly in patients undergoing haemopoietic stem cell transplant (HSCT).  This can result in pain, difficulty in swallowing, phonation and poor nutrition, severely impacting on the patient’s quality of life. Mucositis, painful inflammation and ulceration of the mucous membranes, is one of the commonest side effects of chemotherapy. The oral mucosa consists of rapidly dividing cells that are especially susceptible to the damaging effects of cytotoxic therapy. Oral complications during chemotherapy and radiotherapy can arise not only from direct injury to the oral mucosa, but secondary to cytotoxic induced myelosuppression resulting in profound neutropenia. Good oral hygiene is crucial as without it, mucositis can lead to secondary bacterial, fungal and viral infections.  Minimising mucositis is crucial to the prevention of these complications and to promoting good quality of life.  

2. Related documentation

Mouth Care Guidelines for Parents, Carers & Children (available via the Dentist).

3. Authorised personnel / specific staff competencies

Medical, nursing, pharmacy and dental staff.

4. Equipment / materials
  • Apron
  • Otoscope / torch
  • Sick bowl
  • Soft toothbrush
  • Swabs (if required)
  • Toxicity score / treatment table (OAG scoring, see Appendix 2)
  • Pain assessment tool 
5. Procedure

Diagnosis

  • The patient’s mouth should be regularly examined by a nurse/doctor/dentist using the otoscope/torch as part of routine assessment to observe any changes ie inflammation, ulcerated areas and candida plaques using the scoring chart below (see Appendix 1). External changes ie sore or vesicles on the lips should also be noted and bacterial/viral swabs taken where necessary.
  • All findings (ie affected area, grading, pain scale) should be documented in the casenotes.
  • Swabs should be sent for microscopy and bacterial and viral culture as appropriate.

 

Treatment

  • Patient should be encouraged to maintain good oral hygiene and to maintain an adequate volume of oral fluid.
  • A mouthwash appropriate to the grade of mucositis (see Appendix 3) should be prescribed.
  • Appropriate pain control is recommended together with the continuation of good oral hygiene, as tolerated. The patient's pain should be assessed using the assessment tool in Appendix 3.
  • Patients should be referred for laser therapy if thought to be of benefit.

 

Appendix 1: Mouthcare for children & young people with cancer (CCLG evidence based guidelines)

DENTAL CARE / TREATMENT


At Diagnosis:
Oral & dental assessment

Oral hygiene advice should be given to children and parents prior to commencing cancer treatment and this should be provided both verbally and in writing.

  • Ideally by a dentist or dental hygienist linked to the cancer centre, or a member of the medical or nursing team who has received appropriate training
  • Advice should be given to brush at least twice a day with a fluoride toothpaste (containing 1,000 ppm fluoride +/- 10%)
  • Toothbrush should be for the sole use of the child and changed on a weekly basis. It should be changed following an oral infective episode.
  • For babies without teeth or for children where it is not possible to brush teeth, parents /carers should be instructed on how to clean the mouth with oral sponges. Sponges should be moistened with water
  • Any treatment required should be undertaken by a consultant or specialist paediatric dentist
  • If there is not a paediatric dental unit liaising with the cancer centre, there should be clear communication between the cancer centre and the routine dental provider

During cancer treatment:
Dental assessment every 3-4 months

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

Post Treatment:

Parents should be informed of the possible long term dental or orofacial effects of treatment. 

Monitored for these effects regularly 

By usual dental provider with clear communication and guidance from the cancer centre

BASIC ORAL CARE

At Diagnosis & During Treatment:

  • Brush teeth well twice a day using fluoride toothpaste and soft toothbrush
  • Whilst in-patient, oral assessment using OAG (reference) and score recorded.
    Frequency of assessment determined by individual need
  • OAG score >8 means increased risk of oral complications
  • Use of additional aids eg floss, fluoride tablets and electric toothbrushes – by recommendation of the dental team only. Chlorhexidine is not recommended unless – see below (if unable to brush teeth, clean mouth with oral sponges moistened with water or diluted chlorhexidine

ORAL COMPLICATIONS (FOR DOSES SEE BNF FOR CHILDREN)

   Prevention Treatment

Mucositis

  • Basic oral care (as above)
  • Basic oral care (as above)
  • Appropriate pain control

Pain

  • Adequate analgesia according to unit policy
  • Adequate analgesia according to unit policy

Candidiasis

  • Basic oral care (clinical decision required. If antifungal agent to be used choose one absorbed from GI tract eg fluconazole or itraconozole
  • Check treatment protocols
  • Nystatin is not recommended
  •  Basic oral care plus (Clinical decision required. If antifungal agent to be used choose one absorbed from GI tract eg fluconazole or itraconozole
  • Check treatment protocols
  • Nystatin is not recommended

