Seminars in Oncology Nursing, Vol 23, No 3 (August), 2007: pp 201-212 201

OBJECTIVES:

PREVENTION AND
To review current evidence that
applies to the development of a
nursing plan of care for the pre-
vention and treatment of oral mu-
cositis related to cytotoxic ther-
apy.
MANAGEMENT OF
DATA SOURCES:
Research studies, review articles,
evidence-based guidelines, web-
ORAL MUCOSITIS IN
PATIENTS WITH
based material, and clinical expe-
rience.

CONCLUSION:
Although high-level research evi-
dence regarding mucositis is lim-
CANCER
ited, use of multiple types of evi-
dence in developing a structured
plan of care facilitates improved
patient outcomes and the ad- JUNE EILERS AND RITA MILLION
vancement of the current body of
knowledge.

IMPLICATIONS
PRACTICE:
FOR NURSING

Nurses play a key role in the iden-

tification and use of evidence to
guide the care of patients at risk
for cytotoxic therapy-related oral
mucositis.
KEYWORDS:
Oral mucositis, prevention,
cytotoxic therapy
June Eilers, PhD, RN: Oncology/Hematol-
ogy Clinical Nurse Specialist and Clinical
Nurse Researcher, The Nebraska Medical
Center, Omaha, NE. Rita Million RN, BSN:
Graduate Assistant, University of Ne-
braska Medical Center, College of Nurs-
ing, Omaha, NE.
Address correspondence to June Eilers
PhD, RN, 6604 S 86th St, Ralston, NE
68127; e-mail: jeilers@nebraskamed.com
© 2007 Elsevier Inc. All rights reserved.
0749-2081/07/2303-$30.00/0
doi:10.1016/j.soncn.2007.05.005
T HE ORAL cavity is frequently a prime target for muco-
toxicity because of the effect that cancer therapies have
on normal cells. Although less readily visible, this mu-
cotoxicity is often present throughout the gastrointestinal tract as
well as other mucous membranes in the body. The ease of assess-
ing the oral cavity allows it to serve as a “window” of potential
mucotoxicity in other areas of the body.
TERMINOLOGY RELATED TO ORAL MUCOSITIS
T he terms “mucositis” and “stomatitis” traditionally have been
used interchangeably to discuss the changes seen in the oral
cavity. Recently, there has been an attempt to clarify terminology.
Mucositis refers to the inflammatory process involving the mucous
membranes of the oral cavity and the gastrointestinal tract. Stoma-
titis refers to inflammatory diseases of the mouth including not only
the mucosa, but also dentition, periapices, and periodontium.1,2
There is now a proposal to use the term “alimentary tract mucositis”
for mucositis in the oral cavity and gastrointestinal tract as one
area.3,4 Consistent use of these terms among health care professionals
will enhance communication regarding the findings as well as recom-
mendations for interventions aimed at the prevention and treatment
of mucositis.
Varying degrees of mucositis severity are seen in patients re-
ceiving cytotoxic therapy, ranging from mild sensation changes to
multiple, even confluent, ulcerative, bleeding lesions. Although
these changes may be present throughout the oral cavity and the
gastrointestinal tract, this document will focus on the changes in
the oral cavity. Common complaints of patients related to oral
mucositis include changes in sensation, difficulty talking and swal-
202 J. EILERS AND R. MILLION
lowing, the presence of mouth sores, and some-
times dryness. Often patients experience a cluster
or constellation of signs and symptoms including
pain, bleeding, infection, ulceration, xerostomia,
taste alterations, and altered nutritional status.5,6
Mucositis interferes with comfort, nutrition, com-
munication, and general well-being. Individuals
who have received high-dose therapy have re-
ported oral mucositis to be the most distressing
symptom they experienced.7,8
EVIDENCE-BASED CARE
T he importance of evidence-based practice has
received increased attention over the past de-
cade. When research evidence is limited, there is
a need to look to other forms of evidence to assist
with guiding practice. Goode9 proposed a model
for the use of multiple types of evidence to estab-
lish practice guidelines. In addition to valid and
current research that is at the center of her model,
other sources of evidence that can supplement the
research core include: (1) bench-marking data,
(2) cost effectiveness analysis, (3) pathophysiol-
ogy, (4) retrospective or concurrent chart review,
(5) quality improvement and risk data, (6) inter-
national, national, and local standards, (7) infec-
tion control, (8) patient preferences; and (9) clin-
ical expertise. Although the quantity of research is
steadily increasing, sound research findings re-
garding the prevention and treatment of mucositis
remains limited. Therefore, clinicians need to be
able to look for and evaluate other forms of evi-
dence that can be used and integrate this into
their knowledge base to guide their care of pa-
tients.
ORAL HEALTH
O ral health is an important component of the
overall state of wellness of an individual. The
oral cavity plays a key role in speech (communi-
cation), nutritional intake, and nonverbal expres-
sion of feelings (smiling, kissing). Alterations from
normal oral health influence quality of life
through changes that affect these activities. The
