Mucositis

 june 

Greetings—we will be ready to start in a few minutes. Wellcome on-line. I am looking forward to our chat. June

 june 

Hello—according to my computer it is time to go. June

 june 

I would like to start by welcoming everyone

 june 

ONS also has staff on line in case we need them.

 june 

Some of you may have tried to come in for the last program and there were major technical problems so none of us made it.

 june 

Let's start—what is the greatest challenge you face with mucositis in your clinical setting?

 sbohnenkamp 

Preventing Mucositis

 khowlett 

What is the best product to use when a patient has mucositis? I have one physician who routinely orders caphasol, and another who orders "magic mouthwash."

 june 

Yes, it is interesting—as we talk about mucositis so often we merge prevention and treatment, but they are two different processes.

 june 

What types of things have people found work for you?

 NMANDOLFO 

For treatment I like Magic Mouthwash and Gelclair

 khowlett 

I have had patients do better with normal saline rinses than magic mouthwash.

 june 

OK, let's do a little treatment and then go back to prevention.

 svella 

hi we use difflam for radiation induced mucositis

 Dorothy 

I recently had a pt who used Magic mouthwash and Nystatin and NS rinses and she still had very bad sores for more than 10 days...had to go on TPN

 june 

I first of all want to remind people of the ONS PEP book which has come out. We included in there the lastest evidence we could find.

 june 

The challenge with magic mouthwashes is you need to know what is in your magic solution. I always say I have yet to find magic. Some of them contain an alcohol base so burn and dry

 Dorothy 

usually Benedryl, Mylanta and Lido

 june 

I would agree with the use of NS. That is my automatic fall back on answer for both prevention and treatment as it is cleansing and soothing.

 june 

Nystatin has mixed evidence and limited proven benefit with concern regarding the sugar content.

 june 

Back to the magic mix—some of the products can have an alcohol base - so make sure your pharmicist knows to avoid the alcohol base products—they are available

 sbohnenkamp 

We brush the teeth and then the Normal Saline rinses and mouth moisturizer and increase frequency as their oral assessment changes

 khowlett 

So back to prevention.... as I understand it we really can't prevent mucositis, but we can prevent the severity with good oral care... is this correct?

 june 

I also want to add—that Caphosol does have some evidence—but at the time of the publication was listed as effectiveness not established which was moveed up from the PEP cards

 june 

Does anyone use Palifermin?

 sbohnenkamp 

Our hsopital only let's us use it for bone marrow transplant

 june 

Thanks for the response—it is costly and thus I agree we need to identify who is most likely to need it and likely to benefit.

 june 

I appreciate the comment about brushing - that is a critical component of mouth care or we are allowing build up

 june 

We actually try to allow brushing with soft toothbrush as long as they can tolerate it

 june 

The same is probably true for flossing if they are used to flossing—just don't start someone flossing who has not done so.

 Dorothy 

My pt had such bad sores that gentle massage with the sponge toothbrush caused bleeding.

 june 

That can be a problem and that is why you need to gauge it according to tolerance.

 NMANDOLFO 

I work outpatient, I'd like to know if anyone has used topical morphine sulfate rinse—I read about it on Uptodate.com as an option for treatment.

 june 

The important point also is that most people need to care for their tissues in addition to brushing their teeth.

 june 

Yes I have heard and seen morphine rinse—again make sure your pharmacist uses alcohol free. What about other people?

 Dorothy 

Never used MS, but encourage use of NS even without sores.

 sbohnenkamp 

Does morphine rinses work better than lidocaine?

 NMANDOLFO 

On the ONS PEP —- is there an "protocol" so to speak?

 svella 

Hi I follow the MASCC guidelines

 june 

Another concern with topical MS is that often the process is systemic and so they need more than topical—but that is probably an advantage of swallowing some of it. Yes I think the MS may work better, but not certain I have seen any research RTC.

 june 

Yeah for following the MASCC guidelines for those who do not know they are available on line at MASCC.org

 june 

The ONS PEP information encourages the establishment of a "standard" for your clinical area so that you have a consistent plan that is followed. It should include regular cleansing and brushing, and then interventions based on the anticipated mucotoxicity of the treatment.

 june 

I do think it is interesting how some people do not seem to develop problems even they should and do not do what we recommend

 june 

There probably are pharmacogenetics and genetics in general involved.

 june 

Has anyone worked with patients/families on self assessment?

 june 

The reason I asked about self assessment is that I am convinced that once we initiated the Oral Assessment Guide we saw less severe mucositis. I think it is because we were paying attention to mouths

 june 

If we teach patients/families to self assess could we see an effect there also?

