Oral Mucositis At AUBMC
Nada Nassar, RN, BSN, MSN,
Nursing Quality Improvement
Program
Zeina Kassem, BSN, RN
November 2008
Outline
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VII.
VIII.
IX.
Oral mucositis: definition and description
Incidence, prevalence
Risk factors
Management
Patient education
Implications
Oral Mucositis Project at AUBMC
Evaluation
Future projects
Objectives
By the end of the session the audience will be able
to:
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Acknowledge what is oral mucositis and its
impact on patient’s condition and quality of life
Identify risk factors for oral mucositis
Identify different stages of oral mucositis
Acknowledge the new AUBMC Oral Mucositis
Assessment Tool
Perform complete physical assessment
Identify strategies to prevent oral mucositis and
to manage oral mucositis if present
Definition of Oral Mucositis

Mucositis is an inflammatory and
potentially ulcerative process that
affects the mucous membranes of
the oral cavity and
gastrointestinal tract of individuals
receiving chemotherapy and
radiation therapy as treatments
for cancer.
Definition Oral Mucositis
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Oral Mucositis can lead to serious clinical
complications including hemorrhage,
pain, taste changes, erythema, swelling,
infection and impaired nutritional status.
It significantly affects the patient’s
quality of life, jeopardizes treatment
outcomes, prolongs patient’s length of
stay, increases morbidity and increases
the financial burden on patients.
Definition Oral Mucositis
Historically, literature used the
terms mucositis and stomatitis in
combination (i.e., mucositis/
stomatitis) are almost
interchangeably.
Definition Oral Mucositis
Individuals with mucositis use the
terms pain, bleeding, taste
changes, and dry mouth to report
the symptoms that they experience
and have reported mucositis to be
the most distressing symptom of
high-dose therapy
Definition Oral Mucositis
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Mucositis remains a major dose-limiting
side effect of cancer therapy.
This dose-limiting effect is related to the
risk of life-threatening infections
secondary to breakdown in the mucosal
lining that normally provides the first line
of defence against microbial invasion by
the organisms in the oral cavity.
Incidence and Prevalence
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Oral mucositis occurs in 40% of cancer
patients receiving cytotoxic chemotherapy.
Studies report that 70 to 80% of patients
undergoing bone marrow transplantation
suffer from oral mucositis during treatment.
One million episodes of oral mucositis occur
annually in America.
Risk Factors
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Age ( young children and elderly)
Gender ( women are at greater risk
for severe mucositis)
Oral health and oral hygiene
Reduced salivary function
High expression of cytokines
Altered drug metabolisms
Risk Factors
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Smoking
Alcohol
Specific chemotherapeutic agents( ex:
Bleomycin, Cytarabine, Doxorubicin, 5 FU)
Bone marrow transplantation
Radiotherapy
Management
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Assessment—use of standardized assessment tool
Collaborative management
Oral care protocol, including patient education
Pre treatment dental evaluation, repair, and prevention
Nutrition and fluid management
Prevention of mucositis with 5-fluorouracil—use of 30
minutes of cryotherapy
Treatment—symptom-focused interventions
Management
Assessment
The oral cavity should be assessed regularly
using valid and reliable instruments to
document “normal pattern” of changes
seen with cancer treatment regimens.
Management
Implement an oral care protocol using
a. Non-irritating agents
i. Normal saline with or without baking soda
ii. Sterile water
iii. Avoid mouth washes with alcohol.
b. Soft-bristle toothbrush
i. Continue as long as tolerated if no uncontrolled
bleeding present
ii. Changed frequently especially when patient is
neutropenic (at least every week during aplasia)
Management
c. Floss
If a regular part of patient’s oral care,
continue as long as tolerated if no
uncontrolled bleeding present.
d. Use foam toothettes for cleansing of
soft tissues and for teeth when tooth
brush is not tolerated.
Management
Use a multidisciplinary team approach to oral
care to include the integration of dental health
professionals as indicated by the status of a
patient’s oral cavity.
a. Clean and repair teeth prior to initiation of
immunosuppressive therapy.
b. Treat potential problems prior to initiation
of immunosuppressive therapy
Patient Education
Patients and family care providers should learn
about
a. The importance of oral care during cancer
treatment to decrease morbidity and mortality
b. Systematic care of oral cavity—promote
health and avoid trauma
Patient Education
c. Assessment of the oral cavity (i.e., at
least daily during therapy)
d. Signs and symptoms to report (i.e.,
changes in sensation or taste, presence of
ulcerations and/or bleeding)
Implications
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The first crucial step in treating oral
mucositis is performing a thorough
assessment of patient’s oral cavity.