mucous membranes in the oral cavity provide the
same first line of defense against infections that
external skin does. Maintenance of optimum oral
health requires routine oral care including brush-
ing, flossing, and dental care for cleaning and
prophylactic interventions.
The impact of a diagnosis of cancer and the
demands of treatments often cause patients to
adjust priorities and change routines, including a
decreased focus on preventive care. Patients may
delay regular dental cleaning and maintenance
because they do not have the time or energy to
bother with such basic cares. This neglect may
contribute to the potential for oral cavity prob-
lems during cancer treatment as well as later in
life.
The healthy mouth is comfortable, able to
maintain nutrition, able to protect against infec-
tion secondary to organisms in the oral cavity, and
does not detract from one’s sense of well-being.
The presence of mucositis alters each of these
for the individual. The majority of research re-
lated to the prevention and treatment of oral mu-
cositis has focused on high-dose therapy, head
and neck cancer, and common problems for those
patient populations. However, oral care is an im-
portant aspect of an integrated approach to cancer
care across the disease trajectory from diagnosis,
through treatments of varying intensities, through
survivorship, and at the end of life. Therefore, it is
important to identify evidence-based interven-
tions that are relevant across the disease trajec-
tory so that concerns regarding changes in the
oral cavity are adequately addressed for all pa-
tients throughout their experience with cancer.
MUCOSITIS–PROPOSED PATHOPHYSIOLOGICAL
MODEL
H istorically, mucositis has been seen primarily
as a relatively simplistic process, the result of
non-specific damage to epithelial cells by cyto-
toxic therapies and the delayed replacement of
these cells by cells of the basal layer. Because the
epithelial cells were not replaced in a timely man-
ner, ulcers resulted as the epithelial cells sloughed
from the mucosal surface. In patients with im-
mune suppression, these ulcers became infected
and caused potentially life-threatening systemic
infections.
Sonis and his colleagues10-15 have contributed
significantly in recent years to an enhanced un-
derstanding of mucositis as a complex process
involving multiple phases and biologic interac-
tions. They have proposed a theoretical model for
the development and resolution of mucositis that
has five phases: (1) initiation, (2) upregulation
and message generation, (3) amplification and sig-
 PREVENTION AND MANAGEMENT OF ORAL MUCOSITIS
Initiation
Message generation
Signaling and
amplification
Ulceration
Healing
FIGURE 1. Biological phases of mucositis. Mucositis
takes place in five biologically defined phases. Different
phases may be taking place simultaneously in various
anatomic sites in the mouth.
naling, (4) ulceration, and (5) healing. Each phase
involves a cascade of reactions, setting the stage
for mucositis to be appreciated as more complex
than originally thought (see Fig 1).
Initiation, the first step in the process, is the
generation of reactive oxygen species that drive
other biologic processes and cause direct cellular
damage. Upregulation and message generation oc-
curs because of the activation of a variety of
transcription factors by the reactive oxygen spe-
cies, radiation, and chemotherapy. The transcrip-
tion factors can then activate other cytokines and
pathways that lead to further tissue damage and
breakdown. During signaling and amplification,
the pathways that have been altered continue to
influence one another, leading to an altered mu-
cosal environment. Up to this point in the process,
only minimal visible changes may be apparent.
Ulceration is the appearance of visible changes in
the form of ulcers or lesions. The microflora in the
oral cavity then produces a variety of products
that contribute to the mucotoxic process. These
203
organisms can also cause septicemia. The process
of healing or recovery involves the repair of the
damaged tissue with epithelial cells.
Mucositis is more than just a “bad mouth.” The
process also involves the mucosa of the gastroin-
testinal tract and further research is needed to
determine the generalizeability of the proposed
model to these areas. This five-phase theoretical
model has the potential to revolutionize our ap-
proach to mucositis with new attention being
given to therapies that have the capability to tar-
get different phases and components of the com-
plex process involved.16 Nurses can use this pro-
posed explanation of pathophysiology and the
phases of the mucositis process as a source of
evidence to guide practice. The knowledge that
mucositis is frequently a systemic process rather
than limited to the oral cavity, provides support
for the need for systemic treatments rather than
merely oral rinses if the intent is prevention.
CAUSATIVE FACTORS–WHO IS AT RISK FOR
MUCOSITIS?
s stated by Barasch and Peterson,16, p 91 “can-
A cer therapy-induced ulcerative oral mucositis
is a well defined yet incompletely understood phe-
