PAIN CHILD INTERNATIONAL MUCOSITIS EVALUATION SCALE
ChIMES
1. Which of these faces best describes how much pain you feel in your mouth or throat now? Circle one.
2. Which of these faces best shows how hard it is for you to SWALLOW your salivaspit today because of mouth or throat pain? Circle one.
3. Which of these faces shows how hard it is for you to EAT today because of mouth or throat pain? Circle one.
Not hard
1 Little
bit hard 2
Little more hard
3 Even
harder 4
Very hard
5 Can’t
swallow No
hurt 1
Hurts a little bit
2 Hurts a
little more 3
Hurts even more
4 Hurts a
whole lot 5
Hurts worst
Can’t tell
Not hard
1 Little
bit hard 2
Little more hard
3 Even
harder 4
Very hard
5 Can’t
eat Can’t
tell
Not hard
If yes, did you need the medicine because you had a sore mouth or throat?
Yes No
I can’t tell 5. Have you taken any medicine for any kind of pain today?
6. Please ask an adult to look in your mouth. Can he or she see any mouth sores in your mouth today?
1 Little
bit hard 2
Little more hard
3 Even
harder 4
Very hard
5 Can’t
drink Can’t
tell
4. Which of these faces shows how hard it is for you to DRINK today because of mouth or throat pain? Circle one.
FUNCTION
PAIN MEDICATION
You will need some help from your parent or another adult to answer these questions.
APPEARANCE
The photos shown on the introduction page are examples of what mouth scores may look like.
Yes No
Yes No
Fig. 11.3 ChIMES tool with permission from Tomlinson et al. [
2010 ]
Table 11.2 Prevention and treatment of oral mucositis
Intervention Level of support
Population studied Grade
a
Prevention Aloe Vera
Weak unreliable evidence the solution was benefi cial for the prevention of
moderate to severe mucositis Head and neck cancer receiving
radiotherapy 2C
Amifostine Weak unreliable evidence from
11 low quality trials that amifostine is benefi cial for the prevention of any
mucositis Combinations of head and neck cancer,
other solid tumors and hematologic malignancies receiving radiotherapy,
stem cell transplant, non- myeloablative chemotherapy or a combination
2C
Antibiotic polymyxin tobramycinamphotericin
[PTA]—lozengespaste Weak unreliable evidence that PTA
lozenges may be benefi cial for the prevention of any mucositis
Head and neck cancer receiving radiotherapy
2C Cryotherapy
Found to be benefi cial in the prevention of all the outcome
categories of mucositis—any, moderate and severe mucositis
Hematologic malignancies with chemotherapy or stem cell
transplantation 2B
Glutamine Weak evidence that glutamine
is benefi cial for the prevention of severe mucositis
Combinations of head and neck cancer, other solid tumors and hematologic
malignancies receiving radiotherapy, stem cell transplant, non- myeloablative
chemotherapy or a combination 2B
Granulocyte colony-stimulating
factor G-CSF Weak unreliable evidence that G-CSF
is effective for the prevention of severe mucositis
Combinations of head and neck cancer, other solid tumors and hematologic
malignancies receiving radiotherapy, stem cell transplant, non- myeloablative
chemotherapy or a combination 2C
Honey Weak unreliable evidence with
substantial heterogeneity that honey may be benefi cial in the prevention
of any mucositis Head and neck cancer receiving
radiotherapy 2C
Palifermin keratinocyte growth factor
Found benefi cial for the prevention of all outcome categories of mucositis,
moderate mucositis and severe mucositis
Combinations of head and neck cancer, other solid tumors and hematologic
malignancies receiving radiotherapy, stem cell transplant, non- myeloablative
chemotherapy or a combination 2B
Low-level laser therapy Weak unreliable evidence that laser is
benefi cial for the prevention of severe mucositis
Combinations of head and neck cancer, other solid tumors and hematologic
malignancies receiving radiotherapy, stem cell transplant, non- myeloablative
chemotherapy or a combination 2B
Sucralfate Evidence that sucralfate is effective in
the prevention of severe mucositis, with a 33 reduction in severe mucositis in
treatment group compared to placebo Mostly head and neck cancer receiving
radiotherapy, some trials with participants with other cancer types
2B
Treatment Low-level laser therapy
Limited evidence that low-level laser is benefi cial in reducing the severity of
oral mucositis Children with mixed cancers and adults
with hematologic malignancies 2B
Patient controlled analgesia PCA
Unreliable evidence that less opiate is used per hour and duration of the pain is
slightly reduced with PCA. No evidence that PCA is better than continuous
morphine in controlling pain Adult leukemia or lymphoma
undergoing high-dose chemotherapy and total body irradiation prior to stem
cell transplant 2B
Adapted from Eilers and Million 2011
a
Per Guyatt et al. 2006
; see Preface D. Mills and A.M. Maloney
undergoing allogeneic HSCT while Vitale et al. 2014
showed no signifi cant benefi t in children undergoing autologous HSCT although there
was a trend toward decreased mucositis severity. Further studies are required to assess whether
palifermin will be effective for other chemother- apy modalities and in the pediatric population.