Implications
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The nursing daily physical assessment
form at AUB MC includes a part related to
integumentary system which does not
clearly specify proper assessment of oral
cavity; thus nurses are not properly
assessing oral mucositis based on an
evidence based assessment tool.
Oral Mucositis Project at
AUBMC
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The purpose of the project done at
AUBMC is to adopt or create a tool for
assessing oral mucositis that is well
defined, evidence based, reliable, and
culturally sensitive.
Oral Mucositis Project at
AUBMC
Organizing the Team:
A team was formed from nurses working on
oncology units:
 Seven registered nurses
 1 clinical educator
 1 advanced practice nurse
Oral Mucositis Project at
AUBMC

Assessment of oncology patient’s medical
records was done at the American University
of Beirut Medical Center (AUBMC) that
revealed 39.74% of patients receiving
chemotherapy developed oral mucositis. This
result is similar to those results reported by
the literature and thus oral mucositis is an
important issue that needs to be surveyed by
oncology nurses at AUB MC.
Oral Mucositis Project at
AUBMC

This raises an alarm to the magnitude of
the problem and the importance of
exploring it profoundly in an attempt to
promote patient outcomes.
Oral Mucositis Project at
AUBMC
Briefing:
 A prospective and retrospective review of
patient medical records for the presence
of mucositis was conducted at AUB MC
on the oncology units (3 units) during
the period from November 2007 to
January 2008 (3 months).
Oral Mucositis Project at
AUBMC
Method:
 A form for data collection was developed to
assess the evidence of mucositis, age, gender,
admitting diagnosis, and initiation of mucositis
treatment.
 Retrospective review: patient medical records
were assessed for the documentation of the
evidence of oral mucositis in the progress notes
(doctors and nurses) and medical orders (for
initiation of therapy).
Oral Mucositis Project at
AUBMC
Method:
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Prospective review: patient’s charts on the
units were surveyed for the presence of
assessment and documentation of oral
mucositis.
Oral Mucositis Project at
AUBMC
Results:
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The retrospective study (N=50) revealed a
prevalence of 18% of oral mucositis while
in the prospective study (N=28) revealed
78.57% prevalence. This may be
explained as a result of the awareness
about oral mucositis the importance of its
assessment that was discussed by the
team members collecting data with the
nurses.
Oral Mucositis Project at
AUBMC
Results
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The combined data showed a prevalence
of 39.74% of oral mucositis where 40%
only received treatment. Despite its large
magnitude, this result is similar to what is
reported by the literature (Debra & Knobf,
2004).
Oral Mucositis Project at
AUBMC
Variables
Retrospective Data
N. ( Sample = 50)
Percentage
Variables
Age
Evidence of
Mucositis
Gender
Treatment for Mucositis
20-50
> 50
Male
Female
Yes
No
Yes
No
14
36
21
29
9
41
9
41
28%
72%
42%
58%
18%
82%
18%
82%
Age
Evidence of
Mucositis
Gender
Treatment for
Mucositis
Prospective Data
20-50
> 50
Male
Female
Yes
No
Yes
No
N. ( Sample = 28)
12
16
13
15
22
6
22
6
42.80%
57.14%
46.42%
53.57%
78.57%
21.42%
78.57%
21.42%
Percentage
Oral Mucositis Project at
AUBMC
Variables
Combined Data
N. ( Sample = 78)
Percentage
Age
Evidence of
Mucositis
Gender
Treatment for
Mucositis
20-50
> 50
Male
Female
Yes
No
Yes
No
26
52
34
44
31
47
31
47
33.33%
66.67%
43.58%
56.41%
39.74%
60.25%
40.00%
60.00%
Oral Mucositis Project at
AUBMC
Results:
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Despite the small sample of this
assessment exercise, the need to properly
assess oral mucositis in oncology patients
is identified as a need for AUB MC nurses.
As a result of this needs assessment, a
proposal of an oral mucositis assessment
tool was initiated by the team members.
Oral Mucositis Project at
AUBMC
Literature review
 Literature review exploring the published
assessment tools is conducted utilizing
CINAHL, PubMed, Cochrane…
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The tools were assessed for reliability,
validity, clinical usefulness, level of
evidence, and other reviews available.
Oral Mucositis Project at
AUBMC
Oral Mucositis Assessment tools
There are several assessment tools available in the
literature for performing assessment of oral
mucositis (Elier, 2005).
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Oral Assessment Guide.
Oral Mucosa Rating Scale.