nomenon.” Risk factors for the development of
mucositis and the subsequent changes with can-
cer treatment are multifaceted. The risk factors
that have been identified as having the potential to
influence mucositis have typically been classified
in two categories: patient-related and cytotoxic
therapy-related (see Tables 1 and 2).10,17-22 It is
important to note that discrepancies in study find-
ings related to risk factors may be partially af-
fected by measurement inconsistency. The field is
hampered by inconsistent use of valid and reliable
measures of oral cavity changes, limited sample
sizes, and lack of adequate controls. Other chal-
lenges to the clear articulation of risk factors are
the patterns of malignancy occurrence by age and
gender, variation in disease-related immunosup-
pression for solid tumors versus hematologic ma-
lignancies, and the difference in side effects of the
various cytotoxic therapies.
Additional research is needed to validate these
risk factors in the development of mucositis, de-
termine specific mechanistic relationships,17 de-
termine the degree of impact of the risk factors on
oral health, and identify preventive measures to
decrease or eliminate the associated risk. Until
204 J. EILERS AND R. MILLION
TABLE 1.
Patient-Related Factors Contributing to Increased
Risk for Mucositis10,17-22
Age Increased risk in the very young age
due to increased cell turnover
rate, and in old age because of
decreased rate of healing
Gender Mixed findings to date with a trend
towards increased risk in females
Oral health and A clean, well-maintained oral cavity
hygiene is less likely to develop problems
related to mucositis
Salivary secretory Decreased saliva causes increased
function problems with mucositis
Genetic factors Potential for increased resistance to
mucositis in some individuals–
specifics yet to be identified
Body mass index Poorly nourished individuals are
more likely to experience
increased breakdown and
delayed healing
Renal function Elevated creatinine potentially leads
to increased mucotoxicity
Smoking Affects microcirculation and
potentially delays healing
Previous cancer History of problems with mucositis
treatment as a result of previous cancer
treatment
such data are available, this information should be
taken into account as nurses develop proposed
plans for individualized care.
THE PROBLEM OF ORAL MUCOSITIS IN
CANCER CARE
A lthough there have been numerous advances
in cancer treatment in the management of
side effects such as nausea and vomiting with 5
HT3 agents and bone marrow suppression with
growth factors during the last two decades, the
prevention and treatment of mucositis has not
seen similar strides in improvement during the
same timeframe. In fact, control of side effects
such as nausea and vomiting and bone marrow
suppression has allowed dose escalation and has
actually increased the likelihood of mucositis. We
are now seeing oral cavity changes with cytotoxic
agents not previously identified as likely to cause
mucositis. With the emphasis on dose escalation
and dose-dense treatment protocols, mucositis
has actually become a leading dose-limiting side
effect for many treatment protocols.18 Therefore,
through improved prevention and treatment of
mucositis, nursing has the potential to contribute
significantly to increased long-term survival seen
with more intensive cytotoxic therapy.
Mucositis causes dose reductions and treatment
delays, both of which are counter to the goal of
“intended dose on time” for optimum tumor kill
and treatment results. Immunosuppressed pa-
tients with ulcerative lesions that become infected
require more costly antibiotics, nutritional sup-
port, and, ultimately, longer hospital stays. Con-
sequently, mucositis is associated with higher
treatment costs.23-26 In addition, mucositis has
been associated with a decreased quality of life,
especially in head and neck cancer,27,28 and
affective states in terms of mood disturbance,
depression, and anger in patients receiving che-
motherapy.29
Oral Assessment
Assessment is essential to the prevention and
treatment of mucositis.30 Jaroneski31 identified
assessment as the most significant clinical inter-
vention by nurses caring for patients with oral
mucositis. Oral assessment is an ongoing process,
and its findings guide the development of a plan
that is implemented and evaluated on an ongoing
basis.
Systematic examination of the oral cavity using
a valid and reliable instrument will provide critical
information to guide nursing interventions.30 The
TABLE 2.
Cytotoxic Therapy-Related Factors Contributing to
Increased Risk for Mucositis10,17-22
Specific chemotherapy/biotherapy agent(s)
Mainly antimetabolites, antitumor antibiotics, alkylating
agents, and other miscellaneous drugs
Dose of agent and administration schedule
eg, bolus 5-U is more stomatotoxic than continuous-
infusion 5-FU, low-dose melphalan is less
stomatotoxic than high-dose melphalan
Type of transplant
Allogeneic transplantation carries greater risk of
development of mucositis than autologous
transplantation
Radiation site and fractionation of radiation
