Articulo mucositis 1

OBJECTIVE:
To discuss the assessment and
monitoring of mucositis and pro-
vide an overview of instruments
available to assess or measure
mucositis.
DATA SOURCE:
Published journal articles, texts,
and clinical experience.
CONCLUSION:
The lack of consistent use of valid
and reliable instruments for the
assessment of mucositis have lim-
ited progress in the prevention
and management of mucositis.
IMPLICATIONS FOR NURSING
PRACTICE:
Nurses play a key role in the as-
sessment of oral cavity changes.
Using valid and reliable measures
will foster the ability to predict
risk for mucositis and to test the
effectiveness of protocols for its
prevention and treatment.
ASSESSMENT AND
MEASUREMENT OF
ORAL MUCOSITIS
JUNE EILERS AND JOEL B. EPSTEIN
ACCURATE oral assessment is critical for the pre-
vention and treatment of mucositis in patients
receiving antineoplastic therapy. A comprehen-
sive review of the literature indicates that treat-
ment for mucositis remains inadequate.1-3 Use of
valid and reliable instruments is necessary to measure speciﬁc
changes in the oral cavity so that the effectiveness of interventions
can be clearly articulated. In addition, use of tools that are not
valid and reliable limits the ability to compare outcomes between
interventions and across trials.
There is a wide range in the reported rates of mucositis,4 related
in part to variability across diseases and therapies and to under-
reporting of mucositis as a secondary endpoint of cancer trials.
Poor study designs, small sample sizes, limited assessments of
compliance, and limited use of validated measures of mucositis
have also restricted the development of optimal models. The
purposes of this article are to discuss: (1) criteria for evaluating the
validity and reliability of instruments, (2) how to select an instru-
ment, including concerns with the adaptation of existing instru-
ments, and (3) the use of multiple instruments.
ASSESSMENT AND MEASUREMENT
Measurement is an essential component of scientiﬁc research.5
There is a need for mucositis measurement scales in research
evaluating prophylactic and therapeutic agents in the clinical
setting and in clinical practice to improve performance and patient
outcomes. Effectiveness of interventions and standardized oral
care protocols for mucositis can be evaluated only with assessment
data collected in an organized, systematic manner using valid and
reliable instruments. The typical reports that the oral cavity looks
“better” or “worse,” or has “extensive mucositis,” do not provide
the clinician with the information necessary to plan care.
Selection of the most appropriate instrument to assess mucositis
requires examination of the goals of the assessment. A critical fact
that should guide instrument selection is recognition that the best
From the Department of Oncology/He-
matology, The Nebraska Medical Center,
Omaha, NE; and the Department of Oral
Medicine and Diagnostic Sciences, College
of Dentistry, University of Illinois, Chi-
cago, IL.
June Eilers, PhD, APRN, BC: Oncology/
Hematology Clinical Nurse Specialist,
Clinical Nurse Researcher, The Nebraska
Medical Center, Omaha, NE. Joel Epstein,
DMD, MSD, FRCD: Professor and Head,
Department of Oral Medicine and Diag-
nostic Sciences, College of Dentistry, Di-
rector, Interdisciplinary Program in Oral
Cancer, Cancer Center, University of Illi-
nois, Chicago, IL.
Address reprint requests to June Eilers,
PhD, APRN, BC, 6604 S 86th St, Ralston,
NE 68127.
© 2004 Elsevier Inc. All rights reserved.
0749-2081/04/2001-0005$30.00/0
doi:10.1053/S0749-2081(03)00136-0
22 Seminars in Oncology Nursing, Vol 20, No 1 (February), 2004: pp 22-29

instrument is the one that measures the right
things accurately. The selection process requires
awareness of how to evaluate instruments.
Instruments must be both valid and reliable if
they are to produce the data necessary to guide
practice and improve outcomes.6 Validity is re-
lated to whether an instrument or tool actually
measures what it purports to measure. A number
of terms are used to describe different types of
validity7 (see Table 1). Reliability refers to the
ability of an instrument to measure something in
a consistent and reproducible manner, reflecting
both random and systematic error in measure-
ment when an instrument is used (see Table 1).
The purpose of an instrument also determines
the necessary psychometric and other properties
and how those properties can be tested.8 Instru-
ments may be designed to measure cross-sectional
differences between subjects at a point in time.
These are identified as discriminative instruments
and can be used when no established external
criterion or gold standard is available. It is impor-
tant that these instruments are able to limit the
amount of error in measurement and capture
change when it is present yet not identify change
that is not present. For measurement of mucositis,
which involves change over time, this concept is
particularly important. A second purpose is pre-
dicting or attempting to classify subjects into sets
of predefined measurement categories based on a
gold standard. A third purpose involves evaluating
or detecting the longitudinal change within sub-
jects individually or in a group; these are referred
to as evaluative instruments.
