Care and Support of those Suffering with Mucositis
Mucositis- a painful complication of the Gastro-intestinal tract, from chemotherapy and radiation, which is due to the lowered white blood cell count.
A. Signs- Red, shiny, swollen mouth and gums; blood in the mouth; soreness and pain in the mouth or throat; difficulty in chewing and/ or swallowing; thick saliva or mucus in mouth. Very dry mouth.
Factors that can increase the occurrence of mucositis in the cancer patient.
- Poor oral health and not seeing a dentist or dental hygienist for regular oral care
- drinking alcohol, smoking, or chewing tobacco Irritation from improper fitting dentures, or restorations or teeth that are broken.
- Younger patients develop mucositis more easily than older patients, because they have a higher turn over rate of tissue, but also heal faster because of higher turnover of tissue.
Consequences of Mucositis
- Ranges from mild to severe pain
- Inability to eat or drink, or taste food, so poor nutritional intake
- Lower body mass, which can lead to decrease in healing, cyclical pattern develops
- Potential portal for infectious bacteria, and gingivitis and periodontitis
- Fungal infection
- Increase in antibiotics, and narcotics
- Interruption to therapy
- In combination with neutropenia, can lead to septicemia.
Duration
- 5-10 days following chemotherapy, and lasts from 1-6 weeks or more. When neutrophil count becomes greater than 500 cells/microliters onset of mucositis decreases.
Prevention- Mucositis may happen regardless of preventative steps, but you can minimize occurrence.
Steps for prevention.
- Very important to have a dental exam to determine if any fillings, dentures or broken teeth need to be fixed ONE MONTH prior to the beginning of chemotherapy and/or radiation.
- Have a dental hygiene examination to determine, fluoride needs, salivary products and frequency of hygiene services. Perform scaling and rootplaning as needed, and provide oral health instruction as well as dental aids. With low saliva, decay of teeth increases, which may lead to cavities. Fluoride is the only known mineral that decreases the occurrence of decay. Fluoride trays should be made, 1.1% Sodium Fluoride 10 minute application. This is done through the dental office, or independent dental hygiene office.
- Rinse mouth before and after meals, before bedtime with 1tsp salt to 2 cups water, or 1/2 tsp salt with 2 tbsp of Sodium Bicarbonate in 4 cups of water.
- No smoking
- Avoid whitening toothpaste
- Avoid whitening, or alcohol based mouthrinses
- Use a non-vaseline lip moisturizer
- Limit the use of interproximal cleaning such as toothpicks and dental floss if platelets are below 40,000.
- Avoid lemon or glycerin swabs
- Use an ultrasoft toothbrush, Nimbus is a new toothbrush, which is very soft.
- Drink lots of water.
- Dietary counseling referral,will assist in maintaing adequate nutrition.
- Sucking on ice chips during chemotherapy treatments also helps.
Treatment
Mild occurrence of mucositis.- Use a salt or Sodium Bicarbonate rinse ( as mentioned above) Xylitol mints, gums to help moisten the mouth Biotene products, Toothpaste, rinse and gel work best when combined as three, to moisten the mouth.
Moderate occurrence of mucositis– 1 part of 3% food grade hydrogen peroxide with 2 parts of salt water ( 1 tsp of salt in 4 cups water) Benzocaine topical pain relievers. Orajel etc. Swishing with Chamomile tea, Mylanta or Mallox based acid reflux liquids.
Severe occurrence of mucositis- Prednisone, Advil or Tylenol; Viscous Lidocaine, or Xylocaine 2% Combinations of Lidocaine, mallox, and Nystatin help to make a mouthrinse to ease symptoms called ‘Magic Mouthrinse” ;Prescription for narcotic analgesia.
Conclusion
Although mucositis often varies in degree of severity, the effect on the individual can be difficult and quickly decrease their quality of life. When going through chemotherapy treatments, the prevention of mucositis not only can improve outcomes during cancer treatment, but also help the cancer patient avoid costly and possibly extensive oral care after chemotherapy and/or radiation treatment. A Dental Hygienist in consultation with the Dentist is the best way to help prevent mucositis, and give the patient necessary tools to prevent, treat and minimize the onset of mucositis.
Where to purchase products/ Where to direct the patient ( West Kootenay, B.C)
There are many products available locally, but the dental office is the best place for new and best researched products.
DRY MOUTH
- Oral lubricants: Biotene- Walmart, Shoppers, Pharmasave, should be used in combination, toothpaste, rinse and gel together.
- GC Dry mouth Gel- Other products are available from Dental offices
- Xylitol- L’Bears, any health food store, very important that it is from a natural source and not manmade.
- Coconut oil- Any Natural food store, L’Bears, Mother natures. Oil pulling, something new, not very much research, but coconut oil is a natural antibacterial, and is very lubricating for the mouth.
ORAL CLEANSING-BACTERIAL REDUCTION
- Sodium Bicarbonate- L’Bears health food store, or any health food store.Safeway or Ferraro’s also has an all natural Sodium Bicarbonate product. Bob’s Red Mill.
- Sea Salt- as above, very important to check for purity.
CAVITY REDUCTION
- High Fluoride toothpaste- OTC Wal-mart, Shoppers- Prevident 5000. Can also be purchased for Clean Between in Castlegar. Clinpro 5000
- Fluoride gels- 1.1% Sodium Fluoride, Any dental office, Clean Between in Castlegar.
- Fluoride mouthrinse- ACT mouthrinse-Any dental office, Clean Between in Castlegar.
- Ultrasoft toothbrush- Nimbus, available through any dental offices, Kootenay River Dental Hygiene Inc. Has them in stock.
PAIN MANAGEMENT
- Benzocaine oral mouthrinse, gels and tabs- Any pharmacy.
- Xylocaine or Lidocaine 2% suspension – Rx from family physician.
- Nystatin- Rx from family physician Advil, Tylenol, Antacid liquids, available in any pharmacy.
- *Magic mouthrinse- It is very popular and has an added benefit of doing three things at once. Any pharmacy can make up the solution by name. It includes, Milk of Magnesia, Nystatin, and 2% viscous Lidocaine. It is very easy and safe to use, but needs to be prescribed by a dentist or family physician.
References:
National Cancer Institute. Palliative care in cancer: National Cancer institute. [ Updated 2010/03/16 and 2013/12/18] Available from :http://www.cancer.gov/cancertopics/pdq/supportivecare/oralcomplications/Patient
Rhodes-Nesset S, Larronde D. Dental hygiene care of head and neck cancer patient. Can J Dent Hyg 2014;48(1):20-26
Schiodt M , Hermund NU. Management of oral disease prior to radiation therapy. Support Care Cancer.2002;10(1):40-3.
The Oral Cancer Foundation: Mucositis. [Updated 2014/04/04] Available from:http://www.oralcancerfoundation.org/complications/mucositis.php
BuenoAC, Ferriera RC, Barbosa Fl, Jham BC,Magalhaes CS, Moreira AN. Periodontal care in patents undergoing radiotherapy for hard and neck cancer. Support Care Cancer. 2013;21(4):969-75.
Canadian Cancer Society: Mouth Care [Updated 2014/04/10] Available from: http://www.cancer.ca/en/cancer-information/diagnosis-and-treatment/managing-side-effects/dry-mouth/mouth-care/?region=nu