Xerostoma

  • Basic oral care
  • Basic oral care
  • Consider saliva stimulants/artificial saliva

Herpes

  • Basic oral care
  • Aciclovir is only recommended as a preventative strategy for herpes simplex in patients undergoing high dose chemotherapy with stem cell transplant
  • Basic oral care plus
  • Mild and/or non-progressive lip lesions: topical aciclovir
  • Moderate/severe and/or progressive lip lesions & for mild/moderate oral lesions: oral aciclovir
  • Severe oral lesions or if oral cannot be tolerated: IV aciclovir

Routine recommended oral care

All Patients HSCT / PBSCI Patients
Oral Assessment Oral Assessment

Baseline assessment on admission but daily OAG* not required unless:

  • baseline deviates from normal
  • neutropenia present
  • mucositis present

Then daily OAG until discharge

Baseline assessment on admission & daily until discharge

Mouth Care Mouth Care

Brush teeth and gums well twice daily with a fluoride toothpaste and soft tooth brush.

+

Daily fluoride supplements

If oral candida develops treat with short courses of oral fluconazole

If herpes simplex develops treat with aciclovir

Brush teeth and gums well twice daily with a fluoride toothpaste and soft tooth brush.

+

Daily fluoride supplements

+

Ambisome 1mg/kg THREE times weekly (Mon/Wed/Fri)

NB: 2mg/kg for HSCT patients

+

Aciclovir prophylaxis as per unit policy

 

Appendix 2: Oral assessment guide for children & young people
Category Method of Assessment 1 2 3

Swallow

Ask the child to swallow or observe the swallowing process. Ask the parent if there are any notable changes.

Normal.
Without difficulty

Difficulty in swallowing

Unable to swallow at all.
Pooling, dribbling of secretions.

Lips and corner of mouth

Observe appearance of tissue

Normal.
Smooth, pink and moist.

Dry, cracked or swollen

Ulcerated or bleeding

Tongue

Observe the appearance of the tongue using a pen-torch to illuminate the oral cavity

Normal.
Firm without fissures
(cracking or splitting) or prominent papilla, pink and moist.

Coated or loss of papillae with a shiny appearance with or without redness and/or oral Candida

Ulcerated, sloughing or cracked

Saliva

Observe consistency and quantity of saliva

Normal.
Thin and watery

Excess amount of saliva, drooling

Thick, ropy or absent

Mucous membrane

Observe the appearance of tissue using a pen-torch to illuminate the oral cavity

Normal.
Pink and moist

Reddened or coated without ulceration and/or oral Candida

Ulceration and sloughing, with or without bleeding

Gingiva

Observe the appearance of tissue using a pen-torch to illuminate the oral cavity

Normal.
Pink or coral with a stippled (dotted) surface. Gum margins tight and well defined, no swelling.

Oedematous with or without redness, smooth

Spontaneous bleeding

Teeth
(If no teeth score 1)

Observe the appearance of teeth using a pen-torch to illuminate the oral cavity

Normal.
Clean and no debris

Plaque or debris in localised areas

Plaque or debris generalised along gum line

Voice

Talk and listen to the child.

Ask the parent if there are any notable changes.

Normal tone and quality when talking or crying

Deeper or raspy

Difficult to talk, cry or not talking at all

Oral assessment guide, 2004 - Adapted from Eilers, J. Berger, A. and Peterson, M. (1988) by GOSH Oral Care Working Party. © GOSH

Appendix 3: Assessment of acute pain in children

Recommendations for the Treatment of Oral Mucositis

  • Appropriate pain control is recommended together with the continuation of good oral hygiene, as tolerated
  • Pain associated with mucositis can be severe. Opiates are required for the control of such pain.
  • Allopurinol mouthwash is not recommended for children receiving cancer treatment other than 5-FU
  • Athough there is no evidence base to support the use of the following for treatment of chemotherapy or radiotherapy induced mucositis in children they may be of benefit to some patients:
    • Benzydamine: Difflam Spray - Each metered dose pump spray delivers Benzydamine hydrochoride 0.15% w/v, approximately 175 microlitres per spray. Contains methyl parahydroxybenzoate and Ethanol
    • Folinic acid Mouth wash: May only be useful in cases of mucositis following Methotrexate chemotherapy
    • Betamethasone mouth wash for stem cell transplant patients with GvHD Dissolve 0.5-2mg in 10ml of water, swirl around the mouth for 1-2 minutes or as long as can manage and then spit it out, up to 4 times a day
    • Tacrolimus mouth wash
    • Anti viral (Aciclovir)
    • Metronidazole if bacterial infection is present