Higher concentrated doses in the head and neck region
carries greater risk of the development of mucositis
Combined modality therapy
Combined chemotherapy and radiation therapy carries
greater risk of development of mucositis
 PREVENTION AND MANAGEMENT OF ORAL MUCOSITIS
literature supports the need for the selected mea-
sures to accurately (1) reflect changes seen with
mucositis as compared with the normal mouth,
(2) aid the identification of mucotoxicity of anti-
neoplastic therapies used in cancer treatment,
and (3) allow evaluation of the effectiveness of
interventions that have been used to manage the
mucositis. Instrument selection should be guided
by the purpose of the data collection. Commonly
used cancer-focused assessment tools include the
Oral Assessment Guide (OAG),32 Oral Mucosa
Rating Scale (OMRS),33 Oral Mucositis Index
(OMI),34,35 and the Oral Mucositis Assessment
Scale (OMAS).36 The OAG encompasses changes
in the oral cavity that have been identified as
relevant to cancer treatment, including function
and keratinized/non-keratinized tissue assess-
ment, but does not provide for quantification of
the size of mucosal lesions. The OMRS, OMI, and
OMAS assess the amount of tissue involved with
mucositis in multiple anatomic regions of the oral
cavity, but do not include function. A separate
assessment of oral cavity-related pain must ac-
company use of each of the tools. In addition to
these tools, several other tools provide for the
grading of changes associated with mucositis: the
Western Consortium for Cancer Nursing Research
tool and the Common Toxicity Criteria used by
the World Health Organization and the National
Cancer Institute.37-39
Inconsistent use of tools has hindered progress
in the advancement of knowledge related to mu-
cositis as it does not allow comparison across
studies or combining of data for analysis. In addi-
tion to the selection of a valid instrument, it is
important to provide the necessary education and
training regarding use of the tools to ensure high
levels of reliability in oral assessments. Inter-rater
reliability is also important across disciplines as
dentists, hygienists, physicians, physician assis-
tants, staff nurses, and advanced practice nurses
are involved in conducting oral assessments.
Assessments to detect alteration in the oral
cavity provide for early and individualized inter-
vention and may decrease the risk of secondary
problems such as septicemia and pain.30,40 A
screening assessment such as, “Are you having
any problems with your mouth?” or, “Have you
noticed any changes in your mouth?” can provide
guidance regarding the need to conduct a thor-
ough systematic assessment of the oral cavity in
patients seen intermittently in the outpatient set-
ting. Typically, the frequency of assessment
205
should increase with the presence of oral cavity
changes. During the acute phases of mucositis,
there can be significant changes within hours.
DeWalt and Haines41 found that the oral cavity
status of a normal healthy subject changes within
4 hours when exposed to stressors such as mouth
breathing, NPO status, suctioning, and the admin-
istration of oxygen. Frequent assessments allow
the clinician to track changes, evaluate treat-
ments, and adjust the intervention plan. As the
oral cavity heals, frequency of assessment can be
tapered.
In addition, nursing assessment should include
a pre-treatment assessment of risk for the devel-
opment of mucositis based on the factors identi-
fied in Tables 1 and 2. The pre-treatment assess-
ment should also determine the patient’s usual
oral care practices, ability to perform oral care,
and understanding of the importance of oral care
during cancer treatment. The assessment data
collected provides guidance for the nurse to de-
velop an individualized plan of care with imple-
mentation of evidence-based interventions. Pa-
tients and family members should be informed
regarding changes to watch for and report to
health care providers.
Evidence-Based Interventions
Oral care research studies to date have had two
major weaknesses that interfere with advance-
ment of the science, small samples and inconsis-
tent use of valid and reliable tools. Therefore, the
amount of high-level evidence to provide evi-
dence-based care is limited. Surveys have indi-
cated that oral care practices are frequently not
evidence-based.6,42 Recommendations regarding
the evidence for oral care are available from three
systematic reviews of available research.43-45
A 2004 Cochrane review of 22 interventions for
the treatment of oral mucositis for patients receiv-
ing cancer treatment determined three of the in-
terventions had some evidence of benefit. The
interventions include: allopurinol, immunoglobu-
lin, and human placental extract.44 A 2006 Co-
chrane review of 29 interventions for the preven-
tion of cancer treatment-related mucositis
determined 10 of the interventions had some ev-
idence of benefit. The interventions include ami-
fostine, antibiotic pastille or paste, benzydamine,
calcium phosphate, honey, hydrolytic enzymes,
ice chips, oral care, povidone, and zinc sulphate.45
206 J. EILERS AND R. MILLION

