Prevalence of Oral Complications occurring in a Population of Pediatric Cancer Patients receiving Chemotherapy

Nursing care approaches to oral mucositis in pediatric oncology clinics: a cross-sectional study from Türkiye

PURPOSE

It is important to determine the approaches for oral mucositis (OM) care in pediatric oncology clinics to reflect the profile of practices. The aim of this study was to report on current nursing care approaches for OM in Türkiye.

METHODS

The descriptive, cross-sectional study was conducted with nurse managers in pediatric oncology centers in Türkiye between April and December 2022. The data were obtained online by reaching pediatric oncology nurse managers. The data was collected with the "Oral Mucositis Care Application Form" developed by the researchers based on current literature.

RESULTS

The study reached approximately 60% (n = 41) of pediatric oncology clinics across Türkiye. Oral assessment of children was mainly conducted by nurses (95.1%), and 53.7% of clinics used the WHO Oral Mucositis Assessment Scale. To prevent OM, oral care routines were performed twice a day (36.6%) using sodium bicarbonate (61%) and 0.9% sodium chloride (26.8%) agents. For oral mucositis management, pharmacological agents included glutamine (oral) (51.2%), chlorhexidine (43.9%), and benzydamine hydrochloride (36.6%), while non-pharmacological agents included black mulberry syrup (41.5%), honey (19.8%), and chewing gum (9.8%). Chlorhexidine and benzydamine hydrochloride were used for all mucositis grades, while glutamine was frequently used for grades 2 and above.

CONCLUSIONS

The study revealed that the practices related to preventing and managing oral mucositis in pediatric oncology clinics in Türkiye are heterogeneous. These findings will contribute to the existing literature on the multidisciplinary, systematic, and evidence-based approaches used in oral mucositis care in Türkiye.

Chemotherapy-induced oral mucositis in children and adolescents: a systematic review

PURPOSE

The present systematic review aims to describe the incidence and severity of chemotherapy-related oral mucositis in children and adolescents affected by hematologic and solid tumors.

METHODS

An electronic search was performed on PubMed, Scopus, Web of Science, Cochrane Library, and EBSCO up to the 8th November 2020. The PRISMA protocol was followed for the article selection and inclusion. The risk of bias in individual studies was evaluated through the Newcastle-Ottawa Scale. Data were summarized using mean and standard deviation for continuous variables, while categorical ones were described with frequency and percentage.

RESULTS

A number of 9940 records were obtained after the electronic search. Seventeen of them were included in the qualitative analysis after the two stages of screening, while none of these articles was considered eligible for the quantitative analysis. The mean incidence of oral mucositis was 53.6% and it ranged from 16.7 to 91.5%, while severe oral mucositis accounted for the 15.8% (0.0-35.2%) among selected studies. Most of the articles included both patients with solid and hematologic tumors, while only five of them described oral mucositis in children with acute lymphoblastic leukemia. Even the kinds of chemotherapy administered were extremely variable.

CONCLUSION

In conclusion, about half of the patients submitted to cancer chemotherapy developed oral mucositis with an incidence and severity that varies depending on the primary disease and the kind of drugs administered.

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.

The incidence of severe oral mucositis and its occurrence sites in pediatric oncologic patients

Background

Childhood cancer is one of the main causes of child mortality and its treatment has debilitating effects on the oral cavity. Several oral mucositis (SOM) is one of the most common and may cause undesirable symptoms such as pain and risk of systemic infection.

Material and Methods

This was a longitudinal, retrospective, and observational study determining the incidence of severe oral mucositis (SOM) and its occurrence sites in pediatric oncologic patients, in João Pessoa, Brazil, between 2013 and 2018. Data from 56 patients aged 1 to 18 years were collected from their medical records and through an oral mucosa examination, from the 1st to 5th week of chemotherapy treatment (CT) using the modified Oral Assessment Guide, by previously calibrated examiners (Kappa index > 0.7). The data were analyzed by the Chi-square test, and Odds Ratios were calculated.

