Aim: The main aim was to present the specific aspects of nursing and team care for the oral cavity of a patient after oncologic treatment. The secondary objectives were: to highlight the importance of interdisciplinary care in the treatment of oncology patients; to compare oral care in patients after chemotherapy and radiotherapy.

Material and methods: The main method was a case study. Additional methods included unstructured and semi-structured interviews, observation, document analysis, and assessment scales (VAS, WHO MDU symptom grading criteria, criteria for evaluating complications in the oral cavity and MDU according to NCI CTC criteria). The subjects of the research were patients treated at the Clinic of Radiotherapy and Clinical Oncology of UVN in Ružomberok. One patient underwent chemotherapy and another radiotherapy. Patient selection was purposive.

Results: Through qualitative analysis, we found that both patients had treatment-related oral-cavity involvement. In the first patient, post-radiation mucositis occurred with edema, mucosal burning, impaired taste perception, and difficulty swallowing. The second patient had neutropenia and toxic mucositis. Both patients received local and systemic treatment, along with dietary adjustments. During hospitalization and outpatient therapy, their symptoms were reduced.

Conclusions: Professional oral care for oncology patients is very important. It includes not only treatment of the affected oral mucosa, but preventive measures and thorough oral hygiene are also important. Through responsible attitudes and regular monitoring, nurses and physicians significantly contribute to the identification of the problem, timely treatment, improved comfort, and improved health status of the patient.

Introduction

Cancer treatment fundamentally differs from care in other specialties because it places a substantially greater burden on the patient. As a consequence of treatment, a patient’s quality of life is temporarily or sometimes permanently worsened (Hudáková, Fialová, Kokoruďová, 2012). This deterioration should be considered in treatment planning (Vorlíček, Abrahámová, Vorlíčková, 2006). Anticancer treatment can include surgery, radiotherapy, pharmacotherapy (chemotherapy, hormonal, and biological therapy), supportive treatment, and in some cases palliation. At chemotherapy and radiotherapy, especially when combined, the greatest number of side effects appear clinically. Side effects may be local or systemic and often subside over several weeks or months after treatment ends. In patients with an unfavorable prognosis, they may persist until end of life. One of the most commonly occurring complications is damage to the oral mucosa. The oral cavity is endangered not only by radiotherapy (especially with irradiation in the head and neck area), chemotherapy, but also by consequences of neutropenia and overall bodily weakness. The role of professionals is to mitigate damage early with supportive and targeted treatment, and also to reduce accompanying symptoms such as pain, dry mouth, anorexia, swallowing disorders, and the like.

Infections of the oral cavity in oncology patients

Patients with oncological disease are at high risk for infectious complications due to impaired immune defenses. The underlying malignancy, malnutrition, reduced salivation, as well as chemotherapy, corticosteroid therapy, and immunosuppressive treatment are primary causes (Vokurka et al, 2014; Hudáková, Novysedláková, 2012; O´Connor, 2017). Infections in the oral cavity can be caused by yeasts, fungi, viruses, viridans streptococci, coagulase-negative staphylococci, and anaerobic bacteria (Vokurka et al, 2014). Common manifestations include stomatitis aphthosa, herpetic gingivostomatitis, bacterial stomatitis, herpangina, candidiasis, and mucositis (Rosenberg, 2014; Berč, Palková, 2008; Araujo, 2015).

Healthcare staff must pay attention to all signs of dental infection because this may not only involve tissue and mucosal damage with functional impairment but can progress to sepsis (Vokurka, 2009; Dubinský, 2015). For example, before treating head and neck tumors, dental examination, dental sanitation, and local fluoride treatment are important (British Society for Disability and Oral Health, 2018).

Oral-cavity involvement during chemotherapy

Cytostatics cause painful erythema to ulceration of the mucosa. A frequent problem is toxic oral mucositis. Mucositis appears during intensive chemotherapy and is defined as inflammatory and/or ulcerative lesions affecting the oral cavity. This impaired mucosal barrier allows pathogenic microorganisms to penetrate, increasing infection risk (Wonk, 2014). Salivation can also decrease, taste perception may be disturbed, and patients may experience discomfort and pain, leading to impaired oral intake (Araujo, 2015). The duration of mucositis is directly proportional to the degree of stem-cell depletion in the mucosa. Mucositis may heal within weeks or over months, depending on how quickly mucosal stem cells recover. Therapy includes local anti-inflammatory agents, analgesics, and zinc. Nutritional support is also essential (Rosenberg, 2014; Dubinský, 2015; Gautan et al, 2013).

