Assessment of Oral Mucositis in
Adult and Pediatric Oncology
Patients
Laura Cullen, MA, RN, FAAN
Grace Rempel, BS
Evidence-Based Practice Coordinator
Nursing Research and Evidence-Based Practice
Department of Nursing Services and Patient Care
University of Iowa Hospitals and Clinics
Iowa City, IA
Team
Co-Chairs: R. Evans, BSN, RN, OCN & M.
Farrington, BSN, RN
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Sharon Baumler, MSN, RN, ▼
CORLN
Leslie Brautigam, MNHP, RN ▼
Deb Bruene, MA, RN
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Laura Cullen, MA, RN,
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FAAN
Cindy Dawson, MSN, RN,
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CORLN
Kristin Febus, BSN, RN
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Roger Gingrich, MD, PhD
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John Hellstein, DDS
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Sheryl Lang, MA, RN,
CPNP, CNA-BC
Jessica Jones, BSN, RN
Rachel Lillis, BSN, RN
Jean Ryan, RD, CSP, LD,
CNSD
Jimmy Reyes, MSN, RN,
College of Nursing
Anne Smith, MSN, RN
Jane Utech, BSN, RN, OCN
Brandon Viet, M.A. CCCSLP
What is Oral Mucositis?
Purpose and Rationale
▼ Purpose-Phase
I: To implement an evidencebased oral assessment for adult and pediatric
oncology populations (ambulatory &
inpatient)
▼ Purpose-Phase
II: To implement evidencebased prevention strategies for oral mucositis
for adult and pediatric oncology populations
(ambulatory & inpatient)
Synthesis of Evidence
▼ 40%
of oncology patients develop oral
mucositis (Brown & Wingard, 2004; Dodd, 2004; Fulton, Middleton
& McPail, 2002) resulting from both chemotherapy &
radiation therapy (Avritscher, Cooksley & Eden, 2006; Brown &
Wingard, 2004)
▼ 70-100%
of head and neck patients will
experience oral mucositis (Elting, Cooksley, Chambers &
Garden, 2007; Murphy, 2007)
Synthesis of Evidence
▼ Patients
report that oral mucositis is the
most distressing side effect from cancer
treatment (Jaroneski, 2006)
Synthesis of Evidence
Oral mucositis is problematic and results in:
delayed treatments, reduced treatment dosages,
altered nutrition, dehydration, infections,
xerostomia, pain and increased healthcare costs
(Brown & Wingard, 2004; Sonis, Elting, Keefe, Peterson, Schubert, Hauer-Jensen,
Bekele, Raber-Durlacher, Donnelly & Rubenstein, 2004)
Phase II: Purpose and
Rationale
▼ Purpose-Phase
II: To implement evidencebased prevention strategies for oral
mucositis for adult and pediatric oncology
populations (ambulatory & inpatient)
Phase II: Prevention and
Treatment
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The most frequently identified source of sepsis is
the mouth, creating unintended risk for patients (van
der Velden, Blijlevens, Feuth & Donnelly, 2009)
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Oral mucositis potentially increases the risk of a
local and/or systemic infection (Eilers, 2004; Lalla, Sonis &
Peterson, 2008; Worthington, Clarkson, Eden, 2007)
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Clinician knowledge & skill EBP oral care is
limited (Barker, Epstein, Williams, Gorsky, Raber-Durlacher, 2005; Binkley, Furr,
Carrico, & McCurren, 2004; Potting, Mank, Blijlevens, Donnelly & van Achterberg,
2008)
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Nurse’s knowledge and skill can improve with
education (Potting, Mank, Blijlevens, Donnelly & van Achterberg, 2008)
Phase II: Prevention and
Treatment
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Effective strategies are available to prevent oral
mucositis and treat oral mucositis (Clarkson, Worthington &
Eden, 2007; MASCC; ONS)
– Cryotherapy for 5-FU, Melphalan, and Edatrexate
(Keefe,
Schubert, et al., 2007; Mori, Yamazaki, et al., 2006; Worthington, Clarkson, Bryan,
et al., 2011)
– Keratinocyte growth factor (palifermin®) (Worthington,
Clarkson, Bryan, et al., 2011)
– Sucralfate is effective in reducing the severity (Worthington,
Clarkson, Bryan, et al., 2011)
– Oral care/rinses (Brennan, Elting & Spijkervet, 2010; Cheng, Molassiotis,
Chang, et al., 2001; Glenny, Gibson, Auld, et al., 2010; Harris, Eiler, harriman, et
al., 2009; Hogan, 2009; Joshi, 2010; Keefe, Schubert, et al., 2007; Lalla, Sonis &
Peterson, 2008; Meurman & Grönroos, 2010; Peterson, Bensadoun &Roila, 2008;
Sieracki, Voelz, Johannik, et al., 2009; Sonis, 2011)
Cost Information
▼ Oral
mucositis costs $1,70012,600/patient (or higher) depending
on the severity (Elting, Cooksley, Chambers & Garden,
2007; Jones, Qazilbash, Shih, et al., 2008; Nonsee, Dandade,
Markossian, et al., 2008)
EBP Evaluation
▼ Staff
knowledge
▼ Staff
perceptions
▼ Nursing
documentation of assessment/severity
▼ Nursing
documentation of oral care
▼ Pediatric
patient feedback on oral care kits
Patient Description
▼ Groups:
– Pre = July 2009 to June 2010
– Post = July 2010 to June 2011
▼ Age
Range
– Infants to 21 years old
Diagnosis Types
▼ Leukemia/Lymphoma
▼ Solid
Tumors
▼ Marrow Failure
Types of Transplants*
▼ Matched
Unrelated Donor Bone Marrow
▼ Autologous Peripheral Blood Stem Cells
▼ Unrelated Umbilical Cord Blood
▼ Mismatched Unrelated Donor Bone Marrow
▼ Matched Family Peripheral Blood Stem
Cells
▼ Matched Sibling Bone Marrow
* First transplant only
Oral Mucositis Assessment
▼ Modified
Eilers’ Oral Assessment Guide
▼ 8 categories
– Each category is scored 0-2
• Total Score “0-16”
• “0”=Normal
▼ Documented
twice a day
on admission and then at least
Data
▼ Received
Excel file with list of all Pediatric
Bone Marrow Patients
▼ Received Excel Flow Sheet data
▼ Imported Excel files into Access
▼ Narrowed data to transplants done in FY
2010 and those done in FY 2011
▼ Used only patients having first transplant
▼ Used not more than 2 score values per day
per patient
Severity of Oral Mucositis
Pediatric Bone Marrow Transplant
Confidential Data
Data
▼ Clinical
Question:
– Is there a statistically significant improvement
in oral mucositis in the post group patients?
▼ Q&A
regarding the data
Acknowledge
▼ Oral
care kits
– Pediatrics
– Head & neck cancer
– Adult leukemia and BMT
▼ Nursing
Research and EBP Office
Here’s to a healthy mouth
laura-cullen@uiowa.edu