There is considerable apprehension associated with cancer diagnosis, proportionally more than with other chronic disease such as heart disease. Despite advances in treatment and care, there continues to be a great deal of anxiety and fear associated with diagnosis of cancer and treatment complications (Lewis.,2004). Therefore an important role of the nurse in managing outcome is to recognize, intervene and provide support for the human response to living with cancer and cancer treatment complications (Sorrell,C., 2005).
Cancer is one of the most significant health problems in the world as a major cause of morbidity and mortality. Globally the burden of new cancer cases was estimated to be around 10 million with more than half of these cases originating from the developing world population. Although estimates vary it is estimated that by the year 2020 there will be almost 20 million new cases. The magnitude of the problem of cancer in India, from the population census data 609,000 new cancer cases per year were estimated to have been diagnosed in the country (Radhika, B., 2008).
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Oral mucositis remain a major source of illness despite the use of a variety of agents to prevent them. Oral mucositis is defined as an inflammation and ulceration of the mouth mucosa with pseudo membrane formation. It is a potential source of infection which may lead to death. It manifests first by thinning of oral tissues leading to erythema and leads to ulcer formation. It is at this stage that the primary symptom is severe debilitating oral pain (Naidu,R., 2004).
Incidence and severity of oral mucositis will vary from patient to patient, and treatment to treatment. Approximately 400,000 patients per year may develop acute or chronic oral complications during chemotherapy and radiation therapy. It is estimated that there is 40 percent incidence of mucositis in patients treated with chemotherapy, patients receiving radiation have 30 to 60 percent chance and patients receiving radiation therapy in particular to head and neck have chance of 98 percent (Suman,A., 2004).
Severe mucositis is commonly seen in patients who receive radiation therapy for cancer of the oral cavity and surrounding structures. Oral mucositis also occur secondary to chemotherapy for various solid tumors, the exact pathophysiology of development is not known, but it is thought to be divided into direct and indirect mucositis, chemotherapy or radiation therapy will interfere with the normal turnover of epithelial cells leading to mucosal injury and also occur due to indirect invasion of gram-negative bacteria and fungal species because most of the cancer drugs will cause changes in blood counts (Ramana,V.,2004).
The initial presentation of oral mucositis is erythema followed by white desquamating plaques, which are painful when touched. Epithelial crusting and a fibrin exudates result in a pseudo membrane and ulceration, which is the more severe form of mucositis and patients invariably complaint of pain. Exposure of stromal connective tissue due to loss of epithelial cells is found in the most severe form of mucositis. It usually develops seven to fourteen days after chemotherapy or radiation therapy is initiated (Nathanial,S., 2010).
Various agents are used in order to reduce the incidence and severity of oral mucositis. Chlorhexidine gluconate is an anti microbial agent that appears to be effective in controlling infection. Povidone iodine is an antibiotic agent also appears to be beneficial in controlling radiation or chemotherapy induced oral mucositis. An ideal oral rinse for patients with radiation or chemotherapy induced oral mucositis should reduce the oral microflora, promote reepithelization of soft tissue lesion, normalize the pH of oral fluids and be nontoxic. 1% of povidone iodine mouthwash and 0.12% chlorhexidine mouthwash have all these qualities. Patients with radiation or chemotherapy induced oral mucositis rinse their mouth with 10 ml of mouthwash, twice a day for healing of oral mucositis (Goodman.M,2006).
1.1 Need for the Study: In patients undergoing cancer treatment, oral mucositis is reported as the most debilitating aspect of their treatment. Ulcer may act as a site for local infection and a portal of entry for all oral floras that in some instance may increase the risk for developing septicemia. In addition to direct morbidity, oral mucositis contribute indirectly to increased length of hospitalization and increased cost of treatment.
Oral mucositis affects upto 40 percent of patients who receive radiation therapy. Severe mucositis interrupt the management of cancer which can compromise cure rate. Patients with severe oral mucositis need hospitalization because of severe pain and lose ability to take anything by mouth and need parentral nutrition (Lieberman, A.,2003).
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Many different mouthwashes are commercially available, patients and health professionals struggle to select the most appropriate product for a particular need. Commonly used mouthwash for oral mucositis are chlorhexidine mouthwash and povidone iodine mouthwash. Many of the literature shows that both mouthwashes have an effect on radiation or chemotherapy induced oral mucositis. Mucositis may be severe as to delay treatment and so limit the effectiveness of cancer therapy. Patient with damaged oral mucosa and reduced immunity resulting from chemotherapy and radiotherapy are also prone to opportunistic infections in the mouth. It is therefore extremely important that mucositis should be treated and to prevent related complications. Progress in the prevention and management of mucositis will improve quality of life, reduce cost of care and facilitate completion of more intensive cancer chemotherapy and radiotherapy protocols. Improved management of mucositis that is use of povidone iodine mouthwash may allow implementation of cancer treatment protocols effectively (Dodd., 2003).
