Oral Care Protocol May Prevent Oral Mucositis

Careful attention to a set of oral care measures may help patients avoid chemotherapy-induced oral mucositis, according to new research.

Results showed that a protocol that provides specific instructions on the various components of oral care can reduce the incidence and severity of mucositis in patients receiving chemotherapy. As examples, the protocol states how often patients should rinse and brush their teeth and what they should do if they develop mouth sores.

“Clinical practice guidelines recommend the implementation of systematic basic oral care,” said principal investigator Jennifer Hester, DNP, APRN, AOCNS, ACHPN, palliative care advanced practice nurse at The Christ Hospital in Cincinnati, Ohio. “However, when I looked to the literature for specific guidance on oral care, including which rinsing agent to use, frequency of brushing and rinsing, and escalation of care, I was not able to find the information I needed to bring evidence-based practice to the bedside.”

Oral mucositis can lead to infection and chemotherapy dose reductions or delays. Patients may also develop pain, nutritional compromise, and difficulty in communicating, all of which worsen quality of life.

Hester developed an oral care protocol, and she and her colleagues evaluated its effectiveness in patients receiving standard doses of chemo therapeutic agents known to cause oral mucositis.

With the oral care protocol, patients were given the following instructions.

• Brush your teeth and tongue with toothpaste and a soft toothbrush at least twice daily.
• Rinse your mouth with saline (mild salt water) after every meal and before bed. Swish for 1 minute, and spit.
• Put mouth moisturizer on your lips whenever they feel dry.
• If you wear dentures, clean them after every meal.
• If you usually floss your teeth, it is okay to continue flossing unless you bleed or your nurse or doctor tells you to stop.
• Tell your nurse or doctor right away if you begin to feel any pain in your mouth.
• Avoid hot or spicy foods and drinks that might irritate your mouth as well as commercial mouth washes. The oral care protocol also provided instructions for patients who developed mouth sores.
• Brush your teeth and tongue with toothpaste and a soft toothbrush at least twice a day.
• Rinse your mouth with saline (mild salt water) every 2 hours while you are awake and every 4 hours during the night. Swish for 1 minute, and spit.
• Apply mouth moisturizer on your lips whenever they feel dry.
• If you wear dentures, remove them until your mouth heals.
• If you usually floss your teeth, stop flossing until your mouth heals.
• Tell your nurse or doctor right away if you have trouble eating or drinking. Twenty-five participants in the study were assigned to follow the oral care protocol for 8 weeks, and 24 patients were assigned to usual care. Usual care meant that patients understood the importance of oral care, but they were not provided with “specifics” as far as how often and when to brush their teeth and tongue or what to do if a mouth sore developed.

Results showed that patients in the intervention group were significantly more likely to brush their teeth twice daily, to rinse at least three times daily, and to rinse with saline rather than harsh commercial rinses than those in the usual care group.

As a result, the intervention group had multiple clinical benefits, Hester said. Overall, 4% of patients in the intervention group developed oral mucositis compared with 38% of patients in the control group. Oral mucositis was confirmed by a score greater than 4 on the Oral Assessment Guide, which is a widely validated tool for establishing the presence of mucositis.

Mouth pain was reported in 12% and 46% of the two groups, respectively. Also, 8% of patients in the intervention arm said that mouth sores kept them from eating adequately versus 30% of patients in the usual care arm.

“Current clinical practice guidelines tell patients to use bland rinses, brush their teeth frequently, to floss, and so on but do not specify how often to brush, what kind of bland rinses to use, how much salt or baking soda they should use in the rinse, and a way to escalate if they have mouth sores,” Colleen Bass, BSN, a palliative care nurse at The Christ Hospital, commented in an interview.

She added that the results of the study are promising and may represent the first step toward standardization of basic oral care for patients receiving standard- dose chemotherapy. “We are excited by the results, and we believe that this protocol is something specific that nurses can easily teach and that patients can easily follow,” Bass said. “And, actually all patients in our study felt that they could take good care of their mouth. They just needed specifics in order to be able to do so effectively.”

Besides, she noted, the regimen is definitely cost-effective. “It doesn’t cost them anything,” Bass said. “All patients have to do is have the ability to make a quart of mild salt water each day.”

Finally, Bass said that future re search should aim to examine how normal saline mouthwash compares with commercial rinses in preventing mucositis.