Recommendations for the prevention of oral mucositis

  • Parents and patients should be informed for the importance of keeping the mouth clean and encouraged to practice good, basic oral hygiene
  • The following have all been shown to be potentially beneficial for the prevention of mucositis:
    • Gelclair
    • Caphosol A+B
    • Chlorhexidine gluconate 0.2% mouth wash
Appendix 4: Drug information

Drug

Dosage

Comments

Aciclovir:

  • 200mg, 400mg, 800mg tablets (dispersible)
  • 200mg/5ml susp
  • Cream 5%

Herpes simplex prophylaxis in immunocompromised:

1month-2years: 200mg four times a day
2-18years:        400mg four times daily

Topical preparation is useful if applied to early onset of cold sores, which often reactivate during chemotherapy but should only be used with systemic treatment.
Cream may be used FIVE times daily for skin lesions for 5-10 days

Ambisome:

IV infusion

Prophylaxis: 1mg/kg THREE times weekly (Mon/Wed/Fri)

NB: 2mg/kg for HSCT patients

Prophylactic antifungal dose.

Infuse over 1 hour

Difflam oral spray

  • Difflam spray: local analgesic used to relieve localised oral pain

Difflam Spray:

<6years: 1 spray per 4kg of body weight (max 4 sprays at any one time) every 1.5-3hrs
6-12 years: 4 sprays every 1.5-3hrs
12-18 years: 4-8 sprays every 1.5-3 hours

Due to the anaesthetizing effect on the pharynx, difflam should not be used for pre-school children or immediately before meals as it could lead to choking. Care should be taken with very hot or cold drinks.

Fluconazole:

  • 50mg, 150mg, 200mg caps
  • 50mg or 200mg/5ml suspension

Mucosal candidiasis (except genital):

1 month-12 years: 3-6mg/kg (max 200mg) on the first day then 3mg/kg (max 100mg daily) for 7-14 days in oropharangeal candidiasis (max 14 days except in severely immunocompromised patients)

12-18 years: 50mg daily (max 100mg daily) for 7-14 days in oropharyngeal candidiasis (max 14 days except in severely immunocompromised patients)

Fluconazole should only be used to treat proven fungal infections. Fluconazole should NOT be used prophylactically except in Neuroblastoma high risk patients.

Monitor LFTs fortnightly, discontinue if signs and symptoms of liver disease. Intravenous Fluconazole can be used if the patient unable to tolerate oral medication. Consider interaction with chemotherapy when Fluconazole is used. 

Gelclair:

  • Concentrated oral gel

Mix entire sachet with 40ml of water
Use four times daily or more depending on pain
Rinse around mouth for at least 1 minute or as long as possible to coat tongue and inside of mouth completely

Discard any unused sachet after 24 hours

Gel which provides pain relief by adhering to the mucosal surface of the mouth

Gelclair can be used undiluted

Do not eat or drink for at least 1 hour following treatment

Morphine:

  • MST tablets:5mg
  • 10mg, 15mg, 30mg, 60mg &100mg
  • MST Sachets:20mg & 30mg
  • Morphine Sulphate 10mg/5ml (Oromorph)
  • Sevredol tablets (immediate release morphine sulphate) 10mg & 20mg

See "Guidelines for the Management of Acute and Post-Operative Pain".

Please note that these guidelines only provide starting doses for oral immediate release morphine and not MST preparations

Consult with RHC Pain Team

See BNF for Children for doses

If using part of a MST sachet mix well with water and use immediately. MST sachets should not be used for doses <5mg as sachets do not disperse equally therefore dosing may be inaccurate

Saliva stimulant 
Artificial saliva

Consult Pharmacy for available preparations

Preference is saliva orthana
Also stock Glandosane

Teething gels:

Consult Pharmacy for available preparations

Calgel
Avoid using Bonjela

Caphosol

Mix blue ampoule (A) with clear ampoule (B) Use four times a day

Rinse half of solution around mouth for 1 min then spit out. Repeat with remaining solution. 
Avoid food/drink for 15 mins after use

Chlorhexidine mouthwash

Rinse 5-10ml (depending on patient size) around mouth for about 1 min four times a day

Can apply to mucosa on swabs for very young patients

References

Mouthcare for Children & Young People with Cancer. Children's Cancer & Leukaemia Group (CCLG) Evidence Based Guidelines. Version 1.0 February 2006.

BNF for Children

EUSApharm Medical Information at: www.caphosol.com

Gelclair Product Information Leaflet. Produced by Alliance Pharmaceuticals.

Editorial Information

Last reviewed: 01 February 2018

Next review: 28 February 2020

Author(s): J Sastry

Version: 2

Approved By: Schiehallion Clinical Governance Group

Document Id: RHC-HAEM-ONC-029