The development of evidence-based guidelines on mouth care for children, teenagers and young adults treated for cancer

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Abstract

The aim was to produce evidence-based guidelines on mouth care for children, teenagers and young adults receiving chemotherapy and/or radiotherapy.

Systematic reviews were undertaken and research was graded according to the methods of the Scottish Intercollegiate Guidelines Network. Where no relevant research was identified, an opinion-gathering process was undertaken.

‘Best practice’ recommendations were developed with regard to appropriate dental care and basic oral hygiene. An evaluation of oral assessment tools identified seven which had been assessed for reliability and/or validity. Only Eilers’ Oral Assessment Guide was felt to be relevant for daily clinical practice.

A variety of interventions have been used for the management of oral mucositis, candidiasis, xerostomia and herpes simplex virus; few are supported by research evidence.

Careful oral management of children treated for cancer can improve the quality of life during treatment. The guidelines have the potential to improve patient care by promoting interventions of proven benefit and discouraging use of ineffective or potentially harmful practices which may result in adverse patient outcomes.

Introduction

Oral complications occurring during and following cancer treatment are common and can cause pain, difficulty in swallowing and phonation and poor nutrition. They can clearly impact severely on a patient’s quality of life.1 One of the most common side-effects of cancer treatment is mucositis. The prevalence of chemotherapy-induced oral mucositis has been shown to range from 30% to 75% of patients, depending upon the treatment type.2, 3 In about 50% of patients with mucositis, lesions can be severe causing significant pain, interfering with nutrition and often requiring modification of the chemotherapy regimen. In addition, mucositis may predispose a child to fungal infection (most commonly candidiasis), viral infection and bacterial infection, which may lead onto life-threatening systemic infection. An additional oral complication following cancer treatment is salivary gland dysfunction, which can be caused by both chemotherapy and radiotherapy. Salivary gland damage can also impact on a patient’s quality of life, causing oral discomfort, taste disturbances, difficulty in chewing and swallowing and speech problems. In addition, patients suffering from salivary gland damage are at greater risk of oral infections, including oral candidiasis. Long-term consequences of salivary gland damage include dental caries.

The careful oral management of children treated for cancer can improve the quality of life during treatment. However, there is ‘confusion and conflict’ surrounding what constitutes appropriate mouth care.4 In recent years much emphasis has been placed on the development of clinical guidelines, as a means of improving the quality of health care.5 Guidelines have been viewed as a way of helping to promote evidence-based practice; encouraging clinical practice based on relevant, scientifically rigorous, research evidence.

One of the potential benefits of guidelines is that they can reduce inappropriate variation in clinical practice. There is ample evidence that there are substantial variations in the provision of care in most clinical specialties, which may lead to inequalities in health care.6 Indeed, a survey of mouth care provided to children, teenagers and young adults treated for cancer identified diversity in care across the United Kingdom.7 A wide variety of interventions were shown to be used for both prevention and treatment of oral complications, only some of which have been shown to be effective.8, 9, 10, 11, 12 In order to reduce this variation in practice the Children’s Cancer and Leukaemia Group (CCLG) (formerly the United Kingdom Children’s Cancer Study Group (UKCCSG)) and the Royal College of Nursing Paediatric Oncology Nurses Forum’s (PONF) Mouth Care Group was established. The principle aim of the CCLG-PONF Mouth Care Group was to produce comprehensive evidence-based guidelines on mouth care for children, teenagers and young adults who have undergone or who are receiving chemotherapy and/or radiotherapy for a malignancy (including head and neck cancers), or stem cell transplant (both bone marrow and peripheral blood stem cell transplants).

Section snippets

Materials and methods

The guidelines were developed following the methods outlined by the Scottish Intercollegiate Network (SIGN).13 However, for certain questions addressed in the guidelines, the SIGN methods were not deemed applicable, so adapted, or alternative, methods were used.

Dental care and basic oral hygiene

A total of 73 responses were obtained from the Delphi. Due to the electronic method of distribution, the specific number of health professionals receiving the questionnaire is unknown. The forms were completed by 26 nursing staff (35.6%), 24 medical staff (31.6%), 12 dentists (15.8%) and two dental hygienists (2.6%). Nine respondents (11.8%) did not provide details of their profession.

The median value achieved for 29/32 (90.6%) of the statements was four or five, indicating that the majority of

Discussion

Clinical guidelines are considered to have an important role to play in reducing inappropriate variation in clinical practice, some of which may be ineffective or potentially harmful. In order to be of most use, guidelines need to be comprehensive, valid and relevant. A comprehensive and systematic approach was undertaken in the development of the CCLG-PONF Mouth Care Guidelines and internationally recognised methods of guideline development were followed where possible.14

Previous guidelines or

Conflict of interest statement

None declared.

Acknowledgement

The CCLG is funded by a grant from Cancer Research UK (CRUK). The CCLG-PONF Mouth Care Group also received funding from CLIC-Sargent.

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