Professional Oral Care

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: Oral care was suggested for the prevention of OM in adult and pediatric populations for all types of cancer therapies. No population-specific guidelines were recommended.
• Dental care (by a professional): No guidelines were recommended for dental care in the prevention of OM.
• Normal saline: No guidelines were recommended for normal saline for the prevention or treatment of OM.
• Sodium bicarbonate rinse: No guidelines were recommended for sodium bicarbonate for the prevention or treatment of OM.
• Chlorhexidine: No guidelines were recommended for chlorhexidine for the prevention or treatment of OM in patients receiving standard chemotherapy or hematopoietic stem cell transplantation. Guidelines suggest that chlorhexidine not be used to prevent OM in patients with head and neck cancer treated with radiotherapy.
• Mixed medication mouthwash: No guidelines were recommended for mixed medication mouthwash for the prevention or treatment of OM.
• Calcium phosphate: No guidelines were recommended for calcium phosphate for the prevention or treatment of OM.

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.

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.
 

To assess the usefulness of prophylactic professional oral health (POHC) care done by dentists and dental hygienists for preventing mucositis in patients undergoing chemotherapy

• N = 26  
• MEDIAN AGE = 58 (+/– 9.8) years
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Patients with breast cancer receiving chemotherapy
• OTHER KEY SAMPLE CHARACTERISTICS: No significant differences existed between the two groups with regard to age, BMI, or number of teeth.

• SITE: Single site    
• SETTING TYPE: Outpatient    
• LOCATION: Department of Surgery at Tokyo Dental College, Ichikawa General Hospital

• PHASE OF CARE: Active antitumor treatment

• Randomized controlled trial

• National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0 (NCI-CTCAE)
• Eiler’s Oral Assessment Guide (OAG)
• Evaluation of oral hygiene using plaque control records (PCR)
• Evaluation of dry mouth and oral moisture using the Saxon test and oral moisture checking device (MUCUS) 
• Gustatory measurements using an electrogustometer

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.

• Small sample (< 30)
• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Risk of bias (sample characteristics)
• Findings not generalizable
• Other limitations/explanation: Single gender study and single diagnosis

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

RCT

Oral mucositis was diagnosed by a dentist, assessed every Monday, Wednesday, and Friday.

Japan clinical oncology group criteria-based on NCI-CTC

Bacterial analysis
 

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