TABLE 3.
Cochrane Reviews44, 45
Recommendations for the Prevention and Treatment of Oral Mucositis

Review/
Intervention How Administered Recommendation Level of Support Comments

Allopurinol Mouthwash Cochrane 2004 Weak evidence for treatment Risk of bias
of mucositis
Amifostine Injection Cochrane 2006 May provide minimal benefit See note*
to prevent and reduce the
severity of oral mucositis
in adults with head and
neck cancer with
radiotherapy
Antibiotic Topical pastille or Cochrane 2006 Borderline significant – mild See note*
paste benefit
Benzydamine Mouthwash Cochrane 2006 Weak evidence for use in One trial; available in Canada
head and neck cancer and Europe, not FDA-
with radiotherapy approved in US; see note*
Calcium phosphate Mouthwash Cochrane 2006 May be beneficial One trial; see note*
Honey Rinse and swallow Cochrane 2006 Weak unreliable evidence One trial; see note*
that it may prevent severe
mucositis
Human placental Injection Cochrane 2004 Weak evidence for treatment Risk of bias
extract of mucositis
Hydrolytic enzymes Tablets Cochrane 2006 Head and neck cancer – See note*
moderate benefit, may
reduce severity
Ice chips Topical Cochrane 2006 Moderate evidence for use See note*
cryotherapy with 5-FU bolus
Immunoglobulin Injection Cochrane 2004 Weak evidence for treatment Risk of bias
of mucositis
Oral care Oral hygiene Cochrane 2006 Head and neck cancer with One trial; see note*
radiotherapy – weak
evidence, may be
beneficial
Povidone Mouthwash Cochrane 2006 Weak evidence, more One trial; see note*
effective than water with
radio-chemotherapy
Zinc sulfate Capsules Cochrane 2006 Weak evidence, may prevent One trial; see note*
more severe mucositis

*The review emphasized that the strength of the evidence was variable and consideration should be given to the fact that effects
may be cancer type or treatment-specific and reinforced the need for well-designed, conducted trials.

