الفهرس 
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Abstract
Cancer is a public health problem worldwide and is the second leading
cause of death globally. Chemotherapy is the choicest prescribed cancer
treatment modalities. 5-fluorouracial (5-FU) is a type of chemotherapy drug.
5-fluorouracial has many side effects like any other chemotherapy agent as it
has effects not only on cancer cells, but healthy cell as well. The most
common side effects (are diarrhea, nausea, vomiting, mucositis, poor appetite,
photosensitivity, metallic taste. Oral mucositis represents a major nonhematologic
complication of cytotoxic chemotherapy. It can occur to any
mucosal cells, but most commonly occurs in the cells of the oral cavity and
small intestine.
According to Foundations of supportive care in patients receiving cancer
treatment, management of mucositis includes three key components: basic
oral care, oral care protocols and patient education, and palliative care
including pain management. Antimicrobial agents are competent to manage
oropharyngeal bacterial colonization and formation of dental plaque.
Antimicrobial agents usually use is Chlorhexidine mouthwash. Oral care is an
integral part of basic nursing practice, so oral care should be a particular
priority for nurses caring for patients with cancer. Ideally, whenever providing
care to a cancer patient with oral mucositis, nurses should identify the level of
severity and establish a classification of risk, giving priority to preventive
measures for oral mucositis, regardless of the severity of the condition.
The aim of this study was
To determine the effect of Chlorhexidine on oropharyngeal mucositis
quality of life among cancer patients receiving chemotherapy.
Material and methods:
•Research design: the study followed a quasi-experimental design
•Setting: The present study was conducted at the oncology out-patient
clinic of Alexandria Main University Hospital.
•Subjects: one hundred adult patients who were receiving chemotherapy
and had oropharyngeal mucositis were selected. They were randomly
recruited into 2 groups; group one (control group) and group two (study
group), 50 patients for each group. according to the following criteria:
1. Age: 20 - 60 years old.
2. Able to communicate verbally.
3. Non smoker.
4. Free from metastasis.
5. Have mucositis grade 3 (soreness/erythema + ulceration + can‘t eat
solid foods).
Exclusion criteria:
1. Patients who having allergy to Chlorhexidine hydrochloride 0.2%.
2. Patients who using any other mouthwashes.
3. Patients who are pregnant and/or lactating mothers.
Tools of the study:
Four tools were used for this study
Tool I: The Oropharyngeal Status among cancer patients Nursing
Assessment:
This tool was adopted from Mohamed (2008) to assess mouth condition,
It comprised two main parts:
Part I: Patient’s sociodemographic data and clinical data.
Part II: Oropharyngeal Assessment Guide:
This tool was adopted by the researcher. It was developed by Eilers et al
(1988) to assess mouth condition before and after using of oropharyngeal
hygiene. It consisted of eight categories which are (voice, ability to swallow,
lips condition, saliva, appearance of tongue, appearance of mucous
membrane, gingival condition, appearance of teeth).
Scoring system: It consisted of eight categories; each category on three
likert scale 1:3. 1=normal, 2=altered but not loss function or barrier
breakdown, 3=loss function or barrier breakdown. The least score equal eight
and this mean normal mouth, where more than eight mean that there are
alteration in mouth. Scores were transformed to a 0-100 scale, with zero
representing no mouth problems and 100 representing extreme mouth
problems. Scores between 0 and 100 represented the percentage of total
possible score achieved.
Tool II: Numeric Rating Pain Scale.
This scale is a horizontal 10 cm line that has 2 ends, the left end usually
represents ”no pain”, whereas the right ends usually represents ”worst
possible pain”. The patient was asked to place a mark indicating where the
current pain lies on the line. 0 is ”no pain”, 1-3 represents ”mild pain”, 4-7
represents ”moderate pain”, 8-9 represents ”severe pain”, and 10 is the ”worst
possible, intractable pain”.
Tool III: Oropharyngeal Mucositis Quality Of Life (OMQoL)
Questionnaire:
The OMQoL was developed by Cheng, et al (2007), and was adopted by
the researcher; it is a set of generic, coherent, and easily administered quality
of life measures. It was used to assess quality of life (QOL) for patients with
oropharyngeal mucositis (OM). It consisted of 4 dimensions: Symptoms,
Diet, Social function and Swallowing. The four relevant subscales of
OMQOL were scored separately. A Likert scale was used and all items had
four possible answer options scored from 1 (not at all) to 4 (very much), and
each of the four scores is calculated as the sum of the items included. Scores
are transformed to a 0-100 scale, with zero representing least quality of life
and 100 representing highest quality of life. Scores between 0 and 100
represent the percentage of total possible score achieved.
Tool IV: Hill-Bone Compliance Questionnaire Scale (HBCQS).
The HBCQS was developed by Kim, et al. (2000), and was adapted by
the researcher. It was used to assess patients compliance with mouthwash It
consisted of eight categories; each category on four likert scale 1:4. ; 1
indicating ”none of the time”, 2 indicating ―some of the time ”, 3 indicating
―most of the time ―, 4 indicating ―all of the time ”. Scores were transformed to
a 0-100 scale, with zero representing no mouthwash compliance and 100
representing extreme mouthwash compliance. Scores between 0 and 100
represent the percentage of total possible score achieved.
The study was carried out in four phases:
I. Assessment phase:
It was carried out using the three tools tool I, II, III.to collect baseline
data for all the subjects (study and control group) of the study before using
oral hygiene.
II. Planning Phase:
Health education was designed by the researcher based on recent review
of literature. Booklet was then designed to be introduced to patients in Arabic
language. It included (Instructions related to using Chlorhexidine mouth
solution and health education about oral care).