Results

Most patients were females (54.5%), aged 8.8 years (± 4.8), with hematologic tumors (73.2%), predominantly Acute Lymphoid Leukemia (50.0%). An increase in the occurrence of SOM was observed throughout the CT (P = 0.05), ranging from 12.5% in the 1st to 35.7% in the 5th CT week. In the 1st CT week, there was a predominance of alterations in the lips (5.5%) and saliva (5.5%), while in the 5th, the jugal / palate mucosa (21.4%) remained the most affected site by SOM. Differences in the severity of SOM in the jugal / palate mucosa (P = 0.01) and labial mucosa (P = 0.04) were observed over time. In the 5th CT week, the likelihood of developing SOM was 13.3-fold higher (95% CI: 1.5 - 105.6) in patients with hematologic tumors.

Conclusions

The incidence of SOM was higher in the 5th CT week, most commonly affecting the jugal / palate mucosa, and patients with hematologic tumors were more prone to develop SOM.

Key words:Mucositis, oncology, pediatric dentistry.

Management of Oral Mucositis in Children With Malignant Solid Tumors

Introduction

In recent years, the use of intensive regimens for the treatment of pediatric cancer has led to a marked improvement in patient survival. However, these treatments are associated with an increase in toxic effects. Among these side effects, mucositis (inflammation of the oral cavity) significantly affect the success of treatment. The aim of this study was to assess the prevalence of mucositis in a pediatric population with solid tumor and undergoing chemotherapy, identify the risk factors that influence its occurrence, and verify the usefulness of pain rating scales.

Methods

We registered episodes of mucositis which occurred in a sample of 84 consecutive children with solid tumors between 1 January, 2012 and 30 April, 2018. The World Health Organization (WHO) oral mucositis grading scale and the modified Wong-Baker FACES Pain Rating Scale (WBS) were used to assess the severity of each episode. Moreover, data on the treatments used and blood count results were collected.

Results

The prevalence of mucositis in our population was 50%, without statistically significant difference according to sex and a higher prevalence observed in patients aged >10 years. The presence of neutropenia, higher number of cycles of chemotherapy, and co-existence of lymphomas and sarcomas were identified as factors favoring the occurrence of mucositis. The WBS showed results superimposed on the WHO oral mucositis grading scale in choosing the intensity and duration of mucositis treatment.

Conclusion

Oral mucositis is a common complication of chemotherapy against childhood malignancies. The WHO oral mucositis scale is a valuable tool for assessing its severity in pediatric patients. Furthermore, WBS can be used as an assessment tool to establish the therapy to be adopted for patients in whom direct evaluation of the oral cavity is not possible.

Psycho-Education on Knowledge of Oral Hygiene and Psychological Distress to the Parents with Leukemia Children

Objective:

To analyze the effect of psycho-educational intervention on knowledge of oral hygiene and psychological distress to the parents of children suffering from leukemia.

Methods:

Design of this study was a quasi-experimental pre-posttest control group design. The sample were 70 mothers who had children with leukemia (intervention group = 35 mothers; control group = 35 mothers). The independent variable was psycho-educational, while the dependent variables were oral hygiene knowledge and psychological distress. The instruments used were the knowledge questionnaire and the Depression-Anxiety-Stress Scale (DASS-21). Data were analyzed using the Wilcoxon signed rank test and the Mann Whitney U-test with the significance α =0.05.

Results:

The knowledge most widely known by parents was about how to perform of oral care (37.3%). All parameters of knowledge about oral hygiene have increased after being given a psycho-educational intervention. Psycho-educational interventions had an effect on reducing psychological distress; depression (p=0.000), anxiety (p=0.001) and stress (p=0.000).

Conclusion:

Most parents whose children suffer from cancer experience psychological distress in the form of depression, anxiety and stress with a range of symptoms ranging from mild to moderate. Psycho-educational interventions can increase knowledge about oral hygiene and decrease psychological distress in parents.

