Mucositis

 shecatar 

hello

 June 

Greetings, This is June Eilers — I am on line and we will start shortly.

 shecatar 

What’s the topic today?

 June 

Just incase this is your first time on a chat; please know that you can type your questions and responses at any point in time. It takes a little time for them to show on the screen. In addition the toggle type key indicates if someone is actively typing.

 June 

Our topic for today is mucositis.

 shecatar 

ic

 shecatar 

hmmm I attended last time once about medication error

 shecatar 

once only

 kmishaw 

Good morning, Millie Toth and I (Kathy Mishaw) are joining you.

 June 

Hello, let's get started. I am pleased to be able to join you for this discussion. Please enter your questions at any point.

 aconawa1 

Hello everyone

 June 

What questions do you have as we get started? Or I certainly have some for you.

 aconawa1 

Have you heard of using mauka honey for mucositis

 shecatar 

nope

 kmishaw 

Why did the ONS PEP book (may 2009) drop off "preventing mucositis/ oral care" from the "Preventing Infection PEP"

 June 

Yes I have heard of using honey. I don't know that it is mauka - but honey is included in the PEP book section on mucositis including refs

 June 

We made the decision to separate the mucositis content from the preventing infection section because we wanted the content to stand in its own section as a very important aspect of care.

 June 

When the initial infection card was developed we did not have the mucositis card. It was a second round production. Infection was first round.

 kmishaw 

I agree that it needs its own section, but it has such impact on infection risk, I think maybe it should be in both places...

 aconawa1 

I cover for our wound care nurse where I work and we have been using manuka honey for healing wounds. We currently use numbing and coating cocktails for people with mucositis, but nothing that will heal their sores. I have recently seen researches on this honey in healing mucositis. There is a bee in South America that makes this special honey

 June 

I certainly can understand your concern. However oral mucositis is not the only infection that needs prevented and how do we decide which ones to discuss separately. I am interested in others' input also

 June 

I can try to follow up with the origin of the honey that has been discussed - I know that it is not our version we have in most of our cupboards.

 aconawa1 

It is fairly new, I was just wondering if anyone has used it

 June 

ONS will provide a copy of the topics we discuss today on line and we can make sure I insert that content. My articles are not in front of me now.

 shecatar 

Hmmm isn’t it honey that can invite more bacteria?

 shecatar 

So if we apply for wound healing so... how it can heal it?

 June 

What other agents have people found helpful?

 shecatar 

Sugar is food for bacteria right?

 aconawa1 

In wounds, the honey draws moisture and blood supply to the wound.

 June 

The focus with the honey has been on the source and purity of the product. Again it does require further study, but there at least has been some work.

 martyp 

"Medicinal grade" honey?

 nedaz 

Is there anything that you can do to prevent mucositis?

 June 

We chatted last time about assessment of oral cavity changes. Does anyone teach patients/families how to do self assessments?

 aconawa1 

It is by Dermasciences. The honey has been irradiated and is antimicrobial and can also relieve pain

 June 

Thank you, that is the benefit of working together.

 June 

In terms of prevention - it is interesting that we often discuss treatments without clearly differentiating if they are for prevention or treatment.

 aconawa1 

Yes. The current "cocktails" we use are retroactive

 June 

In fact there is some discussion if we can always prevent mucositis From the PEP content you will see that Palifermin has data for the prevention. In addition there is some early data that Caphosol may be beneficial. We again need more data.

 aconawa1 

What are the benefits of Caphosol?

 June 

I would agree with the retroactive response — we see they have a problem and then wonder what other than pain control to do. I will discuss several points.

 nedaz 

Are baking soda/salt water rinses comparable to over the counter rinses?

 June 

Regular cleansing with a non irritating solution like NS or salt and soda is helpful for both prevention and treatment.

 shecatar 

yes

 aconawa1 

We usually tell patients to get "Prevention" which is OTC

 June 

Once you have breakdown there are other concerns. The other thing to remember the changes start well before we see them.

 June 

Yes there are a number of OTC products. What does Prevention contain?

 shecatar 

Hmmm have you heard about tawas?

 shecatar 

For mucositis?

