ECN Protocol Book. Guidelines for the Oral Care of Patients Receiving Chemotherapy and/or Radiotherapy

Transcription

1 ECN Protocol Book Guidelines f the Oral Care of Patients Receiving Chemotherapy and/ Radiotherapy Name of person presenting document: Reason f document development: Names of development team: Specify groups of staff to whom the document relates: Approved by: Date approved: Next Review date: Version No: 3 Responsibility f review: Reference Netty Wood, Lead Pharmacist, ECN Netwk required guidelines ECN Oncology Pharmacy Group Clinicians within ECN Cancer pharmacy staff within ECN Chemotherapy nursing staff within ECN ECN Chemotherapy Board Lead Pharmacist, Essex Cancer Netwk ECN_Protocol_Book_Guidelines f the Oral Care of Patients_3 Page 1 of 9

2 Contents Introduction... 3 Scope... 3 Contributing Risk Facts... 3 Prevention of al complications:... 3 Management of Oral Complications: Assessment... 4 Level 1 Care... 6 Level 2 Care... 6 Level 3 Care... 6 Oral Pain:... 7 Mouth Ulcers:... 7 Patients on radiotherapy f Head and Neck cancer... 8 Fungal Infections:... 8 Viral Infection:... 8 Bacterial Infection:... 8 Bleeding mucous membranes/gums:... 9 Salivary flow:... 9 References:... 9 Page 2 of 9

3 Introduction Patients treated with chemotherapy and/ radiotherapy are at risk of developing al complications, including infections, mucositis, pain and bleeding. Generally 40% of patients being treated f cancer f the first time will develop al mucositis. At its wst it can produce large, deep and painful ulcers of the movable mucosa of the mouth and opharynx. Those patients most at risk of these complications are those receiving: Radiation f head and neck cancer, with/without chemotherapy High dose chemotherapy f stem cell transplant Patients receiving standard cycled chemotherapy f solid tumours are less at risk, but those patients that develop ulcerative mucositis during cycle one are me likely to develop the condition further during subsequent cycles. Chemotherapy induced mucositis usually follows an acute course: 4-5 days post chemotherapy mucosal breakdown starts, peaks at 7-12 days and then spontaneously resolves. This follows the curve of myelopsuppression and peak mucositis occurs to WBC nadir making local infection, bacteraemia and sepsis a concern. Radiotherapy to the head and neck can induce damage to the al mucosa that can be similar to that seen in patients receiving chemotherapy but it can also result in the permanent dysfunction of the connective tissue, salivary glands, muscle and bone. Mucositis usually develops predictably, the time course being dependent on the treatment the patient is receiving. The ulceration often becomes necrotic, bacteria laden and painful. Patients often find eating intolerable and alternative feeding is required. Radiation received by patient 10-20Gy 30Gy Symptoms occurring Early mucositis occurs with mucosal erythema and superficial sloughing but the underlying mucosa is intact. Often a burning discomft is felt in the mouth. Mucosal integrity is disrupted and ulceration has developed. This lasts f the remainder of the radiation treatment and f a further 2-4 weeks afterwards. Scope This document is intended to provide a tool f assessment, and a framewk of guidelines f the management of al care f adult solid tumour and haemato-oncology patients receiving chemotherapy within Essex Cancer Netwk. These guidelines can not, and do not cover every clinical situation: good common clinical sense and clinical experience will be required when approaching the management of individual patients. Contributing Risk Facts Mouth breathing, causing mucosal dryness Oxygen therapy, causing mucosal dryness Po al hygiene due to a deficit in self care ability Nausea and vomiting Advanced disease/debilitation Immunosuppression, due to medication (e.g steroids) disease Radiotherapy Intensive chemotherapy Inability to take adequate fluids leading to dehydration and dryness of mucosa Po nutritional status leading to po cellular repair Insufficient saliva production leading to infection and mucosal dryness Lack of knowledge/motivation towards al hygiene Previous experience of mucositis Prevention of al complications: Routine al hygiene is imptant to reduce the incidence and the severity of al complications. Patients should be infmed of the al complications that can occur as a result of chemotherapy and radiotherapy, the rationale f the need f good al hygiene, the routine they should use to reduce the risk of al complications occurring. Page 3 of 9