Table 3 provides a summary of the recommenda-
tions from the Cochrane reviews.
The Multinational Association of Supportive
Care in Cancer/International Society for Oral On-
cology (MASCC/ISOO) guideline43 recommended
oral care protocols using a soft toothbrush, patient
and staff education regarding the oral care proto-
cols, valid assessment tools of pain and oral cavity
health, and the inclusion of dental professionals.
Patient-controlled analgesia with morphine was
recommended for oral mucositis pain in hemato-
poietic stem cell transplant patients. Sucralfate
and antimicrobial lozenges were not recom-
mended for prevention of radiation-induced oral
mucositis. Benzydamine was recommended for
radiation-induced mucositis in patients with head
and neck cancer receiving moderate-dose ther-
apy. (Note: although benzydamine is available in
Europe and Canada, it is not approved by the US
Food and Drug Administration.) Chlorhexidine
was not recommended to prevent oral mucositis
in patients with head and neck cancer receiving
radiotherapy or to treat chemotherapy-induced
oral mucositis. Cryotherapy was recommended
for bolus 5-fluorouracil (5-FU) and suggested for
bolus edatrexate and in patients receiving high-
 PREVENTION AND MANAGEMENT OF ORAL MUCOSITIS
dose melphalan. Keratinocyte growth factor-1
(palifermin) was recommended for 3 days before
conditioning treatment and 3 days post-transplant
for patients receiving high-dose chemotherapy
and total body irradiation with autologous stem
cell transplant for hematologic malignancies.
Granulocyte-macrophage colony stimulating fac-
tor (GM-CSF) mouthwashes were not recom-
mended for mucositis prevention in stem cell
transplantation.43
Readers are encouraged to review the publica-
tions discussed above for information on the
agents with evidence insufficient to make a rec-
ommendation. In addition, the Oncology Nursing
Society (ONS) has published the oral mucositis
evidence-based practice quick reference card
(ONS PEPcard), accompanying internet re-
sources, and article. Readers are encouraged to
integrate these recommendations into treatment
plans. All materials are available on the society’s
website at www.ons.org.46 The interventions are
ranked based on the strength of the evidence:
recommended for practice, likely to be effective,
benefits balanced with harms, effectiveness not
established, effectiveness unlikely, not recom-
mended for practice, and expert opinion. Using
oral care protocols involving basic oral care that
includes a soft toothbrush that is replaced regu-
larly and the provision of systematic oral assess-
ment were the only interventions identified as
having adequate evidence to “recommend for
practice” based on the highest level of available
evidence. Cryotherapy for patients receiving bolus
chemotherapy with short half-life (bolus 5-FU and
melphalan) and palifermin for patients undergoing
autologous hematopoietic stem cell transplant for
hematologic malignancies were identified as
“likely to be effective.” The oral care protocols
were articulated in detail in the “expert opinion”
of the ONS PEP quick reference card as follows46:
● Collaborate with a multi-disciplinary team in all
phases of treatment.
● Brush all tooth surfaces for at least 90 seconds
at least twice daily using a soft toothbrush.
● Allow toothbrush to air dry before storing.
● Floss at least once daily or as advised by the
clinician.
● Rinse mouth four times a day with a bland rinse.
● Avoid tobacco, alcohol, irritating foods (acidic,
hot, rough, and spicy).
● Use water-based moisturizers to protect lips.
● Maintain adequate hydration.
207
● Provide written instruction and education to
patients on above items. Verify understanding
with return explanation and demonstration.
● Bland rinses (normal saline, sodium bicarbon-
ate, and a saline and sodium bicarbonate mix-
ture) to remove loose debris and aid with oral
hydration are also recommended.
Individual review articles47-50 also contribute to
the potential evidence base to guide nursing care.
This type of review must be critiqued carefully for
its contribution to the evidence base using a series
of questions such as: “What search terms and
search engines were used?,” “What was the pur-
pose of the review?,” “Are the references ones
that have already been included in other organi-
zational reviews?,” “Are the critiques of research
studies reviewed consistent with other reviewers
and objectively applied criteria?,” or “Does the
review include references of studies with negative
and positive findings?”
Because solid randomized, controlled research
evidence for the prevention and treatment of mu-
cositis is limited, use of other sources of evidence
as recommended by Goode9 to guide the develop-
ment of an organized plan of care is beneficial.
Just as good oral health is related to overall health
and wellness, it is integral to the prevention and
treatment of mucositis.
Although there have not been large randomized
controlled trials to test the benefit of basic oral
care, few experts in the field would question its
foundational importance.51 In fact, using “no oral
care” as a control group in studies of individuals
with significant risk for mucositis would be ques-
tioned ethically. Frequently, studies have in-
cluded basic oral care as a comparison with new
therapies. Interestingly, these studies often fail to
