Treatment-related factors that may increase risk for mucositis include type, dose, and schedule; patient-related risk factors include older age, body mass index, oral environment, and genetic predisposition. Oral mucositis can range from mild changes in sensation to severe oral pain, infection, and ulcerative bleeding lesions. Patients can also experience debilitating anorexia, dehydration, weight loss, and malnutrition because of difficulty eating and drinking—which may lead to dose limitation, treatment delays, and treatment discontinuation.

Gaps in Oral Health Care

In a systematic review, Sajwani et al. found that healthcare providers, advanced practice RNs, and RNs lacked knowledge and skills in oncology oral health care, which affected their ability to make accurate diagnoses, administer appropriate oral care protocols and treatments, and refer patients to dental services. Oral mucositis requires an interprofessional approach that often involves partnerships with dental providers. Only one-third of the nurses surveyed said that they knew about the importance of oral health and referrals for dental consultations prior to initiating treatment.

How APPs Can Bridge Those Gaps

Oncology APPs can transform the care of patients at risk for mucositis by implementing clinical guidelines in practice. Begin by asking, “What are our practice’s recommendations to patients for oral care?” Then involve all stakeholders, including providers and oncology nurses, in the conversation to understand the recommendations and the consistency of their responses.

Oncology APPs can lead the care team in understanding and consistently using evidence-based recommendations, providing education on preventive oral care practices, using reliable and valid scales for the most accurate assessment and documentation (e.g., World Health Organization oral mucositis scale, National Cancer Institute scale for oral mucositis, Oral Assessment Guide), and identifying management strategies.

To reduce knowledge gaps, oncology APPs must educate themselves and other oncology care providers about the most up-to-date management strategies and evidence-based guidelines and recommendations, such as:

• ONS’s symptom interventions for oral mucositis
• Multinational Association of Supportive Care in Cancer and International Society for Oral Oncology’s (MASCC/ISOO’s) guidelines for the management of mucositis secondary to cancer therapy

Once you understand the evidence, determine how to implement it consistently and change previous clinical practices, if needed. For example, “magic mouthwash” may have been used for patients at risk for or experiencing oral mucositis; however, ONS does not recommend it—or agents such as chlorhexidine and sucralfate—for practice.

Another example involves evaluating ways to deliver recommended interventions. Both ONS and MASCC/ISOO recommend oral cryotherapy to prevent mucositis in patients receiving bolus 5-fluorouracil or high-dose melphalan as conditioning for hematopoietic stem cell transplantation. Cryotherapy involves cooling the mouth during chemotherapy; the resulting vasoconstriction reduces the drug concentration to the oral cavity during infusion. It typically requires patients to hold ice or other cold liquids in the mouth prior to and during a chemotherapy infusion, but many patients may struggle to tolerate that strategy. In early 2024, the U.S. Food and Drug Administration granted marketing clearance to a supportive care device that provides efficient and uniform cooling of the oral mucosa. Oncology APPs can investigate the feasibility of implementing new tools and devices in clinical practice.

How APPs Can Guide Future Recommendations

ONS’s symptom interventions initiative conducts periodic reviews of the current evidence and classifications for the interventions. Oncology APPs can contribute their expertise by volunteering for the next review team. If you’re subscribed to ONS emails, watch your inbox for an announcement of the volunteer opportunity in early fall 2024. If you haven’t subscribed, email help@ons.org to opt in for announcements of the latest volunteer opportunities like this one.