Oral Hygiene Guideline for Chemotherapy Induced Mucositis

Oral Hygiene Guideline for Chemotherapy Induced Mucositis

Reference Number Hae2(05) Version 6 Issue Date: 21/08/2020 Page 1 of 21

It is your responsibility to check on the intranet that this printed copy is the latest version


Lead Author: Anne Stout – Lead Chemotherapy Nurse

Additional author(s) Dr R Thomas-Dewing – Lead Chemotherapy Clinician

Mark Henry – Haematology Pharmacist

Division/ Department:: Surgery and Tertiary Medicine

Applies to: (Please delete) Salford Royal Care Organisation

Approving Committee Medicine Management Group

Date approved: 02/07/2020

Expiry date: July 2025

Contents

Contents

Section Page

1 Overview 2

2 Scope & Associated Documents 2

3 Background 2

4 What is new in this version? 3

5 Guideline 3

5.1 Pathophysiology 3

5.2 Prevention and oral health promotion 4

5.3 Risk factors 5

5.4 Potential oral disorders 5

5.5 Assessment 6

5.6 Standard mouth care protocol 7

5.7 Specific interventions 8

5.8 Individual patient interventions 9

5.9 Management of oral pain 9

6 Roles and responsibilities 11

7 Monitoring document effectiveness 11

8 Abbreviations and definitions 11

9 References 12

Group arrangements:

Salford Royal NHS Foundation Trust (SRFT)

Pennine Acute Hospitals NHS Trust (PAT)




10 Appendices 13

Appendix 1 NCI CTC AE Mucositis 14

Appendix 2 Mouth care assessment 15

Appendix 3 Management plan 16

11 Document Control Information 18

12 Equality Impact Assessment (EqIA) screening tool 19

1. Overview This guideline details recommendations for the prevention and treatment of chemotherapy induced mucositis.

If you have any concerns about the content of this document please contact the author or advise the Document Control Administrator.

2. Scope

2.1 This document will be used by medical, pharmacy and nursing staff responsible for prescribing, dispensing and administering cytotoxic chemotherapy for SRFT Haematology patients.

2.2 In addition it may be used by medical, pharmacy and nursing staff caring for patients

admitted to SRFT with mucositis who have received chemotherapy at another Trust 2.2 The document applies to adult patients only Associated Documents

Cytotoxic chemotherapy policy 200TD(C)46

3. Background

3.1 Oral mucositis is a toxicity to which all patients undergoing cytotoxic chemotherapy are exposed.

3.2 The oral mucosa is lined throughout with a mucous membrane consisting of epithelial

cells. An intact oral mucosa provides the first line of defence against infection. The normal cycle of these cells lasts 7 days; therefore there is a continual cell renewal process. Consequently it is these cells in the oral mucosa that are particularly vulnerable to attack by cancer chemotherapeutic agents. The effects of chemotherapy on the mouth require different considerations and complications usually occur between 7-10 days after the administration of cytotoxic treatment and can take 2-3 weeks to heal. The frequency of oral complications is two to three times higher in haematological malignancies than in solid tumours, which may be due to the immunosuppressive characteristics of haematological cancers.




3.3 Evidence suggests that mucositis is not preventable but its consequences can be

minimised through the implementation of effective oral health practices. It is important to identify those patients at risk of developing oral complications as soon as possible. Having knowledge and understanding of the chemotherapy agents used and their side effects and to have an appropriate assessment tool, which will help to identify the most appropriate evidence based intervention for each identified problem.

4. What is new in this version?

4.1 Changes to the assessment tool

5. Guideline

5.1 Pathophysiology

5.1.1 Cytotoxic drugs inhibit cellular replication. Thus the production of new cells is insufficient

to maintain mucosal integrity. Stomatitis may result from damage of the mucous membranes of the mouth and is largely unpreventable.

5.1.2 Problems occur either due to the direct effect of systemic chemotherapy drugs or

indirectly due to the effects of myelosuppression or immunosuppression when neutropenia renders the patient vulnerable to infection. Therefore any drug causing myelosuppression may indirectly cause stomatitis.

5.1.3 Stomatitis is the inflammation of the oral cavity resulting from damage to the mucous

membranes (Holmes, 1993). This includes the lips, gums, tongue, palate, floor of the mouth and throat.