Severe Oral Mucositis in Pediatric Cancer Patients: Survival Analysis and Predictive Factors

This paper investigates the occurrence of severe oral mucositis and associated factors in blood and solid cancer pediatric patients subjected to cancer treatment, using a survival analysis. A longitudinal, descriptive, observational and inductive study of 142 pediatric patients aged from 0 to 19 years was conducted from 2013 to 2017. Data were collected using a form to record the sociodemographic characteristics and health-related aspects of patients and the modified Oral Assessment Guide (OAG). Survival analysis was performed using the Kaplan-Meier method and Cox semiparametric model. The median times to occurrence of severe oral mucositis were 35.3 and 77.1 days for patients with hematologic malignancies and solid tumors, respectively. The Cox model showed that white cell changes and platelet counts as well as the use of natural chemotherapeutic agents are risk factors for the occurrence of oral mucositis among patients with hematologic malignancies. Nonetheless, among patients with solid tumors, the occurrence of oral mucositis was associated with female sex, mixed ethnicity, the presence of metastasis, abnormal creatinine levels, a combination of chemotherapy, radiotherapy, and surgery, and the administration of chemotherapeutic agents included in the miscellaneous group. The time to occurrence of severe oral mucositis and its associated factors varied according to cancer type.

The Contribution of Motor Changes to Oral Mucositis in Pediatric Cancer Patients: A Cross-Sectional Study

This study aimed to investigate the contribution of motor changes to oral mucositis in children and adolescents with cancer undergoing antineoplastic treatment in a referral hospital. This was an observational, cross-sectional study with 70 patients aged 2 to 19 years, diagnosed with any type of cancer and treated in a pediatric hospital cancer ward from April to September 2017. A questionnaire related to the patients' socioeconomic and clinical conditions was used, followed by the Oral Assessment Guide and selected domains of the activity and participation section of the International Classification of Functioning, Disability, and Health tool. The data were collected by previously calibrated examiners (kappa index > 0.75) and analyzed using descriptive statistics and logistic regression (α = 5%). Children and adolescents aged 7 to 10 years were more likely to develop oral mucositis (OR: 3.62). In addition, individuals who had severe difficulty in maintaining a body position (OR: 14.45) and walking (OR: 25.42), and those diagnosed with hematologic cancers (OR: 6.40) were more likely to develop oral mucositis during antineoplastic treatment. Within the limitations of this study, it is concluded that motor changes may contribute to the occurrence of oral mucositis in pediatric cancer patients.

Oral health in children with acute lymphoblastic leukaemia: before and after chemotherapy treatment

AIM

To evaluate changes in the oral health status of children under the age of 14 years with acute lymphoblastic leukaemia (ALL) attending a cancer centre before and after chemotherapy treatment.

MATERIALS AND METHODS

A total of 32 children with ALL without distinction of gender were selected for study. The oral cavity of the patients was evaluated before the induction stage and 17 days later. Clinical evaluation of the submandibular, submental, and cervical lymph nodes was performed. Saliva samples were collected during the early morning hours. Bacterial plaque was assessed by using the Silness and Löe plaque index (SLPI) and gingiva status was evaluated with the gingival Löe and Silness index (GLSI). The WHO toxicity oral scale was used to record the degree of oral mucositis. The resulting data were analysed with McNemar's test, t test (for related samples), and Wilcoxon test.

RESULTS

There were statistically significant differences for palpable lymph nodes, paleness of oral mucosa, and ecchymoseis, respectively, P ≤ 0.000, P = 0.03, and P = 0.01, with these manifestations decreasing significantly after treatment. Incipient gingivitis had frequencies of 71.9% and 75% before and after treatment, respectively. The mean SLPI score declined significantly from 1.16 ± 0.52 (before treatment) to 0.56 ± 0.36 (after treatment) (P < 0.000); salivary flow increased significantly from 0.54 ± 0.34 to 1.22 ± 1.07 after chemotherapy treatment (P < 0.00). Oral mucositis was present in 24 children (75%) with a 1-2 severity level.

CONCLUSIONS

After chemotherapy treatment, there were changes in the oral conditions of children with ALL. Some manifestations decreased after treatment, whereas in others increased.

Adherence to dental treatment reduces oral complications related to cancer treatment in pediatric and adolescent patients

PURPOSE

To analyze the association between adherence to dental treatment and (1) oral complications and (2) clinical and sociodemographic aspects of pediatric and adolescent patients with cancer.

METHODS

A retrospective cohort study with a sample of 147 children and adolescents who underwent cancer treatment of solid tumors or lymphomas was carried out. The patients were divided into three groups according to previously established criteria. Sociodemographic aspects and oncological, dental, and oral complications were analyzed.

