Diagnosing Oral Mucositis

Oral mucositis is diagnosed based on patient history, use of therapy associated with mucosal toxicity, and clinical examination.18 The timing of symptoms in relation to treatment administration is also informative.18 Erythema and light discoloration of the mucosa are early signs of mucositis.13,19

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As OM progresses, patients develop erosive lesions and ulcers. Mouth sores are more prevalent in mobile mucosa than in fixed mucosa.13 The mouth sores are often extremely painful and are typically the most distressing manifestation of OM.8,10 In thrombocytopenic patients receiving high-dose chemotherapy conditioning before HSCT, mouth ulcers may even bleed.6 Mouth sores interfere with patients’ ability to eat, drink, swallow, and talk.10

Radiation and cytotoxic therapies can also cause xerostomia (dry mouth) and dysgeusia (altered taste sensation), further suppressing patients’ desire to eat.6,20 Some patients with OM may find it easier to tolerate a soft or liquid diet. In some cases, total parental nutrition or enteral supplementation via a feeding tube is required to prevent malnourishment.6,18

Various assessment scales are available for rating the severity of OM. The 2 most commonly used in practice are the World Health Organization (WHO) scale and the National Cancer Institute Common Terminology Criteria for Adverse Events (NCI-CTCAE) version 4.03 (Table 1).11,18 The WHO grades OM according to clinical observations and the effect of mucositis on patient’s ability to eat.11,18 The NCI-CTCAE scale relies on the clinician’s observation, patient’s self-reported symptoms, and the effect of OM on the patient’s ability to eat and overall safety. With both instruments, it is important for the clinician to establish whether OM sufficiently explains the patient’s inability to eat.11

Table 1. Who and NCI Scales for Grading Oral Mucositis Severity18

WHO Scale for Oral Mucositis

NCI CTCAE version 4.03

Grade 0 (none): No oral mucositis

Grade 1: Asymptomatic or mild symptoms/ intervention not indicated

Grade 1 (mild): Erythema and soreness

Grade 2: Moderate pain; not interfering with oral intake; modified diet indicated

Grade 2 (moderate): Ulcers, able to eat solids

Grade 3: Severe pain, interfering with oral intake

Grade 3 (severe): Ulcers, requires liquid diet (due to mucositis)

Grade 4: Life-threatening consequences; urgent intervention indicated

Grade 4 (life-threatening): Ulcers, alimentation not possible (due to mucositis)

Grade 5: Death

Abbreviations: CTCAE, Common Terminology Criteria for Adverse Events; NCI, National Cancer Institute; WHO, World Health Organization.

Interventions for Oral Mucositis

The goal of interventions for OM are prevention, treatment, and pain relief. In 2014, the Multinational Association of Supportive Care in Cancer (MASCC) and the International Society of Oral Oncology (ISOO) published updated evidence-based guidelines for managing mucositis secondary to cancer therapy.2

The following year, the European Society for Medical Oncology (ESMO) endorsed the MASCC/ISOO guidelines and updated their own guidelines for managing oral and gastrointestinal mucositis.18 Both sets of guidelines are available for free online. The management approach for OM should be individualized for each patient. Patients should be encouraged to report any oral changes.