Assessment of Chemotherapy-Induced Oral Complications in Children With Cancer

Oral mucositis assessment in pediatric and adolescent oncological patients: A systematic review

Oral mucositis (OM) is a prevalent acute adverse effect of various cancer treatments. Accurate assessment of OM is vital for effective prevention and treatment strategies. However, a lack of validated pediatric instruments for evaluating OM can lead to unreliable data, and hinder interventional and epidemiological research. This study aims to evaluate the methods used for assessing OM in pediatric oncology patients. A systematic review of four databases and a manual search yielded 113 articles. Nine different scales were identified, with the World Health Organization (WHO) scale being the most commonly used (61.9%). The Children's International Mucositis Evaluation Scale (ChIMES) was used in 7.9% of the studies. Of the 8155 pediatric patients evaluated, 47.7% had both hematological malignancies and malignant solid tumors, while 46% had solely hematological malignancies. Despite the prevalence of the WHO scale, it lacks pediatric-specific criteria. Future OM research should incorporate validated tools like ChIMES for improved pediatric assessment.

Oral manifestations associated with neutropenia in Syrian patients diagnosed with hematological malignancies and undergoing chemotherapy: A cross-sectional study

Neutropenia can be caused by a variety of congenital and acquired factors, with Chemotherapy-induced myelosuppression being the most common cause. Neutropenia significantly affects oral health, leading to the manifestation of oral lesions such as ulcers, fungal and viral infections, and mucositis. This study aims to investigate oral lesions in patients with hematological malignancies who developed neutropenia after chemotherapy. This cross-sectional study included 50 patients with hematological malignancies. The participants were divided into 2 groups: the first group consisted of 25 patients with hematological malignancies who developed chemotherapy-induced neutropenia and the second group consisted of 25 patients with hematological malignancies who did not develop chemotherapy-induced neutropenia. Patients were assigned to one of the groups based on the absolute neutrophil count (ANC). Full oral clinical examination was performed to determine the presence of oral lesions. In the Chemotherapy-Induced Neutropenia group, the most common lesion was ulceration, observed in 12 patients (48%). Fungal infections were the second most common, present in 5 patients (20%), followed by viral infections in 4 patients (15%), and mucositis, which occurred in a single patient (4%). A statistically significant association was found between neutropenia and the presence of oral ulcers (P value = .015). In contrast, in the Chemotherapy group, oral changes were less frequent. Fungal infections were the most common, occurring in 4 patients (15%), followed by oral mucositis in 3 patients (12%). Ulceration and viral infections were the least common, each observed in 1 patient (4%). The frequency of various forms of oral ulcers increases with the severity of neutropenia. However, there was no significant increase in other oral lesions in patients with neutropenia.

Dysphagia-related mucositis in children undergoing chemotherapy: The COMEDY pattern

OBJECTIVES

Children undergoing chemotherapy can experience dysphagia due to non-erosive reflux disease (NERD). Oral mucositis (OM) associated with NERD-dysphagia in children with cancer has recently been defined with the acronym COMEDY (Clenching, Oral Mucositis, closed Eyes, DYsphagia). This study aims to identify the prevalence of the COMEDY pattern among chemotherapy-induced OM.

SUBJECTS AND METHODS

Forty-two medical records of children undergoing chemotherapy for haemato-oncologic diseases and presenting OM were reviewed. The following data were collected: age, type of haemato-oncologic disease, presence of dysphagia, type of oral mucosal lesions (i.e. traditional oral mucositis or COMEDY pattern), site of oral lesions, ear-nose-throat (ENT) assessment for the indirect signs of NERD and paediatric neuro-psychiatric (PNP) assessment.

RESULTS

Among 42 children with chemotherapy-related OM, 6 patients (14.2%) showed the COMEDY pattern. Besides the characteristic clinical aspect of the oral mucosa, initially classified as grade II OM, these children suffered from NERD-related dysphagia and PNP issues.

CONCLUSION

A COMEDY pattern can occur in a number of cases of chemotherapy-induced OM; recognizing this pattern may improve the effectiveness of treatment.

