Identifying and Managing Oral Adverse Effects From Cancer Treatments

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Oral complications—including mucositis, dry mouth, and pain, among others—may be a common adverse effect from cancer treatment, and oncology nurses play an important role in identifying them in patients so they can be treated in a timely manner, an expert said.

Oncology Nursing News spoke with Alessandro Villa, DDS, PhD, MPH, Chief of Oral Medicine, Oral Oncology, and Dentistry at Miami Cancer Institute, to learn more about the common oral adverse effects of cancer therapies and how nurses can help patients manage them, which sometimes may require a referral to an oral specialist.

What is an oncology nurse’s role in the management of oral complications in patients with cancer?

Oral complications from cancer therapy are relatively common. They affect about 80% of patients with cancer, not only head and neck cancers, but any cancer. Several targeted agents are associated with some sort of oral toxicity, whether it's mucositis, dry mouth, or new forms of toxicities that affect the oral mucosa. Generally, providers tend to name them as “stomatitis.” But stomatitis is really a general term.

There are different types of toxicities that range from mTOR inhibitor-associated stomatitis to immunotherapy-related adverse events, all of which present in the mouth in a different way. And having nurses involved in the management of oral complications from cancer therapy is fundamental. They really serve as the gateway to oral health in general. There are advantages of improving nursing performance towards oral healthcare for patients with cancer, to make sure that there is adequate knowledge but also to make sure that there is awareness among nurses to identify any early signs and symptoms of oral toxicities to therefore implement any preventative measure or communicating with other oral healthcare team members to improve the oral health of patients with cancer.

You mentioned increasing awareness with oncology nurses. Is it that the topic of oral healthcare is not discussed with patients or is there a knowledge gap in this area?

There's knowledge around oral healthcare, in terms of oral hygiene and dental health of patients. But there's maybe the need for improved awareness and education around mouth complications following cancer therapy. Every patient that is in the hospital for cancer care or as an outpatient receiving chemo or radiation, they should be instructed to maintain good oral hygiene, see their dentist on a regular basis, when allowed and when possible, depending also on their systemic health in general. This is the first step to better dental health.

Then there are the other oral complications from cancer therapy, which include different types of mucosal diseases, which may be identified initially by the nurses. So I think that the expectation is in terms of management to provide palliative care to control the pain of some of these lesions, but also being able to refer the patient when needed to an oral medicine specialist. We specialize specifically in mouth diseases and complications from cancer therapy.

Why is it important for patients with cancer to maintain their oral health?

There are different aspects to it. One is that patients with cancer may be immunocompromised. If a patient is at risk of developing dental infection or odontogenic infection with poor oral health, they are at risk also of developing secondary systemic infections.

Oral health is strictly connected to systemic health. So, if we think, for example, before a patient undergoes a bone marrow transplantation, they are required to see a dentist to make sure that any dental pathology is addressed prior to the transplant. Similarly, patients awaiting to receive radiation therapy to the head and neck and patients awaiting to receive bone modifying agents see a dentist before starting cancer treatment. These are 2 groups of patients with cancer that need to be seen by our dental providers. Nurses and nurse navigators often help with this to make sure that patients see a dentist. And then during cancer therapy, it's important to reiterate the importance of oral health and dental health to our patients to minimize the risk of secondary complications while receiving chemo or radiation.

What can nurses do if they see any of these occurring?

The complication can be secondary to chemotherapy or radiation therapy, and they can affect salivary glands, the mucosa, or the teeth. The first step is to identify what is the causing agent that is leading to complications of the mouth. Is this the chemo? Is this the new drug that the patient is on? Is this because of radiation? Because the management depends on the type of complication.

It's also worthwhile mentioning that, for example, patients undergoing a bone marrow transplant may be at risk of developing acute or chronic graft vs host disease, for which the management is completely different from mucositis from chemotoxic regimens. In general, identifying early signs and symptoms usually translates in better care and management for these patients.

Pain is often a concern for our patients. So controlling the pain and the complication can lead also to better quality of life for patients with cancer in general, and then being able to contact and refer the patient or consult a specialist to manage the oral complication either caused by chemotherapy or radiation.

