Chemotherapy-Induced Oral Mucositis Workup

  • Author: Nathaniel S Treister, DMD, DMSc; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Dec 3, 2010
 

Laboratory Studies

Diagnosis is primarily based on the clinical findings and the chronology of the development of lesions.

  • WBC count with differential (absolute neutrophil count in particular) is a helpful test. Oral mucositis usually occurs when the absolute neutrophil count is less than 500 cells/µL.
  • Cultures (particularly for herpetic infection) should be performed if erythema and ulcers (or vesicles) are located on the keratinized tissues of the hard palate, the attached gingiva, or the dorsum of the tongue or if lesions persist after the period of profound neutropenia has passed. If the patient is on prophylactic antiviral agents, the possibility of breakthrough infection or the development of resistant strains must be considered.
  • Biopsy is indicated, especially if a deep fungal infection is suspected. Infection may present as a rapidly growing discrete ulcer on either the keratinized mucosa or the nonkeratinized mucosa (see Procedures). Biopsy should be considered when oral ulcerations are exacerbated with engraftment and restoration of the white blood cell count, especially when skin changes are absent, because this is suggestive of emerging acute GVHD. However, biopsy is not routinely necessary for oral mucositis.
Next

Other Tests

The severity of oral mucositis can be evaluated using several different instruments. The 2 most commonly used are the World Health Organization (WHO) Oral Toxicity score and the National Cancer Institute (NCI) Common Toxicity Criteria for oral mucositis. While the NCI system previously had separate scores for objective (erythema and ulceration) and functional (pain and ability to eat solids, liquids, or nothing by mouth) components, the recently introduced version 4.0 is entirely functionally based. The WHO score combines both objective and functional elements into a single score that is useful for measuring severity over time. The Oral Mucositis Daily Questionnaire (OMDQ), which evaluates mouth and throat soreness and its impact on daily activities, is a validated instrument that correlates with oral mucositis severity based on the WHO score.[9] Of note, symptoms have been found to precede objective findings by 1-3 days.

Previous
Next

Procedures

A biopsy may be necessary, particularly to rule out a deep fungal infection or CMV infection (although CMV infection usually occurs as a later event). Biopsy should be reserved for highly atypical cases or lesions that are believed to be infectious but that do not respond to appropriate therapy.

Lesions that are suggestive of recrudescent HSV should be cultured or evaluated by cytology.

Previous
Next

Histologic Findings

Routine biopsies are not performed on oral mucositis lesions unless other pathology is suspected, such as a deep fungal infection. In banal oral mucositis, the oral mucosa exhibits ulceration that, unlike other ulcerative conditions, shows a paucity of neutrophils in the fibrin clot. Granulation tissue is present at the base of the ulcer with chronic inflammatory cells. Staining for fungi and viruses may be necessary to identify organisms.

Previous
Proceed to Treatment & Management
 
 
Contributor Information and Disclosures
Author

Nathaniel S Treister, DMD, DMSc  Assistant Professor of Oral Medicine, Harvard School of Dental Medicine; Associate Surgeon, Division of Oral Medicine and Dentistry, Brigham and Women's Hospital

Nathaniel S Treister, DMD, DMSc is a member of the following medical societies: American Academy of Oral Medicine and American Dental Association

Disclosure: Nothing to disclose.

Coauthor(s)

Sook-Bin Woo, DMD, MS  Associate Professor, Chief, Division of Oral Medicine and Oral Pathology, Department of Oral Medicine and Diagnostic Services, Harvard School of Dental Medicine; Chief of Clinical Affairs, Brigham and Women's Hospital; Consultant, Dana Farber Cancer Institute, Beth Israel/Deaconess Medical Center

Sook-Bin Woo, DMD, MS is a member of the following medical societies: American Academy of Oral and Maxillofacial Pathology, American Academy of Oral Medicine, and American Dental Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Ponciano D Cruz Jr, MD  Vice-Chair, JB Shelmire Professor, Department of Dermatology, University of Texas Southwestern Medical Center

Ponciano D Cruz Jr, MD is a member of the following medical societies: Texas Medical Association

Disclosure: RCTS Consulting fee Independent contractor; Mary Kay Cosmetics Consulting fee Independent contractor; Galderma Grant/research funds Other

David F Butler, MD  Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Drore Eisen, MD, DDS  Consulting Staff, Department of Dermatology, Dermatology Research Associates of Cincinnati

Drore Eisen, MD, DDS is a member of the following medical societies: American Academy of Dermatology, American Academy of Oral Medicine, and American Dental Association

Disclosure: Nothing to disclose.

Glen H Crawford, MD  Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital

Glen H Crawford, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Phi Beta Kappa, and Society of USAF Flight Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD  Director, Department of Dermatology, Geisinger Medical Center

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

References

  1. Scully C, Sonis S, Diz PD. Oral mucositis. Oral Dis. May 2006;12(3):229-41. [Medline].

  2. [Guideline] Keefe DM, Schubert MM, Elting LS, et al. Updated clinical practice guidelines for the prevention and treatment of mucositis. Cancer. Mar 1 2007;109(5):820-31. [Medline].

  3. Rosen LS, Abdi E, Davis ID, et al. Palifermin reduces the incidence of oral mucositis in patients with metastatic colorectal cancer treated with fluorouracil-based chemotherapy. J Clin Oncol. Nov 20 2006;24(33):5194-200. [Medline].