Nurses play a critical role in the assessment and management of oral mucositis. However, nurses face several significant challenges in effectively managing oral mucositis. First, the assessment and management of oral mucositis is inconsistent. Second, available treatment options are largely ineffective, aimed at palliation of symptoms, and do not target the underlying pathophysiology. Nursing care has focused primarily on symptom management and pain control. With recent advances in the understanding of the pathophysiology of oral mucositis and the development of interventions, it is hoped that the quality of care provided to patients will improve dramatically as new agents such as povidone iodine mouthwash should allow the goal of management to shift from symptom relief to protection and prevention. Nurses should be educated about these novel options for the management of oral mucositis (Bavier, A., 1990).
The investigator during the clinical experience come across cancer patients with radiation or chemotherapy induced oral mucositis and measures to promote healing of oral mucositis have been found ineffective. From the findings of literature also the researcher realized that it is necessary to conduct a study for comparison of povidone iodine mouthwash and chlorhexidine mouthwash in reducing radiation or chemotherapy induced oral mucositis. This motivated the researcher to find out the most effective mouthwash for radiation or chemotherapy induced oral mucositis.
1.2 Statement of the problem
A COMPARATIVE STUDY TO ASSESS THE EFFECTIVENESS OF POVIDONE IODINE MOUTHWASH VERSUS CHLORHEXIDINE MOUTHWASH ON RADIATION OR CHEMOTHERAPY INDUCED ORAL MUCOSITIS AMONG CANCER PATIENTS IN CARITAS HOSPITAL, KOTTAYAM.
Assess the radiation or chemotherapy induced oral mucositis in cancer Patients.
Assess the effectiveness of povidone iodine mouth wash on radiation or chemotherapy induced oral mucositis in cancer patients.
Assess the effectiveness of chlorhexidine mouthwash on radiation or chemotherapy induced oral mucositis in cancer patients
Compare the effectiveness of povidone iodine and chlorhexidine mouth wash on radiation or chemotherapy induced oral mucositis in cancer patients.
Radiation therapy or chemotherapy will cause oral mucositis.
Povidone iodine mouthwash and chlorhexidine mouthwash helps in healing of oral mucositis.
The use of povidone iodine mouth wash is more effective than chlorhexidine mouth wash on healing of radiation or chemotherapy induced oral mucositis in cancer patients.
1.5.1 There will be significant difference between pretest and posttest grade of radiation or chemotherapy induced oral mucositis in a group using povidone iodine mouthwash.
1.5.2 There will be significant difference between pretest and posttest grade of radiation or chemotherapy induced oral mucositis in a group using chlorhexidine mouthwash.
1.5.3 There will be a significant difference between grade of radiation or chemotherapy induced oral mucositis in group using povidone iodine mouthwash and chlorhexidine mouth wash.
1.6 Operational definition
1.6.1 Effectiveness: It is the outcome of use of povidone iodine mouthwash and chlorhexidine mouthwash on radiation or chemotherapy induced oral mucositis
1.6.2 Mucositis: Radiation or chemotherapy induced inflammation of oral mucous membrane which will be graded by using oral mucositis assessment scale.
1.6.3 Mouth washes:
1.6.3. a) Povidone iodine mouthwash: 1% of povidone iodine mouthwash is a antibiotic solution used to treat radiation or chemotherapy induced oral mucositis
1.6.3. b) Chlorhexidine mouthwash: 0.12% chlorhexidine mouthwash is a antimicrobial solution used to treat radiation or chemotherapy induced oral mucositis
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1.7 General system model: The conceptual frame work of this study derived from General System Theory. According to General system model input, throughput, output explains pre assessment of radiation or chemotherapy induced oral mucositis, providing povidone iodine and chlorhexidine mouthwash and post assessment of oral mucositis. Input represents the pre assessment of oral cavity which includes presence of ulcers, erythema, edema, hemorrhage, and intensity of pain, presence of enteral or parental feeding. Throughput represents the administration of povidone iodine mouthwash for povidone iodine group and chlorhexidine mouthwash for chlorhexidine group. Output represents the post assessment of oral cavity of both groups which brings that there is significant difference in povidone iodine mouthwash and chlorhexidine mouthwash in reducing radiation or chemotherapy induced oral mucositis (Figure 1.1).