Effectiveness Not Established

Saline

for Mucositis

Saline is a solution of sodium chloride in water, and it can be used for multiple purposes including intravenous infusions, nasal irrigation, eye drops, and wound cleaning. Several formulations of saline are available with added ingredients including Lactated Ringer's solution and Acetated Ringer's solution. 

Systematic Review/Meta-Analysis

Hashemi, A., Bahrololoumi, Z., Khaksar, Y., Saffarzadeh, N., Neamatzade, H., & Foroughi, E. (2015). Mouth-rinses for the prevention of chemotherapy induced oral mucositis in children: A systematic review. Iranian Journal of Pediatric Hematology and Oncology, 5, 106–112.

Purpose

STUDY PURPOSE: To evaluate studies on basic oral care interventions to update evidence-based practice guidelines for preventing oral mucositis in patients with cancer receiving chemotherapy
 
TYPE OF STUDY: Systematic review

Search Strategy

DATABASES USED: PubMed and Google Scholar
 
KEYWORDS: Cancer, chemotherapy, children, mouthwash, and mucositis
 
INCLUSION CRITERIA: All papers were published between 2000 and December 2014 and used the terms mucositis, chemotherapy, mouth rinses, oral care, oral care protocol, dental care, dental cleaning, oral decontamination, and oral hygiene. Both research and clinical work were included.
 
EXCLUSION CRITERIA: Review articles, clinical case reports, literature reviews, and other nonresearch articles were excluded. Articles not written in English also were excluded. 

Literature Evaluated

TOTAL REFERENCES RETRIEVED: 151
 
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: No evaluation method was identified.

Sample Characteristics

  • FINAL NUMBER STUDIES INCLUDED = 30
  • TOTAL PATIENTS INCLUDED IN REVIEW = Not reported
  • KEY SAMPLE CHARACTERISTICS: Chlorhexidine, benzydamine, sodium bicarbonate, granulocyte macrophage colony-stimulating factor, iseganan, sucralfate, and normal saline were reviewed. No sample characteristics were reported.

Phase of Care and Clinical Applications

PHASE OF CARE: Active antitumor treatment
 
APPLICATIONS: Pediatrics and palliative care

Results

None of the mouth rinses were definitely effective in preventing chemotherapy-induced oral mucositis in children. Normal saline had a preventive effect in patients receiving chemotherapy, radiotherapy, and hematopoietic stem cell transplantation, but other studies have shown less efficacy than chlorhexidine or honey with saline. Benzydamine was less effective than chlorhexidine.

Conclusions

There was limited evidence for agents to prevent or manage oral mucositis in children.

Limitations

  • Few studies for any single agent used
  • Few data bases used  
  • Limited sample information provided  
  • No quality of research evaluation

Nursing Implications

Mouth rinses are an important component to oral care in the prevention of mucositis in pediatric patients receiving chemotherapy. Nurses need to continue research to develop evidence-based practice guidelines for this debilitating side effect of chemotherapy.

Print

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.

Purpose

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

Search Strategy

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

Literature Evaluated

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.

Sample Characteristics

FINAL NUMBER STUDIES INCLUDED = 52

SAMPLE RANGE ACROSS STUDIES, TOTAL PATIENTS INCLUDED IN REVIEW: Not stated

Phase of Care and Clinical Applications

PHASE OF CARE: Active antitumor treatment

Results

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.

Conclusions

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.

Limitations

Evidence for interventions to prevent and treat OM are limited, making guideline recommendations difficult.

Nursing Implications

Nurses should teach patients appropriate oral care to help prevent OM.

Print

Guideline / Expert Opinion

Blanchard, D., Bollet, M., Dreyer, C., Binczak, M., Calmels, P., Couturaud, C., ... & Albert, S. (2014). Management of somatic pain induced by head and neck cancer treatment: Pain following radiation therapy and chemotherapy. Guidelines of the French Otorhinolaryngology Head and Neck Surgery Society (SFORL). European Annals of Otorhinolaryngology, Head and Neck Diseases, 131, 253–256. 

Purpose & Patient Population

PURPOSE: To provide a SFORL guideline for the management of somatic pain induced by head and neck cancer treatment concerning the management of pain following radiation therapy and chemotherapy
 
TYPES OF PATIENTS ADDRESSED: Patients with head and neck cancer receiving radiation and chemotherapy 

Type of Resource/Evidence-Based Process

RESOURCE TYPE: Evidence-based guideline  
 
PROCESS OF DEVELOPMENT: Literature review and level of evidence grading guides by the L'Agence Nationale d'Accréditation et d'Evaluation en Santé (ANAES) guide to literature analysis and grading
 
SEARCH STRATEGY:
  • DATABASES USED: Not stated
  • KEYWORDS: Not stated
  • INCLUSION CRITERIA: Not stated (based on each reviewer’s experience)
  • EXCLUSION CRITERIA: Not stated

Phase of Care and Clinical Applications

PHASE OF CARE: Active antitumor treatment

Results Provided in the Reference

Many systematic reviews were used as references such as the Cochrane Library, but no number articles reviewed or how these were chosen were mentioned. Selection was based on each reviewer’s experience. 

Guidelines & Recommendations

Guideline 1: To limit early and late toxicity, radiation therapy should at least be conformal and, if indicated, intensity-modulated, to deliver a homogeneous dose to target volumes and spare healthy tissue as far as possible (grade B).
 
Guideline 2: To reduce radiation therapy-induced pain, patients should be prescribed a nutritional assessment with hygiene, diet, postural instructions as well as smoking cessation and alcohol abuse counseling (grade B).
 
Guideline 3: To prevent and treat radiation-induced microsites, it was recommended to:
  • Assess and eradicate dental infection sites ahead of radiation therapy and transmit irradiated volumes to the dentist
  • Use a soft toothbrush and replace it regularly
  • Apply fluoride to dental splints
  • Perform regular mouth rinses with nonalcoholic saline solution
  • Ensure the early diagnosis and treatment of bacterial, fungal, and viral super infections (grade B).
Guideline 4: Stress preventive measures against painful late complications of radiation therapy (expert opinion).

Limitations

  • No clear statement of review process
  • No stated inclusion or exclusion criteria
  • Number of articles retrieved and reviewed for these guidelines was not provided

Nursing Implications

The categorization using the ANAES guides to determine level of evidence and grades was appropriate. However, the search methods used in these guidelines were not clearly stated and need reconfirmation because there was no way to know whether the search was comprehensive. The recommendations were grade B and expert opinions.

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