ORAL MUCOSITIS definition incidence pathogenesis causes and risk factors clinical manifestations assessment management nursing management

1. MUCOSITIS(ORAL)
SWATILEKHA DAS
NURSING OFFICER CUM TUTOR

2. 2
SWATILEKHA DAS

3. MUCOSITIS(ORAL)
• CT or RT induced ,painful inflammation and
ulceration of the mucous membranes lining
the GI tract.
• Oral/oropharyngeal mucositis affects the
keratinized mucosa of the dorsal tongue,
gingiva, and /or hard palate; mucositis can
also develop in the small intestine (GI
mucositis) or the rectal mucosa (Proctitis).
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4. • OM severity ranges from superficial erythema and soreness
to full thickness mucosal ulcerations withy major pain,
delayed , interrupted or discontinued treatment, systemic
infections, hospitalization; impaired oral nutrition and
economic burden.
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5. Incidence
• 20%-40% of patients receiving standard –dose CT
• 60% -100% of those undergoing hematopoietic stem cell
transplantation(HSCT)
• and almost all patients receiving RT for HNC(>50% with
grade 3 or 4)
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6. • Mucositis involves epithelial
mucosa, submucosal cells, and
tissues and basal membrane.
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7. Pathogenesis
Initiation-within seconds of injury to highly proliferative , Nnormal cells &
supporting connective tissues, DNA damage and other cellular responses lead to
tissue changes.
A primary damage response; transcription factors upregulate an innate
response and activate expression of genes and multiple pathways, production
of cytokines and modulators associated with the progression of mucositis.
It becomes clinically apparent in the ulceration phase-loss of mucosal
integrity ,painful lesions, submucosal breach with bacterial colonization and
secondary infection.
Healing occurs after CT or RT stopped.Submucosa and mesenchyme signal
the mucosa to reepithelialize.The mucosa appears normal , but residual
angiogenesis means increased risk for future mucositis episodes.
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9. Causes and
risk factors
CT(cyclophosphamide,
doxorubicin,vincristine,etoposide,ifosfamide,
methotrexate,docetaxel,
palitaxel,cisplatin,carboplatin,oxaliplatin,5-FU,leucovorin)
RT for HNC
Combined CT & RT increases risk to greater degree
Baseline nutritional status below average –body mass
index(BMI)-<18.5
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10. Causes and risk factors
Unintentional
pretherapy weight
loss (>5% over 1
month or >10% last
6 months)
Poor oral hygiene,
peridontal disease
Persistent smoking
or alcohol use
Xerostomia
Impaired renal
function(high serum
creatitine) may
increase risk
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11. Clinical manifestations
A) Cycled or conditioning CT regimen- Mild erythema start 3-
4 days after CT;ulcers thereafter;peak intensity days 7 and 14;
usually resolves in next week
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12. B) RT for HNC
• Oral mucosal erythema and soreness start around week 1
• Cumulative dose 20 to 30 Gy, frank ulcers; pain worsens,
and oral intake decreases
• Continued RT (to total 60-70 Gy );increased cumulative
damage; difficult to control pain
• OM typically resolves 2 to 4 weeks after RT completion, may
persist longer.
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13. C) Progressive
ulcerative OM
More diffuse, ulcers may be accompanied by
:
• Thick secretions that induce coughing,
aspiration and disturb sleep
• Pain that necessitates opioid analgesics
• Impaired speaking, eating and drinking
and swallowing
• High risk gram negative bacterial or yeast
infections and septic complications
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14. Assessment
• History-
• Usual oral hygiene
• Any changes in speaking,
eating and drinking and
swallowing
• Screen for PCM
• Use OM grading scale
• Oral pain/comfort
• Mouth dryness
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15. • Use OM grading scale: World Health Organization Oral
Mucositis Grading Scale
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16. Physical examination
• Recommended – regularly assess OM
• Use a penlight to examine mouth for redness, swelling,ulcerations,white patches
• Auscultatelung for potential for aspiration
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17. Psychological assessment
• Does sore mouth interfere with eating, drinking, talking;
make them feel depressed
• If they no longer enjoy the social interaction eating with
others
• If they act alone because it takes much longer to finish a
meal than others
• Imagery and laboratory tests : nothing specific to OM
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18. Management
• Medical -
• Palifermin (keratinocyte growth factor)- food and drug
administration(FDA) approved for patients with hematologic
malignancy receiving high dose CT /total body irradiation,
followed by autologous HCST; 60 microgram/kg body weight per
day. 3 days before and after conditioning regimen(very costly) to
reduce incidence and severity of OM 18
SWATILEKHA DAS

19. Supportive care
drugs
• Supportive care drugs-
analgesics(Opioids and adjuvants) to
relieve severe pain
• >97% of pts with ulcerative OM require
opioid analgesics(usually
morphine equivalent) by week
4. Opioid doses increase to week 7 ,
usually needed for 6weeks after
treatment completion.
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20. Adding adjuvant analgesics may be
opioid sparing:
• Add gabapentin to analgesic regimen
• Doxepin 0.5% mouthwash
• Simple or niosomal amitryptyline mouthwash or
benzydamine(NSAID mouthwash 15ml, swish 30
seconds and spit), provide temporary pain relief.
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21. Low level laser therapy
Biweekly or weekly- reduces OM
prevalence, severity , duration and
associated pain 21
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22. Research
studies
• Instruct pt to hold ice chips in mouth for 5
minutesbefore CT or RT , during CT or RT, and
after 30minutesafterwards
• Very helpful 5 FU and high dose
melphalan;inconclusiveresults- methotrexate,
etoposide, cisplatin,mitomycin,vinblastine
• Contraindicatedwith oxaliplatin because of risk
for laryngeal dysesthesia.
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23. Nursing management
• Preventive oral care-
Pretreatment and dental examination and instruction for oral hygiene regimen
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24. Nursing management
• Remind pts about helpful dietary tips for painful OM, avoid
spicy foods, hot foods and rinks, eat soft or moistened
foods.
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25. Nursing management
Topical protective /coating agent:
• Benzocaine (ora-base, Oratect gel, hurricaine)+-
analgesics(e.g. viscous lidocaine, magic mouthwash) may
give some temporary relief.
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26. Nursing management
• Use of normal saline, salt and baking soda(0.5 tea spoon
each in 1 cup of warm water) ; or plain water rinses.
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27. Thanks
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