Oral Candidosis in Patients With Advanced Cancer and Nursing Intervention

Andrew N. Davies, et al. (2008) in the work entitled: "Oral Candidosis in Community-Based Patients with Advanced Cancer" reports that oral candidosis is a "significant cause of morbidity in patients with advanced cancer." Oral candidosis is described as "an opportunistic infection...relatively common in patients with early cancer, particularly in those with hematological malignancies, those receiving systemic chemotherapy and those receiving head and neck radiotherapy." (Davies, et al., 2008, p. 509) Davies et al. (2008) states that oral candidosis is not "...a single clinical entity, but a spectrum of very different clinical entities." (p.509) Davies et al. (2008) reports a study that included individuals with a diagnosis of advanced cancer and who were over the age of 18 years. The study reported is a "prospective, observational study" which is a study of a qualitative nature. The study contained a clinical component which involved completion of a study questionnaire and assessment of the Eastern Cooperative Oncology Group (ECOG) "performance status, clinical examination of the oral cavity, measurement of the unstimulated whole salivary flow rate, and performance of an oral rinse." (Davies, et al., 2008, p.509) Additionally it is reported that oral swabs were taken from subjects "with appearances indicative of oral candidosis on clinical examination of the oral cavity." (Davies, et al., 2008, p.509)

The laboratory component of the protocol is stated to have involved "standard procedures to isolate enumerate, and identify yeasts from the clinical specimens. Yeasts were isolated using CHROMagar Candida and indentified using the API 20 C. Aux yeast identification system, and if necessary DNA sequencing." (Davies, et al., 2008, p.509) Data analysis in the quantitative portion of the study was conducted using the software package Statistical Package for the Social Sciences version 13.0 which calculated the descriptive statistics and this is stated to have included both percentages and frequencies for various clinical and microbiological parameters." (Davies, et al., 2008, p. 509) There were a total of 396 participants in the study reported by Davies, et al. (2008). Findings in the study include that the "prevalence of oral candidosis has been reported to vary between 8% and 94% in patients with advanced cancer." (Davies, et al., 2008, p. 512)

A poor ECOG performance status is reported to be "an important risk factor for oral candidosis." (Davies, et al., 2008, p. 512) Findings additionally states that candidosis is "extremely high in patients admitted to hospice." (Davies, et al., 2008, p.512) There are also indications by the study results that there is "an association between systemic corticosteroids and oral candidosis." (Davies, et al., 2008, p.512) There is a "strong association between oral candidosis and the use of topical (inhaled) corticosteroids" however the study did not find an association between "systemic antibiotics and oral candidosis." (Davies, et al., 2008, p.512) The study found that screening for oral candidosis in early cancer is important to begin early treatment before patients develop local symptoms which include those of oral discomfort, taste disturbance and prior to their developing distant complications which includes esophageal candidosis, or systemic candidosis.

The work of Chang, Molassiotis, Chan and Lee (2007) entitled: "Nursing Management of Oral Mucositis in Cancer Patients" reports that reduction of oral mucositis development through promotion of patient compliance with oral care regimens "can be achieved by teaching patients meticulous oral care during chemotherapy, reinforcement of these instructions as well as regular nursing assessment of the oral cavity." (p.20) The study reported in the work of Chang, Molassiotis, Chan and Lee (2007) had the aim of determining the "current nursing oral care practice and mucositis-related outcomes for patients undergoing chemotherapy." (p.20) The study was comprised by two phases with the second phase focusing on the provision to nurses of education on oral care and prevention of mucositis and comparison of patient outcomes for those patients who received chemotherapy. Emphasized in the oral care protocol were: (1) regular oral assessment; and (2) frequent mouth rinsing using normal saline or water. (Chang, Molassiotis, Chan and Lee, 2007, p.20) The study is reported to have been conducted beginning May 2002 and ending October 2004. Study results state that there was a higher incidence of mucositis in Phase I participants as well as higher level of baseline symptoms and longer duration of cancer when compared to patients in Phase II of this study. There was stated to be low adherence of nurses to oral care principles for those patients who were undergoing chemotherapy in Phase I of the study. However, the adherence of nurses to oral care principles in Phase II of the study was "significantly higher than that in Phase I and for the experimental group it was significantly higher than that for controls." (Chang, Molassiotis, Chan and Lee, 2007, p.22)