III. Implementation phase:
Oral care hygiene health teaching was implemented individually for each
patient in the study group. It included teaching patient oral care hygiene
procedure, instructions related to solution to be used by the patients.
Instructions were given by the researcher to subjects to rinse with 20 ml of the
solution for 30 seconds three times daily till healing or two weeks.
IV. Evaluation phase:
This phase was carried out after using mouth solution, weekly (1st week
and 2nd week) using tool I, II, III and IV. Comparison of results between study
group and control group was done.
Data collection:
● Data were collected throughout a period of 1 year from August 2017 to
July 2018.
● Each patient was interviewed individually by the researcher. The
duration of each interview was from twenty to thirty minutes.
For the study group
The first interview (1st day) was to assess mouth condition, assess
oropharyngeal mucositis QOL, and to determine the grade of mucositis
pain by using tools of the research.
● Each patient was received his Chlorhexidine mouthwash.
● Each patient was instructed about the steps of oral health care procedure
and knowledge related to Chlorhexidine mouthwash.
● Patients were informed to rinse with 20ml mouthwash (CHX 0.2%) three
times daily and do not swallow the solution just swish it through his
teeth for 30 seconds and expectorate it.
The second interview (8th day) was for continuous assessment using the
research tools and to provide reinforcement for continuous using of
Chlorhexidine mouthwash through explaining that the effect of
Chlorhexidine that may require more than week to appear.
● During the third interview (15th day) the researcher performed
reassessment, answered any question and informed the patient that
research finished and the patient could get the mouthwash from the
pharmacy.
● The researcher used tool IV to assess patients‘ compliance with
mouthwash.
For the control group
● Routine oral care of the oncology out-patient clinic unit was
administered only.
● During the first, second and third interviews patients‘ mouth condition,
oropharyngeal mucositis QOL, and grade of mucositis pain were
assessed through using the tools I, II and III.
Statistical analysis:
After data were collected, there were coded and transferred into specially
designed formats, so as to be suitable for computer feeding.
•Simple frequency tables and cross tabulations with numbers and
percentages.
•The 0.05 level was used to assess significance of the result.
•Chi-Square, and Fisher’s exact tests were used.
The main results of the study:
•There were no statistically significant difference between patients in the
study and control group regarding sociodemographic and clinical
characteristics (P<0.05).
•The highest percentage of patients in both control and study group (46%,
and 44% respectively) were between 50 < 60 years of age.
•The highest percentage of patients in both control and study group (92%
and 86% respectively), were married.
•The highest percentage of patients in both control and study group (68%
and 74% respectively) were illiterate.
•The highest percentage of patients in both control and study group (72%
and 74% respectively) were housewives.
•The majority of patients in the control and study group (66% and 78%
respectively) were did not have enough monthly income from the
patient’s point of view.
•The full percentage of patients in the control and study group (100%)
their chief complaint were mucositis.
•The highest percentage of patients in the control group (40%) their
medical history was among 3 months < 6 months, but the highest
percentage of patients in the study group (46%) their medical history was
among 6 months< 1 year.
•The highest percentage of patients in both control and study group
(33.5% and 38% respectively) their diagnosis were stomach cancer.
•The highest percentage of patients in both control and study group (50%
and 40% respectively) received 700 mg < 800mg as dose of chemotherapy.
Highly statistically significant differences were detected between study
and control group in 8th and 15th day after oropharyngeal hygiene using
mouthwash in relation to total score of oral assessment guide (P<0.001).
•Highly statistically significant differences were detected between control
and study group in 8th and 15th day after oropharyngeal hygiene using
mouthwash in relation to severity of mucositis pain (P<0.001).
•Highly statistically significant differences were detected between study
and control group in 8th and 15th day after oropharyngeal hygiene using
mouthwash in relation to all dimensions of oropharyngeal mucositis
quality of life (P<0.001).
•General improvement was observed in all dimensions of oropharyngeal
mucositis quality of life in study group than control group during the 8th
and 15th day after oropharyngeal hygiene.
•All patients (100%) in the study group were highly complied with
mouthwash.
Recommendations for patients:
•Patients with mucositis should seek ongoing health education about
mucositis and its self-management practices from specialized health care
provider to improve their health and quality of life.
•Patients with mucositis should perform oral hygiene using mouthwash
(Chlorhexidine 0.2%) 20 ml per time for 30 second, three times daily to
improve their quality of life.
Recommendations for nurses:
•Nurses should perform oral care hygiene for unable patients and teach
able patients to perform it independent.
•Nurses should prevent and decrease oral complication of chemotherapy
for cancer patients receiving chemotherapy through assessing oral cavity
by using standardized grading system as an oral assessment guide
(OAG) tool prior to the initiation of chemotherapy and at least daily
following the administration of it.
•Nurses should measure QOL for all cancer patients receiving
chemotherapy using standardized grading system as oropharyngeal
mucositis quality of life (OMQOL) tool prior to the initiation of using
CHX and after it.
Recommendations for administrators:
•A colored illustrated booklet that updated periodically including
procedure of oral hygiene and all instructions related to using of
mouthwash (Chlorhexidine) should be available and distributed to all
patients with mucositis.
•Specific rooms for health education for patients with mucositis should be
available at any time to teach patients about mucositis management.
Recommendations for mass media:
•It is essential to increase the level of awareness among public, patients and
health care providers regarding importance of performing oral hygiene using
mouthwash (Chlorhexidine) especially during receiving chemotherapy.
Recommendations for future research:
•Further research is recommended to be done to determine the effect of
Chlorhexidine on oropharyngeal mucositis quality of life among cancer
patients receiving chemotherapy.
•Further research also needed for larger number of sample, as well as long
period of study time to confirm the results of the current study.