RESULTS

The mean age of patients was 6.7 ± 6.09 years; 57.1% were males and 42.9% were females. Of the 147 patients, 37.41% had full adherence, 33.3% had partial adherence, and 29.3% had non-adherence to the proposed dental treatment. A statistically significant association between oral complications and adherence to dental treatment (p = 0.006) could be observed. The presence of caries lesions at the initial oral examination presented a statistically significant association with adherence to dental treatment (p = 0.004). Children with caries lesions at the initial dental examination had an 88% higher risk of developing oral complications compared with those without caries (RR = 1.88, 95% CI 1.01-3.49). After adjustments for age and the presence of caries lesions at the initial examination, adherence to dental treatment remained the only independent risk factor for oral complications (adjusted RR = 2.56, 95% CI 1.17-5.57).

CONCLUSIONS

This study has demonstrated that non-adherence to dental treatment was associated with higher incidence of oral complications and it is a risk factor for these complications. The presence of caries lesions at the initial oral examination was associated with non-adherence to dental treatment.

Back to Basics: CLABSI Reduction Through Implementation of an Oral Care and Hygiene Bundle

Children with cancer often undergo treatments that render them severely immunocompromised. Side effects of treatment place them at risk for developing oral mucositis (OM), which can potentially lead to infection and bacteremia. Staff nurses on an inpatient pediatric oncology unit noted inconsistent daily oral hygiene practices despite assessing OM consistently. Basic oral hygiene can reduce the severity of OM, and evidence-based bundled care has shown to increase consistency of practice. Based on findings and recommendations from the literature, an oral care and hygiene bundle was developed. The oral care bundle included a soft bristled toothbrush, fluoride toothpaste, twice-daily brushing and sodium bicarbonate rinses, lip balm, and oral moisturizer. The hygiene component consisted of a daily bath or shower and daily linen changes. Education on the rationale and purpose for the use of an oral care and hygiene bundle was provided to the inpatient direct care staff prior to implementation on two inpatient oncology units. Audits were performed to measure the adherence of the oral care and hygiene bundle. Central line–associated bloodstream infections were measured in collaboration with the quality and infection prevention departments. Since the oral care and hygiene bundle was implemented, laboratory-confirmed bloodstream infection rates decreased from 1.05 to 0.54 per 1,000 catheter days, while mucosal barrier injury rates decreased from 2.98 to 1.27 per 1,000 catheter days.

Potential Therapeutic Effects of Gut Hormones, Ghrelin and Obestatin in Oral Mucositis

Chemotherapy and/or head and neck radiotherapy are frequently associated with oral mucositis. Oral pain, odynophagia and dysphagia, opioid use, weight loss, dehydration, systemic infection, hospitalization and introduction of a feeding tube should be mentioned as the main determinated effect of oral mucositis. Oral mucositis leads to a decreased quality of life and an increase in treatment costs. Moreover, oral mucositis is a life-threatening disease. In addition to its own direct life-threatening consequences, it can also lead to a reduced survival due to the discontinuation or dose reduction of anti-neoplasm therapy. There are numerous strategies for the prevention or treatment of oral mucositis; however, their effectiveness is limited and does not correspond to expectations. This review is focused on the ghrelin and obestatin as potentially useful candidates for the prevention and treatment of chemo- or/and radiotherapy-induced oral mucositis.

Review of a three-year study on the dental care of onco-hematological pediatric patients

The aim of this study was to provide an updated review of dental procedures undertaken at the dental unit of the Onco-hematology service of the Instituto da Criança at the Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (ICr/HC-FMUSP). We retrospectively reviewed 565 of 1902 medical and dental records of patients diagnosed with onco-hematological diseases who were seen in a 3-year study (January 2015 to December 2017). We assessed data regarding population characteristics, onco-hematological diagnosis and dental procedures performed. Of the selected medical records, preventive dentistry was the most common procedure undertaken in this population, followed by oral maxillofacial surgeries, restorative dentistry and oral mucositis treatment. The most prevalent malignant diagnosis was acute lymphocytic leukemia, and the most prevalent nonmalignant diagnosis was sickle-cell anemia. Preventive dental procedures represent most of the dental procedures undertaken in hospitalized onco-hematological pediatric patients.