The impact of oral health education on the incidence and severity of oral mucositis in pediatric cancer patients: a systematic review and meta-analysis

Oral health education is an effective measure to prevent oral mucositis (OM) by improving self-management and effectively engaging patients in their health care. This systematic review aimed to determine the impact of oral health education interventions on the incidence and severity of OM. Bibliographical searches were carried out by two independent examiners in Medline, Scopus, Web of Science, Cochrane Library, Virtual Health Library, and SIGLE, until June 2022. The eligibility criteria were based on the PICO strategy, considering studies with pediatric oncology patients, aged 0 to 19 years, who had attended oral health education activities and had been examined for the incidence and/or severity of OM. Data were extracted for qualitative synthesis and organized in spreadsheets. The quality assessment of the selected studies was performed using the ROBINS-I tool. Meta-analysis was based on the group frequencies of OM ulcerative lesions, adopting a significance level of 5%. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was used to define the certainty of the evidence. The primary search retrieved 1827 articles. After removing duplicate records and screening titles and abstracts for eligibility, a total of 21 articles were selected for full-text analysis. Of these, seven eligible studies were included for data extraction and qualitative synthesis, while four studies were selected for quantitative synthesis. All studies had a longitudinal design; three performed a before-after comparison and four were controlled studies. OM was assessed by the following scales: OAG, WHO, ChIMES, and WCCNR. While data analysis of the selected studies was heterogeneous, the implementation of oral health education strategies was found to reduce the incidence and severity of OM during the follow-up period. The meta-analysis showed a favorable outcome for the educational intervention. The likelihood of patients attending oral health education activities to manifest OM ulcerative lesions was significantly lower (P = 0.002) than that of the control. The GRADE analysis presented a low certainty of the evidence. To conclude, oral health education interventions improved OM outcomes in pediatric oncology patients with a low quality of evidence.

Prevention and Treatment of Oral Complications in Hematologic Childhood Cancer Patients: An Update

Cancers have a highly negative impact on the quality of life of paediatric patients and require an individualised oral treatment program for the phases of the disease. The aim of this study was to update existing research on oral care in children diagnosed with cancer. We carried out a literature search (in English, Spanish and Portuguese) in the Pubmed, Cochrane Library, EBSCO, WOS, SciELO, Lilacs, ProQuest, and SCOPUS databases and the websites of hospitals that treat childhood cancers. We found 114 articles and two hospital protocols. After review, we describe the interventions necessary to maintain oral health in children with cancer, divided into: phase I, before initiation of cancer treatment (review of medical record and oral history, planning of preventive strategies and dental treatments); phase II, from initiation of chemo-radiotherapy to 30-45 days post-therapy (maintenance of oral hygiene, reinforcement of parent/patient education in oral care, prevention and treatment of complications derived from cancer treatment); phase III, from 1 year to lifetime (periodic check-ups, maintenance, and reinforcement of oral hygiene, dental treatments, symptomatic care of the effects of long-term cancer treatment). The use of standardised protocols can avoid or minimise oral cancer complications and the side effects of cancer therapies.

Chemotherapy-associated oral complications in a south Indian population: a cross-sectional study

Over the years, chemotherapy (CT) has evolved as an essential therapeutic modality for cancer, with oral manifestations frequently encountered as complications of cancer CT. Our study aimed to assess the prevalence of oral complications during CT and evaluate the significance of independent risk factors (age, gender, socio-economic status, oral hygiene practices etc). A cross-sectional study was carried out in a tertiary cancer hospital in Bhubaneswar, Odisha, India, in which a total of 138 hospitalized patients undergoing CT and fulfilling the inclusion and exclusion criteria were included. Comprehensive history and rigorous clinical examination eliciting the oral manifestations were carried out. Around 60% of patients exhibited oral manifestations. Xerostomia and lichenoid reactions were the highest and lowest recorded manifestations. Higher frequencies of oral lesions occurred in patients with breast cancer, TNM stage III, and with the administration of the docetaxel. Also, patients in the older age group, poor socio-economic status, poor quality of life, poor oral hygiene practices, and longer CT duration demonstrated more oral lesions. Individuals subjected to a dental evaluation either before or during CT exhibited a reduction in the number of oral features. Several oral complications were reported in the present study. All patients undergoing chemotherapy must receive reinforcement of oral hygiene instructions and dental evaluation before, during, and after chemotherapy treatment. The study also emphasizes the importance of oral health physician inclusion in the multidisciplinary cancer treatment team.