4 If time allows patients should have a dental check up befe they start treatment. Regular dental check ups are imptant but should be avoided while the patient is receiving treatment. If urgent dental wk is needed during treatment the full blood count should be monited to determine the need f prophylactic antibiotics platelet transfusions befe treatment. Table 1: Routine al hygiene: Toothbrushing: Soft nylon bristled brush: Use 2-3 times a day with toothpaste, after food. Rinse mouth frequently with water. Foam toothbrushes: Only use when nmal toothbrushes are unsuitable. Use 2-3 times a day and rinse mouth frequently. Use with an antimicrobial rinse. Electric toothbrushes are permitted as long as they can be used without causing trauma (Avoid in thrombocytopenic patients). Dentures: Clean after each meal and soak in usual denture solution overnight. If toothpaste causes irritation clean with NaCl 0.9% water. Disinfect once to twice a week with appropriate disinfectant eg sterident. Flossing: Use once a day, modify technique to prevent trauma as needed. (Avoid in thrombocytopenic patients). Mouthwash: Use regular salt water as a preventative mouthwash. Additional infmation: Patients should be encouraged to maintain an adequate diet and fluid intake. Alcohol and tobacco should be avoided if possible. Advise patients to take care with rough crunchy food and caution with spicy food due to the risk of irritation occurring. Vaseline, yellow/white soft paraffin nmal lip salve can be used to moisten lips. (Do not use if patient is receiving oxygen therapy radiotherapy (RT)) Patients who experience recurring mucositis despite 1st line care and where po dental condition leads to an increased risk of infection uses Csodyl MW (chlhexidine 0.2%) 10ml BD Patients unable to carry out al routine al hygiene should have their al care carried out f them: Four hourly to begin with to reduce the potential of infection. Two hourly to reduce redness and dryness and reduce the risk of mucositis ulceration occurring. One hourly in patients receiving oxygen, those who are mouth breathing, unconscious who have an al infection. Management of Oral Complications: Assessment A baseline assessment of the al cavity using the following al assessment tool should be carried out f all patients befe starting chemotherapy. When al complications are identified, an al assessment is required to allow a treatment plan to be developed, to monit response to this treatment, and identify any new problems occurring. Table 2: The NCI toxicity criteria f grading al stomatitis: Grade 0 Grade 1 Grade 2 Grade 3 Grade 4 No changes to the patient s al cavity. Painless ulcers, erythema, mild seness is present. Painful erythema, oedema, ulcers are present but the patient can eat solid food. Painful erythema, oedema, ulcers, and the patient cannot eat solid food. Patient requires parenteral enteral suppt as they cannot meet their nutritional needs ally. Page 4 of 9

5 Oral Assessment Tool All patients must receive a level of care based on an individualised assessment. To identify appropriate level of care please calculate sce using Oral Assessment Tool and implement care as guided. F patients in high risk of mucositis treatment groups, please commence care at level 2. Each patient will need to be re-assessed at least once a week. Name Date Oral Assessment Tool Voice Converse with Patient Swallow Lips Tongue Saliva Mucous membranes Gums Taste Ask patient Teeth/Dentures Self-care Assessment Nutritional Status Ask Patient Treatment Oral Cavity Total Sce: 1 = Nmal 2 = Deeper/raspy 3 = Difficult/painful speech 1 = Nmal 2 = Painful 3 = Unable to swallow 1 = Smooth, pink, moist 2 = Dry/cracked 3 = Ulcerated/bleeding 1 = Pink, moist, papillae present 2 = Dry/cracked 3 = Ulcerated/bleeding 1 = Watery 2 = Thick ropey 3 = Absent 1 = Pink and moist 2 = Reddened/coated 3 = Ulcerations/bleeding 1 = Pink and firm 2 = Oedematous/red 3 = Spontaneous bleeding 1 = Nmal 2 = Impaired/changed 3 = No taste 1 = Clean, no debris 2 = Localised plaque/debris 3 = Generalised plaque/debris 1 = Perfms al care by self 2 = Needs encouragement and education 3 = Refuses/unable to perfm al care 1 = Nmal 2 = Soft diet 3 = Fluids only/nbm 1=Chemotherapy 1=Radiotherapy (Head & Neck) INTERVENTION LEVELS Sce = Level 1 Care Sce = Level 2 Care Sce = Level 3 Care Page 5 of 9

