Professional oral care involves the examination, cleaning, treatment of dental caries, management of periodontal disease, and appropriate tooth extraction by dental professionals. Provision of professional oral care during cancer treatment was studied in relation to prevention of oral mucositis.
McGuire, D.B., Fulton, J.S., Park, J., Brown, C.G., Correa, M.E.P., Eilers, J., . . . Lalla, R.V. (2013). Systematic review of basic oral care for the management of oral mucositis in cancer patients. Supportive Care in Cancer, 21, 3165–3177.
STUDY PURPOSE: To systematically review oral care interventions for the prevention and treatment of oral mucositis (OM) in patients undergoing cancer treatment
TYPE OF STUDY: Systematic review
DATABASES USED: Ovid MEDLINE
KEYWORDS: mucositis, stomatitis, cancer, oral care, oral care protocol, dental care, dental cleaning, oral decontamination, oral hygiene, saline, sodium bicarbonate, baking soda, chlorhexidine, magic/miracle mouthwash, calcium phosphate
INCLUSION CRITERIA: Primary research article, reflects a variety of research designs, rested the effects of intervention on severity of OM or mucositis-related symptoms
EXCLUSION CRITERIA: Review articles, clinical case reports, literature reviews, non-research articles
TOTAL REFERENCES RETRIEVED = 129
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Hadorn et al. criteria was used to assess the flaws in the selected publications, and levels of evidence were rated using the Somerfield schema.
FINAL NUMBER STUDIES INCLUDED = 52
SAMPLE RANGE ACROSS STUDIES, TOTAL PATIENTS INCLUDED IN REVIEW: Not stated
PHASE OF CARE: Active antitumor treatment
The guidelines are as follows.
Oral care protocols are recommended to patients for the prevention and treatment of OM. Chlorhexidine is not recommended for patients with head and neck cancer who receive radiotherapy treatment.
Evidence for interventions to prevent and treat OM are limited, making guideline recommendations difficult.
Nurses should teach patients appropriate oral care to help prevent OM.
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.
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.
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.
Saito, H., Watanabe, Y., Sato, K., Ikawa, H., Yoshida, Y., Katakura, A., ... Sato, M. (2014). Effects of professional oral health care on reducing the risk of chemotherapy-induced oral mucositis. Supportive Care in Cancer, 22, 2935–2940.
To assess the usefulness of prophylactic professional oral health (POHC) care done by dentists and dental hygienists for preventing mucositis in patients undergoing chemotherapy
Further studies are needed to investigate the addition of professional oral care along with self-care. In this study, oral mucositis was not improved or made worse by professional oral care. There is a definite role for better education regarding self-care and adherence to self-care with oral hygiene. Patients need to understand how their oral care can affect the side effects they may experience from the medication.
Yoneda, S., Imai, S., Hanada, N., Yamazaki, T., Senpuku, H., Ota, Y., et al. (2007). Effects of oral care on development of oral mucositis and microorganisms in patients with esophageal cancer. Japanese Journal of Infectious Diseases, 60(1), 23–28.
All patients received initial tooth brushing with a dental brush by a dentist and scaling to teeth with an ultrasonic scaler.
Special care group:
Dentist performed oral care with irrigation and suctioning for 15 minutes three days per week for two to four weeks between 7:00 pm and 8:00 pm after dinner. 20 ml of 0.5% povidone-iodine was ejected through the e-brush, then suctioned. This was done in the mouth, sides of the teeth, tongue, and mucosal surfaces. Patients rinsed with 0.5% povidone-iodine to clean the oral cavity. A combination of physical and chemical cleaning was used.
Patients with newly diagnosed esophageal squamous cell carcinoma (SCC) treated with chemoradiotherapy
The study was comprised of 40 patients (20 in the regular oral care group and 20 in the e-brush group).
The mean patient age was 66.2 years (SD = +/– 7.9 years) and 58.0 years (SD = +/– 6.3 years), respectively.
October 2003–January 2005
Oral mucositis was diagnosed by a dentist, assessed every Monday, Wednesday, and Friday.
Japan clinical oncology group criteria-based on NCI-CTC
Incidence of oral mucositis was significantly lower in the special care group (4 of 20 [20%] versus 11 of 20 [55%] [p = 0.048]).
Induced stable microflora consisting of oral streptococci
Small study; labor intensive intervention; unclear about costs