22 Seminars in Oncology Nursing, Vol 20, No 1 (February), 2004: pp 22-29

OBJECTIVE:

ASSESSMENT AND
To discuss the assessment and
monitoring of mucositis and pro-
vide an overview of instruments
available to assess or measure
mucositis.
MEASUREMENT OF
DATA SOURCE:
Published journal articles, texts,
and clinical experience.
ORAL MUCOSITIS
CONCLUSION:
The lack of consistent use of valid JUNE EILERS AND JOEL B. EPSTEIN
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.
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,
A
CCURATE 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

M easurement is an essential component of scientific research.5

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
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
 ASSESSMENT AND MEASUREMENT OF ORAL MUCOSITIS
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
Testretest reliability-Repeat performance with same
subject
Inter-rater reliability-Performance by equally trained
individuals
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-
23
jects individually or in a group; these are referred
to as evaluative instruments.
MUCOSITIS AS A SIDE EFFECT
M ucositis 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
24 EILERS AND EPSTEIN
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 patients 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
O ral 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-
 ASSESSMENT AND MEASUREMENT OF ORAL MUCOSITIS
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.
25
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 patients 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 patients 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
26 EILERS AND EPSTEIN
(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,
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?
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 patients 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
 ASSESSMENT AND MEASUREMENT OF ORAL MUCOSITIS 27

TABLE 3.
Cancer-Focused Assessment Tools Yielding a Numerical Rating as a Score

Title Components Addressed Rating Approach Used Comments

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