Oral mucositis in paediatric cancer patients undergoing allogeneic hematopoietic stem cell transplantation preventively treated with professional dental care and photobiomodulation: Incidence and risk factors

BACKGROUND

Oral mucositis (OM) is an important side effect related to allogeneic hematopoietic stem cell transplantation (allo-HSCT), and it has been associated with a significative reduction of quality of life. A negative impact of OM in paediatric patients could result in increased use of parenteral feeding and opioids, longer periods of hospitalization, and a higher risk of systemic infection.

AIM

To investigate the clinical features and clinical outcomes associated with OM development and severity in hematological cancer paediatric patients undergoing allo-HSCT who underwent professional dental care (PDC) and photobiomodulation (PBM) as prophylactic treatment.

DESIGN

Medical data and OM presentation were retrieved retrospectively from all patients younger than 18 years who received allo-HSCT between 2013 and 2016. The incidence of OM was assessed and graded by two oral medicine specialists following the WHO guidelines, and it was correlated with clinical parameters.

RESULTS

Forty-nine consecutive paediatric patients were included. OM was diagnosed in 73.5% of patients, and in 36.1% of patients, OM was classified as severe. Acute lymphoblastic leukemia as a primary diagnosis and the use of a myeloablative regimen were associated with OM development. The primary diagnosis and use of total body irradiation (TBI) were associated with aggressive OM. Neither the incidence nor the severity of OM affected the overall survival, whereas only the use of a myeloablative regimen and a high body mass index (BMI) were determinants of lower OM-free survival rates.

CONCLUSIONS

A myeloablative conditioning and a high BMI were observed to be independent prognostic determinants of a lower OMFS rate. The cluster analysis allowed us to outline patient profiles with greater susceptibility to the development and severity of oral mucositis, which seems to be a useful tool to determine the risk of OM in paediatric patients.

The effectiveness of an oral health education and prevention program on the incidence and severity of oral mucositis in pediatric cancer patients: a non-randomized controlled study

PURPOSE

To investigate the effectiveness of an Oral Health Education and Prevention Program (OHEPP) on the incidence and severity of oral mucositis (OM) in pediatric cancer patients. The OHEEP was a ludic strategy for promoting oral health and monitoring the oral health condition.

METHODS

We compared the incidence and severity of OM in patients who attended the OHEPP against those under similar conditions who did not receive educational interventions. Both groups were examined for 6 weeks by calibrated examiners (k > 0.8) using the modified Oral Assessment Guide (OAG). A total of 14 patients aged 2 to 18 years were included in each group and matched for sex, age, tumor type, and treatment modality. The incidence and severity of OM were compared using the chi-squared test (α = 5%), and the relative risk and effectiveness of the OHEPP were calculated with a statistical power of 0.97. Differences in total OAG scores between the groups were determined by the Mann-Whitney test (α = 5%).

RESULTS

There was a higher incidence of OM in patients who did not attend the OHEPP (P = 0.005), and the relative risk of developing OM was significantly lower in OHEPP attendants (RR: 0.73; CI 0.60-0.92). No difference in the occurrence of severe OM was observed. OHEPP reduced the risk of developing OM by 1.4-fold, with an effectiveness of 27%. There was a difference in total OAG scores (P = 0.041).

CONCLUSION

Participation in OHEPP was an effective measure to reduce the incidence of OM in pediatric cancer patients.

MASCC/ISOO clinical practice guidelines for the management of mucositis: sub-analysis of current interventions for the management of oral mucositis in pediatric cancer patients

OBJECTIVE

The aim of this sub-analysis was to highlight the MASCC/ISOO clinical practice guidelines for the management of oral mucositis (OM) in pediatric patients and to present unique considerations in this patient population.

METHODS

This sub-analysis of the pediatric patient population is based on the systematic review conducted by the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISSO) published in 2019/2020. Studies were scored and assigned a level of evidence based on previously published criteria. Data regarding adverse effects and compliance was collected from the original publications.

RESULTS

A total of 45 papers were included and assessed in this sub-analysis, including 21 randomized controlled trials (RCTs). Chewing gum was demonstrated to be not effective in preventing OM in pediatric cancer patients in 2 RCTs. The efficacy of all other interventions could not be determined based on the available literature.

