The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [325]
The use of oral cryotherapy, in which ice chips are placed in the mouth during the administration of chemotherapy and for up to 30 minutes afterwards, is recommended for patients receiving 5-fluorouracil and edatrexate chemotherapy (Rubenstein et al. 2004). Oral cryotherapy for an hour is recommended for patients receiving high-dose melphalan as it can reduce the severity of mucositis (Keefe et al. 2007). Cryotherapy is thought to work by causing vasoconstriction, resulting in reduced delivery of the chemotherapy agent to the tissues in the mouth. Whilst it is a simple procedure, it can be uncomfortable for patients who may be unable to tolerate it for long periods and is only effective for chemotherapy drugs with a short half-life (Aisa et al. 2005).
Other agents for which there is limited evidence include allopurinol, benzydamine mouthwash, used to prevent oral mucositis in patients undergoing head and neck radiotherapy, and calcium phosphate mouthwash (Keefe et al. 2007, Worthington et al. 2007a).
Analgesic agents
For patients with oral mucositis, it is unclear if analgesic agents used topically are effective. There is evidence that systemic opioids are effective, and both continuous infusion and patient-controlled analgesia (PCA) using morphine have been used in patients receiving high-dose chemotherapy and stem cell transplantation. Patients using PCA have been found to use less opioid in total (Clarkson et al. 2007a, Rubenstein et al. 2004).
Antifungal agents
Colonization of the mouth with yeast occurs in one-third of the population. In patients receiving steroids or antibiotics, the balance of oral flora can be altered and oral candidosis can occur. Predisposing factors also include xerostomia and the presence of dentures. Topical treatment is normally effective using an antifungal oral suspension or lozenges (Finlay and Davies 2005). In patients having anticancer treatment, the use of prophylactic topical antifungal treatments has been investigated. These have not been shown to be useful in preventing oral Candida and partly or fully absorbed antifungal agents such as fluconazole or miconazole are recommended (Clarkson et al. 2007b).
Contraindicated agents
A number of agents widely used in the past have been found to have detrimental effects and are no longer recommended. Glycerine and lemon swabs have been used for dry mouth but the acid content can damage tooth enamel and the overall effect is to increase oral dryness (Hahn and Jones 2000). Hydrogen peroxide is also not recommended as it can cause mucosal abnormalities (Berry et al. 2007).
Non-pharmacological support
Fluoride
Fluoride helps to prevent and arrest tooth decay, especially radiation caries, demineralization and decalcification. High-dose fluoride toothpaste may be recommended for patients with xerostomia (NHSQIS 2004).
Commercial mouthwash
Over-the-counter mouthwashes are not generally recommended. Many have a high alcohol content which can cause stinging, particularly for patients with sensitive mouths (Milligan et al. 2001).
Bland rinses
Several agents have been used to rinse the mouth, moisten the mucosa and loosen and remove debris. Normal saline has been recommended by a number of authors as part of a patient’s oral care. This relatively cheap and generally well-tolerated solution can alleviate discomfort although it is not effective at removing heavy amounts of debris (Milligan et al. 2001). Patients with mucositis can benefit from frequent rinsing of the mouth with warm normal saline to remove debris without causing irritation (Meechan 2005). The use of water has also been suggested to rinse the mouth after meals to remove debris (Sweeney 2005). Its use in critical care has been discouraged due to risk of infection in vulnerable patients, but sterile water may be an alternative (Berry et al. 2007). Sodium bicarbonate has been used in some centres although there is some evidence that patients