6 Level 1 Care Sce 12-20: Low Risk Patient 1. Brush natural teeth f 90 seconds using a soft toothbrush and pea size amount of fluide toothpaste twice a day. 2. If dentures a partial plate are wn, remove and brush them thoughly with a denture toothpaste after each meal and soaking them overnight in cold water. Disinfect once twice a week using a cleaning agent such as Sterident. Rinse mouth f half a minute after meals and befe going to bed. 3. When dentures are removed clean inside of mouth, flo, palate, cheeks and tongue using a small-headed soft toothbrush and a pea size amount of toothpaste. 4. Apply aqueous cream to moisten lips if necessary. Lip balm may be used (not f RT patients). 5. Allow time f teaching and suppting patients and their carers. Level 2 Care Sce 21-26: Low-High Risk Patient 1. Brush natural teeth f 90 seconds using a soft toothbrush and pea size amount of fluide toothpaste twice a day. 2. Rinse mouth f half a minute every 2-4 hours with tap water ( nmal saline). 3. If dentures a partial plate are wn, remove and brush them thoughly with a denture toothpaste after each meal and soaking them overnight in cold water. Disinfect once twice a week using a cleaning agent such as Sterident. Rinse mouth f half a minute after meals and befe going to bed. 4. When dentures are removed clean inside of mouth, flo, palate, cheeks and tongue using a small-headed soft toothbrush and a pea size amount of toothpaste. 5. Apply aqueous cream to moisten lips if necessary. Lip balm may be used (not f RT patients). 6. Allow time f teaching and suppting patients and their carers. 7. Provide patient with a regular analgesia as required. 8. Good al hygiene with Difflam (Benzydamine 0.15%) 10-15ml every 1½ to 3 hours. Dilute with equal volume of water if stinging occurs. Level 3 Care Sce 27-39: High Risk Patient 1. Brush natural teeth f 90 seconds using a soft toothbrush and pea size amount of fluide toothpaste twice a day. If necessary substitute toothbrush with sponge sticks gauze and gloved hands. 2. Moisten mouth every hour with tap water ( nmal saline). 3. If dentures a partial plate are wn, remove and brush them thoughly with a denture toothpaste after each meal and soaking them overnight in cold water. Disinfect once twice a week using a cleaning agent such as Sterident. Rinsing is especially imptant after meals and befe going to bed. 4. When dentures are removed clean inside of mouth, flo, palate, cheeks and tongue using a small-headed soft toothbrush and a pea size amount of toothpaste. 5. Apply aqueous cream to moisten lips if necessary. Lip balm may be used (not f RT patients). 6. Allow time f teaching and suppting patients and their carers. 7. Provide patient with a regular analgesia as required. 8. Good al hygiene with Difflam (Benzydamine 0.15%) 10-15ml every 1½ to 3 hours. Dilute with equal volume of water if stinging occurs. Patients who are on melphalan and bolus 5-fluouracil may benefit from holding ice in their mouth f one hour after treatment. REMEMBER: As well as al assessment, the management of al complications of specific areas is also required. Page 6 of 9