It is reported by Chang, Molassiotis, Chan and Lee (2007) that the "prevalence of mucositis at day 8 in the phase II study was greater for the experimental group receiving the oral care protocol" however it is reported additionally that there was no statistical significance "adjusted for 5FU chemotherapy, as more of the corresponding patients received such treatment. " The same is stated to be true as of day 16. Stated to be an additional factor that influencing this study's findings was "...the overall low level of mucositis. Moreover, as the assessment of mucositis occurred at fixed days post commencement of chemotherapy, there was no assessment of the pre-treatment levels of mucositis." (Chang, Molassiotis, Chan and Lee, 2007, p.23.) Also reported in the findings of Chang, Molassiotis, Chan and Lee (2007) is: "The Oral Nursing Care Monitor developed for this study indicated an improvement in the level of oral care from phase I to phase II and a significantly higher level of oral care provided by the experimental group nurses in phase II. However as the maximum possible score was 24, the mean of 15.2 shows the need for further improvement in oral care as well as the education and follow-up of nurses in the implementation of oral care for patients receiving chemotherapy." (p.23)

The work of Alred, et al. (1991) entitled: "Oral Health in the Terminally Ill: A Cross-Sectional Pilot Survey" reports that patients who are terminally ill "have a number of signs and symptoms related to the mouth. These include mucosal soreness and ulceration, candidosis, glossitis and Xerostomia." (Alred, et al., 1991, p.59) Alred et al. (1991) report a study that included 20 patients/participants who were all suffering from malignant disease that was advanced and formed. Not included were patients with AIDS and cardiac disease. The group was chosen through random sampling and involved measurement of salivary flow rates. Mouth dryness was stated to have been "only ascribed to the extreme situations, in that there was almost total lack of saliva at any sites in the mouth." (Alred, et al., 1991, p. 59)

Details were secured concerning the participants "edentulous/teeth present / partial denture; presence of dental care is (decayed teeth); oral hygiene using the criteria of the Debris Index, recorded form the buccal surfaces of all teeth present, gingivitis based on gingival inflammation: graded as no or minimal inflammation, mild gingivitis, moderate gingivitis, or severe gingivitis; xerostomia, mucosal abnormalities; and denture type and quality of fit (good moderate or poor)." (Alred, et al., 1991, p. 60) The study reported by Alred, et al. (1991) states that 75% of the patients "complained of at least one oral symptom, indicating a high prevalence of oral signs and symptoms among patients with terminal illness." (Alred, et al., 1991, p. 61)

Alred, et al. (1991) state that 60% of denture wearers "wore their prostheses continuously...despite professional recognition of the importance of leaving dentures out at night..." (p. 63) This emphasized the importance of clearly explaining to patients "the values of leaving dentures in a denture cleaner overnight...particularly in view of their high rate of candidal carriage and candidiasis." (Alred, et al., 1991, p.63) Conclusions in the study of Alred, et al. (1991) state a prevalence of "...oral coliform carriage in a group of healthy adults (median age 62 years) has been reported as 12%" compared with 47% of the terminally ill patients." (p.63) In addition it is reported that "An increased prevalence of coliforms has also been reported in the oral flora of patients on cytotoxic therapy for malignant disease," in patients who have received radiotherapy for oral and laryngeal cancer, and in patients with acute leukemia, where their importance as a potential source of systemic infection has been implied." (Alred, et al., 1991, p. 63)

The work of Davies, Brailsford and Beighton (2005) entitled: "Oral Candidosis in Patients with Advanced Cancer" reports a study with the objective of determining "the epidemiology, aetiology, clinical features and microbiological aspects of oral candidosis in a cohort of cancer patients receiving specialist palliative care." (p.698) The study reported is stated to be a collaborative study involving the Department of Palliative Medicine at the Royal Marsden Hospital and the Dental Institute at Kings College London. The inclusion criteria for the study were:…