Oral Mucositis Index (uses subset of Mucosa
Rating Scale).
Oral Mucositis Assessment Scale.
Spijkervet Radiation Mucositis Scale.
Oral Mucositis Project at
AUBMC
Oral Mucositis Assessment tools
Western Consortium for Cancer Nursing Research Scale.
World Health Organization (WHO).
National Cancer Institute Common Toxicity Criteria
(NCICTC) scale.
Several studies conducted favor the utilization of WHO,
Oral Assessment Guide and National Cancer Institute
Common Toxicity Criteria (NCICTC) assessment tools due
to their practicality (Raber et al, 2000).
Oral Mucositis Project at
AUBMC
Oral Mucositis Assessment tools
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The WHO tool assesses the oral mucositis for erythema,
ulceration, and diet tolerance without clearly identifying
the severity of pain.
The Oral Assessment Guide assesses erythema and
functioning of the oral cavity without identifying the
other aspects such as diet tolerance and pain.
National Cancer Institute Common Toxicity Criteria
(NCICTC) assesses ulceration erythema and pain but is
not very clear and comprehensive.
Oral Mucositis Project at
AUBMC
Creating Our Own Tool
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After studying the above mentioned tools,
the team members opted to create an
assessment tool to include all the needed
criteria included in the 3 tools.
Oral Mucositis Project at
AUBMC
Approvals
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Approval from the administration was
secured.
Two oncologists were consulted and they
validated the usage of this tool to enhance
multidiscplinary involvement.
Oral Mucositis Project at
AUBMC
Pilot Phase
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The Piloting process:
Unit
Process
Timeline
9North
Training of RNs
2 weeks
Implementation
2 months (Nov, Dec 2008)
Evaluation
Ongoing with the implementation
Training of RNs
1 week
Implementation
2 months (Nov, Dec 2008)
Evaluation
Ongoing with the implementation
Overall Evaluation
All through
BMT
Team
members
Oral Mucositis Project at
AUBMC
Training Phase
The training of RNs included:
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Stages of oral mucositis
Timing and duration of assessment
Assessment sequence
Equipment needed
Sites to be evaluated
How to perform the physical examination
Oral Mucositis Project at
AUBMC
Training Phase
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How to document findings
How to link the findings from the Oral Mucositis
Assessment Tool to the Nursing Care Plan,
Multidisciplinary Notes and the intershift report.
Pocket guide oral mucositis assessment tool was
developed for all oncology nurses
Oral Mucositis Project at
AUBMC
Implementation Phase
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The Oral Mucositis Assessment Tool will be
launched on all oncology units after the
completion of the pilot and evaluation by the
team members.
Evaluation
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The continuous evaluation that is being
conducted till now (15 days) is very
promising and showing high rates of
compliance on behalf of nurses.
Expected Patient
Outcomes
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Optimized practice patterns, use of the
best evidence based nursing interventions
for oral mucositis that will improve the
quality of life of cancer patients receiving
chemotherapy and radiotherapy.
Future Projects
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The project is considered to be a research
study and is presented to the nursing
research council in AUBMC.
References
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Auritcher et al (2004). Scope and Epidemiology of
Cancer Therapy –Induced Oral and Gastrointestinal
Mucositis. Seminars in Oncology Nursing, 20, 3-10.
Debra, J. and Knobf, M. (2004).Assessing and Managing
Chemotherapy-Induced Mucositis Pain. Clinical Journal
of Oncology Nursing, 8,662-628.
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Duncan, M. and Grant, G.(2003). Review Article: Oral
and Intestinal Mucositis –Causes and Possible
Treatments. Aliment Pharmacotherapy, 18,853-874.
Elier, J. (2005). Measuring Oncology Sensitive Patient
Outcomes: Evidenced Based Summary.
References
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Oncology Nursing Society (2007). Mucositis. What
Interventions are Effective for Managing Oral Mucositis
in People Receiving Treatment for Cancer?
Raber, J. et al. (2000).Oral Mucositis in Patients Treated
with Chemotherapy for Solid Tumors: A Retrospective
Analysis of 150 Cases. Supportive Care in Cancer, 8,366-
371.
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Rubenestein, E. et al, (2004). Clinical practice Guidelines
for the Prevention and Treatment of Cancer Therapy –
Induced Oral and Gastrointestinal Mucositis. Cancer 100,
2025-2026.
Sonis, ST. et al. (2004). Perspective on Cancer Therapy
Induced mucosal injury: Pathogenesis, Measurement
Epidemiology, and Consequences for patients. Cancer
100, 1995-2025.