Oral-cavity involvement during radiotherapy

Mucosal damage may manifest as erythema and, at higher doses, exudative inflammation—mucositis—up to the development of ulcerations (Vorlíček, Abrahámová, Vorlíčková, 2006; Jurga, 2010). Post-radiation mucositis is most commonly diagnosed in radiotherapy for head and neck cancers. It appears in up to three quarters of patients and can approach 100% in patients receiving high-dose radiotherapy. The severity of post-radiation mucositis is assessed with the World Health Organization oral mucositis grading scale, which has five levels: no change, soreness/erythema, erythema/ulceration and ability to eat solid food, ulceration/liquid diet only, and no alimentation possible. The oral mucositis grading scale according to CTCAE is also used. In the recommendations of the European Oral Care in Cancer Group (2017), the Oral Assessment Guide (OAG) and the Patient-Reported Oral Mucositis Experience Questionnaire are also included.

The incidence of severe mucositis in radiotherapy is 85% (Rosenberg, 2014; O´Connor, 2017). As a consequence of severe mucositis, patients develop oral pain, dysphagia, weight loss, and need for enteral feeding via feeding tube. Mucositis is a common reason for interruption of irradiation. Acute toxicity can be fatal (Dubinský, 2015; Hajdu, 2017).

Nursing care for the oral cavity of oncology patients

Nursing care and specific nursing interventions depend on the patient’s condition, treatment intensity, and type of oncological disease.

Assessment is an essential component. It requires taking a medical history, physical examination, regular monitoring of physiological functions, tracking laboratory parameters, and evaluating present symptoms.

When assessing, the nurse uses evaluation tools:

  • Oral mucositis grading scale by WHO, criteria for oral-cavity complications and MDU according to NCI CTC criteria (clinical, functional oral mucositis, oral bleeding, dry mouth, dysphagia), and OAG (Nemcová, 2008).
  • Visual analog scale (VAS), Brief Pain Inventory, Numerical Rating Scale (NRS) (European Oral Care in Cancer Group, 2017)—for pain assessment.
  • Nutritional status assessed by Body Mass Index (BMI), Malnutrition Universal Screening Tool (MUST), Mini Nutritional Assessment (MNA), Subjective Global Assessment (SGA), among others.
  • Assessment of potential physical, psychological, and functional problems in patients with cancer (PNAT) (Bužgová, 2013).
  • Screening for mood disorders, anxiety, and depression.
  • Coping with illness based on the Kübler-Ross model.
  • Assessment of patient needs (SCNS), evaluation of the importance and saturation of psychosocial needs in patients with cancer (PNI), and overall quality of life (questionnaire EORTC QLQ-C30).

Nursing interventions focus on prevention and treatment of mucositis, xerostomia, anorexia, malnutrition, pain, dysphagia, and reduced immunity. Education of the patient is central to care (about treatment side effects, hygiene of irradiated areas and the oral cavity, treatment, and symptom relief), and meeting biological, psychosocial, and spiritual needs.

Nursing interventions for impaired oral mucosa (00045)

  • Regularly inspect the oral cavity for painful defects, lesions, and bleeding.
  • Monitor the patient’s ability to take food, fluids, and medications orally.
  • Regularly monitor body weight.
  • Ensure optimal intake of food and fluids. Provide food according to the patient’s needs, and adjust it to soft or porridge-like consistency; avoid inappropriate foods and beverages (too hot, acidic, spicy, and so on).
  • Maintain oral hygiene.
  • Perform local oral care as prescribed by the physician.
  • During healing of injured mucosa, avoid wearing dental prostheses.
  • Relieve pain; monitor pain regularly, evaluate analgesic effects, and educate the patient about possible opioid side effects (Lalla, Sonis, Peterson, 2008).
  • Administer medications as prescribed—oral or parenteral.
  • Inform the physician about improvement or worsening of mucosal changes in the oral cavity (British Society for Disability and Oral Health, 2018).
  • Take an oral swab when candidiasis is suspected.
  • Pay attention to the patient’s psychological support.
  • Cooperate with the patient’s family.
  • Document the current oral-cavity state and all interventions performed (Hudáková, Novysedláková, 2012; Vorlíček, Abrahámová, Vorlíčková, 2006; Hynková, 2012).