11.4.2 Low-Level Laser Therapy
LLLT is an emerging therapy in the prevention and treatment of OM. LLLT is local application of a
monochromatic, narrowband, coherent light source. The action of LLLT is disputed, but a cytoprotective
effect before and during oxidative stress has been reported following its use. Red and infrared LLLT is
believed to have an anti-infl ammatory effect Bjordal
2012 . The current Multinational Association of
Supportive Care in Cancer MASCC and International Society of Oral Oncology ISOO
guidelines for adult patients receiving high-dose chemotherapy or chemotherapy and HSCT recom-
mend LLLT if the institution is able to support the technology and training in LLLT Keefe and Gibson
2007 . A meta-analysis by Bensadoun and Nair
2012 reported reduced risk of OM as well as
reduced duration and severity of OM with both red and infrared LLLT. Pediatric data are limited and
confl icting. In a randomized, placebo-controlled trial of 21 pediatric oncology patients with
chemotherapy-
related OM, Kuhn et al. 2009
showed that LLLT reduced the duration of OM. This result has been supported by Abramoff et al.
2008 who similarly showed a reduction in OM frequency
with LLLT as well as decreased pain and OM sever- ity in those presenting with OM. These results con-
fl ict with Cruz et al. 2007
who showed no benefi t for prevention in children with cancer in a random-
ized trial. As with palifermin, further data are
required to support LLLT in the pediatric population given the younger age and therefore likely improved
ability to heal compared to an older cohort.
11.4.3 Glutamine
Glutamine is considered a conditionally essential amino acid as stress and catabolic states lead to its
depletion Storey 2007
. Theoretically, glutamine repletion may prevent damage to normal tissues
such as the oral mucosa during cytotoxic thera- pies Storey
2007 . Adult studies showed benefi t
with Saforis AES-14, an oral L-glutamine swish-and-swallow suspension, but after United
States Food and Drug Administration FDA approval, the drug was discontinued Posner and
Haddad
2007 . Studies in pediatric patients are
confl icting; Anderson et al. 1998
and Aquino et al.
2005 showed benefi t in pediatric patients
undergoing cytotoxic therapies and HSCT, while Ware et al.
2009 showed no
benefi t. In the review by Storey
2007 , it is concluded that stud-
ies, though promising, show an inconsistent ben- efi t in pediatric patients and are limited by small
patient numbers as well as a variety of glutamine dosages, dose intervals and administration tech-
niques which hamper the ability to make fi rm conclusions about glutamine effi cacy.
11.4.4 Cryotherapy
Cryotherapy has not been systematically studied in pediatric oncology patients but has shown ben-
efi t in the prevention of OM from short-acting chemotherapeutic agents such as 5-fl uorouracil
5-FU in adult patients Posner and Haddad
2007 . Administration of ice chips simply causes
vasoconstriction and therefore decreased blood fl ow to the oral mucosa during bolus infusions of
5-FU. Benefi t of this intervention on longer- acting agents is unclear although the recent
Cochrane review did show potential decrement of OM incidence with prophylactic cryotherapy in
adult patients Posner and Haddad
2007 ; Eilers
and Million 2011
.