MUCOSITIS AS A SIDE EFFECT
Mucositis is an important toxicity of cancer
treatment, and it needs valid and reliable
measurement.9 The increased recognition among
health care providers of the importance of mucosi-
tis is evidenced by the multidisciplinary National
Institute of Health conferences in 1989 and
2000,10,11 recent plenary and educational sessions
at the meetings of the American Society of Clini-
cal Oncology, the Oncology Nursing Society, and
the Multinational Association of Supportive Care
Cancer/International Society for Oral Oncology;
and this issue of Seminars in Oncology Nursing.
The importance of mucositis among patients and
families is supported by patients’ identification of
it as the most bothersome side effect of high-dose
therapy12 and radiation therapy for head and neck
cancers.13
Critical analysis of the existing literature on
mucositis supports the need for instruments to
accurately reflect the changes seen in the oral
cavity with mucositis, to articulate the potential of
antineoplastic agents to damage mucous mem-
branes so that risk of mucositis can be deter-
mined, and to test the effectiveness of interven-
tions to prevent and treat mucositis. It is
important to document the normal progression of
oral cavity changes seen as mucositis develops
and resolves. Knowledge regarding the usual
changes seen and the underlying pathobiology of
mucositis14,15 can help guide measurement. In
addition, Sonis’ evolving model14,15 provides a
framework for improved understanding of the pro-
cess of mucositis, and suggests that mucositis
measurement scores should indicate more exten-
sive involvement during the ulcerative phase than
during the initial or healing phases. Just as a
wound specialist determines interventions based
on the stage of the wound, nurses and others
should similarly base their oral care interventions
on the phases of this pathobiologic process.
Careful assessment of the oral cavity after anti-
neoplastic therapy can ascertain the degree and
duration of changes in the oral cavity and articu-
late the clinical changes seen during progression
and resolution of the lesions, including those that
might be due to clinical trauma from speaking or
eating. The mechanisms by which chemotherapy
leads to oral mucosal damage and the degree of
TABLE 1.
Criteria for Instrument Validity and Reliability
Evaluation of validity-the ability to measure what is
intended to be measured
Face validity-Includes relevant items (weakest form of
validity)
Content validity-Adequately covers topic
Criterion validity-Performance compared with
established instruments
Construct validity-Theoretical soundness of
instrument
Evaluation of reliability- the ability to measure in a
consistent and reproducible manner
Internal consistency-Correlations of multiple indicators
of concept within instrument
Test–retest reliability-Repeat performance with same
subject
Inter-rater reliability-Performance by equally trained
individuals
ASSESSMENT AND MEASUREMENT OF ORAL MUCOSITIS 23

damage are poorly understood.16 Surprisingly, it is
not known which antineoplastic drugs are se-
creted in saliva and whether the presence of drugs
in salivary excretion causes additional tissue dam-
age. Lists of chemotherapy agents with high po-
tential for mucous membrane damage are incon-
sistent. There is a lack of adequate information
regarding what constitutes the dose at which risk
of mucositis increases, and what combinations of
agents may decrease the threshold for mucositis.
Just as knowing the emetogenic potential of a
chemotherapy protocol guides interventions for
nausea and vomiting,17 knowledge regarding the
likelihood of mucositis with a given protocol facil-
itates assessment and targeted therapies. Grading
the severity of mucosal reactions across multiple
courses of treatment can measure the degree of
involvement with each course of therapy, thus
enhancing prediction of probable mucositis with
the next course, and decisions about prophylactic
protocols.
The mucositis caused by antineoplastic agents
may also be manifested throughout the gastroin-
testinal and genitourinary tract, causing esophagi-
tis, gastroenteritis, and cystitis. Because the
mouth is readily accessible and visible, and the
other sites are not, the oral cavity can serve an
index of other mucosal tissue damage in the body.
Indeed, it has been noted that “the mouth often
tells us even more than it says.”18 The systemic
nature of mucositis can necessitate reduction of
antineoplastic therapy doses and treatment de-
lays, potentially influencing response to cancer
treatment.19-21 Thus, it is important to assess mu-
cositis over time.
Mucositis can alter normal oral functions, espe-
cially nutritional intake and speech. For each of
these changes, pain is the most common symptom
that patients report, thus oral cavity function is
highly dependent on the effectiveness of pain
management. For this reason, the ability to eat
(measured in some oral assessment instruments)
may be more of an indicator of unrelieved pain
than a measure of mucositis severity.