  4. Sonis S, Treister N, Chawla S, Demetri G, Haluska F. Preliminary characterization of oral lesions associated with inhibitors of mammalian target of rapamycin in cancer patients. Cancer. Jan 1 2010;116(1):210-5. [Medline].

  5. Sonis ST. Pathobiology of oral mucositis: novel insights and opportunities. J Support Oncol. Oct 2007;5(9 Suppl 4):3-11. [Medline].

  6. Ruescher TJ, Sodeifi A, Scrivani SJ, Kaban LB, Sonis ST. The impact of mucositis on alpha-hemolytic streptococcal infection in patients undergoing autologous bone marrow transplantation for hematologic malignancies. Cancer. Jun 1 1998;82(11):2275-81. [Medline].

  7. Bochud PY, Calandra T, Francioli P. Bacteremia due to viridans streptococci in neutropenic patients: a review. Am J Med. Sep 1994;97(3):256-64. [Medline].

  8. Cutler C, Li S, Kim HT, et al. Mucositis after allogeneic hematopoietic stem cell transplantation: a cohort study of methotrexate- and non-methotrexate-containing graft-versus-host disease prophylaxis regimens. Biol Blood Marrow Transplant. May 2005;11(5):383-8. [Medline].

  9. Stiff PJ, Erder H, Bensinger WI, et al. Reliability and validity of a patient self-administered daily questionnaire to assess impact of oral mucositis (OM) on pain and daily functioning in patients undergoing autologous hematopoietic stem cell transplantation (HSCT). Bone Marrow Transplant. Feb 2006;37(4):393-401. [Medline].

  10. Brizel DM, Murphy BA, Rosenthal DI, et al. Phase II study of palifermin and concurrent chemoradiation in head and neck squamous cell carcinoma. J Clin Oncol. May 20 2008;26(15):2489-96. [Medline].

  11. [Best Evidence] Vadhan-Raj S, Trent J, Patel S, et al. Single-dose palifermin prevents severe oral mucositis during multicycle chemotherapy in patients with cancer: a randomized trial. Ann Intern Med. Sep 21 2010;153(6):358-67. [Medline].

  12. Spielberger R, Stiff P, Bensinger W, et al. Palifermin for oral mucositis after intensive therapy for hematologic cancers. N Engl J Med. Dec 16 2004;351(25):2590-8. [Medline].

  13. Barasch A, Peterson DE. Risk factors for ulcerative oral mucositis in cancer patients: unanswered questions. Oral Oncol. Feb 2003;39(2):91-100. [Medline].

  14. Epstein JB, Schubert MM. Oral mucositis in myelosuppressive cancer therapy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Sep 1999;88(3):273-6. [Medline].

  15. Peterson DE. Research advances in oral mucositis. Curr Opin Oncol. Jul 1999;11(4):261-6. [Medline].

  16. Plevova P. Prevention and treatment of chemotherapy- and radiotherapy-induced oral mucositis: a review. Oral Oncol. Sep 1999;35(5):453-70. [Medline].

  17. Rapoport AP, Miller Watelet LF, Linder T, et al. Analysis of factors that correlate with mucositis in recipients of autologous and allogeneic stem-cell transplants. J Clin Oncol. Aug 1999;17(8):2446-53. [Medline].

  18. Sonis ST. Mucositis as a biological process: a new hypothesis for the development of chemotherapy-induced stomatotoxicity. Oral Oncol. Jan 1998;34(1):39-43. [Medline].

  19. Sonis ST. Oral complications. Cancer Med. 2000;5:2371-9.

  20. Sonis ST. Oral mucositis in cancer therapy. J Support Oncol. Nov-Dec 2004;2(6 Suppl 3):3-8. [Medline].

  21. Spijkervet FK, Sonis ST. New frontiers in the management of chemotherapy-induced mucositis. Curr Opin Oncol. Aug 1998;10 Suppl 1:S23-7. [Medline].

  22. Wilkes JD. Prevention and treatment of oral mucositis following cancer chemotherapy. Semin Oncol. Oct 1998;25(5):538-51. [Medline].

  23. Woo SB, Lee SJ, Schubert MM. Graft-vs.-host disease. Crit Rev Oral Biol Med. 1997;8(2):201-16. [Medline].

  24. Woo SB, Sonis ST, Monopoli MM, Sonis AL. A longitudinal study of oral ulcerative mucositis in bone marrow transplant recipients. Cancer. Sep 1 1993;72(5):1612-7. [Medline].

 
Previous
Next
 
Hairy tongue.
Multiple mucoceles on the hard palate.
Erythematous oral mucositis lesion on the buccal mucosa.
Ulcerative oral mucositis lesion on the buccal mucosa.
Ulcerative oral mucositis lesion on the lateral and ventral surfaces of the tongue.
Ulcerative oral mucositis lesions on the labial mucosa and the floor of the mouth.
Oral pseudomembranous candidiasis on the hard palate.
Herpes simplex virus ulceration on the dorsal surface of the tongue.
Herpes simplex virus ulceration on the hard and soft palate. Note lesions on the right upper lip and the dorsum of the tongue.
Acute graft versus host disease involving the dorsal surface of the tongue. This is a keratinized site that is usually not involved by oral mucositis.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.