show the desired significant difference, contribut-
ing support for the importance of basic oral hy-
giene.52-54 The literature recommends changing
the toothbrush regularly,43 but there is limited
research to substantiate a specific frequency. The
question of whether to use a toothbrush versus
foam toothettes during aplasia has been reviewed
in the literature. The evidence supports the role of
both toothbrushes and toothettes rather than re-
placing toothbrushes with toothettes. It has been
identified that toothbrushes are necessary for ad-
equate cleaning of the enamel surfaces of teeth
and toothettes are beneficial for mucous mem-
branes during mucotoxic therapy.55-59 Toothettes
are less irritating to the mucous membranes and
208 J. EILERS AND R. MILLION
provide for an acceptable mechanism to cleanse
and/or treat these tissues.
Evidence regarding the importance of flossing to
remove plaque (and thus the bacteria responsible
for plaque formation) supports the importance of
encouraging patients to incorporate flossing into
routine care, even through periods of mucositis
and aplasia. However, if flossing has not been a
routine practice, patients should not initiate the
practice during aplasia. Just as the first line of
defense is lost with a breakdown in skin integrity,
the risk for life-threatening infections escalates
when mucosal lesions are present in the oral cav-
ity. Frequent rinsing of the oral cavity aides the
removal of organisms and may decrease the accu-
mulation of debris.
Because there is no universally effective agent
for the prevention of mucositis, treatment of the
problems experienced by patients with mucositis
is an area for nursing intervention. Three areas of
focus include: treatment of pain, dryness, and
ulcerations.
Treatment of Pain
The pain associated with mucositis is frequently a
major complaint for patients. This is related to the
highly sensitive nature of the neurons located in the
oral cavity. Pain leads to difficulty speaking and
swallowing, thus affecting nutritional intake and
communication. Pain is the symptom that receives
the greatest amount of attention even when ulcer-
ations are visible, because research has not identi-
fied an agent that effectively treats the lesions other
than symptomatically. Although topical coating
agents may be effective initially for pain manage-
ment of limited superficial lesions, knowledge that
mucositis is a systemic process provides theoretical
support for the use of systemic modes of pain man-
agement related to severe mucositis.60-65
Treatment of Dryness
Changes in the lips, perceived as dryness, is fre-
quently an early indicator of oral cavity changes.
The use of non-drying lip balms can promote
patient comfort and decrease trauma secondary to
patients physically chewing, biting, or otherwise
removing dry tissue from their lips. The oral mu-
cous membranes may feel dry to the patient and
actually appear dry on assessment. Non-irritating
rinses, sucking on ice, and sips of water may be
perceived as beneficial. Mouth moisturizers may
also promote comfort.46
Treatment for Ulcerations
The patient complaint related to ulcerations is
most frequently pain and the related difficulty
with talking and swallowing. Patients often have
little appreciation for the septicemia risk with the
membrane breakdown secondary to mucositis and
may avoid mouth care because of the pain they
are experiencing. When ulcers are present, fre-
quent rinsing with a non-irritating solution may
decrease this risk of septicemia. However, patient
compliance will most likely be dependent on the
adequacy of the pain control.
NURSING IMPLICATIONS-ESTABLISHING A
ROUTINE STANDARD OF CARE
T he use of standards or protocols helps to fa-
cilitate the establishment of routine care for
groups of patients in a clinical area,6,66-69 and
provides for consistency across disciplines. The
standards or protocols direct specific interven-
tions and frequency of care that may be both
treatment- and stage-specific. Institutional stan-
dards may include dental involvement that can
contribute to improved outcomes.70 Use of a con-
sistent practice provides for a continuous quality
improvement process to address the identification
of areas for improvement, especially when there
are discrepancies in care processes and out-
comes.71
Nurses play a key role in planning and directing
oral care for patients receiving cytotoxic therapy
for cancer, as depicted in Fig 2. The building
blocks of information that are essential include:
(1) assessment of the oral cavity, (2) knowledge of
the process of mucotoxicity, (3) awareness of mu-
cositis phases and anticipated changes, and (4)
knowledge of evidence-based practice. This infor-
mation is integrated for a recommended standard
plan of care. Implementation of evidence-based
practice for a patient involves integrating the pa-
tient’s values and preferences regarding their care
into an individualized plan of care. As seen in Fig
2, the standard care routine is modified based on
patient values and preferences. For example, if the
patient has not flossed routinely, because they
prefer not to or do not value it as important, just
prior to cytotoxic therapy is not the best time to
start.
Figure 3 illustrates use of the essential building
blocks over time through assessment, planning,
implementation, and evaluation of care for a pa-
 PREVENTION AND MANAGEMENT OF ORAL MUCOSITIS 209

