The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [324]
(Davies 2005a, Malkin 2009)
Inspection should be undertaken in good light, gloves should be worn, a pen torch should be available, and any dentures or plates should be removed. It is helpful to have a set order in which areas are examined so nothing is missed. The following areas should be inspected.
The lips: are they dry, cracked or bleeding?
The upper and lower labial sulci (inner part of the lip towards the vestibule): the lip should be retracted with a gloved finger or tongue depressor.
The buccal mucosa on the right and left sides: is it intact, soft, moist, coated, ulcerated or inflamed?
The dorsal surface of the tongue (ask the patient to stick out the tongue): is it dry, coated or ulcerated?
The ventral surface of the tongue (ask the patient to lift the tongue up and move it from side to side): can the patient move it normally?
The floor of the mouth should also be inspected: is the normal saliva pool present, is the saliva watery?
The hard and soft palate: are they intact, ulcerated or red?
The gums: are they inflamed or bleeding?
The teeth: are they present, cared for, loose or stained, is debris present?
(Davies 2005a, Hahn and Jones 2000)
Pharmacological support
The choice of an oral care agent will be dependent on the aim of care. The agent may be used to remove debris and plaque, prevent superimposed infection, alleviate pain, provide comfort, stop bleeding, provide lubrication or treat specific problems (Dickinson and Porter 2006). A wide variety of agents are available and choice should be determined by the individual needs of the patient and the particular clinical situation together with a detailed nursing assessment. There is ongoing debate on the efficacy of agents presently available and there remains insufficient evidence to clearly state the best agents to use in the clinical setting.
Chlorhexidine gluconate
Chlorhexidine gluconate is an effective antibacterial and antiplaque agent. For the patient who is unable to use a toothbrush, it can provide a chemical method of stopping plaque build-up. As chlorhexidine is released from tissues for up to 12 hours, it only needs to be used twice daily. Chlorhexidine does not remove plaque which is already present so brushing of teeth should continue as far as possible (Sweeney 2005). It is also available as a gel formulation which may be useful for those requiring a non-foaming alternative to toothpaste (patients at risk of aspiration or with swallowing difficulties). Chlorhexidine has not been shown to be effective in preventing oral mucositis in patients with head and neck cancers undergoing radiotherapy or in treating oral mucositis in patients receiving chemotherapy although it may be used as part of an oral protocol for its antiplaque and antibacterial action (Barasch et al. 2006, Rubenstein et al. 2004).
Artificial saliva
Saliva substitutes which are mucin based are more effective than those which are carboxymethylcellulose based for relieving dry mouth (xerostomia) (Davies 2005b). Recommendations are to use several sprays around the mouth, to use the tongue to spread the artificial saliva around the mouth and to use it at least prior to meals and at any other time when the mouth feels dry (Davies 2000).
Coating agents
Several agents have been used to coat the oral mucosa and they are thought to have a protective effect although there is limited evidence to support their use. Sucralfate has not been shown to be effective in preventing or treating chemotherapy- or radiotherapy-associated oral mucositis (Clarkson et al. 2007a, Worthington et al. 2007a).
Other agents
Several other treatments have been found to be useful in prevention of oral mucositis related to chemotherapy. Palifermin is a recombinant form of human keratinocyte growth factor which stimulates cell growth in the alimentary tract. In trials it has been found to have an effect in preventing oral mucositis in haemato-oncology patients having high-dose chemotherapy and total body irradiation with autologous stem cell transplantation and its use is recommended