CONCLUSION

There is limited or conflicting evidence about interventions for the management of OM in pediatric cancer patients, except for chewing gum which was ineffective for prevention. Therefore, currently, data from adult studies may need to be extrapolated for the management of pediatric patients. Honey and photobiomodulation therapy in this patient population had encouraging potential. Implementation of a basic oral care protocol is advised amid lack of high level of evidence studies.

Management of oral mucositis in pediatric patients receiving cancer therapy: A systematic review and meta-analysis

BACKGROUND

One of the most common complications of cancer chemotherapy is oral mucositis (OM). OM affects more than 75% of patients undergoing chemotherapy and represents a significant burden to patients and caregivers. We performed a systematic review and meta-analysis of published studies to investigate the effects of agents and techniques in reducing OM.

PROCEDURE

This systematic review investigated, critically appraised, and rated the evidence on agents used to manage OM in children undergoing cancer therapy. A comprehensive search of the relevant literature was performed from January 2006 to December 2017. MEDLINE, Scopus, the Cochrane Database of Systematic Reviews, EMBASE, and the Web of Science were searched. Nine eligible studies were identified. Using random-effects models, standardized mean difference was estimated between treated and control groups across all studies. The Cochran test and the I2 index were performed for heterogeneity between studies. The significance level was set at P = 0.05.

RESULTS

Palifermin reduced the incidence (OR = 4.131, P = 0.000), duration (St diff mean = 0.803, P = 0.000), and severity (St diff mean = 0.637, P = 0.000) of OM in pediatric cancer patients significantly. However, the laser did not show significant efficacy in decreasing the incidence rate of OM (OR = 2.870, P = 0.364).

CONCLUSION

This review provided a comprehensive examination of available options for children who have OM. The results support the possibility of a positive effect of palifermin on reducing OM in children receiving cancer therapy.

Guide for health professionals addressing oral care for individuals in oncological treatment based on scientific evidence

OBJECTIVE

Oncological treatment can cause changes in the oral cavity compromising oral functions. The aim of the study was, based on a systematic review, to draft a guide directed at the team of health professionals involved in the oral care of oncological patients.

METHODS

A systematic search of the literature was performed for articles published between 2000 and April 2017. Searches were made of electronic databases and hand search. The inclusion criteria were systematic reviews of randomized clinical trials (RCTs) and RCTs published in English, involving pediatric and adult oncological patients and focused on the prevention and treatment of oral complications as well as studies addressing the maintenance of oral health. Among the 1237 studies identified, 129 were pre-selected and 54 were selected to form the basis for the clinical guide.

RESULTS

The studies analyzed stress the need for oral assessments as well as preventive and curative actions prior to oncological treatment. To minimize the severity of oral problems, the studies emphasize daily oral care, the treatment of xerostomia with saliva substitute and hydration, and low-level laser therapy, nystatin, acyclovir, respectively, for the prevention and treatment of oral mucositis, oral candidiasis, and infection by herpes simplex virus. Thus, the guide produced addresses oral assessments and professional and home care before, during, and after oncological treatment.

CONCLUSION

The guide drafted has the function of assisting health professionals involved in the oral care of patients with cancer, enabling the prevention or treatment of oral complications stemming from oncological treatment.

A Randomized Placebo- Controlled Double Blind Clinical Trial of Quercetin in the Prevention and Treatment of Chemotherapy-Induced Oral Mucositis

INTRODUCTION

Oral Mucositis (OM) is a serious complication of chemotherapy that results in painful debilitating inflammation that sometimes ends in interruption of treatment.

AIM

The study evaluated the effect of quercetin (a natural flavonoid) on preventing and treating chemotherapy induced OM in patients with blood malignancies. Materials and Methods: This double-blind, placebo controlled randomized trial was carried out on 20 adult patients who underwent high dose chemotherapy for blood malignancies. Patients were divided into two groups (10 patients in the intervention group and 10 patients in the control group). Patients in the intervention group were administered 250 mg quercetin capsules twice daily for four weeks.

RESULTS

Nine out of 20 patients developed OM (three in the intervention group and six in the control group). The incidence of OM was lower in the intervention group although it was not statistically significant (p=0.189). The mean severity of OM was higher in the intervention group (2.6 vs 2). Healing time, age, gender, type of malignancy, drug type and duration of OM were not different in two groups.