When salivary gland function is altered by cel-
lular damage from antineoplastic therapies, pa-
tients experience varying degrees of xerostomia or
dry mouth, accompanied by a high degree of dis-
tress. Permanent loss of salivary function is ex-
pected in radiation therapy when the treatment
field includes the salivary glands, but in the che-
motherapy setting xerostomia will typically im-
prove over time. Accurate data regarding what to
expect are not readily available because of the
lack of adequate assessment measures and incon-
sistent reporting.22,23 Thick saliva is another con-
cern of patients who have varying degrees of xe-
rostomia because it interferes with eating, may
aggravate nausea or stimulate vomiting in nause-
ated patients, and ultimately results in weight
loss. Some aspects of saliva that may be assessed
by nurses include clinical report of dryness or
thick saliva by patients, overall impression, volu-
metric measurement, and viscosity.
The fact that mucositis is not limited to the oral
cavity adds to the challenge for the clinician. Pa-
tients with mucositis in the throat and esophagus
experience increased pain and may require sys-
temic analgesia.24 The need to assess pain with
mucositis is not questioned. However, the integra-
tion of pain as a component of an oral assessment
measure that renders a composite score may not be
as optimal as measuring it separately, particularly
when multiple dimensions of pain are important to
assess.
In contrast to the patient’s expressed concerns
about pain or dry mouth, health care professionals
often focus more on tissue changes including ulcer-
ation and erythema. The ulcerations are especially
important in the immune-suppressed patient be-
cause of the risk of secondary systemic infection
caused by the loss of barrier function. Treatment of
infections in these patients can cause additional
challenges because the use of multiple antimicrobial
agents alters the normal microbial balance in the
oral cavity. This can result in an overgrowth of
organisms such as yeast that can complicate the
assessment of changes.
ORAL CAVITY ASSESSMENTS
Oral assessments can be conducted by a wide
variety of individuals, including research as-
sistants, dental personnel, nurses, aides, lay care-
givers, and patients. Oral assessment needs to be
preceded by thorough training, requires attention
to detail, and must be performed consistently.
Timing of assessments in terms of frequency
and sequence vis-a`-vis eating, oral care, pain, and
the pathobiological process is important. DeWalt
and Haines25 found that changes in the oral cavity
could be noted within 4 hours if stressors were
present and no interventions were initiated. The
performance of oral hygiene before an oral assess-
ment and the quality of that oral care may influ-
ence the findings because elapsed time from the
last cleansing and or rinsing could affect the pres-
24 EILERS AND EPSTEIN

ence of debris and the amount of moisture
present. In addition, selection and timing of inter-
ventions for pain will influence reports of pain
intensity, which if included in the oral assess-
ment, will affect the results. Finally, the Sonis
model14,15 suggests an expected trajectory of tis-
sue damage, breakdown, and healing if the patient
does not experience additional complications. As-
sessments need to be completed at a frequency
that allows for the identification of measurable
changes in oral tissue during each phase of the
model. If assessment is too infrequent, it may not
identify important changes as mucositis develops
and resolves, but if it is too frequent, it may result
in excessive patient burden and data.
Appropriate lighting is critical to adequately view
all areas of the oral cavity. Halogen light sources are
the standard in research studies. Individuals per-
forming regular assessments in the clinical setting
can use an otoscope or ophthalmoscope as a light
source; at home, individuals may need to rely on
flashlights. A tongue blade or dental mirror and
gauze provide assistance for visualization of the oral
cavity. The gauze can be wrapped around the tongue
to allow retraction from side to side. For some pa-
tients, not all areas may be easily visualized because
of mucosal pain or a sensitive gag reflex.
The goal of the assessment determines the ex-
tensiveness of the exam. Although it may not be
realistic to expect staff nurses to conduct an ex-
tensive assessment for every oncology patient,
regular assessments are essential in patients re-
ceiving antineoplastic treatments that cause mu-
cosal damage. Unfortunately, implementation of
this practice has been inconsistent, even within
bone marrow transplant centers.26 Establishment
of oral care standards that include consistent as-
sessment27,28 is an important means through
which nurses can facilitate assessment.
ASKING THE RIGHT QUESTIONS
A variety of oral cavity-related problems have
been identified as occurring in individuals re-
ceiving chemotherapy,6 including sore mouth, sore
gums, mouth ulcers, sore lips, dry lips, sore tongue,
dry mouth, and taste change. Similarly, individuals
receiving radiation therapy to the head and neck
region13 will experience a variety of oral problems
including dry mouth, mouth sores, taste changes,
pain, and sore throat. Although the cluster of symp-
toms may vary, in most instances the oral cavity
changes are not limited to one symptom.