11.5 Oral Care
The purpose of basic oral care is to reduce symp- toms of oral pain and bleeding related to cancer
therapy and to prevent soft tissue infections that may have systemic sequelae. In addition, mainte-
nance of good oral hygiene reduces the risk of future dental complications Rubenstein et al.
2004 . A study by Clarkson and Eden
1998
examining the dental health of children with cancer found that 43 of patients had untreated
decay and only 35 had been seen by a dentist since diagnosis. Their study exemplifi ed the lack
of dental preventive care for pediatric oncology patients and stressed the need to continue to pro-
vide primary oral hygiene during pediatric cancer therapy Clarkson and Eden
1998 . A European
multidisciplinary group, in collaboration with the United Kingdom Childhood Cancer Study Group
UKCCSG and the Paediatric Oncology Nurses Forum PONF, was established in 2001 princi-
pally to produce comprehensive, evidence-based guidelines on mouth care for children and adoles-
cents being treated for cancer. The potential ben- efi ts of such guidelines include improved patient
care, consistency of care, the promotion of inter- ventions of proven benefi t and a reduction in use
of ineffective or potentially harmful practices Glenny et al.
2010 .
The UKCCSG-PONF Mouth Care for Children and Young People with Cancer guidelines used the
agreed-upon methodology of SIGN Scottish Intercollegiate Guidelines Network to aid them in
their development of evidence-based guidelines Glenny et al.
2010 . A consensus approach was
utilized to establish the scope and basic structure of the guidelines. Three key areas were identifi ed
and covered by the guidelines: 1 dental care and basic oral hygiene, 2 methods of oral assess-
ment, and 3 drugs and therapies Glenny et al.
2010 . The group conducted a systematic review
of the literature to examine these three key areas and, where no evidence existed, a consensus opin-
ion on best practice was determined Glenny et al. 2010
. Additionally, the American Academy of Pediatric Dentistry AAPD has published guide-
lines on the dental management of pediatric patients receiving chemotherapy, HSCT or radia-
tion AAPD 2013
. The overarching purpose of these guidelines is to recognize that the pediatric
dental professional plays an important role in the care of pediatric oncology patients. The AAPD
guidelines focus on basic oral hygiene and dental care for pediatric oncology patients before, during
and after cancer therapy.
The AAPD and UKCCSG-PONF guidelines make recommendations in fi ve areas, as summarized
in Table 11.3
: 1 orodental care at the time of can- cer diagnosis, 2 oral hygiene at diagnosis and dur-
ing cancer treatment, 3 orodental care during cancer treatment, 4 orodental care after cancer
therapy, and 5 prevention and treatment of xero- stomia Glenny et al.
2010 .
The UKCCSG-PONF guidelines emphasize the importance of oral assessment throughout
cancer treatment utilizing the discussed oral assessment tools. Frequency of oral assessment
should be determined on an individual basis and should be increased if oral complications arise
Glenny et al.
2010 . The AAPD describes the
importance of identifying and stabilizing, or elim- inating, existing and potential sources of infection
or local irritants in the oral cavity. Emphasis on the education of patients and parents on the
importance of oral care should occur throughout therapy as well as in regard to the potential short-
and long-term effects of therapy. The AAPD fur- ther elaborates on care when the use of radiation
will affect the orofacial region with the goal of reduction of radiation to healthy oral tissue
through consultation with the radiation oncologist and utilization of lead-lined stents, prostheses and
shields to spare structures such as the salivary glands. Patients who receive radiation therapy
involving the masticatory muscles should be edu- cated on daily oral stretching exercises to decrease
the potential of trismus AAPD
2013 .
Finally, for patients that experience xerosto- mia, the AAPD recommends fl uoride rinses and
gels for the prevention of caries as well as the use of humidifi cation for symptomatic relief.
11.6 Oral Infections
Patients experiencing OM are predisposed to infections of the oral cavity. Viral, fungal and bac-
terial infections may arise with incidence depen- dent on the use of prophylactic anti-
infective regimens, oral status prior to chemotherapy, and
secondary to the duration and severity of neutro- penia. The most frequent documented source of
sepsis in the immunocompromised cancer patient is the mouth Allen et al.
2010 . In adults, chemo-
therapy and radiotherapy in patients with head