 June 

I have not hears about tawas unless it goes by another name also. Does anyone else know about it?

 hbelansky 

June there was also a question about the benefits of Caphosol.

 shecatar 

hmmm its a rock

 shecatar 

like salt

 kmishaw 

It is vital to assure that the salt and soda rinses are properly mixed. If the salt is isotonic the soda added it wonderful. It the salt is too much and is hypertonic, then the mucosa will be challenged, physics will pull the water from the cells and they will "prune-up," resulting in increased mucosal damage. At our institution we use soda solution, rather than salt and soda for routine cleaning.

 shecatar 

but in Philippines

 shecatar 

tawas is more effective than salt for mucositis

 June 

Thanks for the reminder — Caphosol has some early data for prevention or decreased severity of mucositis especially in head and neck cancer patients. It also has some data for saliva substitute in terms of dental changes.

 shecatar 

tawas is a crystal stone

 June 

It is interesting how many different recipes I have heard for salt and soda.

 June 

Thanks for the information on tawas — I will have to do some more homework on that one.

 shecatar 

your welcome

 shecatar 

mostly it use as deodorant too

 shecatar 

lolz

 shecatar 

but a crystal tawas is good for mucositis

 shecatar 

a lot of Filipino use it

 June 

Kmishaw can you talk more about your experience?

 June 

There are a number of different "alternative" treatments available in other countries Unfortunately many do not have adequate evidence to support regular use and we are not always certain about purity and effects.

 June 

We need to work internationally to enhance our efforts and awareness. Thanks for sharing.

 June 

Another example would be Benzydamine HCL that is used in Europe and Canada, but not approved in the US and the trial was actually stopped.

 June 

I thought I saw someone typing, but if nothing else comes through let's talk about how you decide when to use systemic versus topical pain control.

 kmishaw 

When patient's mix salt OR salt/soda, frequently the mixture is hypertonic resulting in the mucosa drying and potentially cracking/sloughing. We recommend soda (which helps to break up the plaque) mixture 1/2 tsp to 8 oz. If too much soda ... no trauma to mucosa ... just tastes bad.

 June 

Remember the membranes we see in the mouth do not stop where we can no longer see. If they have oral mucositis from a systemic mucotoxic therapy they probably have mucositis in other parts of their GI tract

 shecatar 

hmmm most of our patient here are addicted to morphine or tramal

 June 

In the hospital we actually use bottled NS so do not have to worry about mixing it for our high dose therapy patients.

 martyp 

I don't think its likely that most oncology patients are "addicted" and I prefer not to use that term

 kmishaw 

That's correct June. The NS is isotonic, but when pts go home, we try to give them a cost effective solution for cleaning.

 June 

I think that is important to acknowledge that if they have mucositis they are most likely at risk for significant pain and we are obliged to treat they pain. As a pain management consultant at our hospital I know that we struggle regarding what to do when we see behaviors that we question. The bottom line is ethically we owe it to them to treat their pain

 kmishaw 

When pts have Grade3/4 is when they usually require pain meds, but if grade 1/2 sometime a simple coating solution helps with discomfort

 June 

I think you are probably correct — but the challenge is the use of grading scales. There are agents like Gelclair that do have support for topic coating when there is limited number of lesions

 kmishaw 

Oral pain is very significant and must be addressed...i.e. pt's tell me they would rather go through a thoracotomy again than get a grade3/4 mucositis

 martyp 

I've not heard that before—that's pretty dramatic.

 mferrell 

Agree with martyp. As far as topical vs. systemic pain tx, I think many can require both. You can certainly start with topical but think that if not effective or relief is too short, systemic may be necessary.

 June 

Yes patients describe mucositis pain as the worst pain they ever had. I think it is related to the nervation of the oral cavity. In addition I can not help but think that if we would apply good pain management i.e. it takes less medication to prevent than to treat or peel them off the ceiling we could prevent some of the discomfort.

 kmishaw 

Grade 3/4 almost always requires parenteral pain med (i.e. PCA)...can't swallow; heme pts (including HSCT) pts are the ones getting severe mucositis that indicate that it is the worst pain they have experienced

 aconawa1 

When patients have so much pain they are unable to talk, eat, etc that leads to further frustration and malnutrition

 June 

Oh yes, and there are so many other things we have to take into account. Especially in the very young patient. We have actually had to intubate patients to protect their airway.

 kmishaw 

Are we through w/ pain...Can I ask about flossing and the instructions you give your patients?

 June 

The other reason pain is such a severe problem is it is almost impossible not to swallow and they end up spitting their saliva and even that hurts.

 aconawa1 

The population that I take care of is adults and older adults. Most of them come to the infusion center with dehydration as well

 aconawa1 

because they are unable to drink

 June 

Yes, let's move to flossing. We base it on the patient’s history. If someone has always flossed it is important to have them continue flossing to decrease the bacterial load in their oral cavity

 June 

The catch is if they have not flossed - during mucositis is not the time to try to learn, they will cause more trauma. We tell them to continue as long as they can. If we see uncontrolled bleeding we certainly intercede, but otherwise have them decide

 June 

BTW we do the same for brushing with soft toothbrush.

