Assessment of oral mucositis, oral health outcomes, and implementation of a standardized oral health care protocol for a pediatric inpatient population receiving cancer treatment.

Abstract

Rationale: Oral mucositis can compromise cancer treatment, reduce quality of life, and lead to debilitation among childhood cancer patients. Recent clinical trials have recognized oral care to prevent oral mucositis, however, few studies have reported oral health outcomes of children receiving cancer treatment. Aim and Objectives: This research was undertaken to assess oral mucositis incidence and oral care outcomes, and to explore possible risk factors for oral mucositis among inpatient children receiving cancer treatment at the Women’s and Children Hospital, Adelaide, Australia. The objectives were to investigate the evidence on oral mucositis prevention, assess and validate the combined use of the Children’s International Mucositis Evaluation Scale (ChIMES) and the World Health Organization (WHO) oral mucositis scale in recording oral mucositis incidence, develop and implement a standardized hospital oral care protocol, and to record prospectively oral mucositis incidence, oral health outcomes, and possible risk factors. Methods: A systematic review was conducted to assess the current evidence on oral mucositis prevention among children. Results of a previous retrospective study were used to design a prospective pilot study. The pilot study was carried out for seven months during which the new oral care protocol was implemented and the ChIMES and the WHO oral mucositis scale were validated through daily recording of oral mucositis in the oncology ward. Measures of reliability and compliance were assessed among nurses and dental staff involved in recording oral mucositis and oral health status. The pilot study was followed by a prospective clinical observational study and recorded measures of oral mucositis (12 months) and oral health status (24 months). Measures of oral health outcomes were assessed initially and then every three months through clinical examination to record dental caries and oral hygiene while measures of oral mucositis was recorded daily during the hospital stay of recruited children. The incidence of oral mucositis, oral health outcomes, and dental treatment utilization were then analyzed to explore possible risk associations. Results: The systematic review supported the benefit of implementing a standardized oral care protocol to prevent oral mucositis among children. Thirty-eight children were conveniently sampled during the pilot study during which high levels of reliability and compliance (87%) in using ChIMES and WHO oral mucositis scales were achieved. Dental referrals increased from 53% to 100% after adopting the comprehensive oral care protocol. Sixty-seven children were recruited during the prospective part with oral mucositis incidence similar to that of the pilot study (33% versus 34%). Dental caries prevalence was 28% with absence of new carious lesions throughout the 24 months follow up. Regular dental reviews were significantly related to shorter duration of oral mucositis (adjusted rate ratio=0.94; 95% CI=0.89-0.99; Pvalue= 0.026) and hence fewer days of hospital stay. On the other hand, an increase in days of hospital stay was significantly related to oral mucositis incidence (adjusted rate ratio=1.64; 95% CI=1.002-2.69; P-value=0.049). Conclusion: Implementing a comprehensive oral care protocol and consistent recording of oral mucositis have resulted in low rates of oral mucositis and dental caries incidence among inpatient children receiving cancer treatment.