7 Management of Oral Complications: Specific Areas Oral Pain: First line Second line Third line Difflam (Benzydamine 0.15%) 10-15ml every 1½ to 3 hours. Dilute with equal Mouthwash volume of water if stinging occurs. Difflam (Benzydamine 0.15%) spray. 4-8 sprays to affected area every 1½ to 3 hrs Co-codamol soluble 30/500 tabs 1-2 tabs as mouthwash qds Mphine sulphate liquid 10mg/5ml, 5mg as a mouthwash f 2-3 mins PRN and swallowed up to 4 hourly Aspirin 300mg soluble Mphine sulphate liquid do not swallow other times. tabs as 10mg/5ml, 5mg as a if not tolerated: mouthwash/gargle tds mouthwash f 2-3 mins Oxycodone liquid 5mg/5ml, can be given with lemon mucilage + PRN. Do not swallow. 5mg as a mouthwash f 2-3 to if not tolerated: mins PRN and swallowed up improve palatability Oxycodone liquid to 4 hourly do not swallow Analgesia, if aspirin contraindicated due to thrombocytopenia/ clotting abnmality: 5mg/5ml, 5mg as a mouthwash f 2-3 mins PRN and swallowed up to 4 hourly do not swallow other times and/ Regular systemic opioid may be required. This may be in Paracetamol 500mg other times the fm on fentanyl patches soluble tabs 1-2 tabs where the patient cannot as mouthwash qds Hydroctisone and tolerate al intake. aspirin mucilage Alternative below must not be Co-codamol soluble (5mg/300mg per 5ml) as obtained from the community 30/500 tabs 1-2 tabs mouthwash/gargle 10ml pharmacies as mouthwash qds TDS/QDS + Mphine in Oral Balance gel applied topically to painful Lidocaine 5% ointment 10% spray (max 20 sprays in 24hrs) PRN* + areas 4 to 6 hrly PRN + (Available from Glasgow infirmary) * Can cause secondary throat numbing, infm patient not to use immediately pri to eating. + Hospital pharmacy departments may need several days notice to obtain agent. Note: Lemon is acidic and can also dry the al cavity. Mouth Ulcers: To be used after other agents to prevent the effect of other preparations being blocked by the coating action of these agents Bonjela up to 3 hrly Hydroctisone 2.5mg pellets. 1 lozenge 4 times a day allowed to dissolve slowly in the mouth in contact with the ulcer. Small numbers of ulcers (1-3) Difflam (Benzydamine 0.15%) 10-15ml every 1½ to 3 hours. Dilute with equal volume of water if stinging occurs Difflam (Benzydamine 0.15%) spray. 4-8 sprays to affected area every 1½ to 3 hrs Me complex ulcers larger, difficult to reach, me than 3 Carmellose paste (Orabase), apply to large ulcers PRN Sucralfate 1g/5ml liquid, 5ml qds used as a mouthwash f 1 minute then spit out swallowed. Alternative below must not be obtained from the community pharmacies Tetracycline mouth wash (250mg capsules opened and put in to 10ml water) QDS f 5/7 + + Hospital pharmacy departments may need several days notice to obtain. Page 7 of 9