The term mucositis commonly refers only to
erythema and ulceration, not to the other changes
seen in the oral cavity. Because consensus has not
been reached on the essential components for oral
assessment in patients treated for cancer, it is
important to consider the intent and use of termi-
nology. For example, discussions about “mucosi-
tis” may refer only to lesions, whereas discussions
about “oral cavity changes” should refer to xero-
stomia, ability to swallow, etc. Therefore, one
must determine which changes will be assessed,
how data will be used, and who will be completing
the assessment. In addition, it is important to
understand that mucositis can have an impact on
quality of life29,30 particularly the patient’s affec-
tive state.31 In studies for which the outcome(s)
involve the impact of changes in the oral cavity, it
may be relevant to differentiate the intensity of
the patient’s experience and the impact of that
experience on quality of life.
Mucositis as an acute side effect has received
considerable attention, but chronic effects in the
oral cavity have also begun to be addressed. Acute
complications include ulcerations, mucositis,
hemorrhage, dry mouth, candidiasis, taste
changes, and pain. Chronic complications include
dry mouth, mucosal sensitivity, soft-tissue and
osteonecrosis, and dysphagia. Distinction be-
tween effects helps to understand the nature and
impact of various changes such as ulceration
(acute effect) and xerostomia (chronic effect).
Measurement tool(s) chosen should reflect the
purpose of the data collection any time oral cavity
assessments are planned. Validity and reliability
are essential for both research and clinical instru-
ments. Depending on how the data will be used,
research instruments may require more detail
than clinical instruments and should be able to
show clinically significant differences if they ex-
ist.32 Instruments used by clinicians on a regular
basis in the clinical setting must be relevant for
the questions being asked, clear, concise, easy to
use, clinically feasible in the setting, and provide
relevant data for management.
Prevention and treatment trials for mucositis
have had varied endpoints (eg, tissue specific in-
jury scales, symptom assessment, and/or func-
tional assessment). Outcomes may include alter-
ations in comfort level (eg, pain) or changes in
speech, swallowing, oral intake of food and medi-
cation, and salivary function. Measures of tissue
specific change that include mucosal ulceration
(size and number of ulcerations present), the ar-
eas of the oral cavity involved, and tissue redness

(erythema) are needed to assess mucositis. For
example, Stokman et al33 reported correlations
between degree of trypan blue staining and sever-
ity of oral mucositis, thus linking cell death (in-
ability to exclude trypan blue in vitro) with clini-
cal observations of degree of oral mucosal injury.
At the other end of the spectrum, overall oral
cavity assessment scales may be useful from a
clinical perspective to track general status and
document patient experience. Such general as-
sessment data may also be useful in the testing,
licensing, and marketing of oral care products.
Understanding of the desired outcome(s) of a spe-
cific intervention will direct selection of the instru-
ment and extensiveness of the examination. If the
purpose is to test the effectiveness of prophylactic or
therapeutic interventions, assessment must focus
on the oral cavity changes that accompany cancer
treatment. For example, Janken et al23 conducted a
study to determine if nursing interventions im-
proved the amount of moisture in the oral cavity. If
the goal of an intervention is to improve plaque
control and/or removal of accumulated debris, these
variables should be included. If the identification of
possible infections is a concern, clinical criteria for
infection need to be stated, a thorough examination
performed, and appropriate cultures collected. If
decreased tissue damage is the anticipated outcome,
a specific tissue damage scale should be used as a
primary endpoint. If a change in comfort level is
anticipated, a patient self-report pain scale should
be used. If any of the aforementioned changes are
not directly related to the intervention, they do not
need to be included in the instrument(s).
SELECTING AN INSTRUMENT
A measure of mucositis must be able to detect
change over time and to discriminate mucosi-
tis from other changes (eg, is any moisture that is
present an indication of recent oral hygiene or an
indicator of salivary gland function?). Just as se-
lection of the correct measurement instrument is
essential for research studies, selection of an as-
sessment tool for routine use is also important for
optimal care outcomes. The knowledge, skills, and
abilities required to perform oral assessment must
be considered when selecting an instrument.34 If
the instrument requires specialized training, sup-
port staff and lay individuals may not have the
skills necessary for reliable use of the instrument.
When the instrument includes functional activi-
ties such as speech, mastication, and swallowing,
a patient who is on a ventilator or otherwise
unable to respond will obviously limit completion
of the assessment. Self-report of subjective phe-
nomena such as discomfort or dryness requires
patient participation as well.