CONCLUSION

The incidence of mucositis was lower in the quercetin group, but mucositis was more severe in the intervention group, which may be due to lower oral health status in the intervention group.

Efficacy of a Solution Composed by Verbascoside, Polyvinylpyrrolidone (PVP) and Sodium Hyaluronate in the Treatment of Chemotherapy-induced Oral Mucositis in Children With Acute Lymphoblastic Leukemia

The aim of this study was to assess the efficacy of a solution composed by verbascoside, polyvinylpyrrolidone, and sodium hyaluronate (Mucosyte) in the treatment of chemotherapy-induced oral mucositi (OM). Patients between 5 and 18 years receiving chemotherapy for acute lymphoblastic leukemia and with OM grade 1 or 2 were randomized in group A (treated with Mucosyte, 3 mouthwashes/d per 8 d) and group B (treated with placebo, ie, an inert water-based solution, 3 mouthwashes/d per 8 d). The OM scoring was performed at day 1 (diagnosis of OM-T0), after 3 days of treatment (T1), and at day 8 (T2). Pain was evaluated through the visual analog scale with the same timing of OM measurement. A total of 56 patients were included (28 patients per group). Group A experienced a statistically significant decline of OM at T2 (P=0.0038); a statistically significant difference in pain reduction between 2 groups both at T1 and at T2 (P<0.005) was observed. The use of Mucosyte mouthwashes in children with chemotherapy-induced OM may be recommended as supportive therapy.

Investigation of the effects of planned mouth care education on the degree of oral mucositis in pediatric oncology patients

This study was designed as a longitudinal study with the purpose of investigating the effects of providing mouth care education to pediatric oncology patients on the degree of oral mucositis. The study sample included 16 children aged 8 to 18 years who were hospitalized in the pediatric oncology and hematology clinics at a university hospital. The results revealed a statistically significant difference between the degree of mucositis before and after the education given to children undergoing chemotherapy (P < .05). The median pain values were significantly different before and after the education (P < .05) as well. It was also found that there was a strong positive statistically significant correlation between the degree of mucositis and mean pain score both before and after the education (P < .001). Consequently, it is reported that both the degree of mucositis and pain levels decreased when children were given planned mouth care education before chemotherapy and when they regularly performed mouth care.

Efficacy of HPA Lanolin® in treatment of lip alterations related to chemotherapy

The side effects of chemotherapy on the lips may cause esthetic and functional impact and increase the risk of infection. HPA Lanolin^® is an option for supportive therapy because it has anti-inflammatory, antimicrobial and moisturizing properties.

Decayed, missing and filled teeth index and dental anomalies in long-term survivors leukaemic children: a prospective controlled study

Objective: The aim of this prospective controlled study is the comparison between long-term children survived leukaemia and a control group in terms of the decayed, missing or filled permanent teeth (DMFT) and dental anomalies. Study design: Fifty-two long term children survived leukaemia, aged from 8 to 15 years (27 females, 25 males; mean age 11.5 years) were evaluated for the possible effects of the anti-leukaemic therapy on dental development and compared to a control group of 52 healthy children (27 females, 25 males, mean age 11 years). All long-term children who survived were at least 24 months in continuous complete remission. The study of the dental status with a routine oral examination and panoramic radiographs was performed. The DMFT (recorded according to the WHO criteria) and dental anomalies were registered and evaluated. Results: The results of this study evidence that long-term children survived leukaemia, in comparison with the control group, have an higher risk to develop dental caries and show a greater severity of dental anomalies including V-shaped roots, dental agenesis, microdontia, enamel dysplasias. Conclusions: Paediatric patients with haemathological diseases require a special attentions in dental care in addition to the antineoplastic treatment. Therefore, oral hygiene and oral health can be maintained thanks to a close cooperation between the paediatric oncohaematologists, pediatrics dental surgeons and dental hygienists.

Key words:Paediatric leukaemia, dental anomalies, children.