5.1.4 Mucositis is the erythematous, erosive inflammatory and ulcerative response of the oral

cavity and gastrointestinal tract to certain chemotherapy agents (Shih et al, 2003). 5.1.5 Thinning and ulceration of the mucus membrane occurs within four to seven days of the

commencement of chemotherapy. Fluid and food intake are also reduced, due to nausea, vomiting and general malaise. This compounds the problem as debris and plaque accumulate in the mouth (Turner, 1996). Thus the mucus membrane is ineffective to invasive infections and there is an increased risk of gingivitis and dental caries. Nausea and vomiting may also result in malnutrition and therefore poor tissue healing and repair.

5.1.6 However, stomatitis tends to be self-limiting and resolves once treatment has completed.

Indirect effects occur within 7-14 days usually coinciding with the nadir period when patients are neutropenic. The mucosa, which is already compromised, becomes more susceptible to bleeding and infection. Healing occurs as the neutrophil count returns to normal (Holmes, 1997).

5.1.7 Most oral infections amongst chemotherapy patients originate from their own microflora,

with the oral cavity acting as the primary source in the development of septicaemia in




immunosuppressed patients (Eilers et al, 1988; Holmes, 1997). By reducing the number of microbes in the oral cavity patients may be able to reduce their risk of acquiring a systemic infection (Ransier et al, 1995).

5.1.8 Patients with impaired renal and/or hepatic function are at an increased risk of oral

complications due to the reduced metabolism and/or excretion of antineoplastic drugs (Holmes, 1997). This is thought to be because persistently high levels of cytotoxic agents within blood or tissue delays re-epitheliaisation.

5.1.9 Mucositis can affect quality of life causing pain and difficulty with eating, drinking,

swallowing and talking. In combination with other issues occurring at this time, it can contribute to fatigue and low mood. It is imperative to introduce measures to prevent mucositis, recognise it promptly and treat effectively.

5.2 Prevention and oral health promotion

5.2.1 Although mucositis is not completely preventable, the severity can be reduced through the implementation of effective oral health practises. During pre-chemotherapy counselling emphasis should be placed on prevention and oral health promotion. In addition patients can be given the Macmillan leaflet “Mouthcare during chemotherapy”.

5.2.8 Need to promote good patient education, prior to commencing chemotherapy about the

risk of mucositis and the importance of effective oral hygiene prior to and during chemotherapy. Important that patients are empowered to assess their own mouths and report any complications so treatment can be initiated promptly.

5.2.2 Prior to commencement of chemotherapy (where possible) ensure patients at an

increased risk of mucositis (refer to risk factors) are identified and referred to their primary care dental hygienist and dietitian.

5.2.3 Encourage routine six monthly assessments with a dentist throughout treatment and

follow up. Advise patients to seek advice from their dentist prior to undergoing any ongoing treatment.

5.2.4 If dental work is required once chemotherapy has commenced, it is essential the patient

has a full blood count check within 48hours of the proposed treatment and their medical team is consulted. Need to assess whether platelet transfusion is required pre-treatment and whether prophylactic antibiotic cover is necessary.

5.2.5 Optimise nutritional intake as this will assist in maintaining the integrity of the mucosa,

increase rate of mucosal repair and reduce deterioration of existing mucositis. 5.2.6 Encourage patient to stop smoking and drinking alcohol as they may aggravate the

effects of mucositis. 5.2.7 Ensure patients have well fitted dentures. If they fit poorly there is more likely to be

movement and potential irritation to the mucosa. 5.2.8 Advise patients with dentures to avoid/reduce the intake of sugary drinks and snacks

between meals and to rinse their mouth thoroughly with water after cleaning.




5.3 Risk factors

5.3.1 Factors that are likely to increase the incidence of mucositis include:

Intensive Chemotherapy Regimens

Bone Marrow Transplantation

Diagnosis of Leukaemia

Concurrent chemotherapy and radiotherapy particularly to the head and neck

Combinations of treatment including chemotherapy, radiotherapy, anti-microbials and corticosteroids

Elderly and Children

Poor oral/dental health

Deficits in self-care ability

Comorbidities

Altered Fluid or Nutritional Status (dehydration/malnutrition)

Administration of medicines that alter the integrity of the oral mucosa

Exposure to additional stressors (alcohol, tobacco, drugs, oxygen therapy)

Liver/Renal Impairment

Previous episodes of mucositis (Cancer Research UK, 2009; UKOMIC, 2019) 5.3.2 Cytotoxic chemotherapeutic drugs associated with an increased risk of mucositis include:

Actinomycin-D Amsacrine Bleomycin Capecitabine

Carboplatin Cisplatin Cyclophosphamide Cytarabine

Daunorubicin Docetaxel Doxorubicin Epirubicin

Etoposide Fludarabine 5 Fluorouracil Gemcitibine

Gemtuzumab Hydroxycarbamide Idarubicin Irinotecan

Lomustine 6-Mercaptopurine Melphalan Methotrexate

Mitomycin C Mitoxantrone Oxaliplatin Paclitaxel

Pemetrexed 6-Thioguanine Vinblastine Vincristine

5.3.3 Chemotherapy drugs in bold are those given in Haematology regimens at SRFT.

5.4 Potential oral disorders

5.4.1 According to Thurgood (1994) potential oral disorders that occur frequently are:

Candida (oral thrush) Caused by a yeast-like fungus, candida albicans, which normally inhabits the vagina and digestive system. It commonly manifests as soft white plaques on the mucosa and tongue.

Gingivitis Inflammation of the gums leading to swelling and bleeding caused by plaque that has built up on the teeth.

Leukoplakia A white patch on the tongue or cheek that cannot




be rubbed off.

Stomatitis Inflammation and infection of the oral mucosa

Ulceration Aphthous ulcers are white, small, punched out lesions of epithelial surfaces of the mouth, probably of viral origin.

Xerostomia A dry mouth.

5.4.2 The following oral disorders are seen less commonly: -

Dental caries Decay and crumbling of tooth structure caused by the formation of plaque following the deposit of bacteria onto teeth, gums and tongue.

Dysgensia Impairment of the sense of taste.

Parotitis Inflammation of the parotid salivary glands.

Periodontal deterioration

Disease of the gums and other structures supporting the teeth. Caused by the release of toxins from plaque. These initiate a local immunological response which attacks teeth and gums.

5.5 Assessment

5.5.1 Visual assessment of the oral cavity is the vital first step in the implementation of an

individualised plan of care for patients who are undergoing chemotherapy. The Clinical Haematology Unit utilises the NCI CTC AE (2017) assessment (Appendix 1) and an oral assessment tool to inspect a patient’s mouth (Appendix 2). The tool should be used to identify an appropriate management plan (Appendix 3). In addition staff should also refer to sections 5.6, 5.7, 5.8 and 5.9 for managing problems including pain.

5.5.2 Assessment and action required to maintain oral hygiene 5.5.3 Equipment required:

Clean procedure gloves

Torch

Tongue depressor

Toothbrush and paste

Kidney dish if required

Suction equipment if required

Tissues or wipes

Mouth washes and medication if prescribed

5.5.4 Procedure:

Explain the procedure to the patient

Wash hands

Put on gloves




Examine lips for any sores or cracking

Use torch and tongue depressor, if required, to inspect the oral cavity

Use flow chart to guide assessment and action

Assist patient to clean teeth and use mouthwashes if necessary

5.6 Standard mouthcare protocol

5.6.1 Key aims of all oral care are to:

Keep mucosa clean, soft, moist and intact to prevent infection

Keep lips clean, soft, moist and intact

Maintain pink and moist tongue free from ulceration and avoid a dry mouth

Remove debris and dental plaque without damaging gingiva

Alleviate pain and discomfort whilst optimising oral intake

5.6.2 All patients should have a baseline oral assessment undertaken by a registered practitioner on admission to hospital to identify usual oral care routine and identify the advice/care required to maintain or promote individual oral hygiene. This should be documented in the pre-chemotherapy assessment documentation and any problems identified.

5.6.3 In-patients who have had chemotherapy should have a daily oral assessment until

discharge. Following the scoring system refer to the specific interventions for actions. 5.6.4 Patients should brush their teeth every morning and evening as well as after every meal. Use a

soft-bristled or child's toothbrush. Toothbrush bristles can also be softened in hot water. An electric toothbrush can clean teeth very effectively. Toothbrushes should be stored with the brush head upwards and replaced frequently to prevent problems with infection.

5.6.5 For patients with dentures, dentures should be cleaned after each meal and removed

overnight, cleaned and stored in water in a closed container. Debris must be removed as candida may be present and be harboured in the dentures therefore; they should be stored in clean water and never left dry when out of the mouth.

5.6.6 Chlorhexidine antiseptic mouthwash should be used four times a day, after each meal and

at bedtime, after brushing teeth. Patients can dilute it with water to increase tolerance if necessary. Prolonged use can stain the teeth; hence it is advisable to brush teeth prior to using the mouthwash.