8 Patients on radiotherapy f Head and Neck cancer All opharyngeal patients undergoing radiotherapy- to include cancer of the al cavity, tonsil, tongue, flo of mouth and pharynx F the prevention and management of lesions and symptoms of al mucositis To start at the beginning of treatment: MuGard Rinse the mouth with 5-10ml, 4 to 6 times a day Fungal Infections: Antifungals f treatment and prophylaxis are usually given f 7-10 days and then reviewed Long term prophylaxis may be required in patients that are receiving intensive chemotherapy who are long term immunosupressed Longer treatment courses may be needed in severely immunocompromised patients Usual cause Signs/symptoms Prophylaxis Treatment Candida Albicans Creamy white patches inside the cheeks/on tongue. May also present with a red tongue generalised stomatitis. Nystatin MW 1ml QDS Fluconazole mg od Itraconazole liquid 200mg od* Nystatin MW 1ml- 5ml QDS Fluconazole mg od Itraconazole mg od Amphotericin lozenges 10mg to dissolve in the mouth QDS * Liquid to be used f patients receiving intensive chemotherapy who are likely to be long term immunosupressed (e.g. patients receiving bone marrow transplant) due to license. Viral Infection: Often requires systemic antiviral treatment Treatment should continue until healing is complete and no new lesions have occurred After treatment has finished patients should be prescribed aciclovir mg QDS long term to prevent symptoms reoccurring. Usual cause Signs/symptoms Prophylaxis Treatment Small reddish painful Aciclovir 400mg blisters on the lips Aciclovir mg Herpes simplex 5 x day f minimum 5 ulcers within the QDS days until resolved mouth Bacterial Infection: Results from the accumulation of bacterial plaque Swab area micro, sensitivity and culture Pungent smell suggests anaerobic infection Usual cause Signs/symptoms Prophylaxis Treatment Good al hygiene, with Difflam (Benzydamine 0.15%) Metronidazole 400mg 10-15ml every 1½ to 3 tds, if anaerobic Red swollen gums that hours. Dilute with infection suspected, Streptococcus bleed easily with red equal volume of water adjusted as per painful lesions on the if stinging occurs sensitivities al mucosa (consult local Csodyl MW microbiology advice) (chlhexidine 0.2%) 10ml BD Page 8 of 9

9 Bleeding mucous membranes/gums: Check platelet count and clotting profile Administer blood products if necessary Rinse mouth with water PRN Tooth brushing may be contra-indicated in patients with severe thrombocytopenia (low platelet count) who are susceptible to bleeding. Treatment Tranexamic acid mouthwash 10% 5ml qds if bleeding source is visible in the mouth (Injection can be used ally as mouthwash) Tranexamic acid tablets po 1g tds Salivary flow: Saliva type Absence of saliva Thick & ropey saliva Excessive saliva Treatment Regularly rinse mouth with water. Use ice chips and/ use saliva replacement product PRN. Oral balance gel is available f use. Chewing gum may help Regularly rinse mouth with water. Use ice chips fresh pineapple chunks (avoid pineapple if there is mucositis ulceration present note this is acidic and may not be suitable f all patients) Use NaCl 0.9% 5ml nebulised PRN Hyoscine hydrobromide topical patches 1mg/72 hours Hyoscine hydrobromide s/c mg PRN max 4 hourly Hyoscine hydrobromide s/c infusion mg over 24 hours References: Berger A M, Eilers J (1998). Facts influencing al cavity status during high dose anti-neoplastic therapy: a secondary analysis. Oncology nursing fum. Vol.25. no9 pp Buglass E A (1995). Oral hygiene. British Journal of nursing. Vol. 4 No 9 pp Christie Hospital NHS trust (2000) Oral Hygiene protocol. Eilers J,berger A M, Peterson M C (1988). Development, testing and application of the al assessment guide. Oncology nurses fum. Vol15. no3. pp Ginsberg (1961), Howarth (1997), Beck (1979), Dudjack (1987) cited by Royal Marsden Manual of Clinical Nursing Procedures, 6th edition (2004) JNCI Cancer Spectrum (2006) Oral Complications of Chemotherapy and Head/Neck Radiation. jncicancerspectrum.oxfdjournals.g Keefe DM, Schubert MM, Elting LS, Sonis ST, Epstein JB, Raber-Durlacher JE, Migliati CA, McGuire DB, Hutchins RD, Peterson DE; Updated clinical practice guidelines f the prevention and treatment of mucositis. Cancer Mar 1;109(5): London Cancer Standards Oral Care Group (2002) and modified by Brighton and Wood, edits (2005) The Royal Marsden Hospital Handbook of Cancer Chemotherapy (2005), Elsevier Churchill Livingstone Royal Marsden Manual of Clinical Nursing Procedures, 6 th edition (2004) Stevens Brighton and Wood, (2005) The Royal Marsden Hospital Handbook of Cancer Chemotherapy, Elsevier Churchill Livingstone The Royal Free Hampstead NHS Trust (2000) Guidelines f al care Page 9 of 9