A primary clinical goal of oral assessment is to
assist in developing comprehensive oral care pro-
tocols to improve the patient’s functional status,
control pain, promote nutrition, identify the pres-
ence of infection, and assess progress of oral
changes.35 In addition to the aforementioned cri-
teria for selection of a tool, the potential user must
also consider practicality for the user and poten-
tial burden for patients. See Table 2 for questions
that can guide instrument selection.
Beck36 set the stage for the study and measure-
ment of oral cavity changes in patients receiving
chemotherapy with her Oral Exam Guide. Be-
cause of the increased incidence of mucositis in
patients receiving high-dose chemotherapy with
or without hematopoietic cell transplant, studies
of mucositis conducted in this population have
driven the development and testing of instru-
ments that focus predominantly on specific oral
cavity changes and rate them on various scales.
Examples include the Oral Assessment Guide,37
the Oral Mucosa Rating Scale,38 and the 34-item
and 20-item Oral Mucositis Index39,40 (see Table
3). The majority of these instruments focus pri-
marily on aspects of mucosal tissue damage such
as erythema and ulceration, as well as less com-
mon changes such as edema and atrophy.
A second approach is the use of scales that
grade toxicity, which are generally used in the
conduct of cancer treatment clinical trials to de-
termine whether treatment should reduced or de-
layed. A Canadian group, the Western Consortium
for Cancer Nursing Research, convened a multi-
disciplinary panel of experts for the development
TABLE 2.
Instrument Selection: Asking the Right Questions
What information regarding the oral cavity is needed?
How will the data collected be used?
Does the instrument address the necessary areas of
concern?
Does the instrument have established validity and
reliability?
Is the instrument able to provide the specificity needed?
Who will be conducting the assessment?
What skill/training is needed to complete the
assessment?

TABLE 3.
Cancer-Focused Assessment Tools Yielding a Numerical Rating as a Score
Title Components Addressed Rating Approach Used Comments
Oral Exam
Guide
(OEG)36
Three components to exam guide
A. Visual inspection/observation by clinician: Lips
(texture, color, moisture), tongue (texture, color,
moisture), mucous membranes of palate, uvula &
tonsillar fossa (color, moisture), gingival (color,
moisture), teeth (shine, debris) dentures (fit), saliva,
voice, ability to swallow
B. Perception by patient: Lips, tongue, gingival,
saliva, teeth, dentures, taste, voice, eating
C. Physical condition: Level of consciousness,
breathing habits, diet, self-care ability.
Each aspect is rated on 1
to 4 scale: 1 ϭ normal/
no problem, with
increasing alterations/
problems to rating of 4
Provides for collection of extensive
data
Potential primarily as a research
tool, not seen as readily useable
by clinician
Varied criteria for rating categories
does not allow for ready use of
instrument unless clinician has
tool in sight.
Solicits subjective input from
patient regarding subjective
experience
Oral
Assessment
Guide
(OAG)37
Clinician assessment: Voice, swallow, lips, tongue,
saliva, mucous membranes, gingival, and
teeth/dentures
Each aspect is rated on a
1 to 3 scale: 1 ϭ
normal, 2 ϭ altered but
not loss of function or
barrier breakdown, 3 ϭ
loss of function or
barrier breakdown
Includes both oral cavity functions
and physical aspects. Clear,
concise, and clinically relevant to
direct care clinician. Ease of
rating scale allows for ready use
of instrument by clinician once
learn eight areas to assess. Used
in multiple clinical settings. Does
not include specific measure of
size or extent of lesions
Does not differentiate the various
areas of the mucous membranes
Oral
Mucosa
Rating
Scale
(OMRS)38
Type and severity of clinically evident oral mucosal
changes: atrophy, erythema, ulceration, and
pseudomembranous, hyperkeratotic, lichenoid, and
edematous changes.
0 to 3 rating scale (normal
to severe)
Developed to classify and quantify
oral mucosal changes and
disease
Includes separate scales for pain and dryness Visual analogue scale. No
dryness/worst possible
dryness and no pain/
worst possible pain
Does not include functional
performance
Separates subjective complaints
from objective changes (lesions)
Oral
Mucositis
Index
(OMI)39,40
34-Item OMI-Clinician (usually dental professional)
assessment; 11 atrophy items (lips, labial mucosa,
buccal mucosa, floor of mouth, soft palate & tongue);
11 ulcer/pseudomembrane items (lips, labial mucosa,
buccal mucosa, floor of mouth, tongue) 10 erythema
items (lips, labial mucosa, buccal mucosa, floor of
mouth, tongue)
Atrophy, ulceration,
erythema, edema.