Periodontal Lesions and Gingival Problems in Children with Acute Lymphoblastic Leukemia

Dentists both as clinical practice and research increased progressively their interest in leukemia, because the oral complications are common during the outcome of the disease, dental management is complex, and the mouth is a potential source of morbidity. The aim of this review is analyzing the most important periodontal problems due to childhood Leukaemia. Infact only with an appropriate periodontal treatment oral health could be mantained and restored before development of irreversible periodontal damage. Our experience suggests that even if detrimental impact of antineoplastic therapy on oral cavity is unavoidable, it could be diminished with an adequate and correct preventive or curative therapy contributing to a better quality of life of children treated for cancer.

Oral Mucositis in Children with Acute Lymphoblastic Leukemia

There are many types of cancers in children that are very different from those found in adults: leukaemia, lymphoma, and brain tumours are rather common in children. Acute lymphoblastic leukaemia (ALL) is the most common type of malignancy encountered. The role of pediatric dentist is very important before, during and after therapy: up to 24% of life-threatening infections arise from oral sites and areas. Early dental intervention and preventions procedures may significantly reduce oral complications associated with myelosuppressive cancer treatment. It is really important to evaluate the oral health surveys and to cut out potential sources of infection in mouth in these patients concurrent with their medical therapy. The aim of this review is summarizing the main features of oral mucositis in Childhood Acute Lymphoblastic Leukaemia, providing a little review for the approach, diagnosis and treatment of oral mucositis of ALL, which is frequent and potentially dangerous: it's important considering oral lesions of this type of childhood cancer in order to prevent complications before, during and after chemo or radio therapy to improve the quality of life of little patients.

Tendências da produção do conhecimento de enfermagem no controle de infecção em oncologia

Os clientes com câncer apresentam complicações significativas de morbi-mortalidade relacionadas à infecção. Esta revisão integrativa tem como objetivo analisar a produção científica da enfermagem acerca do controle de infecções nos clientes com câncer. A busca dos 37 artigos incluídos foi por meio eletrônico em bases de dados, no período de 2002 a 2009. Os dados foram analisados na perspectiva da Metodologia de Categorização Epistemológica para a Pesquisa na Enfermagem. Os resultados indicam que a produção é internacional, mais setorizada na área da oncologia clínica, com ênfase nos clientes como sujeitos das investigações, tendência exógena da origem da infecção e prevalência de artigos de revisão de literatura. Conclui-se que a produção do conhecimento no controle de infecção é prioridade no cenário nacional, as ações devem ser baseadas numa visão sistêmica, considerando a complexidade que envolve os profissionais na prestação do cuidado de enfermagem.

A systematic review of oral assessment instruments: what can we recommend to practitioners in children's and young people's cancer care?

BACKGROUND

Observing and recording the signs and symptoms of oral mucositis are an important part of oral care, essential to the prevention and treatment of mucositis. Structured oral assessment enables a more informed and accurate identification of signs and symptoms and will enable early and individualized interventions.

OBJECTIVE

A United Kingdom-based mouth-care group conducted a systematic review of the published literature through to March 2004 and repeated in 2008. The goal of this review was to identify and evaluate the range of instruments used to assess oral mucositis to recommend in evidence-based guidelines the "best" instrument to use in the field of children's and young people's cancer care.

METHODS

Search sources included the Cochrane Library, MEDLINE, EMBASE, and CINAHL. Studies were selected using defined criteria and reviewed by 3 pairs of group members.

RESULTS

Fifty-four individual oral assessment instruments were identified with only 15 reporting evidence of reliability and validity testing. Only 3 articles reported on oral assessment exclusively in our population.

CONCLUSIONS

The guidelines recommend only 1 assessment instrument, the Oral Assessment Guide, or adaptations of this instrument, to be used in clinical practice. Five factors influenced this recommendation: purpose of assessment, population, outcomes assessed, and quality of the instrument and ease of use.

IMPLICATIONS FOR PRACTICE

The Oral Assessment Guide has been consistently judged to be user-friendly and appropriate for everyday clinical practice with both adults and children, as well as a useful research tool.

Oral microbial and respiratory status of persons with mental retardation/intellectual and developmental disability: an observational cohort study

OBJECTIVE

The objective of this study was to determine the prevalence of select microorganisms in oral biofilms and to investigate relationships between oral and respiratory status in persons with mental retardation/intellectual and developmental disabilities (IDD).

