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The ideal oral mucositis scale should be objective, validated, and reproducible across all clinical settings.
It should be sufficiently sensitive to measure parameters of the oral mucositis experience across different treatment
modalities. The scale should be able to precisely measure
elements consistently associated with oral mucositis and
require minimal
training to produce systematic, accurate results. In addition, it should be
characterized
by intrarater and interrater reliability.1 No scale established
to date meets all these criteria or is accepted universally.
The most relevant scales for clinical management are those based on the National Cancer Institute (NCI) or World Health
Organization (WHO) design. In an analysis of approximately 400 trials, as a component of the evidence-based review for the
Multinational Association of Supportive Care in Cancer (MASCC) clinical practice guidelines, it was determined that most of
the studies utilized the NCI (43%) or WHO (38%) scales. Ten percent of the studies utilized a study-specific scale.
Five percent of the studies used a cooperative group scale, such as those used by the Radiation Therapy Oncology Group (RTOG).1
See Figure 1.
Figure 1. Frequency of Use in Clinical Studies
Sonis ST, et al. Cancer. 2004;(100)9:1995-2025.
NCI and WHO.
Several scales are available to assess oral mucositis. The WHO Oral Toxicity Scale measures anatomical, symptomatic
and functional components of oral mucositis. Severity of oral mucositis is graded from 0 (no oral mucositis) to 4 (alimentation not possible).
The NCI is graded from 0 (no oral mucositis) to 5 (death) as shown in Table 1.2
Table 1. Scales for Assessment of Oral Mucositis: NCI and WHO
| Grade 0 |
None |
| Grade 1 |
Painless ulcers, erythema, or mild soreness in the absence of ulcers |
| Grade 2 |
Painful erythema, edema, or ulcers but eating or swallowing possible |
| Grade 3 |
Painful erythema, edema, or ulcers requiring IV hydration |
| Grade 4 |
Severe ulceration or requiring parenteral or enteral nutritional support or prophylactic intubation |
| Grade 5 |
Death related to toxicity |
| Grade 0 |
None |
| Grade 1 |
Soreness +/- erythema, no ulceration |
| Grade 2 |
Erythema, ulcers. Patients can swallow solid diet |
| Grade 3 |
Ulcers, extensive erythema. Patients cannot swallow solid diet |
| Grade 4 |
Oral mucositis to the extent that alimentation is not possible |
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World Health Organisation. Handbook for reporting results of cancer treatment. 1997;pp.15-22.
Western Consortium of Cancer Nursing Research.
The revised Western Consortium of Cancer Nursing Research
(WCCNR) scale measures anatomical changes associated with oral mucositis. The severity of oral mucositis is graded from 0 (no lesions or bleeding)
to 3 (coalescing lesions that are very red and bleed spontaneously), as shown in Table 2.3
Table 2. Scales for Assessment of Oral Mucositis: WCCNR
| Grade 0 |
Lesions: none; Color: pink; Bleeding: none |
| Grade 1 |
Lesions: 1-4; Color: slight red; Bleeding: none |
| Grade 2 |
Lesions: > 4; Color: moderate red; Bleeding: with eating and oral hygiene |
| Grade 3 |
Lesions: coalescing; Color: very red; Bleeding: spontaneous |
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WCCNR. Can Oncol Nurs J. 1998;8:160-165.
Common Toxicity Criteria for Adverse Events version 3.0.
The updated NCI Common Toxicity Criteria
for Adverse Events version 3.0 (CTCAEv3) was released in 2003.4 The CTCAEv3 measures clinical components of
oral mucositis and clinical, functional and symptomatic components of oral and gastro intestinal (GI) oral mucositis.
Severity of oral mucositis is graded from 0 (minimal symptoms) to 4 (most severe/life-threatening) or even 5 (death)
as shown in Table 3.
Table 3. Scales for assessment of oral mucositis: CTCAEv3
| Grade 1 |
Erythema of mucosa
|
Upper aero digestive: minimal symptoms, normal diet; minimal respiratory symptoms
Lower GI: minimal discomfort |
| Grade 2 |
Patchy ulcerations or pseudo-membranes |
Upper aero digestive: symptomatic; respiratory symptoms interfering with function
Lower GI: intervention indicated |
| Grade 3 |
Confluent ulcerations or pseudo-membranes |
Upper aero digestive: symptomatic
and unable to adequately aliment/hydrate orally; respiratory symptoms interfere with ADL
Lower GI: ADL affected |
| Grade 4 |
Necrosis; spontaneous bleeding; life-threatening |
Symptoms associated with life-threatening consequences |
| Grade 5 |
Death |
Death |
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Adapted from Common Terminology Criteria for Adverse Events Version 3.0 (v3.0). Available at: http://ctep.cancer.gov.
CTCAE v3.0 = Common Terminology Criteria for Adverse Events Version 3.0
ADL = activities of daily living
| 1 |
Sonis ST , et al. Cancer. 2004:100(suppl 9):1995-2025. |
| 2 |
World Health Organization. Handbook for reporting results of cancer treatment. 1997;pp.15-22. |
| 3 |
WCCNR. Can Oncol Nurs J . 1998;8:160-165. |
| 4 |
Common Terminology Criteria for Adverse Events Version 3.0 (v3.0). Cancer Therapy Evaluation Program. http://ctep.cancer.gov. 2003. |
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ABOUT ORAL MUCOSITIS
ABOUT KEPIVANCE®
TOOLS AND RESOURCES
FOR NURSES
FOR PHARMACISTS
IMPORTANT PRODUCT SAFETY INFORMATION
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