 NMANDOLFO 

I am sure that is true - is the guide online at ONS or how can we get it and use it as a tool in our clinics? I typically use the CTC criteria to grade mucositis, but don't usually take it one step further with the formal assessment...

 svella 

patients are told to clean their mouths regulary and any complication to contact their Dr.

 june 

I am always willing to share—it is available in ONS publications but you can always contact me through ONS and I will send it your way.

 june 

The interesting point about the OAG as compared to CTC—is the OAG addresses oral cavity changes that are more global also

 june 

From a nursing viewpoint we can address general oral care which is going to be important on an ongoing basis especially if they have salivary gland changes

 june 

That is an area where there also is some Caphosol data because it has served as a saliva replacement

 june 

Yes, I am willing to share anyone else can just email me through ONS.

 stephanie@ONS 

For those who have just entered you will be able to view the entire transcript online in about 48 hours after the chat.

 june 

Another topic I think we should address is the use of cryotherapy. Do you use it and when?

 NMANDOLFO 

What do you think about topical kaolin/pectin...? I saw this online as an option for mucosal coating agent. Any ideas or do you recommend Gelclair over that as a "coating agent". I have seen a lot of success with gelclair as a "coating agent".

 NMANDOLFO 

I have not used cryotherapy for mucositis... what is the role?

 svella 

No, I work in an inpatient and ex. 5fu and it is given viw infusion over 12hrs

 june 

Yes Gelclair is an agent that is used—it seems to be effective for small to med sized areas, but not when they have major problems.

 june 

The kaolin/pectin products are less predictable in terms of "recipe" depending on your source.

 june 

Cryotherapy is believed to help by causing vasoconstriction as a topical agent. The challenge is with the long infusions because patients can only tolerate ice for so long. we tend to do it for bollus and shorter infusions, but not long infusions

 june 

We use it with high dose melphalan and 5 FU

 june 

Another challenge is determining compliance

 NMANDOLFO 

Gotcha—yes, I have used Ice with 5FU, but yes... longer infusions are a challenge..

 june 

BTW patients on oxaliplatin do not tolerate it due to the problem with cold so we still need to find an approach for the colon patients on those protocols

 june 

Isn't it interesting that for as often as we struggle with mucositis we still lack adequate support for so many agents. Anyone doing research? You knew I would get that in

 june 

If you are part of any clinical trials starting up that will include a risk of mucositis—try to include a nursing arm for mucositis prevention or treatment

 june 

I will type short bursts for this, so if you want to ask a question, please do

 june 

Another important thing to remember is the proposed model for mucositis in terms of the many phases. Think of it as we do wounds

 june 

You want to prevent breakdown. If there is debris we need to do cleansing—keep patient clean

 june 

If the patient is experience dry mouth—need to moisturize.

 june 

If there is breakdown keep it clean, but be gentle to the new baby cells

 june 

Back to prevention—do you have a pretreatment system for dental assessment?

 svella 

In most cases no

 june 

I want to encourage you to look in your patients' mouths and ask them about usual care - including dental visits.

 june 

As our treatments are more aggressive we need to make sure they have started out as health as they can. There are good teaching materials available from Dental Association on line. You just need to work out communication with the patient's usual dentist if you don't have one they should use

 june 

That is one component included in the MASCC guidelines that is not so present in our ONS PEP cards. MASCC includes dentist and other disciplines

 june 

We have about 10 mins left—I want to add if you submit a question and we do not get to it, we will follow up with you by including it on the typed copy

 june 

OK another point—you may have noticed in PEP information that Chlorhexidine comes alcohol free and alcohol based—that is probably why the evidence to date has been so mixed

 june 

If you use it, check to see if it is alcohol free. The alcohol free is more readily available in Europe.

 june 

I know that when a nurse friend of mine tried to get it at "my" institution we did not have it. Can you believe that??

 svella 

It is difficult to get an alcohol free mouthwash. the commercial ones all have some degree of alcohol

 june 

You are correct and that is why you have to be so careful and warn your patients to check ingredients in what they prefer.

 june 

BTW you can also use flavoring agents (avoid alcohol) in your NS rinse if that makes it so patients like it better

 june 

You always want to work to accomplish frequent rinsing to cleanse the oral cavity

 stephanie@ONS 

If no one else has any questions for June we will wrap this chat up. ONS would like to thank you for coming tonight. Please join us agian for another Hot Topic!

 june 

Thanks to everyone for participating

 NMANDOLFO 

I have found this chat very helpful.. I am in the process of developing a protocol for our office on mucositis. Thanks everyone!

 svella 

It has been great meeting you

 june 

Until we meet again... keep up the good work —we do make a difference