5.6.7 Lips may be moistened with Vaseline, soft paraffin or the patient’s own lip salve.

However, if the patient is on oxygen therapy a water soluble lubricant must be used. 5.6.8 Adequate oral fluid intake and self-care measures should be encouraged and the

necessary equipment, information and education provided to meet the individual needs identified. Advise patients very hot, cold, spicy, salty, coarse or dry foods may cause additional irritation and damage the mucosal lining and gums.

5.6.9 Susceptibility to mouth ulcers associated with Herpes simplex or Candida is increased

with prolonged neutropenia. Consequently, haematology patients receiving intensive




chemotherapy regimens eg. DA, FLAG-Ida, ESHAP should be commenced on antiviral and antifungal prophylaxis.

5.6.10 Cryotherapy (the therapeutic administration of cold as a prophylactic measure for oral

inflammation) involves enabling a patient to suck an ice lolly 5 minutes before, during and up to 25 minutes after bolus administration of short infusions such as high dose melphalan.

5.7 Specific interventions

5.7.1 In conjunction with the management plan in Appendix 3 the following interventions can

also be implemented.

Oral assessment Chemotherapy

Low risk

For non-intensive & non stomatotoxic chemotherapy regimes: Follow standard mouthcare protocol. Use soft toothbrush whilst neutropenic For intensive chemotherapy regimes/ stomatotoxic drugs: Follow standard mouth care protocol. Use soft toothbrush whilst neutropenic (i.e. total neutrophil count <1) For intensive chemotherapy regimes only: Follow prophylactic antifungal and viral agents as prescribed.

Medium risk

Continue standard mouth care protocol, increasing tooth brushing to following meals and at bedtime. Use soft toothbrush. Introduce Benzydamine pre meals & before bedtime rinsed around the mouth - review after 3 days. Consider Gelclair gel to be introduced in moderate mucositis. Continue antifungal and antiviral agents as prescribed.

High risk

Continue standard mouth care protocol as long as possible. Re-initiate brushing as soon as possible. Introduce syringe driver & Gelclair. Continue antifungal & antiviral agents as prescribed. Ensure fluid balance chart commenced. IV fluids/parenteral support may be required. Doctors should consider a reduction in the chemotherapy dose or defer next course if necessary.




5.8 Individual patient interventions

5.8.1 Often patients require assistance with oral hygiene. Standard mouth care should be maintained. In addition, water soaked swabs may be required to keep the mouth moist. Suction may also be required to remove excess secretions. The use of soft paraffin applied to the lips after mouth care will keep them moist and prevent drying and cracking of skin (caution needs to be observed when oxygen in use).

5.8.2 If ulceration is present, but there is no candida coating the tongue, teeth or mucosa,

Benzydamine (difflam) mouthwash should be used in addition to standard mouth care. Benzydamine enhances oral care as it contains a topical anaesthetic so consequently has a numbing analgesic effect, therefore, must be prescribed by medical staff. However, it has no antibacterial effect so should not be used in isolation.

5.8.3 If the tongue, teeth or mucosa are coated and candida is present, anti-fungal

preparations must be used along with standard care and Benzydamine mouthwash. Nystatin or amphotericin will act on the candida. When candida is present it may also be harboured in the patient’s dentures (Buglass, 1989), therefore brushing dentures at least four hourly is recommended.

5.8.4 If there is no candida present carefully brushing the tongue with Chlorhexidine 2%

solution is suggested. This acts by preventing the development and build up of plaque and also has an anti-microbial effect (Kite and Pearson, 1995; Thurgood, 1994). Pineapple chunks contain a proteolytic enzyme, which helps remove adherent coatings (Regnard, 1997).

5.8.5 If the patient’s mouth is dry (Xerostomia), it is important to treat the cause. Artificial

saliva, Bioxtra Oral gel, can be used without any detrimental effect and is particularly useful in patients with impaired saliva production. The use of ice cubes, pineapple chunks and ice-lollies may provide comfort as will using soft paraffin to moisten the lips.

5.8.6 If on assessment the patient has a painful mouth it is important to determine the cause.

This could be due to ill-fitting dentures, chemotherapy, radiotherapy, or infection. Topical analgesics are effective along with standard mouth care in relieving pain. Benzydamine as described earlier has an anti-inflammatory effect. Choline salicyfate dental gel has a local numbing effect.