Assessment of
Oral Cavity

Patient Values
Knowledge of & Preferences
Mucotoxicity Individualized
Recommended Plan of
Standard Plan Care
Awareness of of Care
Mucositis
Phase
& Anticipated
Changes

Knowledge of
FIGURE 2. Building an evidence-based Evidence-
plan of care. (Reprinted with permis- Based
sion.13) Practice

tient receiving mucotoxic cancer therapy. Assess-
ment of the oral cavity is an ongoing activity that
guides the planning of the nursing interventions
for implementation and then evaluation across
the stages of the mucositis trajectory. At baseline,
the assessment will provide an indication of cur-
rent oral health and usual care. During the future
stages of the trajectory, the assessment provides
critical information regarding the current state of
the oral cavity. Knowledge of the process of mu-
cotoxicity facilitates the nurse’s ability to identify
patient-related risk factors at baseline and treat-
ment-related risk factors once the specific cyto-
toxic-therapy protocol is identified. For example,

Initiation of
Baseline Cytotoxic During Mucotoxic Recovery
Therapy Therapy Changes
A A A A A

E P E P E P E P E P

I I I I I

Focus Focus Focus Focus Focus

Oral Care: Oral Care: Oral Care: Oral Care: Oral Care:
- After meals & - Every 4 hours - Every 4 hours - Every 1 to 4 hours - Decreasing frequency
at bedtime based on assessment based on assessment
Determine: Determine: Determine: Determine: Determine:
- Patient related - Therapy related - Patient compliance - Effectiveness of - Plan for future rounds
risk factors risk factors with mucositis intervention of therapy (if indicated)
treatment plan
Teaching: Teaching: Teaching: Teaching: Teaching:
- Need for good - Risk factors for - Reinforce as - Use of symptom - Importance of on-going
oral hygiene mucositis needed management oral hygiene & dental
- Mucositis treatment (ie pain, etc) care
plan
A = Assessment P = Planning I = Implementation E = Evaluation

FIGURE 3. Mucositis assessment, planning, implementation, and evaluation process.

210 J. EILERS AND R. MILLION
if the patient is elderly and is scheduled to receive
bolus 5-FU, the nurse is aware of these two risk
factors in the development of mucositis (Tables 1
and 2).10,17 Awareness of mucositis phase and
anticipated changes in the theoretical model for
mucositis aids the nurse in anticipating changes
and planning interventions founded in the knowl-
edge of evidence-based practice. Use of estab-
lished evidence will facilitate the identification of
appropriate interventions for optimum outcomes.
Evidence indicates the above-mentioned patient
would benefit from the use of cryotherapy during
the 5-FU administration.43
Oral care and teaching continues throughout
the phases of mucositis as well as the recovery
phase of the mucositis trajectory. Although the
oral cavity heals during this phase of the trajec-
tory, it is not believed to return to normal and the
risk for future problems with mucositis is in-
creased. Once established, the routine oral care
standard will help to establish the critical impor-
tance of oral health and oral care to promote
optimum patient outcomes.
FUTURE RESEARCH AND PRACTICE ISSUES
T here is limited valid and reliable research
regarding mucositis and its treatment, and
there exists an urgent need for well-designed stud-
ies using valid and reliable measures. This could
lead to the development of a mucotoxicity rating
scale for chemotherapy agents similar to what is
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