 June 

Sometimes I am asked about other electronic dental devices — what is your policy/ practice?

 kmishaw 

So if pt doesn't routinely floss, then don't start; if pt routinely flosses continue to floss gently below gum line if plts stay > 50K; modify flossing to gum line only if <50 but >20;

 shecatar 

hmmm people here in middle east I don’t see them flossing

 shecatar 

lolz

 kmishaw 

I forgot waxed floss

 June 

The key is you never want to cause more trauma or breakdown. Thus the need to have the skill

 martyp 

Good point

 June 

Did you have other areas you want to discuss?

 June 

Are people aware of and using cryotherapy?

 kmishaw 

Any recommendations on what to clean toothbrush with....we know to air dry...and also how long can someone keep their toothbrush before replacing?

 nursenow 

Re Cryotherapy: can you site some research articles for evidence based practice

 kmishaw 

What was the response regarding electric tooth brushes (SoniCare) and water pics?

 martyp 

I've used cryotherapy with bolus 5-FU, bolus methotrexate and bolus doxorubicin.

 June 

I have asked the time question myself. We try to base it on their ANC. If they don't have white cells —"more often" some say weekly. Others say if they get an infection change when you treat with antibiotics. Others say if "Just regular suppression" once a month.

 June 

We have them rinse them with hot water and allow to air dry

 nursenow 

We have used cryo for high dose melphalan on our sct patients

 June 

OK for cryotherapy - we use it for bolus 5 FU and short term infusion, also for short term infusion high dose melphalan. Remember not to use it with oxaliplatin combinations due to the cold intolerance.

 June 

One other question or thought is it is hard to gauge compliance with cryo. How much how long etc.

 hbelansky 

June - do you have any suggestions for where participants can go for additional resources on cryotherapy?

 kmishaw 

We start the ice chips about15 minutes before we start, then they chew on ice during the infusion (remember it is a short infusion) and then they continue to chew for about 30 min post infusion; so chewing on ice for a little over one hr...

 June 

Again we included cryotherapy in the ONS PEP card book that was produced with the content from all of the cards. Have you seen/used it?

 martyp 

Yes. It's great to have all PEP cards in one place

 June 

The timing you presented is pretty typical... Have you seen any aversion to ice or iced drinks?

 June 

We have about 5 minutes remaining - I want to be certain we discussed your concerns. Anyone else.

 kmishaw 

No the pts are all compliant...it is helpful when other pts warn them to do this i.e. comply with the ice regimen

 Anita 

June

 kmishaw 

Any issues with culturing oral cavity?

 June 

I should add — the other restriction would be if patients have oral cavity cancer lesions then certainly avoid.

 June 

Culturing the oral cavity can help if you suspect an infection you want to treat. The problem is the oral cavity is never sterile so you will always have organisms and need to decide which ones to be concerned about

 kmishaw 

June, what are we avoiding in the oral cancer pt?

 Anita 

kmishaw I just became connected due to technical problems will you have a transcript of the questions submitted

 Anita 

I missed the whole thing

 June 

Avoid use of cryotherapy/ice because if you cause vasoconstriction which is what we think we are doing you are limiting the exposure of the oral tumors to the chemotherapy

 hbelansky 

Anita - the transcripts from this chat will be posted early next week. Be sure to check the Hot Topic Chat site.

 kmishaw 

June is there a transcript available for Anita and the rest of us?

 Anita 

I had much to say because my husband had a grade 4 mucositis and I wanted to learn more

 Anita 

oh great

 June 

We are at time. I want to thank everyone and encourage you to join future chats with ONS also

 Anita 

My husband was treated for a head and neck ca with chemo and erbitux . He didn’t have a skin reaction to the erbitux but the radiation was a different story

 kmishaw 

June, can you reply regarding transcript? thxs

 Anita 

my husband is sill dealing with tongue issues 21/2yearslater

 June 

Yes it will be available next week ONS provides on the web site if you can not locate call the office

 Anita 

thank you

 kmishaw 

Thanks, good bye everyone

 Anita 

bye

 June 

Anita sounds like more first hand experience than any of us would want.

 Anita 

I did that is why I wanted so much to enter this discussion

 hbelansky 

Anita if you have specific questions, feel free to email me at hbelansky@ons.org and I would be happy to forward on your questions if that is OK with June.

 Anita 

my computer is having trouble with spacing

 hbelansky 

Thank you June for a great discussion!

 June 

Yes, bye