5.9 Management of oral pain

5.9.1 There are a range of interventions which may help to reduce discomfort and pain depending on the severity:

Medicine

Comments

Paracetamol suspension mixture (Rosemont) (500mg in 5mls) * see below

Give half an hour before meals and before bedtime. Do not exceed maximum daily dose and do not take with other medicines containing




**see below paracetamol.

Benzydamine mouthwash or spray

Local anaesthetic effect. Use 10mls 4 x daily. Give 5-10mls before meals. Can cause stinging. May be diluted 50/50 with water. Use 7 consecutive days only as tolerance may develop.

5.9.2 If pain still not under adequate control, consider adding:

Codeine liquid 25mg/5ml Codeine linctus 15mg/5ml

Monitor bowel function as aperients may need to be titrated accordingly. Can be given 4-6 hourly but do not exceed maximum dose daily (240mg). Dilute 50/50 with water.

Choline salicyfate dental Apply to the affected mouth ulcers up to three hourly

Gelclair 15ml sachets Mix the contents of one sachet with water, rinse around the mouth and spit out. Use an hour before food as it forms a protective layer over the mucosal lining.

Hydrocortisone 2.5mg Muco-Adhesive Buccal tablets

One tablet to be allowed to dissolve in contact with the ulcer 4 times a day.

Orabase May be applied to affected areas after meals and at bedtime

5.9.3 If pain control still ineffective move onto strong opioids either orally or by subcutaneous

or intravenous route:

Strong Opioid systemic analgesia Morphine Sulphate Liquid 10mg/5ml Oxycodone Liquid 5mg/5ml Morphine Sulphate M/R twice daily Oxycodone M/R twice daily Morphine or Oxycodone subcutaneous pump

Monitor bowel function as aperients may need to be titrated accordingly.

*Soluble Paracetamol is often beneficial if patients are unable to tolerate Paracetamol mixture. ** Reduction in dosage applies to low body weight:

40 – 50kgs maximum dose 3g per 24 hours

30 - 40kgs maximum dose 2g per 24 hours

<30kgs seek further advice




6. Roles & responsibilities

6.1 Ward staff: This guideline has been created to reduce the severity and duration of

chemotherapy induced mucositis and minimise the complications of pain, oral and systemic infection, bleeding and malnutrition. All patients who sustain chemotherapy induced mucositis will be cared for according to this guideline. Within this Trust oral care is regarded as a clinical practice. A clinical practice may be defined as an aspect of care, which may be undertaken by registered nurses who accept accountability for their actions and feel competent to undertake the procedure. There is no formal assessment for these practices but there may be aspects of care that require a period of supervised, guided practice. They should form part of preceptorship or mentorship programmes. Health care assistants may carry out oral care and student nurses may deliver oral care to patients but only under the supervision of a registered nurse who feels competent in this aspect of care and in the supervisory role. However, a registered nurse should carry out oral assessment.

6.2 Haematology Unit Matron will manage the implementation of this policy. 6.3 Lead Chemotherapy Nurse and Haematology Clinical Nurse Specialists will disseminate

this policy to Haematology Nursing staff on the Clinical Haematology Unit. 6.4 Chemotherapy Service Group will review and monitor use of this guideline.

7. Monitoring document effectiveness

Key standards: Staff will use mouth care assessment tool to assess patients mouths and provide care in line with management plan and this policy.

Method(s): Compliance will be monitored via in patient risk assessment completion and datix reports. Staff experiencing difficulties with implementing this policy/guideline should contact their line manager.

Team responsible for monitoring: SRFT Chemotherapy Service Group and Clinical Haematology team

Frequency of monitoring: SRFT Chemotherapy Service Group meets every quarter where this policy will be reviewed and minuted. Datix reports will be monitored quarterly at CSG meetings. Issues from this Group are fed back via a representative who sits on the SRFT Medicines Management Group. Haematology Business meeting occurs bi monthly and issues with policies can be discussed

Process for reviewing results and ensuring improvements in performance: Any incidents should be reported through submission of adverse incident reports (DATIX) and will be collated and reviewed by the individual divisions, the Chemotherapy Service Group and Pharmacy to highlight risk management issues.

