Introduction

Mucositis is the damage and inflammation that occurs to the oral mucosa as a result of cytotoxic therapies, characterised by erythema and ulceration of the oral mucosa. Mucositis can extend from the oral cavity and into the gastrointestinal tract. Common symptoms of mucositis range from pain, dysphagia, bleeding, poor nutritional status and increased risk of infections. These can directly lead to increased inpatient admissions, high opioid consumption, weight loss as well as dose limiting and/or delays in treatments. 

Mucositis is a common complication of both chemotherapy and radiotherapy treatment. The severity of the mucositis is often dictated by the strength, cycle and type of neoadjuvant therapy administered.  

The incidence of paediatric mucositis varies, butit is anticipated to occur in 20-40% of patients receiving conventional chemotherapy and in at least 80% of patients receiving high dose chemotherapy as conditioning for a stem cell transplant. Symptoms usually develop 5-10 days post the first dose of chemotherapy. Several therapy and patient specific factors, including the chemotherapy drug, the type of malignancy, age, neutrophil count and level of oral care are important in the pathogenesis of oral mucositis. 

Although we cannot entirely prevent the incidence of mucositis, health professionals have an important role to play in managing the severity and duration that mucositis has on patients going through their chemotherapy journeys.  

Aim

The aim of this guideline is to provide all health professionals with adequate guidance and support using a comprehensive overview of oral care and mucositis from studies and international paediatric cancer centres. 

Definition of Terms

• ALL: acute lymphoblastic leukaemia 
• Allogeneic: donation not from self 
• COPADM: chemotherapy regimen involving the agents cyclophosphamide, vincristine prednisolone, doxorubicin and methotrexate  
• Gingivitis:inflammation of the gingivae (gums) caused by bacterial plaque accumulation 
• GI tract: gastrointestinal tract 
• Haemopoietic stem cell transplant (HSCT): transplantation of the blood forming components/cells of the body 
• Mucositis: inflammation and/or ulceration of the mucous membranes and/or ulceration of the oral cavity (stomatitis), often involving the oesophagus (oesophagitis) 
• OAG: oral assessment guide 
• Oesophagitis: inflammation and/or ulceration of the mucous membranes involving the oesophagus 
• PCA: patient controlled analgesia 
• Stomatitis: inflammation and/or ulceration of the mucous membranes in the oral cavity 
• TBI: total body irradiation; radiation of the entire body used as preconditioning regimen for HSCT  

Oral Assessment

Daily oral assessments are required for all inpatients undergoing chemotherapy, immunotherapy, radiotherapy and/or a stem cell transplant. It is the nurse's responsibility, in conjunction with the treating medical team to undergo adequate mucosal assessments and provide rationale hygiene and/or treatment measures.  
 
The Oral Assessment Guide (OAG) is a global tool adapted by Eilers et al (1988) still used today in assisting nurses and doctors to determine the patient’s oral health and function. Results of this score should be documented daily. This tool can be added on EMR for all paediatric oncology/HSCT patients under the ENT assessment in the ‘Focused assessment Flowsheets’. 

Below is the Oral Assessment Guide (OAG) Rating Scale (Adapted from Eilers et al, 1988). 

Each of the eight categories is scored 1, 2 or 3.   

• An OAG score of 8 indicates a healthy oral cavity 
• An OAG score of 24 indicates severe mucositis  

The OAG provides parameters for the assessment of each child's mouth and the implementation of a plan of care based on these findings. The recommended management for oral hygiene in paediatric oncology and HSCT patients is based on the OAG score. 

Management

Basic mouth care & prophylaxis 

Various cancer and radiotherapy treatments will determine the severity and likelihood of mucositis occurring in each patient.  

Group A ‘Very high risk’- These patients include AML, Burkett’s lymphomas receiving COPADM, autologous stem cell rescue, & HSCT patients 

Group B ‘High risk’- ALL induction, relapsed ALL, infant ALL, high risk neuroblastomas, Ewing’s sarcomas, osteosarcomas, B cell NHL, anaplastic large cell lymphomas, brain tumours, sarcomas.  

Although mucositis is not entirely avoidable, nurses and health care professionals can contribute to alleviating and reducing the severity of mucositis. Both risk groups should receive ‘basic oral care’ with the goal to provide comfort to the patient and reduce the bacterial load in the oral cavity, therefore preventing potential infections and discomfort. This is focused on mechanical cleaning as stated below. 

Tooth brushing 

The use of fluoride toothpaste strengthens tooth enamel and decreases the risk of dental cavities. 

Patients should use a soft toothbrush. Low neutrophil and platelet counts are not a contraindication to using them however a toothbrush can be substituted with a foam brush in babies or patients with bleeding gums or severe mucositis. Normal tooth brushing should be resumed at the earliest opportunity.  

Fluoride toothpaste (0.22% fluoride for 6 years+ and 0.11% for under 6 years old) should be used when brushing teeth. Residual toothpaste should be spat out and patients should avoid rinsing or eating for 30 minutes.  