Scored from 0 (none) to
3 (severe) and are
summed for a total
score
Uses a strong dental focus. Format
assumes clinical examiners have
sufficient experience to recognize
and score the types and grades
of changes the tool measure
20-Item OMI Clinician assessment: rates four types of
mucosal changes in nine anatomic areas: atrophy
(dorsal tongue), edema (lateral tongue), erythema
upper and lower labial mucosa, right & left buccal
mucosa, floor of mouth, soft palate, and dorsal,
lateral, and ventral tongue; ulceration or
pseudomembrane (upper and lower labial mucosa,
right and left buccal mucosa, floor of mouth, soft
palate, and dorsal, lateral and ventral tongue)
Same rating scale Modified to facilitate use by
nondental health professionals
(deleted items less likely to be
accurately and reliably assessed
by nondental health
professionals)
Exclusively objective measure of
oral tissue injury in mucositis.
Does not include functional or
subjective assessment (pain)
Provides for erythema and
ulceration subscores.
Oral
Mucositis
Assessment
Scale
(OMAS)
Two components: Clinician assessment-Objective
measures of mucositis: erythema and
ulceration/pseudomembrane in eight anatomic
locations of the oral cavity
Patient report-Two subjective outcomes-pain and
difficulty swallowing and ability to eat
Erythema-0 (none) to 2
(severe) ulceration/
pseudomembrane
formation, 0 (no lesion)
to 3 (Ͼ3 cm sq)
Patient report on 100 mm
visual analog scales: 0
(no problem) to 100
(worst problem)
Ability to eat-categorical
scale-types of food
Provides for quantifiable statistical
measurement of functional,
objective, and subjective
parameters within one brief tool
that is clinically relevant and
presented in an easily used
format with a reproducible
scoring system. Focuses on
mucous membranes does not
include other oral cavity changes.
Works well for multi-site study that
includes nondental health
professionals as examiners.
Quantification of size of lesions
requires more training than
briefer clinical tools

of a descriptive staging system to measure the
progressive severity of chemotherapy-induced
oral cavity changes.41 A similar staging approach
to mucositis is the basis for the common toxicity
criteria used by the World Health Organization42
and the National Cancer Institute.43 In addition to
specific grading criteria for chemotherapy and
transplant, the National Cancer Institute has de-
veloped grading criteria for radiation therapy that
are used by the Radiation Therapy Oncology
Group.44 Although these grading scales have been
extremely useful in national and international tri-
als, they do have limitations in their ability to
examine a broader spectrum of objective, subjec-
tive, and functional outcomes.
Both of the approaches described above have
limitations in studies of prophylactic or therapeu-
tic agents, which require precise measurement of
oral cavity changes such as erythema and ulcer-
ation, as well as the effects of the agents on sub-
jective and functional outcomes such as pain and
ability to eat. Recognition of this measurement
gap stimulated the development and testing of the
Oral Mucositis Assessment Scale by a multidisci-
plinary group of content experts45 (see Table 3)
and another detailed research scale.46
It is important to recognize that modifications
to an existing instrument potentially alter the
psychometric properties, thus if researchers or
clinicians modify an instrument, the specific
changes should be articulated and the revised
instrument tested for validity and reliability. This
process has been demonstrated by McGuire et
al,40 who reduced the somewhat complex 34-item
Oral Mucositis Index to the 20-item Oral Mucositis
Index, an instrument more easily completed by
non-dental health professionals such as nurses.
Thorough assessment may require use of more
than one measure or modification of an existing
measure. Both of these decisions require addi-
tional planning. When an intervention is targeted
to decrease pain, it is important to include a valid
and reliable measure of pain. This pain assess-
ment can be accomplished using a numerical as-
sessment such as a 0 to 10 visual analogue or
numerical rating scale; asking questions specific
to pain with swallowing, worst pain, and least
pain; a comprehensive multidimensional pain in-
strument, or the pain item on the Oral Mucositis
Assessment Scale.45 If an intervention is targeted
to prevent xerostomia or increase moisture of the
mucous membranes, it may be necessary to add a
more specific measure of salivary function.23,47
Deciding what to do with the presence of infec-
tion in the oral cavity is complex. Some could
argue that infection (ie, thrush or candida) should
be included as part of an instrument. This ap-
proach is problematic because the thrush inter-
feres with visualization of the extent of ulcerative
lesions and can actually be present independent of
ulcerative mucositis lesions. Similarly, herpes vi-
ral infections in aplastic patients can cause ulcer-
ation, visual changes in the mucosal tissue, and
severe pain. Because institutions can also vary in
their prophylaxis, diagnosis, and treatment of oral
infections, nurses may need to rely on dental
associates to assist with diagnosis of infections.