8. Abbreviations and definitions

DA – Daunorubicin and Cytarabine chemotherapy regimen ESHAP – Etoposide, Cisplatin, Cytarabine and Methylprednisolone chemotherapy regimen FLAG-Ida – Fludarabine, Cytarabine, Idarubicin and GCSF chemotherapy regimen




G – grams Kg – kilograms Mg – milligrams Mls – millilitres NCI CTC AE – National Cancer Institute Common Toxicity Criteria Adverse Events SRFT – Salford Royal NHS Foundation Trust

9. References

Buglass E A (1995) Oral Hygiene, British Journal of Nursing, 4(9): 516-519 Dose, A.M (1995) The symptom experience of mucositis, stomatitis and xerostomia. Seminars in Oncology Nursing, Vol. 11(4), pg. 248-255. Eilers, J. Berger A.M. Petersen, M.C. (1988) Development, Testing, and Application of the Oral Assessment Guide. Oncology Nursing Forum, Vol. 15(3), pg. 325 - 330. European Oral Care in Cancer Group Oral care guidance and support 1st ed. European Oral Care in Cancer Group Holmes, S. (1997) Cancer Chemotherapy-A Guide for Practice, Second Edition. Asset Books, Surrey, Chapter 11, pg. 190 -199. Humber and Yorkshire Coast Cancer Network (2011) Guidelines for the management of chemotherapy and/or radiotherapy induced acute mucositis in adults, Humber and Yorkshire Coast Cancer Network Kite, K & Pearson, L (1995) A rationale for mouth care: the integration of theory with practice. Intensive and Critical Care Nursing, Vol. 11, pg. 71 -76. Madeya, M. (1996a) Oral Complications From Cancer Therapy: Part 1 - Pathophysiology and Secondary Complications. Oncology Nursing Forum, Vol. 23(5), pg. 801 - 807. Murphy, L & Murphy F (2005) Oral mucositis: a challenge for nurses. Cancer Nursing Practice. Vol. 4(6), pg. 21-24. National Cancer Institute (2017) Common Toxicity Criteria for Adverse Events version 5.0. Department of Health and Human Services, USA Pan Birmingham NHS Cancer Network (2011) Guideline for the management of chemotherapy induced oral complications, Pan Birmingham NHS Cancer Network Ransier, A. et al (1995) a combined analysis of a toothbrush, foam brush, and A chlorhexidine-soaked foam brush in maintaining oral hygiene. Cancer Nursing, 18(5): 393-396. Regnard, C. et al (1997) Mouth care, skin care, and lymphoedema. British Medical Journal, Vol. 3(15), pg. 1002 - 1005.




Royal Cornwall Hospitals NHS Trust (2012) Guideline on the prevention and treatment of oral complications in chemotherapy patients, Royal Cornwall Hospitals NHS Trust Surrey, West Sussex and Hampshire Cancer Network (2011) Guidelines for prevention and management of oral mucositis, Surrey, West Sussex and Hampshire Cancer Network Thurgood, G. (1994) Nurse maintenance of oral hygiene. British Journal of Nursing, Vol. 3(7), pg. 332 - 353. Turner, G. (1996) Oral care. Nursing Standard, April 3, 10(28): 51-56. White, R. (2000) Nurse assessment of oral health: a review of practice and education. British Journal of Nursing, Vol. 9(5) pg. 260 – 266. UK Oral Management in Cancer Care Group (2019) Oral care guidance and support in cancer and palliative care 3rd ed. UKOMiC, Alderley Edge

10. Appendices

Appendix 1 – NCI CTC AE Mucositis

Appendix 2 – Mouth care assessment

Appendix 3 – Management plan




Appendix 1 NCI CTC AE Mucositis

Gastrointestinal disorders CTCAE term Grade 1 Grade 2 Grade 3 Grade 4 Grade 5

Mucositis oral Asymptomatic or mild symptoms; intervention not indicated

Moderate pain or ulcer that does not interfere with oral intake; modified diet indicated

Severe pain; interfering with oral intake

Life-threatening consequences; urgent intervention indicated

Death

Definition: A disorder characterized by ulceration or inflammation of the oral mucosal.

Navigational Note: -

Oral pain Mild pain Moderate pain; limiting instrumental ADL

Severe pain; limiting self care ADL

- -

Definition: A disorder characterized by a sensation of marked discomfort in the mouth, tongue or lips.

Navigational Note: -

CTCAE v5.0 – November 27, 2017




Appendix 2




Appendix 3 Management plan

Low Risk– Independent Patients

Ensure patient has toothbrush and fluoride toothpaste (supply if necessary)

Brush teeth twice daily with fluoride toothpaste.

Dentures should be removed, cleaned with liquid soap and water twice a day and rinse well before

refitting. Dentures should be removed and soaked in water overnight, in a clean named denture pot.

Use denture cleaner as directed by manufacturer.

Mouth Moisturiser to be applied if required.