Gels and mouthwashes 

Chlorohexidine 0.5% based gels and mouth rinses (0.2%) have a broad antimicrobial activity. Gels and rinses (chlorhexidine based) can also prevent plaque. It is important to use alcohol free solutions. Rinsing the mouth with chlorhexidine 0.2% mouth rinse should not be used as a substitute for tooth brushing.  

Application of a moisturising cream to the lips is also recommended.  

Treatment of established mucositis 

The goals of treating established mucositis vary depending on the patient's OAG score as well as the severity of mucositis.  

Table 3 below shows the WHO Oral Mucositis Grading scale. 

Pain 

The morbidity of mucositis is mostly associated with the inflammation and ulceration it causes in the oral cavity, therefore causing significant pain. The pain of swallowing and even communicating negatively impacts oral intake, medication compliance and maintenance of oral hygiene. 

Pain should be effectively managed in conjunction with the medical teams to establish an opioid routine that works well for the patient. This is likely to involve IV opioid infusions such as morphine.

Topical anaesthetics and analgesics must also be considered to protect and promote healing. Lidocaine Gel 2% will provide anaesthesia to mucous membranes, applying a thin layer to the affected area. Alternative mix 10ml of Gastrogel (aluminium and magnesium hydroxide/trisilicate) with 10ml of Lidocaine 2% oromucosal viscous gel to create a ‘pink lady solution’. This can then be rinsed around the mouth and swallowed to sooth the mouth and lining of the oseophagus.

Regular pain assessments adequate documentation is vital to ensure the patient’s pain is effectively managed. Regular pain assessment is required using a validated tool as per the ‘ Pain Assessment and Measurement clinical guidelines (nursing)’.       

If the mouth is too painful for cleaning with a toothbrush (and/or bleeding gums), the mucosa can be cleaned with oral sponges moistened with chlorhexidine mouthwash. Timely analgesia important to facilitate mouth care procedures. 

Consult the ‘ Pain Management’ clinical practice guidelines for further information on opioid or PCA infusions.

Nutrition 

Secondary to pain, a patient with mucositis is also at risk of nutritional decline if not managed appropriately. Certain food and drinks should be avoided that could cause mucosal irritation or increased pain. 

It is important to try to compensate for weight loss during this time through enteral or intravenous feeding. Enteral feeding via a nasogastric tube has shown to be protective for the gut mucosa. However, a NGT needs to be available in a patient prior to the establishment of mucositis. Once classified as severe, an NGT insertion is not recommended. Early education and awareness of the timing of NGT insertion is important.  

Parental nutrition (TPN and lipids) may be temporality appropriate for patients with severe mucositis.  

Proton pump inhibitor such as omeprazole or pantoprazole may be useful for the prevention of epigastric pain after treatment.   

Some foods and drinks should be avoided during mucositis as these can illicit more pain and/or make the ulcers worse and delay recovery. Some foods to avoid include: 

• spicy foods
• sharp and rough foods such as potato chips and popcorn
• Acidic foods such as citrus, carbonated drinks and juices 
  
• Foods/drinks high in temperature such as tea and coffee. 
  

Infections 

Secondary to oral cavity stasis and colonization of oral lesions by microbial flora, infections are another risk associated with mucositis that must be effectively managed to prevent further complications.  

Both fungal and viral infections are possible during a period of mucositis and prophylactically treatment is recommended in high-risk patients such as those undergoing stem cell transplant or other high-risk protocols such as COPADM.

Oral colonisation with streptococcal species can result in bactermeia in patients with severe mucositis and therefore the addition of vancomycin to emperic antibiotics for febrile neutropenia should be considered. 

Antifungal prophylaxis agents (oral or intravenous as tolerated) are recommended for paediatric oncology and HSCT patients at risk of invasive fungal infection (IFI). An azole antifungal agent, such as fluconazole, may be prescribed. Nystatin is not absorbed by the GI tract and does not have a role in treating established oral candida.  

Aciclovir is recommended as a prophylactic and treatment measure for herpes simplex virus in patients undergoing haemopoietic stem cell supported therapy. 

Dental Considerations 

Elective dental treatment should be delayed until the child is either in remission or on maintenance chemotherapy. 

During immunosuppression all elective dental procedures should be avoided. 

Fixed orthodontic appliances and space maintainers should be removed if the patient has poor oral hygiene, or the treatment protocol carries a risk of developing moderate to severe mucositis. 

Links

Pain Assessment and Management clinical guidelines (nursing)

Pain Management clinical practice guidelines 

Evidence Table

The evidence table for this guideline can be found here.  

Please remember to read the disclaimer. 

The revision of this nursing guideline was coordinated by Holly Wilson, Clinical Nurse Consultant, Children's Cancer Centre and approved by the Nursing Clinical Effectiveness Committee. Updated August 2023.