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There are
multiple scoring methods to grade mucositis. Objective, subjective,
and a combination of both findings have been used to measure the
severity of mucositis. For instance, some assessments of mucositis
only assess the anatomic distribution of mucosal lesions whereas
others incorporate the patient's ability to chew and swallow.
Click here
for a table summarizing the most commonly-used scales for assessing
oral mucositis.
A major impediment
to mucositis research has been the lack of an accepted, validated,
and objective scoring system for mucositis. Instead, individuals
and groups have developed many scoring systems, often with different
objectives. The widely used World Health Organization (WHO) and
National Cancer Institute (NCI) scales were developed to describe
toxicities associated with a particular chemotherapeutic regimen
or radiation therapy. The WHO scale combines both objective mucosal
changes (redness and ulceration) with functional outcomes (ability
to eat) to arrive at a score. NCI Common Toxicity Criteria (NCI
CTC) for mucositis have been developed for patients receiving
radiation therapy, chemotherapy, and conditioning regimens for
bone marrow transplantation. The NCI CTC scale for radiation-induced
mucositis is based totally on objective findings whereas the scale
for chemotherapy and bone marrow transplant-associated mucositis
includes elements such as difficulty with swallowing, IV fluid
support, and intubation to assist with patient management.
Oncology nurses
have developed scoring systems for the assessment of mucositis
and for patient management (Eilers
et al., 1988; Dyck et al.,
1991). Many of these scales have a holistic quality; they
include elements that are not defined traditionally as being related
directly to mucositis. For example, the Western Consortium for
Cancer Nursing Research (WCCNR) has a staging system that includes
functional and subjective outcomes such as speech quality, avoidance
of spicy foods, swallowing, lip and mucosal dryness, infection,
bleeding, and cleanliness.
Some research
groups have attempted to develop mucositis scoring systems that
are applicable as research tools (Schubert
et al., 1992; Spijkervet
et al., 1989). These systems have attempted either to eliminate
subjective findings completely or to evaluate them independent
of objective findings and then integrate them into a comprehensive
score. As has been the case with some management scales, several
of the research scales have called for the evaluation of individual
sites in the mouth to produce a single score.
The Oral Mucositis
Assessment Scale (OMAS) was developed and tested by a panel of
experts for the purpose of investigative applications. The panel
included nurses, dental hygienists, physicians, dentists, statisticians,
and representatives of the pharmaceutical and biotechnology industries.
This scale separates objective and subjective findings. Primary
indicators of mucositis were the degrees of ulceration and redness
measured in specific sites in the mouth. Secondary indicators
included oral pain, difficulty swallowing, and the ability to
eat as assessed by the patient. A single score is not produced
from this scale, rather a score for ulceration and redness based
on different locations in the mouth are used (Sonis
et al., 1999).
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