NB: It’s important to replace toothbrushes if patient has C Diff, D&V, Norovirus

Medium Risk – These patients may require assistance with mouth care

and delivered more frequently.

As a minimum, teeth should be brushed with fluoride toothpaste twice daily.

In addition, please consider the following:

Encourage fluid intake if not on fluid restriction Apply oral moisturiser lips and mouth Do not use Vaseline/petroleum jelly products if the patient is

on oxygen therapy.

Provide mouth care 30 mins after each meal – Use a toothbrush/sage green foam swab & bite block and saline to remove all debris and apply mouth moisturiser, this is especially important if patient is on a modified diet.

Refer to medical team if infection/pain/bleeding is present.

Suction may sometimes be required.

Dentures to be removed and cleaned with an appropriate denture product twice a day.

If the tongue and or the oral tissues are coated swab the mouth for candida and start prescribed anti-fungal

treatment. If using a topical anti-fungal treatment NB advise the patient to take no fluids or food for 30 mins

after applying. If the patient also wears a denture then the topical anti-fungal ointment should also be applied

to the fitting surface of the denture, denture brush/toothbrush should be replaced.

High Risk – These patients are fully dependent on regular mouth care

and those patients who require oral suction

Provide mouth care using Four Hourly Suction Kit following procedures outlined during training. If oral cavity particularly coated, provide mouth care in between using sage green foam swabs.

Refer to medical team if infection/pain/bleeding is present.

Use Bite Block if required.

Dentures should be removed, cleaned and stored in a clean, named, denture pot.




Palliative and End of life care patients During this time dignity and comfort should be our main priority. Individuals with own teeth

Put small amount (pea size) non foaming toothpaste on a small (child’s) tooth brush.

Clean Upper and lower teeth back and front where possible

Gently massage oral gel outside and inside gums as tolerated by individual

Use sage green foam swabs if required If Individuals wear dentures, wear as tolerated

Dentures to be removed if causing pain, distress or ill-fitting denture raises concerns regarding occlude airway partially in semi/unconscious patients.

Dentures to be removed overnight or as needed and rinsed after meals and cleaned thoroughly, twice a day, by brushing with toothpaste with a small / medium headed toothbrush, rinse thoroughly and keep in water.

Apply moisturising balm to lips if dry/cracked- Do not use Vaseline/petroleum jelly products if the resident is on oxygen therapy.

To be repeated 2-4 hourly and as required. If using lubricating oral gel Check for residual gel in mouth and clean before reapplying- residual gel may indicate that a smaller amount is needed.

If oral thrush present guidance as above

Support patient & family to be involved with mouth care if able / would like to participate

Document mouth care




11. Document Control Information

All sections must be completed by the author prior to submission for approval

Lead Author: Anne Stout Lead Chemotherapy Nurse

Lead author contact details:

0161 206 0210 [email protected]

Consultation List the persons or groups who have contributed to this guideline. (please state which Care Organisation)

Name of person or group

Role / Department / Committee (Care Org)

Date

SRFT Chemotherapy Service Group

Consultants, Senior nurses, Pharmacists involved in SRFT chemotherapy

provision 2019/20

SRFT Clinical Haematology team

Consultants, SpRs, Senior Nursing team, Pharmacists, SRFT Clinical haematology

2019/20

Endorsement List the persons or groups who have seen given their support to this guideline. (please state which Care Organisation)

Name of person or group

Role / Department / Committee (Care Org)

Date

SRFT Chemotherapy Service Group

Consultants, Senior nurses, Pharmacists involved in SRFT chemotherapy

provision 05/06/2020

Richard Cooper Medicines Management Group 02/07/2020

Keywords / phrases: Mucositis, Stomatitis, Oral assessment, Chemotherapy

Communication plan:

All Clinical Haematology staff including medical team, nurses and pharmacists will be notified that the revised document is available on the Intranet via e mail.

Document review arrangements:

This document will be reviewed by the author, or a nominated person, at least once every 5 years or earlier should a change in legislation, best practice or other change in circumstance dictate.

This section will be completed following committee approval

Guideline Approval: Name of Approving Committee: Medicines Management Group

Chairperson: Dr Richard Cooper

Approval date: 02/07/2020

Formal Committee decision X Chairperson’s approval (tick)




12. Equality Impact Assessment (EqIA) screening tool Legislation requires that our documents consider the potential to affect groups differently, and eliminate or minimise this where possible. This process helps to reduce health inequalities by identifying where steps can be taken to ensure the same access, experience and outcomes are achieved across all groups of people. This may require you to do things differently for some groups to reduce any potential differences.