Oral-cavity care of patients after oncologic treatment—case study

In the empirical part, this article presents qualitative study results carried out at the Clinic of Radiotherapy and Clinical Oncology (KRaKO), Central Military Hospital–University Hospital in Ružomberok (UVN FN). Before the study, an analysis of medical records was performed, focusing on the occurrence of adverse reactions after chemotherapy and radiotherapy and the most frequent nursing interventions. From the reviewed records we found that the most common adverse effect after chemotherapy was nausea, vomiting, hair loss, fatigue, oral-cavity changes, elevated temperature, and neutropenia. In radiotherapy, changes in the skin at the irradiation site and oral-cavity changes, and fatigue were common. Oral-cavity care consisted of systemic and local therapy, dietary adaptation, and intake of adequate fluids.

Objectives of the study:

The main objective was: to present the specifics of nursing and team care of the oral cavity of a patient during oncologic treatment.

Secondary objectives:

  1. To highlight the importance of interdisciplinary care in treating oncology patients.
  2. To compare oral-cavity care in patients receiving chemotherapy and radiotherapy.

Material and methods:

The main method was a case study. Supplemental methods included unstructured and semi-structured interviews, observation, document analysis, and assessment scales (VAS, WHO MDU symptom grading criteria, criteria for evaluating oral-cavity complications and MDU according to NCI CTC criteria).

The study sample consisted of oncology patients treated at the Central Military Hospital in Ružomberok. The first patient underwent chemotherapy and the second radiotherapy combined with chemotherapy. Patient selection was purposive. Data collection was done with informed consent from both patients.

Case study 1.

A 49-year-old patient with right-sided hypopharyngeal-laryngeal carcinoma, with suspected right cervical lymph node metastases. A percutaneous endoscopic gastrostomy (PEG) and tracheostomy had been placed. The patient was admitted to the Clinic of Radiotherapy and Clinical Oncology for oncological treatment/induction chemotherapy.

Subjectively, the patient reported normal body temperature, scratching behind the tracheostomy during swallowing and also without swallowing. The PEG was functional; he could eat solid food with fluids, and had lost 5 kg over the previous three months. He reported no pain (VAS 0), no breathing difficulties, palpitations, or chest pain, appetite was good, and elimination was unremarkable. Laboratory values at admission were within normal limits.

Analysis and interpretation

On day one of hospitalization, a peripheral venous cannula was inserted, premedication was given, and the prescribed chemotherapy was initiated. Because of the risk of complications, daily oral-cavity monitoring by a nurse using the Oral Mucositis Grading Scale (Tab. 1) was introduced. The patient was educated about possible treatment side effects and collaboration with the interdisciplinary team. From day two to five, no complications occurred, and the patient was receiving combined oral and PEG feeding.

On day six, the patient felt weak and reported abdominal pain and loose stools. Objectively, physical examination found him afebrile, cardiorespiratorily stable, abdomen soft and non-tender, with normal bowel sounds, and no edema in the lower extremities. Oral-cavity assessment revealed grade 2 mucositis and moderate pain—VAS 6. CTCAE assessment indicated focal ulcerations and moderate difficulties requiring diet modification.

On day seven, body temperature rose to 38°C. Laboratory studies were ordered (complete blood count, CRP, swabs from rectum, nose, and neck, urine culture and susceptibility testing). Physical examination of the oral cavity showed marked tongue hyperemia. Subjectively the patient reported pain, burning, and stinging, especially in the tongue. Nutrition was given exclusively through PEG. Nursing care focused on monitoring health status, local oral monitoring, vital-function monitoring, and systemic and local treatment. At the physician’s indication, the nurse administered systemic antibiotic therapy. The oral cavity was treated locally with borax glycerin and Gelclaior three times daily. Attention to the patient’s psychological state was important, and therapeutic communication was provided.