CONCLUSION
Accurate assessment of the oral cavity changes
that accompany cancer treatment is essential
for optimal patient outcomes. Regular use of ac-
curate assessment measures and participation in
clinical research studies will enable nurses to ad-
dress unanswered questions about mucositis. Be-
cause the mouth provides a window to other mu-
cous membranes in the body,18 this assessment
can also provide for increased attention to gastro-
intestinal tract and other changes secondary to
therapies that affect mucous membranes. Having
the knowledge, skills, and abilities to rigorously
assess or measure mucositis will position oncology
nurses to make a difference for patients.
REFERENCES
1. Clarkson JE, Worthington HV, Eden OB. Interventions for
preventing oral mucositis for patients with cancer receiving
treatment. Cochrane Database Syst Rev 2003;3:CD000978.
2. Rubenstein EB , et al. Clinical practice guidelines for the
prevention and treatment of cancer therapy-induced oral and
gastrointestinal mucositis. Cancer 2003 (in press).
3. Plevova P. Prevention and treatment of chemotherapy-
and radiotherapy-induced oral mucositis: a review. Oral On-
cology 1999;35:453-454.
4. Avritscher EBC, Cooksley C, Elting LS. Scope and epide-
miology of oral and gastrointestinal mucositis. Semin Oncol
Nurs 2004;20:xx-xx.
5. Streiner DL, Norman GR. Health Measurement Scales: A
Practical Guide to Their Development and Use. New York, NY:
Oxford: 1995.
6. Sitzia J, Dikken C, Hughes J. Psychometric evaluation of
a questionnaire to document side-effects of chemotherapy. J
Adv Nurs 1997;25:999-1007.
7. Jacobson SF. Evaluating instruments for use in clinical
nursing research. In: Frank-Stromborg M, Olsen SJ, eds. In-

struments for Clinical Health-Care Research. Boston, MA:
Jones & Bartlett: 1997; 3-19.
8. Guyatt GH, Kisrshner B, Jaeschke R. Measuring health
status: what are the necessary measurement properties? J Clin
Epidemiol 1992;45:1341-1345.
9. McGuire DB, Peterson DE. Introduction. Semin Oncol
Nurs 2004;20:xx-xx.
10. Consensus development conference on oral complica-
tions of cancer therapies: diagnosis, prevention, and treat-
ment. Bethesda, MD: National Institutes of Health; 1990;No. 9.
11. National Cancer Institute. Mucosal injury in cancer pa-
tients: new strategies for research and treatment. J Natl Cancer
Inst Monogr 2001;29:1-51.
12. Bellm LA, Epstein JB, Rose-Ped A, et al. Patient reports
of complications of bone marrow transplantation. Support
Care Cancer 2000;8:33-39.
13. Rose-Ped AM, Bellm LA, Epstein JB, et al. Complications
of radiation therapy for head and neck cancers. The patient’s
perspective. Cancer Nurs 2002;25:461-467; quiz 468-469.
14. Sonis ST. Mucositis as a biological process: a new hy-
pothesis for the development of chemotherapy-induced stoma-
totoxicity. Oral Oncol 1998;34:39-43.
15. Sonis ST. Pathobiology of mucositis. Semin Oncol Nurs
2004;20:xx-xx
16. Epstein J, Schubert M. Oral mucositis in myelosuppre-
sive cancer therapy. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 1999;88:273-276.
17. Doherty KM. Closing the gap in prophylactic antiemetic
therapy: patient factors in calculating the emetogenic potential
of chemotherapy. Clin J Oncol Nurs 1999;3:113-119.
18. Eilers J. When the mouth tells us more than it says-the
impact of mucositis on quality of life. Oncol Support Care Q
2003;1:31-43.
19. Bonadonna G, Valagussa P. Dose-response effect of ad-
juvant chemotherapy in breast cancer. N Engl J Med 1981;304:
10-15.
20. Frei E III, Canellos GP. Dose: a critical factor in cancer
chemotherapy. Am J Med 1980;69:585-594.
21. Hryniuk W, Bush H. The importance of dose intensity in
chemotherapy of metastatic breast cancer. J Clin Oncol 1984;
2:1281-1288.
22. Epstein JB, Tsang AGF, Warkentin D, et al. The role of
salivary function in modulating chemotherapy-induced oro-
pharyngeal mucositis: a review of the literature. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 2002;94:39-44.
23. Janken JK, Beal LF, Fieler VK. Measuring mouth mois-
ture: a case study in instrument development. Clin Nurse Spec
1989;3:114-118.