1a) Have you undertaken any consultation/

involvement with service users, staff or other

groups in relation to this document?

Yes Document circulated to Chemotherapy

Service Group and Haematology team for

comment

1b) Have any amendments been made as a

result?

Yes – changes made to reflect up to date

medication prescribing guidelines

2) Does this guideline have the potential to affect any of the groups below differently or

negatively? This may be linked to access, how the process/procedure is experienced, and/or

intended outcomes. Prompts for consideration are provided, but are not an exhaustive list.

Protected Group Yes No Unsure Reasons for decision

Age (e.g. are specific age groups excluded? Would the same

process affect age groups in different ways?) X

Sex (e.g. is gender neutral language used in the way the

guideline or information leaflet is written?) X

Race (e.g. any specific needs identified for certain groups such

as dress, diet, individual care needs? Are interpretation and translation services required and do staff know how to book these?)

X

Religion & Belief (e.g. Jehovah Witness stance on blood

transfusions; dietary needs that may conflict with medication offered.)

X

Sexual orientation (e.g. is inclusive language used? Are

there different access/prevalence rates?) X

Pregnancy & Maternity (e.g. are procedures suitable for

pregnant and/or breastfeeding women?) X

Marital status/civil partnership (e.g. would there be any

difference because the individual is/is not married/in a civil partnership?)

X

Gender Reassignment (e.g. are there particular tests related

to gender? Is confidentiality of the patient or staff member maintained?)

X

Human Rights (e.g. does it uphold the principles of Fairness,

Respect, Equality, Dignity and Autonomy?) X

Carers (e.g. is sufficient notice built in so can take time off work

to attend appointment?) X

Socio/economic (e.g. would there be any requirement or

expectation that may not be able to be met by those on low or limited income, such as costs incurred?)

X

Disability (e.g. are information/questionnaires/consent forms

available in different formats upon request? Are waiting areas suitable?) Includes hearing and/or visual impairments, physical disability, neurodevelopmental impairments e.g. autism, mental

X




health conditions, and long term conditions e.g. cancer.

Are there any adjustments that need to be made to ensure that people with disabilities have the same access to and outcomes from the service or employment activities as those without disabilities? (e.g. allow extra time for appointments, allow advocates to be

present in the room, having access to visual aids, removing requirement to wait in unsuitable environments, etc.)

X

3) Where you have identified that there are potential differences, what steps have you taken to mitigate these? Patients with learning disabilities or dementia may find it more difficult to understand this treatment. There may be communication difficulties between staff and patients who don’t speak English or who are deaf or non-verbal. Chemotherapy treatment is generally not suitable for anyone who is pregnant or breastfeeding parents. A pregnant patient that was diagnosed with a condition that required treatment with chemotherapy would be transferred to Manchester Foundation Trust where there are the Haematology and Obstetric services required.

4) Where you have identified adjustments would need to be made for those with disabilities, what action has been taken? Patients with learning disabilities or dementia would be spoken to in language appropriate to their understanding. Best interest meetings are arranged to discuss treatment. Treatments and side effects are discussed with relatives, carers and advocates as appropriate for the individual. Interpreters, usually via Language Line but in person if appropriate, are used to explain the treatment to patients who don’t speak English. For a deaf or non-verbal patient requiring the support of someone to sign, we can also access this through the hospital in order to explain the treatment to them. Patients with disabilities or additional communication needs will be given the additional time they need in appointments and all patients are encouraged to bring family, friends or carers to appointments. Patients with disabilities would be treated in an area of the Haematology ward appropriate for them.

In-patients who are not able to independently manage their oral care for any reason will be supported by nursing staff to do so.

5) Where the policy, procedure, guidelines, patient information leaflet or project impacts on patients how have you ensured that you have met the Accessible Information Standard – please state below: ……………………………………………………………………………………………………………… EDI Team/Champion only: does the above ensure compliance with Accessible Information Standard

o Yes

o No

If no what additional mitigation is required:

Will this guideline require a full impact assessment? No Please state your rationale for the decision:




(a full impact assessment will be required if you are unsure of the potential to affect a group differently, or

if you believe there is a potential for it to affect a group differently and do not know how to mitigate

against this - Please contact the Inclusion and Equality team for advice on [email protected]) Author: Type/sign: Anne Stout Date:19.11.2019

Sign off from Equality Champion: Date:04.12.2019

mailto:[email protected]