When we consider dry mouth, which is often a complaint of these patients receiving cancer therapy, there are over-the-counter moisturizers that can be given to patients. … If a patient has dry mouth, they are also at a higher risk of developing dental cavities and secondary fungal infections. That's why the importance of maintaining good oral hygiene during and after cancer therapy is fundamental for these patients. So there's a lot that nurses can do to help at least identify and minimize toxicities at the beginning of treatment. Eventually, these patients do benefit also from a consultation.

What advice would you give oncology nurses regarding the management of these complications?

The first step is to assess the oral cavity by doing an oral examination, assessing every area of the mouth. It takes about 1 to 2 minutes to do an oral exam: inspect the lip, the lip mucosa, the gingivae, buccal mucosa, the floor of the mouth, the tongue, and the hard and soft palate.

Some complications tend to affect 1 type of oral mucosa and some other complications, a different type of mucosa. I'll give you a practical example. An HSV infection in an immunocompromised patient with cancer can affect any area of the mouth. Canker sores that can occur following, for example, mTOR inhibitors—mTOR inhibitor stomatitis—they tend to affect the non-keratinized mucosa, which means the sides of the tongue, the inside of the cheeks, but it doesn't usually affect the hard palate or the gums. So even by differentiating between the 2, it may help be helpful to identify because mTOR inhibitor stomatitis responds well to topical steroid therapy. Whereas other oral complications from cancer therapy do not respond to topical steroid therapy.

That's why identifying the cause of the condition, it's really what ultimately guides treatment. They may appear clinically similar, but the treatment is different, whether it's from sirolimus vs radiation therapy, or sirolimus vs 5-FU in a patient receiving that drug.

One of the things that is important is to make sure that this is a team effort. The beauty of our healthcare system is that nurses really do a fantastic job in working together with other providers. [Oncology nurses] often are the ones that accompany the patients at the beginning, and they see these complications from cancer therapy, whether it's from stem cell transplantation, targeted therapy, whether it's an infection, which is another complication. So I would reiterate the importance of working as a team.

Do oral complications ever get to point where the dose of the therapy has to be adjusted or stopped completely?

Some of the complications are acute and some of the complications are chronic. Acute complications such as mucositis, for example, in a patient receiving conditioning regimens for bone marrow transplant or patients receiving radiation therapy for head and neck cancers tend to resolve eventually on their own once the chemotherapeutic agent or radiation therapy is discontinued. The Multinational Association for Supportive Care in Cancer (MASCC)/International Society of Oral Oncology (ISOO) societies have released updated guidelines on the management of oral mucositis.

There are some drugs that are approved depending on the complications to prevent or mitigate the effects of the chemotherapy or radiation. For chronic complications, these patients need to be followed over time, so dry mouth tends to be a chronic complication. If dry mouth comes from chemotherapy though, it also resolves upon discontinuation of the chemo drug.

Immunotherapy can cause mouth complications in 3 different forms: dry mouth, taste changes, or mouth sores, which resembled an autoimmune disease called Lichen planus or some cases resemble Steven Johnson Syndrome, with a lot of ulcers and crusting of the lips. Some of these patients, depending on the severity, may need to stop immunotherapy. It is a shared decision with the oncologist, but I think that nurses being at the frontline and the first one to see these complications play a big role there. So yes, some are so severe that do require discontinuation of the drug; severe cases of radiation therapy induced oral is a common cause of hospitalization for

patients with head and neck cancer. Finally, some cases of oral mucositis are so severe that patients may have to skip some sessions of radiation therapy, which translates in worse prognosis.

Are there any resources for oncology nurses to learn more about oral complications from cancer therapy?

There are some recommendations that are very helpful that are from 2 societies: ISOO and MASCC. The Head and Neck Cancer Alliance is a great resource for patients.

With ISOO, we created an application that you can download on your phone. It's called the ONCOllab. It's still in the making, but what we did we put on different complications from cancer therapy that affects the mouth. Depending on the type of provider that you are, you can select and see what you can do. If you are a physician, click on physician for dry mouth. If you are a nurse, what you can do as a nurse if a patient has dry mouth from chemo. These are some of the new things that are available with great educational information.

This transcript has been edited for clarity and conciseness.