A study of 21 patients with head and neck cancers demonstrated that pain at rest, during swallowing, and during speaking increased by week 6 from baseline, and, although it decreased, remained elevated 2 weeks after the end of radiation treatments.8 Pain was greatest during swallowing, followed by speaking and at rest. The study used the Oral Mucositis Weekly Questionnaire-Head and Neck Cancer (OMWQ-HN) and the Functional Assessment of Cancer Therapy-Head and Neck Cancer (FACT-H&N) to evaluate QoL outcomes within the functional, emotional, and social domains. All parameters worsened during radiation treatment and remained worse compared with baseline 2 weeks after radiation treatments were completed. These changes corresponded to worsening Oral Mucositis Assessment Scale (OMAS) scores, which demonstrated worsening OM symptoms during treatment that improved after radiation treatment ended, but remained elevated compared with baseline. This suggests that worsening QoL is related to worsening symptoms of OM.

In another study of 344 patients with solid tumors treated with chemotherapy, patients with OM demonstrated a significantly lower overall QoL, particularly in the physical and emotional domains, compared with patients without OM, as assessed by FACT-H&N (P < .001).9 Similarly, a study of 60 patients with OM as a result of chemotherapy and/or radiation demonstrated that physical pain, physical limitation, and psychologic discomfort had the worst scores.10 In a study of 57 adult patients receiving chemotherapy, 75% of patients experienced OM and reported that ulceration was the most significant problem (88%), whereas pain during swallowing was considered the most distressing effect (88%) associated with OM.11

OM is a serious toxicity associated with chemotherapy and radiation therapy that can be dose-limiting.3 Treatment in the form of preventative and supportive care is important to improve QoL and prevent or reduce the severity of symptoms.


Although several grading scales exist for the severity of OM, the most commonly used include the World Health Organization (WHO) Oral Toxicity Scale and the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE; Table 2 and Table 3).1

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Table 2. World Health Organization Oral Toxicity Scale Grading of Oral Mucositis4

Grade 1

Grade 2

Grade 3

Grade 4


Soreness, with or without erythema

Erythema, ulcers; still able to swallow solid foods

Ulcers with extensive erythema; unable to swallow solid foods

Ulcers with extensive erythema; alimentation not possible


Painful areas of erythema, no ulcers

Areas of erythema, some painful ulcers present

Erythema present on most of mucosal surfaces; many painful ulcers present

Erythema present on most of mucosal surfaces; extensive painful ulcers present

Table 3.
National Cancer Institute CTCAE Scoring for Oral Mucositis1




None or mild


Moderate pain; not interfering with oral intake


Severe pain; interfering with oral intake