Kashiwazaki, H., Matsushita, T., Sugita, J., Shigematsu, A., Kasashi, K., Yamazaki, Y., et al. (2011). Professional oral health care reduces oral mucositis and febrile neutropenia in patients treated with allogeneic bone marrow transplantation. Supportive Care in Cancer : Official Journal of the Multinational Association of Supportive Care in Cancer, 20(2),367-373.

To evaluate the effects of professional oral health care (POHC) given by dentists and dental hygienists on the development of oral mucositis and FN after allogeneic BMT.

1.    Pre-BMT, two dentists examined patient’s oral health, including x-rays, baseline hygiene, and clinical exam of hard and soft palate, looking for risk factors for oral infection.  
2.    All dental problems were treated up until HSCT.
3.    Dental hygienist gave mechanical cleaning of the mouth and instructed patients on how to properly clean the mouth and teeth.
4.    During HSCT period, all patients had to be able to perform proper oral hygiene themselves, which included brushing their teeth after every meal and before going to bed and oral rinsing with normal saline solution every three hours during the day.
5.    When xerostomia developed, a mouth-wetting agent containing baking soda was applied locally several times a day.
6.    Dentists and hygienists performed weekly oral exams and POHC on all patients and monitored compliance.
7.    When OM developed, extra-soft toothbrushes were used, and patients gargled with a saline rinse containing lidocaine. Opioids were used for severe OM pain.  
 

The sample was comprised of 140 patients. The median age for non-POHC was 43 (with a range of 15-66 years), n = 62. The median age for POHC was 47 (with a range of 18-77 years), n = 78.   

Males (%): 54; Females (%): 46

Key Disease Characteristics: Adult patients with ALL, AML, MDS, CML, malignant lymphoma, adult T-cell leukemia/lymphoma, MM, and other (6.7%)

Other Key Sample Characteristics:

1.    BMT was done by conventional or reduced-intensity stem cell transplantation.
2.    Conditioning regimens included Fludarbine/Busulfan, Fludarabine/Melphalan, Cytoxan/VP-16/total body radiation, Cytoxan/total body radiation, and others (8.6%).
3.    Cyclosporine A or tacrolimus and short-course methotrexate were given for GVHD prophylaxis.
4.    Median age, administration of Cytoxan/VP16/TBI and GVHD prophylaxis were significantly different between groups.
5.    The number of reduced-intensity stem cell transplant (RIST) was higher in the POHC group.
 

Site: Inpatient

Location: Hokkaido University Hospital, Sapporo, Japan

Phase of Care: Active treatment

Retrospective study from February 2002 until December 2009.  Data collected from clinical records.

1.    OM was graded using the WHO scale.
2.    Daily exams by nurses and physicians per instructions of the dentist in charge and at least weekly confirmation of assessments by dentists. (It is not stated if this is only in the POHC arm, but it is likely only in the POHC group.)
3.    FN was defined as a single axillary temperature of >37.5°C with a peripheral neutrophil count of <0.5 X 10⁹/L.    
 

1.    The incidence of OM was significantly lower in the POHC group (66.7% versus 93.5%).
2.    The incidence of FN and maximal level of CRP were both significantly lower in the POHC group (P < 0.035).
3.    The conditioning regimen and POHC were significantly associated with the incidence of OM in the univariate analysis.
4.    Only POHC remained significant in the multivariate analysis.
 

The incidence of OM in patients with POHC was significantly lower than in those without POHC.

Retrospective study

Higher number of RIST patients in the POHC group, which may account for the lower number o f cases of OM seen.

Long time from the non-POHC group and POHC make comparison to historical control less accurate. Additional intervening variables could be responsible for changes seen.

1.    This retrospective study helps to support the need for diligent oral hygiene prior to and during OM in high-risk patients.
2.    The intervention in this study is not expensive and does not introduce additional medications to patients, which put the patient at risk for additional side effects.
3.    This study reinforces the use of saline rinses.
4.    FN was lower in the study group, and interventions that can help decrease the incidence of this significant and sometimes deadly side effect of chemotherapy are worth considering (perhaps the risk of infection via the oral cavity was reduced through the use of meticulous mouth care).
5.    This intervention would require education to the patient and the caregivers prior to treatment and monitored during treatment, which oncology nurses are well positioned to do.
6.    This study was done inpatient, and it would be nice to see an outpatient prospective study done to see if the results are the same.