STUDY DESIGN

We conducted a 6-month-long observational cohort study with 63 persons with IDD. Oral examinations, oral sampling, and medical record reviews were performed at baseline and then monthly. Polymerase chain reaction (PCR) was used to analyze all baseline oral samples for the presence of Streptococcus pneumoniae, Methicillin-resistant Staphylococcus aureus (MRSA), Prevotella melaninogenica, and Candida albicans. PCR analyses were also performed on participants' samples collected in the month before being diagnosed with a respiratory infection.

RESULTS

All subjects had P. melaninogenica detected by PCR in their oral samples. Fifty-five percent (35 of 63) of participants had S. pneumoniae, MRSA, and C. albicans in their oral samples at baseline. No dental decay was detected clinically, oral hygiene was fair, and dysphagia was common. During the 6 months of the study, there were 22 respiratory infections (35% of participants)-12 pneumonias, 7 sinusitis, 1 bronchitis, and 1 upper respiratory tract infection. Participants with microorganisms in their baseline samples were significantly more likely to develop any respiratory infection and those who had poor oral status were significantly more likely to develop pneumonia. Almost 60% of participants who developed respiratory infections had the same microorganism detected in the sample collected in the month before infection as had been detected in their baseline sample.

CONCLUSION

Potentially pathogenic microorganisms in the oral cavity and poor oral status significantly increased the risk of developing respiratory infections, including pneumonia, in persons with IDD. The results suggest that colonization with these microorganisms may persist despite routine tooth brushing. Meticulous comprehensive oral hygiene of the oral cavity may be needed to reduce oropharyngeal microbial load.

The complexity of symptoms and problems experienced in children with cancer: a review of the literature

To adequately help children with cancer, care providers need to understand the complexity of symptoms and problems associated with the illness that children are experiencing, which can enable them to better tailor patient care individually to each child. In this integrative literature review, we identified the types of symptoms and problems that children with cancer can experience during treatment and rehabilitation; the terms/expressions they use to describe their symptoms and problems; how children's symptoms and problems vary during the course of their illness; and how they vary and co-vary with age, gender or race. Of the 1175 titles identified, 110 articles met the inclusion criteria and were included in the review. Seventy-eight were research-based. A total of 219 distinct symptoms or problems were identified in the literature either as the main problem or a symptom of the main problem. There is significant evidence that children and adolescents experience numerous and complex symptoms, and problems during and after treatment for cancer. Children use many different expressions to talk about their symptom experiences. However, few articles looked at how children's symptoms and problems varied during the course of their illness or the variations in symptom severity and degree of bother, or examined the relationship between children's symptom experience and age, gender, or race. Most instruments that were used to measure symptoms were interviewer-administered questionnaires, often adaptations from adult versions, and in younger children, symptoms were often obtained from adult informants. The insights gained from this review can be helpful to researchers and clinicians who wish to better understand how symptoms and problems are experienced from the children's own perspective. However, more research is needed: to better understand differences in symptom experiences among different age groups; to identify differences among children from distinct cultural, ethnic, or socio-economic backgrounds; to clarify how symptoms and problems interfere with daily life; and to refine assessment methods that allow even younger children to communicate their symptom experiences in an age-adjusted manner.

Designing an oral mucositis assessment instrument for use in children: generating items using a nominal group technique

GOALS OF WORK

There was a need to develop a mucositis instrument that would be specific for use with children. This paper describes the step of generating items in the process of developing a new instrument for the assessment of oral mucositis in children.

MATERIALS AND METHODS

Nine health care professionals with expertise in pediatric cancer, mucositis assessment, and oral assessment in children were invited to participate in a nominal group technique to generate items that should be included in an instrument.

RESULTS

Thirty items were generated initially. Voting processes established that six of these items were thought to be necessary for inclusion: (1) presence of ulcers, (2) pain assessment, (3) amount of pain medication received, (4) effect on eating, (5) drooling-pooling of saliva, and (6) effect on drinking. Using these six items, an initial draft of an instrument was developed that could be used to assess oral mucositis in children, namely, the Children's International Mucositis Evaluation Scale.

CONCLUSION

The six items generated by this process provided the basis for a simple, feasible, and reliable instrument. With increased clinical research investigating interventions to reduce and prevent oral mucositis, such an instrument will be critical to the effective conduct of this research in children. Further testing of this instrument is necessary.