On day eight, neutropenia was confirmed in labs. Systemic therapy orders were adjusted. The oral exam remained unchanged; mouth rinses and tea from medicinal comfrey were recommended. Psychologically, the patient’s mood changed and he felt anxious and depressed.

From day nine to ten, symptoms eased. On oral-cavity assessment, mucositis was grade 2 (pain and erythema). Systemic and local treatment continued.

At discharge, physical and psychological symptoms were minimized. Oral mucositis grade was 1 and VAS was 4. The patient had accepted the current state and expressed willingness to continue treatment. He was educated about oral-cavity care, dietary regimen at home, and other treatment options.

Tab. 1 Oral mucositis grading scale in case study 1.

Case study 2

A 50-year-old patient with a diagnosis of lateral tonsil carcinoma and right cervical lymph node metastases. He had undergone surgical treatment—tonsil resection. A nasogastric tube (NG) was in place. The patient was electively admitted to KRaKO to start concurrent postoperative radiotherapy (RT) and chemotherapy (CHT). Subjectively, he had no cardiovascular or gastrointestinal complaints, was afebrile, and had mild pain at the surgical site (VAS 2), with no other complaints.

Analysis and interpretation

On the first day of hospitalization, the patient reported mild pain at the operative wound and tingling in the right side of the face. RT began to the neck region and regional nodes. He was educated about possible complications related to RT and CHT and ways to address them (dietary changes, increased fluid intake, care of irradiated skin, oral-cavity care). Planned nursing interventions focused on daily oral-cavity monitoring using the Oral Mucositis Grading Scale (Tab. 2), as well as regular monitoring of physical and psychological condition, and application of local and systemic treatment.

On day two, CHT was initiated. After CHT, he reported mild anorexia. Radiotherapy was then performed for seven days. In subjective reporting, the patient described neck swelling, scratching in the throat during swallowing and even without swallowing, and swallowing difficulties. He denied pain (VAS 0). On objective oral-cavity assessment with the oral mucositis grading scale, grade 2 was determined, later grade 3. Diet was changed to porridge consistency, and sipping of nutritional drinks (Nutridrinks) was ordered. He applied Radiocar to the neck area.

On day nine, CHT was again administered. He again reported anorexia. On skin evaluation in the RT field, a hyperemic reaction of grade I was found, and Radiocar with oral cavity rinsing using Gelclair, as well as repeated comfrey infusions, were continued. Panthenol tablets were added and advised to be chewed. Weight monitoring showed a 4 kg loss. He could swallow porridge consistency. He reported altered taste and xerostomia. He was educated on food intake (smaller, more frequent meals) and proper use of Nutridrink.

On day eleven, the burden increased, and the patient’s psychological state changed (he became depressed, with depressed mood) and considered stopping treatment. Therapeutic communication was conducted. On day fourteen, trismus and a post-radiation reaction of grade 3 were added on top of earlier complications—on skin and oral-cavity mucosa.

On day twenty-one, concurrent CHT was completed and RT continued. Locally, effervescent acetylsalicylic acid (acetylspirin) was prescribed; he was instructed to let it dissolve in the mouth for half an hour before meals. Subjectively, he reported reduced pain (VAS 4), with liquid diet. On physical examination, oral mucosa was still swollen, painful, with focal ulcerations. Neck swelling was reduced. Radiocare was still applied locally to intact skin areas. Framykoin plus Calcium pantothenate was applied to areas with disrupted skin integrity. He was educated about avoiding shaving in irradiated areas and hygiene techniques (washing with baby soap and gently drying by pressing a cotton towel). Mood and psychological state improved.

Tab. 2 Oral mucositis grading scale in case study 2.

Discussion

This article focused on oral complications accompanying oncologic treatment. Changes in the oral mucosa occur in almost all patients receiving radiotherapy for head and neck cancer. Multiple clinical studies report onset in the first week of treatment (Knoss, Ostmann, 2010; Franco et al, 2017; Hajdu, 2017). In addition to mucosal defects, treatment is also accompanied by significant pain (O´Connor, et al, 2017; Firoozeh et al, 2016), dysphagia, trismus, xerostomia, taste disturbances, weight loss, and lymphedema (Hajdu, 2017; Hudáková, Novysedláková, 2012; Vokurka, 2014).

