Page 32 Complete Your CE Test Online - Click Here ● ● Temporomandibular dysfunction. ● ● Salivary abnormalities. If the patient is already myelosuppressed at the time of dental treatment, some corrections or prophylaxis may be needed (e.g., platelet transfusions or antibiotics if ANC is less than 2000). Mucositis should be managed by good oral hygiene and avoidance of spicy, acidic, hard, and hot foods and drinks. Dental brushing and flossing should be performed daily with assistance from professional staff: ● ● A soft nylon-bristled toothbrush should be used two to three times a day with techniques that specifically maintain the gingival portion of the tooth and periodontal sulcus and keeping them free of bacterial plaque. ● ● Rinsing the toothbrush in hot water every 15 to 30 seconds during brushing will soften the brush and reduce risk for trauma. ● ● Oral rinsing with water or normal saline three to four times while brushing will further aid in removal of dental plaque. ● ● Rinses containing alcohol should be avoided. ● ● Toothpaste with a relatively neutral taste should be considered because flavorings can irritate oral soft tissues. ● ● Brushes should be air dried between uses. ● ● Ultrasonic toothbrushes may be substituted for manual brushes if patients are properly trained in their use. ● ● Patients skilled at flossing without traumatizing gingival tissues may continue flossing throughout chemotherapy administration. ● ● Although toothbrush disinfectants have been suggested, their routine use to clean brushes has not been proven of value. The mouth should be cleaned after meals. If xerostomia is present, plaque and food debris may accumulate secondary to reduced salivary function, and more frequent hygiene may be necessary. Dentures need to be cleaned with denture cleanser every day and should be brushed and rinsed after meals. Rinsing the oral cavity may not be sufficient for thorough cleansing of the oral tissues; mechanical plaque removal is often necessary. Care must be exerted in the use of the varied mechanical hygiene aids that are available; dental floss, interproximal brushes, and wooden wedges can injure oral tissues rendered fragile by chemotherapy. Foam toothbrushes have limited ability to clean teeth but may be useful for cleaning other areas of the mouth, palate, and tongue. To manage discomfort and dryness, topical anesthetics – such as lidocaine in gels, ointments, or sprays – can help, as can diphenhydramine solution. Mucosal coating agents – such as Amphojel; kaolin-pectin suspension; hydroxypropyl methylcellulose film-forming agents (e.g., Zilactin); and Gelclair (approved by FDA as a device) – can help. Water-soluble lubricating agents, such as artificial saliva, can be used for xerostomia. A single application of topical doxepin, a tricyclic antidepressant, in cancer patients produces analgesia for four hours or longer. Its application to damaged mucosa does not cause burning. Topical morphine has been shown to be effective for relieving pain, but there is concern about dispensing large volumes of the medication. Topical fentanyl prepared as lozenges in a randomized placebo- controlled study showed relief for pain of oral mucositis. Systemic analgesia (such as opioids) should be used for pain unrelieved by these measures. NSAIDs are contraindicated when thrombocytopenia is present. Head and neck radiation typically causes acute oral toxicities, such as mucositis, in almost all recipients. In contrast to chemotherapy stomatitis, which tends to resolve after treatment ends, head and neck radiation can induce permanent tissue damage to mucosa, bone, and taste buds that results in lifelong risk for the patient. Amifostine can be used to help prevent damage to the salivary glands. Patients who do not respond well to topical treatments and symptomatic nursing management should be referred for dietary consultation to avoid dehydration and weight loss. Peripheral neuropathy Chemotherapy-induced peripheral neuropathy (CIPN) is a result of damage to the peripheral nerves. Symptoms depend on which peripheral nerves (sensory, motor, or autonomic) are affected. CIPN usually starts in the feet and hands that may spread proximally to arms or legs. It is one of the most common reasons that cancer patients stop treatment early. It can sometimes be lessened by lowering the chemotherapy dose or delaying doses, which might diminish the pain. Other patients report symptoms last long beyond chemotherapy treatment for months or years. These drugs are associated with CIPN: ● ● Platinum compounds (cisplatin, carboplatin, oxaliplatin). ● ● Plant alkaloids (vincristine, vinblastine, vinorelbine, etoposide). ● ● Taxanes (docetaxel, paclitaxel, cabazitaxel). ● ● Epothilones (ixabepilone). ● ● Bortezomib. ● ● Thalidomide. ● ● Lenalidomide. ● ● Eribulin. Damage to sensory nerves can cause the following: ● ● Tingling, numbness, or “pins-and-needles” in feet and hands. ● ● Inability to feel heat or cold in extremities. ● ● Inability to feel pain in the extremities. ● ● Hyperesthesia (increased sensitivity to heat, cold, or pressure). Damage to motor nerves can cause the following: ● ● Weak or achy muscles, loss of balance, difficulty with fine motor function (buttoning shirts or opening jars). ● ● Twitching, cramping, or muscle wasting. ● ● Dysphagia or dyspnea if chest or throat muscles are affected. Damage to autonomic nerves can cause the following: ● ● Gut motility problems, such as constipation or diarrhea. ● ● Hypotension with dizziness and lightheadedness. ● ● Sexual problems: Men may have erectile dysfunction and women may not reach orgasm. ● ● Sweating too much or too little. ● ● Urinary issues, such as leakage or incomplete bladder emptying. Injury prevention is important after CIPN develops. Advise affected patients to take actions to prevent falls: ● ● Get help moving rugs out of pathways to reduce the risk of tripping. ● ● Wear sturdy shoes with soft soles, not slippers that feet can accidentally slide out of. ● ● Home care services may be needed to put rails along the walls and in the bathroom. ● ● Use gripper bathmats in the shower or tub. ● ● Get up slowly after sitting or lying down, especially if the patient reports dizziness. ● ● Take extra care in the kitchen and shower. ○ ○ Use potholders in the kitchen to protect hands from burns. ○ ○ Be careful when handling knives or sharp objects. ○ ○ Use oven gloves to handle hot pans, oven racks, and dishes. ○ ○ Ask someone to check the water temperature, or use a thermometer to make sure bath or shower water is not too hot. Set hot water heaters between 105°F and 120°F to reduce risk of scalding when washing hands or dishes. ● ● Protect hands and feet. ○ ○ Wear shoes, both inside and outside. ○ ○ Wear protective gloves when gardening, cleaning, or doing repairs. ○ ○ Check arms, legs, and feet for cuts or scratches every day. ○ ○ When the weather is cold, wear warm clothes, gloves, and socks to protect hands and feet. ● ● Slow down and ask for help. ○ ○ Let others help with difficult tasks. ○ ○ Slow down and allow more time to do things. For patients with long-term CIPN, nurses may also want to ask the doctor to offer a referral to occupational therapy to help the patient with safety and mobility in the home and community. Pain management for CIPN In 2014, the American Society of Clinical Oncology put out a review of evidence and a recommendation noting that no agents have been proven to prevent CIPN, and recommended duloxetine as a proven pain