Establishing Literature-Based Items for an Oral Mucositis Assessment Tool in Children

Although there are numerous instruments for oral mucositis (OM) assessment in adults, there is a lack of validated instruments for use in children. The objectives of this systematic review were to describe literature-based items that should be considered for a pediatric mucositis scale and other issues that should be considered when assessing mucositis in children. Literature search of PubMed and bibliography searches identified articles relevant to the assessment of mucositis and mucositis assessment studies in children. The elements established from the literature were grouped under objective, subjective, and functional items. Other issues that require consideration include the conditions for the assessment of the oral cavity and the etiology of OM. The resultant list included 23 items that have been used in mucositis assessment scales. This list of items may be used as an initial step in developing a new pediatric OM scale that particularly focuses on the unique issues in children.

Attitudes and practices of nurses on a pediatric cancer and stem cell transplant ward: adaptation of an oral care protocol

This study evaluated nurses' current practices and understanding of oral health for hematology and oncology patients. A written questionnaire administered to 33 nurses on the pediatric cancer and blood disorders unit of Children's Medical Center of Dallas included questions on oral evaluation, oral hygiene, and case-based questions. Information gathered was used to develop an oral care protocol. The study found that nurses were proficient in diagnosing obvious conditions including mucositis and pseudomembranous candidiasis, but they were less than proficient when diagnosing less easily recognizable conditions such as xerostomia. The nurses were found to have inadequate knowledge of the treatment and oral hygiene protocols for conditions that they could and could not diagnose. The protocol based on the questionnaire results included information gathering, oral hygiene protocol, evaluation of viral infection, evaluation of fungal infection, oral assessment guide, and treatment protocol. Through information gathering, an oral health care policy may be developed and implemented to aid in the treatment of children undergoing care for malignancies.

Measurement of oral mucositis in children: a review of the literature

GOALS OF WORK

The assessment of oral mucositis is important. There is a paucity of validated oral mucositis assessment instruments for use in children. This paper reviews the available mucositis measurement tools and their applicability to a paediatric population.

MATERIALS AND METHODS

Literature search of PUBMED and bibliography searches identified articles relevant to mucositis measurement tools and the measurement of mucositis in paediatrics.

RESULTS

The relevant issues in the literature could be grouped into three categories: (1) development and evaluation of oral assessment tools, (2) oral assessment in the paediatric population, and (3) challenges to the assessment of oral mucositis in children. There were numerous validated mucositis assessment scales for use in adults. Only three of these scales have received limited evaluation for use in the paediatric population. The unique challenges presented by the paediatric population are excluded from much of the discussion in the literature.

CONCLUSION

The paper demonstrates the need to consider the issues specific to children. It must be determined whether previously developed tools are ideally suited for children enrolled on mucositis clinical trials.

The role of basic oral care and good clinical practice principles in the management of oral mucositis

BACKGROUND

The Basic Oral Care Group is one of eight subcommittees functioning within the Mucositis Study Group Guidelines Panel of the Multinational Association of Supportive Care in Cancer and International Society for Oral Oncology (MASCC/ISOO). The Basic Oral Care Group, comprised of the four authors of this paper, represented the disciplines of nursing (DBM, JJ), dentistry (MEPC), and pediatric dentistry (PW). This group reviewed research and clinical literature to update the original 2004 Mucositis Management Guidelines in the areas of basic oral care, bland rinses, protocols and education, and good clinical practices such as pain management, oral assessment, oral care, and dental care.

MATERIALS AND METHODS

Over 100 articles published between 2000 and 2005 were identified, and 32 of these were useful for the analysis. Each article was rated by at least two authors using a structured rating form and systematic determination of levels of evidence, based on the American Society of Clinical Oncology criteria. Discussion at the 2005 MASCC/ISOO Geneva pre-conference meeting of the Guidelines Panel resulted in the development of consensus on the interpretation of the literature.

RESULTS

Based on the literature and on Panel discussions, a revision of the original guidelines for protocols and education was produced by the group, and they developed a set of recommendations related to good clinical practices.

CONCLUSIONS

Although research remains scanty for components of basic oral care, bland rinses, protocols, and education, the original 2004 guidelines with the help of newer literature from 2000 to 2005 and expert consensus among the Guidelines Panel enabled the development of useful clinical practice guidelines for managing oral mucositis in patients receiving cancer treatment with radiation and/or chemotherapy.