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Mouthcare and mucositis

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Shared care information

Patients often present with mucositis some days after their chemotherapy when they have been discharged. Mucositis can be extremely painful and opiate analgesia is often required. Mucositis can also be complicated by secondary infection (see: Stomatitis) especially with candida or HSV and swabs should be considered. This can be discussed with the paediatric oncologist on call during working hours.

Mouthcare - overview

The oral cavity is a frequent site of complications:

  • Mucositis from chemo - or radiotherapy.
  • Gingivitis or stomatitis may be due to bacterial (alpha-haemolytic Strep, anaerobes), viral (most commonly HSV) or fungal infection (most likely candida albicans)
  • Focal mucosal ulceration (usually HSV)
  • Dental abscesses
  • Bleeding
  • GVHD of the oral mucosa can present as a diffuse mucositis (pale or erythematous) or as pale plaques (leucoplakia) vaguely resembling candida
  • AML (particularly M4/5) may present with gingival infiltration.

Good mouth care is important because:

  • infection in the oral cavity is a potential source of Gram +ve and anaerobic bacteraemia
  • overgrowth by candida may allow the yeast to become invasive (candidaemia)
  • infection in the mouth (in addition to chemotherapy-induced mucositis) produces pain, reduces oral intake, and has implications for adequate nutrition

Education of parent and child

The role of the nurse is pivotal in achieving these aims:

  • Implementing the risk-adapted guidelines.
  • Hands-on help with mouth care if mucositis severe or patient uncooperative.
  • Initial (and continuing) education of child and parents.

Basic mouthcare

Patients are seen by a dentist after diagnosis but any dental therapy should be derferred until the neutrophil count is > 1.0 x 109/l unless it is very urgent.

Teeth should be cleaned twice daily (after meals, if eating) with a small-headed, soft toothbrush and mild fluoride toothpaste.

Older children should floss teeth once daily. Low neutrophil and platelet counts are not a contraindication.

Rinse mouth with tap water after eating.

The majority of children will only require basic oral hygiene. However, some may require additional measures.

See Prophylactic Mouthcare Protocol

Treatment of established Thrush

  • Add fluconazole if not already taking this.
  • If patient is on either fluconazole or itraconazole already, consider mycology swab to assess antifungal activity against the candida strain.

Oral assessment guide

Follow this link to view a pdf version of the guide

Mucositis - overview

This occurs following the administration of some types or combinations of chemotherapy due to interruption in the replication of mucosal epithelial cells.

The incidence and severity of oral mucositis is related to:

  • prior oral hygiene and presence of pre-existing dental disease
  • type of chemotherapy particularly:
    -anthracyclines
    -alkylating agents
    -HD IV methotrexate (cause a characteristic anterior mucositis which needs to be distinguished from herpes simplex)
  • dose of chemotherapy
  • combination of mucositis-inducing chemotherapy e.g., doxorubicin + cyclophosphamide + methotrexate as for Non-Hodgkin lymphoma
  • schedule of chemotherapy. More likely to occur when chemotherapy "spaced out" e.g., given weekly rather than a number of days in a row
  • conditioning treatment for stem cell transplant incorporating TBI with chemotherapy.

It typically occurs when the patient becomes neutropenic, i.e., 7 - 10 days after start of chemotherapy block, but can occur very early with HD IV methotrexate and high dose melphalan.

Treatment of established Mucositis

In addition to the preventative measures described, the following should be considered:

  • Nutrition - Enteral feeding (even 5 ml/hr) has been shown to be protective for gut mucosa. Once mucositis is severe, an NG cannot be inserted so discuss NG nutrition with parents early in the chemotherapy course.
  • Diarrhoea associated with mucositis rarely needs treatment. Loperimide is the first line treatment if diarrhoea associated with mucositis does require treatment. Octreotide may be useful as second line therapy.
  • Pain control - consider:
    -morphine infusion with nurse controlled analgesia (NCA) or PCA
    -lignocaine viscous 2% as mouthwash
    -mylanta/lignocaine viscous 2% mixture equal parts
    -sucralfate should not be used to treat oral mucositis in patients receiving chemotherapy for cancer, or in patients receiving radiation therapy for head and neck cancer.
  • Chlorhexidine Mouthwash - commence when oral assessment score is > 10. Use chlorhexidine 0.2% (Perioguard) tds. If also using nystatin, use at least 1 hour apart as chlorhexidine inactivates nystatin.
  • Consider using prophylactic antifungal therapy.

References

  1. Lalla R V, Bowen J, Barasch A, et al. MASCC = ISOO Clinical Practice Guidelines for the Management of Mucositis Secondary to Cancer Therapy. 2014:1453-1461. doi:10.1002/cncr.28592.
  2. Peterson et al on behalf of the ESMO guidelines working group. Management of oral and gastrointestinal mucositis:ESMO clinical recommendations. Annals of oncology 2009; 20 (supp 4):174 - 177.

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Document Control

  • Date last published: 22 February 2017
  • Document type: Clinical Guideline
  • Services responsible: National Child Cancer Network
  • Author(s): Karen Tsui
  • Owner: Karen Tsui
  • Review frequency: 2 years