With chemotherapy, changes mainly arise related to treatment intensity, type, or resulting neutropenia (Lalla, 2008). Mucosal defects become evident within several weeks of treatment onset (Vokurka, 2014; Gautam et al, 2013). The role of healthcare professionals is to monitor the patient regularly. The nurse checks the mucosa and oral-cavity changes daily while providing oral hygiene care (Araujo, 2015), while the oncologist at least weekly. The patient is educated about self-care options; interprofessional team members must recognize changes early and start local and systemic treatment promptly (European Oral Care in Cancer Group, 2017; National Institute of Dental and Craniofacial Research, 2009). The aim of the qualitative study was to present the specificities of nursing and team care for the oral cavity of patients after oncologic treatment. In both case studies the nurse regularly assessed oral status, using the validated assessment tools described above. Oral-cavity care was basic and specific at the time of pathological change identification. Activities included education (initial, fundamental, comprehensive, and re-education), therapeutic communication, care for accompanying symptoms, and meeting patient needs. In meeting needs, there was strong emphasis on psychosocial needs, as both patients developed psychological deprivation. The quality of care was also evident at discharge: both patients were stabilized and problems were subsiding (Tab. 1, Tab. 2). Similar findings are reported in other studies (Araujo, 2015; Knoss, Ostmann, 2010; Bučková, Karabová, 2013), which state that nurses’ knowledge of anticancer treatment complications, use of standardized assessment tools, and individualized care are key to treatment effectiveness.

A further goal was to highlight the importance of interdisciplinary care in oncology treatment. Ambulatory and institutional oncology care requires collaboration among multiple professionals and the patient and family. Key professionals include the oncologist, nurse, nutrition assistant, physiotherapist, psychologist, psychiatrist, and chaplain (Vorlíček, Abrahámová, Vorlíčková, 2006; Berč, Palková, 2008; Jurga, 2010). For oral-cavity care, this includes the dentist, dental hygienist, oncologist, nurse, and speech therapist (National Cancer Center Japan, 2016). At our clinical unit, these were mainly the oncologist, nurse, dentist, and patients. Collaboration was effective, although during mid-treatment of the second patient there were problems, which were later resolved through mutual communication and rebuilding trust.

The final aim was to compare oral-cavity care in patients receiving chemotherapy and radiotherapy. Oral-cavity care during chemotherapy focuses on prevention of infection during neutropenia; patient education about regular oral hygiene, mouth rinses, gum chewing, and saliva-stimulating lozenges (Harding, 2017), regular oral mucosal assessment, and supportive treatment is crucial. If infection occurs, antibiotic therapy is indicated, along with special oral care (three times daily), regular oral hygiene, and mouth rinses if oral intake and fluids are still possible orally. During radiotherapy, complications are expected and usually appear earlier. Treatment depends on mucositis grade and associated manifestations (Murphy, 2009). This was also true for our patients. In the patient receiving radiotherapy, mucosal changes appeared earlier and were accompanied by other complications—xerostomia, pain, anorexia, later trismus, and post-radiation reaction grade 3 on skin and oral mucosa. Treatment was local (local mucosal care, and care of irradiated skin) and systemic. In the patient treated with chemotherapy, symptoms began on day 6, and the complication was neutropenia, which threatened overall health and required full enteral nutrition.

Conclusion

The oral cavity is the gateway to the human body. The mouth is the beginning of the respiratory system, and it is also where food is initially processed and where vitamins, minerals, and other life-sustaining substances are taken in. Therefore, preserving its physiological functions is very important. Problems arise during aggressive treatment (chemotherapy, radiotherapy) and reduced host immunity. Dental infection greatly worsens quality of life and can even lead to stopping treatment or death. Therefore, the role of healthcare professionals is to coordinate interventions, initiate therapeutic measures early, and individualize care using a holistic approach, helping restore lost function and enabling patients to resume a full life.

Authors: PhDr. Katarína Zrubáková, PhD. Katedra ošetrovateľstva FZ KU Ružomberok

Mgr. Anna Herinková Klinika radiačnej a klinickej onkológie ÚVN SNP FN Ružomberok

MUDr. Roman Podoba, PhD. Klinika radiačnej a klinickej onkológie ÚVN SNP FN Ružomberok

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