24. Epstein JB, Schubert MM. Managing pain in mucositis.
Semin Oncol Nurs 2004;20:30-37
25. DeWalt EM, Haines AK. The effects of specified stressors
on healthy oral mucosa. Nurs Res 1969;18:22-27.
26. Ezzone S, Jolly D, Replogle K, et al. Survey of oral
hygiene regimens among bone marrow transplant centers.
Oncol Nurs Forum 1993;20:1375-1381.
27. Graham KM, Pecoraro DA, Ventura M, et al. Reducing
the incidence of stomatitis using a quality assessment and
improvement approach. Cancer Nurs 1993;16:117-122.
28. Yeager KA, Webster J, Crain M. Implementation of an
oral care standard for leukemia and transplantation patients.
Cancer Nurs 2000;23:40-47; quiz 47-48.
29. Eilers J. Stomatitis as a side effect of cancer treatment.
Quality of Life - A Nursing Challenge 2003;5:68-74.
30. Epstein JB, Phillips N, Parry J, et al. Quality of life, taste,
olfactory and oral function following high-dose chemotherapy
and allogeneic hematopoietic cell transplantation. Bone Mar-
row Transplant 2002;30:785-792.
31. Dodd MJ, Dibble S, Miaskowski C, et al. A comparison of
the affective state and quality of life of chemotherapy patients
who do and do not develop chemotherapy-induced oral mu-
cositis. J Pain Symptom Manage 2001;21:498-505.
32. Estabrooks CA, Hodgins MJ. Clinical significance: Play it
again Sam. . .. Clin Nurs Res 1996;5:371-375.
33. Stokman MA, Spijkervet FK, Wymanga AN, et al. Quan-
tification of oral mucositis due to radiotherapy by determining
viability and maturation of epithelial cells. J Oral Pathol Med
2002;31:153-157.
34. Griffiths J, Boyle S, eds. Oral assessment. In: A Colour
Guide to Holistic Oral Care: A Practical Approach. Aylesbury,
England: Mosby-Year Book: 1993;87-98.
35. Hyland SA. Assessing the oral cavity. In: Frank-Strom-
borg M, Olsen SJ, eds. Instruments for Clinical Health-Care
Research. Boston, MA: Jones & Barlett; 1997:519-527.
36. Beck S. Impact of a systematic oral care protocol on
stomatitis after chemotherapy. Cancer Nurs 1979;2:185-199.
37. Eilers J, Berger AM, Petersen MC. Development, testing,
and application of the oral assessment guide. Oncol Nurs
Forum 1988;15:325-330.
38. Kolbinson DA, Schubert MM, Flournoy N. Early oral
changes following bone marrow transplantation. Oral Surgery
1988;66:130-138.
39. Schubert MM, Williams BE, Lloid ME, et al. Clinical
assessment scale for the rating of oral mucosal changes asso-
ciated with bone marrow transplantation. Development of an
oral mucositis index. Cancer 1992;69:2469-2477.
40. McGuire DB, Peterson DE, Muller S, et al. The 20 item
oral mucositis index: reliability and validity in bone marrow
and stem cell transplant patients. Cancer Invest 2002;20:893-
903.
41. Western Consortium for Nursing Research. Priorities for
cancer nursing research: a Canadian replication. Cancer Nurs
1987;10:319-326.
42. WHO Handbook for Reporting Results for Cancer Treat-
ment. Geneva, Switzerland: World Health Organization: 1979.
Availableathttp://whqlibdoc.who.int/publications/9241700483.
pdf (accessed September 18, 2003).
43. Common Toxicity Criteria v3.0. National Cancer Insti-
tute. Bethesda, MD: 2003. Available at http://ctep.cancer.gov/
forms/CTCAEv3.pdf. (accessed September 18, 2003).
44. Cox JD, Stetz J, Pajak TF. Toxicity criteria of the Radi-
ation Therapy Oncology Group (RTOG) and the European
Organization for Research and Treatment of Cancer (EORTC).
Int J Radiat Oncol Biol Phys 1995;31:1341-1346.
45. Sonis ST, Eilers JP, Epstein JB, et al. Validation of a new
scoring system for the assessment of clinical trial research of
oral mucositis induced by radiation or chemotherapy. Mucosi-
tis Study Group. Cancer 1999;85:2103-2113.
46. Spijkervet FK, vanSaene HK, Panders AK, et al. Scoring
irradiation mucositis in head and neck cancer patients. J Oral
Pathol Med 1989;18:167-171.
47. Fox PC, Busch KA, Baum BJ. Subjective reports of
xerostomia and objective measures of salivary gland perfor-
mance. J Am Dent Assoc 1987;115:581-584.

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